Working With the Person With Schizophrenia 9780814788813

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Working with the Person with Schizophrenia

Working with the Person with Schizophrenia THE TREATMENT ALLIANCE Michael A. Selze r Timothy B. Sulliva n Monica Carsky Kenneth G . Terkelsen

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NEW YOR K U N I V E R S I T Y P R E S

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N E W

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Y O R

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L O N D O

Copyright © 198 9 b y Ne w Yor k Universit y All right s reserve d Manufactured i n th e Unite d State s o f Americ a Library o f Congres s Cataloging-in-Publicatio n Dat a Working wit h th e perso n wit h schizophreni a : the treatmen t allianc e Michael A . Selze r . . . [e t al.]. p. cm . Bibliography: p . Includes index . ISBN 0-8147-7891- 7 1. Schizophrenia . 2 . Psychotherapis t an d patient. I . Selzer , Michael A. , 1 9 3 4 - . [DNLM: 1 . Physician-Patien t Relations . 2 . Psychotherapy . 3. Schizophrenia—therapy . W M 20 3 W9266 ] RC514.W63 198 9 616.89'82—dc20 DNLM/DLC for Librar y o f Congres s 89-897 1 CIP New Yor k Universit y Pres s books ar e printed o n acid-fre e paper , and thei r bindin g material s ar e chosen fo r strengt h an d durability . Book design by Ken Venezio

Contents

Preface vi i Acknowledgments i x Introduction 1 1 A Model for Understanding Schizophrenia 1 5 2 Understandin g the Subjective Experience of the Person with Schizophrenia 6 3 3 Fro m Understanding to Action: The Alliance and the Treatment Program 11 7 4 Th e Man with a Bug in His Brain: An Initial Interview 16 7 v

vl Contents 5 Th e Case of Sharon: A Hospital Sta y Involving Noncompliance, Violence, and Staf f Conflic t 23 3 6 Th e Case of Maryann : Psychotherap y an d Communit y Management, Rehabilitation , an d Rehospitalizatio n 26 9 7 Th e Case of Roger : Outpatien t Psychotherapy — From Apathy t o Communit y Involvemen t 30 1 8 Beyon d Psychoeducation : Raisin g Family Consciousnes s About th e Priorities of Peopl e with Schizophreni a 34 5 Notes 37 3 References an d Suggeste d Reading s 37 7 Index 39 1

Preface

About ten years ago a former teacher of mine , Leon Shapiro, called to offer m e "the job you've always said you wanted." Leon, who had just been appointed Medical Director of The New York Hospital, Westchester Division, was asking me to create and direct a long-term treatment unit for chronic schizophrenics. "A kind of asylum," he suggested "with, of course, unlimited opportunity to teach." It was this last phrase, as he well knew, that made this an offer I could not refuse. For the next eight years, I lived out my wish to work intensively with this very special population, surrounded by colleagues whose eagerness to lear n wa s sufficien t t o overcom e th e challenge s pose d b y the inpatients' (apparent) indifference, withholding , rejection, and hopelessness. In thinking bac k o n tha t time , wha t stand s ou t i s th e degre e th e staf f maintained comraderie. Despite the discouragement, fright, and helplessness the patients engendered in us, we maintained our curiosity. Discussions of clinical issues were lively and intense, frequently ending without a consensu s havin g bee n reached—thi s despit e th e fac t tha t ther e was vii

viii Preface considerable grou p pressur e t o presen t a unite d fron t t o th e patients . There wa s a continua l pressur e t o com e t o closure , t o defin e wha t th e "right thing " wa s an d then d o it . Th e complexit y o f th e problems , however, di d no t allo w fo r absolute , party-lin e solutions , an d th e nee d to kee p issue s ope n wa s respected . I n mos t instances , w e cam e t o lear n that, howeve r muc h w e wishe d (an d needed ) t o fee l responsibl e an d i n charge, w e lacke d precis e answers . T o b e sure , ou r ow n anxiet y ofte n led u s to impos e ou r belief s o n th e patients, bu t they quickl y showe d u s how ineffectua l w e were. Over thi s nea r decad e o f tria l an d error , student s cam e an d went . Three i n particula r stoo d ou t i n term s o f thei r dedicatio n to , persisten t inquiry about , an d affectio n fo r thei r patients : Monic a Carsky , Ti m Sullivan, an d Ke n Terkelsen. Whe n I began t o thin k abou t writin g thi s book, i t seeme d natura l t o as k the m t o collaborat e onc e again—t o pu t on pape r som e o f th e experience s w e ha d shared . A s w e talke d abou t what th e focu s shoul d be , th e issu e tha t surface d agai n an d agai n wa s the questio n o f formin g a n alliance . Ho w doe s a partnershi p emerge ? What contribute s t o it s development ? Wha t informatio n d o we , a s professionals, need in order to begin trying to create such a partnership? We focuse d first on wha t ha d allowe d u s to maintai n a n explorator y attitude in the face of al l the clinical demand s to provide quick solutions. Gradually, throug h ou r reminiscences, we recognize d that , without hav ing been awar e of it , we had bee n guided b y a common se t of principle s that had never been explicitly articulated . The task then became one of settin g down thi s model an d illustratin g it wit h clinica l examples . W e hop e tha t th e livelines s an d enthusias m that marked our work will be shared by our readers. A wor d abou t authorship . Th e concept s i n thi s boo k are , i n larg e part, derived from ou r clinical experience . The actual writin g summarizing tha t experience , wa s assigne d t o particula r authors . Eac h o f u s contributed t o th e introduction . Chapter s 1 , 2 , an d 3 wer e writte n b y Drs. Sullivan an d Selzer; chapter 4 b y Drs. Selzer and Sullivan; chapters 5, 6 , 7, an d 8 by Drs. Carsky and Terkelsen. We hope the reader will see this book a s a collaborative effort . MICHAEL SELZE R M.D .

Acknowledgments

The Ne w Yor k Hospital , Westcheste r Division , Extende d Treatmen t Service was the laboratory i n which we created, tested, and modified th e ideas tha t cam e t o for m thi s book . W e ow e a deb t o f gratitud e t o th e staff an d patients , al l o f who m playe d a crucia l rol e i n shapin g ou r thinking. I n tha t sense , thi s boo k i s a collaboratio n o f hundred s o f people. We wis h particularl y t o than k Dr . Rober t Michels , Chairma n o f th e Department of Psychiatry at Cornell, Dr. Otto Kernberg, Medical Direc tor o f th e Westcheste r Division , an d Dr . Richar d Munich , Chie f o f th e Extended Treatment Service. A specia l thank s t o ou r secretary , Chery l DelMastro , wh o manage d to deciphe r fou r differen t style s o f illegibilit y whil e maintainin g he r composure. Finally ou r editor , Kitt y Moore , win s th e enduranc e meda l o f hono r for bein g patient , supportive , an d neve r critica l whe n w e perpetuall y missed our deadlines.

ix

Working with the Person with Schizophrenia

Introduction

The last thirty years have bee n a time of grea t progress in schizophreni a research an d treatment. Advance s i n psychopharmacology hav e enable d patients wh o woul d hav e onc e bee n doome d t o a lifetime o f insanit y t o live wit h a minimu m o f psychoti c symptoms . Thi s developmen t ha s transformed ou r view of th e nature of schizophrenia an d set in motion a wide-ranging reassessmen t o f th e arrangement s o f care . Onc e viewe d a s the result of externa l stres s on a n otherwise health y psyche, the disorde r is now see n principally a s a biochemical illness . The great asylum hospitals, regarde d fo r a century a s optimal habitat s fo r patients wit h schizo phrenia (1) , ar e bein g close d o r converte d int o short-ter m treatmen t centers. Previously considered the principal source of th e disorder, fami lies are now courted as primary caregivers and encouraged to collaborate with clinician s i n promoting th e patient' s retur n t o communit y life . A n array of community-based supportiv e services has surfaced as towns and villages that shunned these patients begin to see them as disabled citizens with a right to live alongside the rest of the community. 1

2 Introduction Although thes e advance s hav e altere d th e cours e o f th e syndrome , those receiving treatment still d o not "ge t better" in the usual sense of that term . They experienc e wha t w e hav e com e t o cal l a remission of symptoms. The y ar e n o longe r insane . The y hav e lef t th e institutions . They hav e rejoine d thei r families . Bu t th e grea t majorit y continu e t o suffer fro m los s o f vitalit y an d interes t i n ordinar y activit y an d fro m inability t o achiev e an d maintai n a sens e o f competence , dignity , an d meaning i n thei r dail y lives . Eve n thoug h the y resid e i n communities , they ar e no t altogethe r lik e thei r fello w citizens , an d rarel y d o the y belong wholeheartedly. No longer inmates and no longer acutely ill, they are not well. For patient s an d thei r familie s an d thei r doctors , th e absenc e o f aliveness, the inaccessibility of dignified social roles, and prolonged, even life-long dependenc y on others are central concerns. Patients (2-3 ) an d their relatives (4 ) complain bitterly of th e adverse effects o f medicatio n on their vitality and reject the very treatments that open the way to life in the community. Frustrated doctors (5) mount often fruitless attempts to persuade patients to adhere to the prescribed treatments. Investigators search fo r les s bothersom e way s t o us e existin g drug s (6-8) , fo r ne w drugs wit h les s troublin g sid e effect s (9) , an d fo r way s t o understan d noncompliance (10). Gradually, as drug treatment has brought the psychotic states under better control, attention has turned to these quality-of-life problems . In the early 1970s , the practice of referrin g to many of these clinical phenomena as the negative symptoms of schizophrenia emerged (11). Largely because o f recen t successes , professional s an d th e lait y alik e hav e assumed tha t these phenomena ca n likewise b e understood i n biologica l terms and that they will give way to advances in drug treatment. Beginning in the late 1970s, investigators working from this perspective developed method s o f codifyin g th e los s o f vitalit y (12 ) an d advance d a variety of psychobiological models to account for it (13-18). All o f thi s notwithstanding , ou r experienc e an d tha t o f other s in volved in day-to-day care of patients in community and hospital settings continually compel us to take the view that these human beings are very active force s i n thei r ow n right , exertin g unnotice d an d unmeasure d influences o n the course of thei r illnesses. Moreover, it is apparent that the status of patienthood , whic h often require s participation i n a great many disagreeable clinical encounters and even more painful encounters

Introduction 3 in th e ope n community , significantl y contribute s t o th e los s o f vitalit y and o f dignity . Ye t i t appear s tha t few professional s ar e awar e o f th e quality o f lif e problem s o f ou r patients , an d the y ar e certainl y no t oriented t o dealin g with them. The relative dearth of availabl e literatur e and research support s thi s view. I n our daily work, ou r routine encoun ters with hospita l staf f an d community worker s demonstrated thei r pervasive tendency t o speak of the patient as merely a victim of a biological illness. In addition, families hav e championed th e biological perspective , searching for better drug treatments an d often appearin g uninterested in human measure s tha t migh t hav e a n impac t o n th e patient' s qualit y o f life. I n short , al l participant s hav e seeme d inten t o n applyin g medica l treatments—on seekin g to extinguish symptom s without giving any particular attentio n t o th e impac t tha t th e illnes s an d th e treatmen t wa s having o n th e suffere r o r t o th e adaptiv e response s (o r surviva l strate gies) employed b y patients to cope with their predicament. This volum e gre w ou t o f a fel t nee d t o giv e voic e t o ou r patients ' experience o f losin g acces s t o th e kin d o f predictable , benevolent , re warding involvement s tha t mak e u p lif e fo r mos t citizen s an d t o spea k of th e implication s o f tha t perspectiv e fo r th e stud y o f chroni c schizo phrenia an d especiall y th e negativ e symptom s o f th e illness . Ou r aim , however, i s no t jus t t o cal l attentio n t o ho w har d i t i s t o liv e wit h schizophrenia. Rather , w e hop e t o elucidat e a metho d o f talkin g wit h patients adapte d t o dail y encounter s wit h peopl e strugglin g wit h th e effects o f schizophrenia , whethe r tha t work i s proceeding i n hospital o r community settings , in clinical or rehabilitation facilities . The method elaborated in the chapters to follow draw s heavily on the premise tha t an understanding o f th e sufferer's experienc e o f th e illness, of th e treatments applie d thus far , an d of wha t th e sufferer ha s lost an d what futur e h e o r sh e hope s fo r i s critica l t o th e qualit y o f th e allianc e between onesel f an d th e sufferer . Thi s kin d o f understandin g goe s fa r beyond th e convention s o f diagnosi s and , we believe , complicate s i n n o small measure the pursuit of conventiona l treatmen t methods. While th e importanc e o f formin g a treatment o r therapeuti c allianc e is stressed i n some text s an d training programs (19—23) , it is easy t o b e misled abou t th e natur e o f th e relationshi p on e ha s forme d wit h a schizophrenic individual . Som e individual s appea r thoroughl y negative , refusing attempt s a t contact an d declining treatmen t effort s unles s coerce d into institutions , wher e the y ofte n repea t a pattern o f withdrawal . Oth -

4 Introduction ers "tak e t o th e road. " Anothe r ver y larg e grou p o f person s maintai n some degre e o f contac t wit h famil y an d clinicians , bu t refus e t o follo w advice or to fully engage in what those others feel would be the best type of treatmen t or rehabilitation program . The allianc e often feel s tenuous , shifting, an d is full o f surprises , and the clinician an d program personnel may gro w frustrate d o r fee l hopeless , perhap s eve n endin g thei r effort s with tha t particular person . Even an apparently stron g working allianc e with a schizophrenic individua l ma y be , unknow n t o th e clinician, buil t upon delusiona l o r distorted expectation s an d perceptions, whose disap pointment later leads to a rupture of the relationship, a rupture that feels as mysterious a s it is unanticipated t o the clinician. Yet ou r experienc e suggest s tha t partnership s ca n indee d b e forme d with eve n th e mos t apparentl y negativisti c persons , provide d th e clini cian ha s a s a n initia l goa l th e understandin g o f th e person' s subjectiv e experience. Thi s require s th e clinicia n t o kee p i n check , a t leas t tempo rarily bu t often fo r lon g periods o f time , the need to diagnos e accordin g to objectiv e standards , the wish t o influence behavio r a s an end in itself, and th e impuls e fo r therapeuti c zeal . Th e formatio n o f a treatmen t partnership with the severely disturbe d an d demoralized person require s the clinicia n t o becom e th e person' s collaborator . Evidenc e o f thi s col laboration ma y appea r onl y i n tiny , subtl e ways , seemingl y light-year s away fro m th e matur e doctor-patien t collaboration s t o whic h w e ar e accustomed fro m work wit h less beleaguered individuals . When w e spea k o f a treatmen t partnershi p a t thi s level , w e ar e referring t o a for m o f cooperativ e ventur e (th e natur e o f whic h wil l b e exemplified i n th e chapter s t o follow ) i n whic h tw o individual s under take som e activit y i n a spirit o f share d interes t an d mutual respect . Th e clinician's overal l goa l i s tha t th e patien t shoul d b e abl e t o hav e a lif e that i s "better " i n som e wa y tha t i s meaningfu l t o th e patient—mor e autonomous, enjoyable, and gratifying i n relationships and activities and less constricte d b y th e illness . Specifi c treatmen t recommendations—t o take medication , t o g o t o a day program, t o se e a psychotherapist—ar e always subordinate d t o the goal of a better life as defined b y the patient. Just a s the clinicia n ma y initiall y nee d t o infe r what th e patient's notio n of "better " is all about , s o to o mus t he or she infer how th e patient wil l experience th e treatmen t recommendation s i n term s o f th e patient' s broader goals . A therapeutic collaboratio n i s on e o f man y relationship s

Introduction 5 we for m t o ge t alon g i n life , bu t the individua l strugglin g wit h schizo phrenia is simultaneously mor e in need and more frightened of such help than most . Thus , w e mus t star t wit h simple , basi c assumption s abou t why we are meeting with this person. The formatio n o f a n alliance require s th e satisfaction o f a t least two conditions: First , th e suffere r canno t b e s o frightene d o r paine d a s t o refuse all contact, and, second, the clinician has to become truly involved in a n effort t o understand , eve n whe n thi s i s an unpleasant experience . Part o f wantin g t o for m a relationshi p entail s seein g th e othe r a s a human bein g strugglin g t o live , n o matte r ho w appearance s ma y beli e this perspective . The clinicia n mus t respec t th e adaptiv e inten t o f th e other's behavio r an d beliefs , eve n whe n thes e appea r senseles s o r self destructive.3 Fo r a schizophreni c individual , preservin g dignit y ma y be more important tha n endorsing everyda y perceptions a s reality, an d the loss o f a world-vie w that , whil e delusional , affirm s one' s significanc e may fee l lik e to o hig h a price t o pay for acces s t o th e disappointment s and demand s o f ordinar y life . Apath y ma y represen t a ver y activ e at tempt t o avoi d th e pain o f involvemen t wit h other s an d to protec t a n inner life held sacred by the schizophrenic individual who has in so many other way s los t th e ability t o automaticall y carr y ou t the cognitive and emotional functions that make us human and make life worth living (24). To develo p thi s relationship , whic h wil l pav e th e wa y fo r a futur e treatment alliance , the clinician need s curiosity abou t the other person' s experience, includin g the person's experienc e o f the self, th e illness, and the clinician, among other things. The clinician hopes to find an arena in which patien t an d therapis t ca n collaborate : a discussion , a mutua l exploration, a project. Ofte n thi s involve s identifyin g a n area o f enjoy ment o r one of pai n tha t th e sufferer decide s t o shar e o r one of uncer tainty o r conflic t i n the person's inne r world ; i t involve s an y are a tha t can be designated as a discussion topi c of mutual interest. As an example, consider the following. The case of a young man with schizophrenia i s presented a t a conference i n a psychiatric hospital . H e has had several prior stays and reluctantly returne d for what other s saw as sever e deterioratio n i n his functioning. Th e presentation reveal s tha t the patien t i s totall y withdraw n an d apatheti c abou t al l aspect s o f th e treatment progra m i n th e hospital . The staf f hav e draw n o n wha t i s known o f hi s educationa l attainment s an d his interest s i n repeate d ef -

6 Introduction forts t o coax , cajole , o r temp t hi m int o program s fo r recreatio n an d rehabilitation, al l to no avail. The trainee presenting the case is clearly frustrated and pessimistic, as is the rest of the staff. In the conference interview with a consultant, the patient ignores his doctor an d hi s specia l nurs e an d assign s thes e role s t o other s i n th e room. The consultant comments that there is another nurse who believes that she has been working with the young man, rather than the nurse he has pointed out, and there is some bland discussion about these differing views of reality. The consultant, believing the patient's pointed omission of his special nurse indicates his involvement (albei t conflicted) wit h the nurse, then asks the patient, "What do you imagine this other [ignored] nurse might be feeling?" The patient offers the view that the nurse might feel hurt and that only a cruel person would put her in such a position. The consultant then suggests that, someone who was fightingfor his life might do this to the nurse, for reasons of his own having nothing to do with cruelty , an d only with survival. The patient break s down i n tears and suddenl y seem s huma n an d vulnerable , i n shar p contras t t o th e picture o f numb , aloof withdrawa l h e had previously bee n presenting. Alerted by this unexpected revelation, the staff begi n to discuss ways to deal wit h th e patient—no w see n a s a more comple x individual—wit h more interest and more hope. The consultant's openness to the young man's experience was based on the assumption that schizophrenic individuals seek security, survival, and protection of self-esteem even when these efforts are not evident. In this case , th e consultant' s validatio n o f th e patient' s wis h t o survive , even i f i t mean t engagin g i n hurtfu l behavio r an d i n distortion s o f external realities, enabled the temporary formation of an alliance within which the patient could relate momentarily as one suffering human being to another . T o for m a reliable treatmen t partnership , thi s momen t o f unity an d alivenes s would hav e to b e repeated i n a stable relationshi p over time, but the evidence that it was possible helped the staff to avoid limiting assumptions about the implications of the young man's negativistic stance and withdrawn behavior for the future. There are , o f course , myria d barrier s t o th e kin d o f understandin g exemplified i n this vignette. People living with schizophrenia have commonly encountered numerou s others who have revealed a commitment to behavioral change long before they displayed an interest in the direct personal experienc e o f th e sufferer . Thes e prio r encounters , whethe r

Introduction 7 inside o r outsid e clinica l domains , hav e ofte n taugh t th e suffere r t o b e wary o f self-revelation . I n addition , ther e ar e th e man y effect s o f th e illness itsel f o n th e sufferer' s abilit y t o ge t him - o r hersel f understood , the effect s o f grie f fo r wha t i s los t an d despai r abou t th e future , al l o f which diminis h th e sufferer' s capacit y t o engag e wholeheartedly i n conversation abou t hi s or her experiences. Ther e ar e also constraint s pose d by th e need s an d prerogative s o f institutions . And , o f course , ther e ar e pressures o f time , money , an d th e expectation s o f improvement . Com pounding al l o f thes e issues , ther e ar e the sufferer' s man y an d constan t fundamental huma n needs—for personal comfort, for concrete provision of foo d an d housing—any o f whic h ma y intrud e unexpectedl y int o an d interrupt o r capsiz e th e dialogue , bu t whic h nevertheles s mus t b e at tended to in the service o f fosterin g th e sufferer's belie f i n the clinician' s humanity. Finally, there is the impact of the story on the listener, including certain powerful impulse s generated in the listener—to observ e fro m a distanc e rathe r tha n b e with, t o mend , t o fle e th e inquiry . Thus , eve n given a certai n dedicatio n t o th e task , th e suffere r an d hi s o r he r inter ested listene r ar e bot h har d presse d t o creat e an d sustai n a n interper sonal field within which thi s kind of understandin g ca n evolve. Wit h al l these barriers, it is small wonder that we understand so little of the inner world of our patients with schizophrenia . The primar y obstacle s t o th e formatio n o f thi s kin d o f allianc e ar e conditions tha t forestal l th e developmen t o f empathy . Eithe r the perso n suffering fro m schizophreni a o r the individua l h e o r she encounters ca n be th e primar y sourc e o f an y give n obstacle . Societ y view s individual s with menta l illness , especiall y schizophrenia , a s alie n an d sometime s dangerous. Althoug h thes e aspect s o f schizophreni a ar e exaggerate d i n the media, they do form a cultural contex t tha t tends to militat e agains t clinicians developin g a vie w o f th e individua l wit h schizophreni a a s a suffering huma n being with ordinary needs. A similar effect derive s fro m the common vie w o f schizophreni a a s a mysterious malad y tha t inalter ably transform s th e individua l int o a caricature o f humanity—a s i n th e common notio n tha t schizophreni a refer s t o a "split " personality . The idea tha t schizophreni a i s a n illnes s wit h it s root s i n th e biolog y o f th e brain an d whic h affect s th e personality i n comple x an d largely invisibl e ways i s mad e mor e difficul t t o gras p b y thes e popula r oversimplifica tions. Modern clinica l trainin g abou t schizophreni a ha s begu n t o incorpo -

8 Introduction rate information abou t th e neurophysiological aspect s o f th e illness an d the benefits an d risks of th e medications used to treat its symptoms. The idea tha t famil y an d communit y suppor t i s importan t t o th e long-ter m course o f th e illnes s i s widel y accepte d now . Wha t i s ver y ofte n no t taught explicitl y i s ho w t o understan d an d dea l wit h th e aspect s o f th e illness tha t d o no t respon d t o medicatio n o r t o socia l supports . Fo r example, th e negativ e symptom s o f schizophreni a hav e com e mor e t o the attentio n o f clinician s i n recen t years . The practicin g clinicia n wh o has learned only t o record symptoms an d to prescribe medication i s at a serious disadvantage . Again , however , th e implici t messag e i n muc h contemporary clinica l trainin g encourages th e clinicia n t o distanc e him or hersel f fro m th e patient : th e docto r i s well ; th e patien t i s sic k an d needs to take the medications. The possibility that the doctor could, and perhaps should, try to understand the sick person's subjective experienc e and us e thi s understandin g t o maximiz e treatmen t result s o r t o chang e the goals o f treatmen t altogethe r i s a more threatening proposition. I t is also one that may never even occur to traditionally trained practitioners, for who m th e ide a o f th e effec t o f psychologica l variable s o n treatmen t response and course in schizophrenia i s a new one (25—27). Obstacles t o ful l understandin g o f th e experienc e o f havin g schizo phrenia ar e also create d b y the patient an d others with whom h e or sh e lives. For example, social pressure s may deman d the use of explanation s of negativ e symptom s that ignore psychological variables, attributing all such manifestation s t o lazines s o r t o biologica l deficits . Similarly , th e schizophrenic person' s idiosyncrati c interpretation s o f event s will b e the subject of criticis m an d exasperation becaus e they seem so unrealistic o r so demandin g o f specia l awarenes s b y others . Famil y member s hav e their ow n stron g feeling s abou t havin g a schizophrenic relative , feeling s they may manage by mixtures of denia l an d acceptance of illness , anger, sadness, disappointment , anxiety , an d avoidance , an y one o f whic h ca n interfere wit h thei r effort s t o for m th e kin d o f partnershi p wit h th e patient that we are espousing. Intertwined wit h thes e processe s ar e th e schizophreni c person' s ow n intensely mixe d feeling s abou t bein g understood . Ver y frequently , th e patient will provide some hints about personal wishe s an d fears, only t o retreat behin d distractin g symptoms , withdrawal , anger , negation , pro vocative behaviors , o r a wall o f indifference . A s w e hav e note d earlier , the schizophreni c individua l ofte n feel s tha t revealin g a wis h t o b e

Introduction 9 understood is tantamount to inviting intrusion and relinquishing contro l over hi s o r he r life . Fo r on e whos e sens e o f sovereignt y i s alread y weakened, th e usua l respons e i s vacillatio n betwee n involvemen t an d negation of involvement, betwee n revealing and obfuscating . The clinicia n ma y hav e correspondingl y mixe d feeling s abou t ho w much interes t h e o r sh e ha s i n a schizophreni c individual' s subjectiv e experience. While a capacity fo r empathy is frequently a prerequisite fo r the choic e o f a caree r a s a clinician , th e attemp t t o empathiz e wit h a person wh o i s delusiona l i s a specia l case . I t produce s a grea t dea l o f distress, a s a rule , commonl y evokin g distancin g maneuver s tha t ar e supported b y cultur e an d training . Th e clinicia n wh o woul d wor k wit h patients wit h schizophreni a mus t posses s o r acquir e a n unusuall y hig h degree o f toleranc e fo r ambiguit y an d uncertainty . A t th e sam e time , clinicians o f variou s discipline s coul d b e helpe d b y a mode l tha t coul d inform a variety o f therapeuti c intervention s an d encompas s th e varie d and inconstant expression of the illness. Prior models have failed to resolve a crucial issue: how t o understan d the relative contributio n o f biologica l an d psychological variable s i n the production of the schizophrenic syndrome. This failure has at times been a consequence of biase d assumptions about the illness and at other times been du e t o a lac k o f adequat e scientifi c information . A n unfortunat e result ha s bee n th e developmen t o f tw o differen t camp s (th e purel y psychological an d th e purel y biological) , eac h o f whic h view s schizo phrenia from its own isolated perspective. In recent years, this division has been exacerbated for various reasons, but on e i n particular . I t ha s bee n demonstrate d tha t pharmacologi c treatments ar e effective i n ameliorating certai n aspect s o f th e illness . A t the sam e time , psychotherapeuti c intervention s hav e faile d t o demon strate their efficacy i n a statistically rigorou s fashion. Fe w converts hav e been made to either cause. Instead, increasing rigidification ha s polarized the field into two positions : adherents to the biological treatmen t mode l and thos e wh o advocat e a psychotherapeutic model . Mos t unfortunat e has bee n th e failur e t o arriv e a t a consensus fo r developin g an d usin g a model that incorporates both perspectives. Differing view s o n treatmen t ar e reflecte d i n differin g notion s o f etiology. Thos e wh o vie w schizophreni a a s essentially a n illness respon sive to biologica l treatment s se e the various manifestation s o f th e disor der as immediate consequences o f biological abnormalitie s and all symp-

10 Introduction toms as having a physiologic etiology (28-29). This position is represented in particula r b y thos e wh o divid e schizophreni c symptomatolog y int o positive an d negative symptom syndromes (30—32) . They view positive symptoms as the product of the toxic physiologic disorder that underlies schizophrenia and all negative symptoms as the consequence of cerebral deterioration and consequent functional deficits . This view is frequently supported by references to biological studies that demonstrate the many perceptual an d cognitiv e difficultie s experience d b y schizophreni c pa tients as well a s to those studies that demonstrate increased ventricular brain ratios o n CA T scans i n chronic schizophrenics . Th e studies tha t demonstrate apparen t reduction in cerebral mass are used in particular to support the view that chronic schizophrenics with negative symptoms are simpl y sufferin g fro m a chroni c dementin g process . Th e negativ e symptoms of the syndrome, those that most vex clinicians, families, and researchers, are seen to be "deficit" symptoms of a progressive deteriorating mental illness, a concept similar to Kraepelin's first projection of the irreversible downward decline of dementia praecox. Those wh o espous e psychotherapeuti c intervention s hav e tende d t o ascribe many, if not all, of the symptoms of schizophrenia to underlying psychological conflicts , ofte n du e t o developmenta l trauma s tha t have given rise to a schizophrenic psychological state . Major writers such as Winnicott, Searles , Frieda Fromm Reichman, an d Otto Will have been the forerunners o f thi s view. Most often, th e theories postulated a psychological traum a relating to maternal-infant interaction s o r other disturbances in object relations. These pathologic interactions are hypothesized to impair the individual's capacity to tolerate intimate relationships because o f hi s or her fears an d wishes regardin g boundary disruption . This intensely ambivalent attitude toward merger compels the individual to rejec t relationship s a s wel l a s mos t socia l interactions . Thi s vie w focuses on the way in which schizophrenic symptoms appear directed to distancing the individual from others, denying meaning in relationships, and tendin g t o focu s o n autisti c absorption , rathe r tha n purposefu l other-directed activities. It assumes, for example, that such distance from others i s a psychologica l stat e fo r whic h th e individua l ambivalentl y strives. The manner in which these two points of view have been elaborated in the past two decade s has led to polarization rathe r than resolution. Adherents of th e biological mode l view the psychotherapy literatur e as

Introduction 1

1

farfetched, unscientific , founde d i n speculatio n rathe r tha n empirica l observation. The y als o denounc e psychologica l theorie s abou t schizo phrenia a s neglectin g th e biologica l inpu t fo r whic h scientifi c researc h has establishe d a place i n an y mode l o f thi s illness . B y the sam e token , psychotherapeutically incline d clinician s an d researcher s vie w th e bio logical mode l a s unnecessaril y pessimistic , sayin g i t deanimate s th e pa tient and leads to treatment programs or styles that inadequately addres s patients' experiences . Thes e clinician s believ e suc h program s offe r littl e in th e wa y o f understandin g patients ' psychologica l state s an d fai l t o give a sens e tha t the y ca n contro l an d affec t thei r live s i n way s othe r than simpl y acceptin g th e treatment s psychiatrist s prescribe . The y com plain that, a t a theoretical level , the biological mode l doe s not allo w fo r or recogniz e th e possibilit y tha t psychologica l reaction s o r indee d psy chological conflict s pla y a role in at least some schizophrenic symptoms . And clinicians als o criticiz e th e biological mode l i n its extreme for m fo r its dictate that patients adopt a passive role in their treatment. Clearly, a mode l o f schizophreni a mus t includ e a n understandin g o f and referenc e t o th e biologica l disorder s tha t hav e bee n demonstrated . At th e ver y leas t i t mus t allo w tha t man y o f th e symptom s ma y b e secondary to the genetically acquired and perhaps developmentally elab orated illness. We believe , however, that such a model mus t at the same time addres s th e psychologica l experienc e o f th e individua l wh o strug gles t o adap t t o and , wher e possible , contro l rathe r tha n b e controlle d by the core physiologic disturbance . Thus it must allow fo r the possibility tha t som e o f th e symptom s ma y b e a consequenc e o f psychologica l reactions t o th e disorder. Suc h a model woul d provide a more complet e picture o f th e illnes s an d th e patient , whic h w e believ e i s necessar y fo r optimal treatmen t and research efforts. I n seeking to treat an illness that attacks th e ver y cor e o f wha t make s u s human—the capacitie s fo r inti macy, communicatio n an d thought , an d productivity—w e fai l i f w e ignore any of these functions. An ideal model would generate hypothese s about way s t o allo w th e individua l t o experienc e a sens e o f self-estee m and contro l over hi s o r he r life , a s wel l a s hypothese s abou t whic h symptoms migh t b e amenable t o psychotherapeutic intervention , i n particular those that heretofore ha d been poorly responsive or unresponsive to biologica l interventions . I t should als o predict way s t o mos t success fully combine biologi c and psychosocial treatmen t efforts . Why a model a t all? Without a conceptual mode l stipulating potential

12 Introduction treatment goal s an d ho w chang e occurs , i t i s difficul t t o asses s th e efficacy o f an y intervention. I f we are not clear about the relative contri bution o f psychologica l an d biologica l variable s an d d o no t hav e a model t o tease out those issues, then we are handicapped in our capacity to construc t researc h t o asses s psychotherapy , pharmacotherapy , o r re habilitative efforts . I n attemptin g t o asses s th e efficac y o f a particula r drug, fo r example , i t would b e essential t o stud y o r contro l fo r psycho logical variables as well a s biological ones . Although we know that most positive symptoms respond well to medication, negative symptoms, such as amotivation , frequentl y prov e refractory . Thi s coul d b e construe d t o be due to the patient's difficulty i n acknowledging that he or she is ill. In this instance , i f th e patien t coul d b e helpe d t o acknowledg e an d accep t the illness , h e o r sh e migh t manifes t a positiv e response . I n addition , research suggest s (33-35 ) tha t insight int o illnes s increase s th e patient' s compliance wit h medication . Perhap s thi s woul d b e due , i n part, t o th e fact tha t a n insightful patien t ma y b e more gratifyin g t o wor k wit h an d would therefor e motivat e th e docto r t o b e mor e investe d i n th e treat ment. Perhap s thi s increase d involvemen t o f th e clinicia n woul d the n make the patient a more active participant. Clearly , other interpretation s of th e patient' s behavio r ar e possible . Ou r poin t her e i s tha t wit h th e current leve l o f ou r knowledge , nonbiologica l factor s nee d t o b e care fully considere d an d studied i n our treatment an d research efforts , espe cially since the biological componen t has not been clearly delineated. There appea r t o b e subgroup s o f schizophreni c patient s wh o exhibi t varying degrees of symptomatology an d different patterns , with differin g levels o f severit y (36—37) . A s ha s bee n show n i n researc h wit h othe r diagnostic groups , outcom e assessment i s a highly volatil e variabl e tha t is dependent o n one' s bein g certain tha t on e i s dealing with appropriat e and comparabl e cohort s o f patients . A conceptua l mode l combinin g knowledge abou t bot h th e biolog y an d psycholog y o f schizophreni a can als o hel p to establis h a useful nosolog y o f th e diseas e itself , permit ting th e delineatio n o f thos e psychologica l an d phenomenologica l vari ables potentially important in differentiating subgroup s of patients. In establishing a conceptual mode l tha t integrates biological variable s with a n understandin g o f th e psycholog y o f th e schizophreni c patient , the ter m "functiona l deficits " i s a n especiall y limitin g one . "Deficit " connotes a degree of finality and irreversibility an d pessimism an d may , in fact , b e misleadin g whe n applie d i n particula r t o th e negativ e symp -

Introduction 1

3

toms expresse d b y th e schizophreni c patient . Suc h a ter m suggest s tha t the patien t i s mentall y dea d or incompetent . Thi s i s a damaging notio n when i t dominate s th e thinkin g o f anyon e workin g wit h a n individua l with schizophrenia , fo r i t treat s th e patien t a s merel y th e unfortunat e recipient o f som e drea d malady an d avoid s th e possibility o f identifyin g areas o f struggl e withi n th e patien t regardin g thes e ver y issue s o f com petency an d awareness . Furthermore , a s w e hop e t o elucidat e i n th e conceptual mode l tha t follows, som e of th e negative symptom s o f schiz ophrenia, whil e appearin g t o reflec t functiona l deficits , ma y i n fac t b e a consequence o f compensator y adaptiv e psychologica l functionin g i n response t o th e illness , whic h precipitate s th e productio n o f th e schizo phrenic syndrome . I n an y case , unti l ther e i s mor e convincin g evidenc e to th e contrary , area s o f suboptima l functionin g i n schizophreni c pa tients ca n b e examine d fo r possibl e psychologica l variable s i n th e hop e that ther e ma y b e a n opportunit y fo r mor e productive adaptatio n lead ing to greater autonomy an d improved self-esteem . In summary , w e ar e intereste d i n addin g t o biologica l model s o f schizophrenia a metapsychological mode l that integrates the individual' s subjective experience with his or her biological substrate . We believe this is necessary because in few other conditions does the individual's personality an d reactio n t o th e illnes s becom e s o intimatel y interwove n wit h the manifestations o f th e disease. The patient's awarenes s tha t he or she is ill an d his o r her feeling s abou t acceptin g help fro m professional s ar e key variable s i n th e disease , a s importan t a s th e ver y conditio n tha t affects th e ability t o perceive, think, an d trust others. While som e migh t speak o f a perso n wh o suffer s fro m schizophreni a a s the y spea k o f a person wh o suffer s fro m som e othe r disease , her e w e tal k abou t a n illness that pervades the person's experience of sel f an d of lif e in general. Learning about how thi s person experiences life is crucial, we believe, to planning adequate treatment and evaluating our efforts . After w e presen t a mode l t o provid e a framewor k fo r lookin g a t individuals wit h schizophreni a i n thi s way , i n subsequen t chapter s w e will outlin e way s t o perceiv e an d respon d t o patients ' activ e effort s i n the variou s clinica l context s o f evaluation , somati c an d psychologica l therapies, hospital programs, management, an d rehabilitation. What thes e seemingl y disparat e clinica l context s shar e i s a require ment fo r a "treatmen t partnership. " I n orde r t o engag e i n an y kin d o f therapeutic endeavor s wit h a schizophreni c patient , i t i s necessar y t o

14 Introduction consider the person's ability to collaborate with the clinician. To assess this abilit y an d t o foste r a workin g partnership , w e believ e tha t th e clinician must be committed to understanding the subjective experience of th e schizophrenic person. This includes the experience of thi s illness in its biologica l an d psychosocial manifestations , it s impact on others, and, very importantly, th e patient's attempt s t o adap t t o th e illness in ways that preserve his or her self-esteem. These adaptations, which may seem unhealthy or inappropriate or illogical t o the outsider, are not to be lightl y dismisse d o r thoughtlessl y challenged . The y represen t th e schizophrenic person's attempt s to hold on to his or her humanity and to cope with and seek to influence th e environment while in the throes of an illness that threatens to upset what makes us human: the ability to feel, t o thin k an d plan, to trus t and care about others. The clinician' s responsibility is to listen for these messages of human concerns, to hear them a s guides to understandin g wha t th e individual need s an d wants and how the clinician can help.

1 A Model for Understanding Schizophrenia

1 hi s book aim s to provide clinicians with the means to understand their schizophrenic patient s an d th e skill s necessar y t o engag e thos e patient s in treatment . W e d o no t intend t o presen t a mode l fo r psychotherapy , although ou r views ar e based o n wor k wit h chroni c schizophreni c indi viduals i n supportiv e psychotherapy , a s wel l a s i n directin g inpatien t treatment programs . Ou r focu s wil l b e o n th e therapeuti c relationshi p with th e schizophreni c individual ; it s characteristics , vicissitudes , an d idiosyncracies an d its central importance to any therapy. Because of the disorder's effect o n thinking and behavior, the affecte d individual experience s an d manage s relationship s i n way s tha t provok e frequent misunderstandin g by and confusion i n others. To avoid makin g inaccurate an d misleadin g assumptions , th e clinicia n mus t no t onl y un derstand the disorder but also the individual's reaction to it. The psychological respons e t o schizophreni a mus t b e studied i n the patient's mani fest an d als o implie d communication . Thi s approac h i s crucial , fo r th e subjective, psychologica l reactio n t o th e illnes s bes t inform s u s o f th e patient's capacit y an d motivatio n fo r treatment . Th e decipherin g o f th e patient's communications depend s on our familiarity with the issues that typically concern schizophrenic individuals, our comfort with the intense feelings the y arous e i n us , an d ou r willingnes s t o recogniz e simila r (a s well a s different ) experience s i n ourselves . T o thi s end , th e followin g chapters wil l explor e characteristi c theme s encountere d whe n workin g with schizophreni c patient s an d develo p a framewor k fo r comprehend ing them. Recent literatur e (1-2 ) ha s describe d th e limitation s o f empirica l descriptions o f psychiatri c disorders , includin g schizophrenia , an d un derlined th e importanc e o f identifyin g theoretica l bia s i n an y concep 17

18 Working with the Person with Schizophrenia tual model . DS M III-R , a s a kind o f empirica l model , whil e aidin g in defining more distinct groups of phenomenologically similar individuals, has not brought clarity to the muddle of symptoms and signs associated with schizophrenia , an d it is limited by its emphasis on empirical phenomenology. Such models have been unduly influenced by the diagnostic emphasis o n th e flagrant symptoms o f th e disorder—that is , delusion s and hallucinations , initiate d b y Bleule r an d perpetuate d b y Schneide r and others . Th e attempt s o f Cro w an d other s (3-6 ) t o divid e schizo phrenic symptom s int o tw o categorie s ("positive " o r "negative" ) an d further to delineate two distinct schizophrenic syndromes, while able to claim empirical support , suffer fro m a n excessively reductionisti c spirit and as yet have not furthered the treatment of schizophrenia. Investigators hav e tende d t o categoricall y describ e th e medication unresponsive symptom s o f schizophreni a a s "negativ e symptoms " (7). (One notable exception is Wing, who has drawn attention to the role of the patient's reaction to the illness [8].) It has often bee n suggested that these symptoms represent "deficits" in neurological functioning, perhaps associated with a neurologic syndrome, an d dementia. This conceptual approach makes broad and unsubstantiated assumptions about the etiology of a complex syndrome, whose symptoms may be multidetermined. Though ther e i s accumulatin g evidenc e o f brai n patholog y associate d with schizophrenia, the literature has not conclusively demonstrated that "psychological" factors are irrelevant to symptom pathogenesis (9—10). The comple x behavior s represente d i n th e "negative " sympto m syn drome ar e too readil y seen as mere expressions o f fronta l lob e pathology. Nevertheless, it is likely that disturbances in frontal lob e functioning ar e implicate d i n th e phenomenolog y and , probably , etiolog y o f schizophrenia, since most schizophrenia patients have some disturbance in cognitive performanc e (11-12) . Thes e area s of dysfunction , thoug h significant, d o not support the conclusion that broad, irreversible cognitive deterioration is the rule in treated schizophrenics nor that the varied and variabl e "negativ e sympto m syndrome " i s entirel y th e resul t o f neurologic deficits . I t i s no t eve n clea r tha t th e "negativ e sympto m syndrome" is an entity. Recent researc h (13—17 ) suggest s a mor e reasonabl e vie w o f th e schizophrenic syndrome , wher e "positiv e symptoms " (hallucinations , paranoia, agitation) are seen as functionally an d neuroanatomically dis-

A Model for Understanding Schizophrenia 1

9

tinct fro m discret e ye t profoun d disturbance s i n subcortical , frontal , and prefronta l cortica l brai n activity . Thes e latte r "deficits, " whic h may conceivabl y var y in severity , ca n explai n man y o f th e symptomati c features o f schizophrenia : impairmen t i n task performance o n problem solving; becoming overwhelme d b y excessive stimulatio n fro m th e environment; difficult y processin g th e emotiona l complexitie s o f interper sonal relationships ; an d ineffectiv e us e o f learne d pattern s o f copin g with stress or challenges (18-20) . If this accumulating research is accurate, then it begins to explain part of wha t clinician s se e i n thei r wor k wit h schizophreni c patients . Ther e still remai n th e perplexin g problem s o f amotivation , apathy , avolition , and withdrawal , whic h ar e ofte n suc h a prominen t an d discouraging aspect o f th e syndrome . Suc h symptom s ma y b e reveale d t o b e du e t o further, a s ye t undiscovered , discret e neurologica l deficits ; i n som e pa tients the y ma y b e par t o f a depressiv e syndrome . Ou r thesi s i s tha t i n many patient s thes e "negative " symptoms ar e part of th e psychologica l reaction t o th e illnes s proces s itself . Furthermore , denia l an d th e ofte n associated conviction s stemmin g fro m delusiona l interpretation s o f event s represent, i n part , a psychologica l respons e t o th e illness . Althoug h distorted ideatio n originate s i n physiologically provoke d perceptua l dis tortions, delusiona l symptom s ar e the consequence o f a complex elabo rative and integrative psychological process . The essential hypothesis of our model is quite straightforward : 1. Ther e is a complex biologica l basi s to the schizophrenic disorder . a. Ther e ar e als o secondary , physiologicall y determine d phenomen a (e.g. , depressive syndromes). 2. Significan t aspect s o f th e "symptomati c picture " of schizophreni a ar e mani festations o f psychologica l response s t o th e disorde r o r effort s t o adap t t o i t (however well or ill), involving the innate resources of th e mind and demanding o f th e clinicia n a n understandin g o f cognitiv e mechanism s an d "psycho dynamics" (which we would consider an aspect of cognitive functioning) . a. Socia l behaviors , whic h includ e relationship s wit h caregivers , ar e heavil y influenced b y thes e psychological reaction s an d ar e often a major barrie r to effective engagemen t in and motivation for treatment. 3 b. Whil e al l behavior , o r menta l activity , ma y ultimatel y hav e a biologica l basis (i.e. , we ar e not attemptin g t o "separate " psychological an d biolog ical processes) , i t i s usefu l t o thin k o f som e aspect s o f th e schizophreni c patient's menta l lif e a s part of th e "normative " proces s o f adaptatio n t o stress.b

20 Working

with the Person with Schizophrenia

With thi s conceptualizatio n o f th e disorder , w e ca n devis e a rationa l approach t o th e treatmen t o f th e schizophreni c individua l wit h an y modality: 1. Thos e symptom s tha t w e kno w t o b e physiologicall y stimulate d an d fo r which w e hav e somati c treatment s (usuall y medications ) ar e firs t treate d appropriately an d wit h respec t fo r th e complicate d effect s o f thes e treat ments.0 2. Th e symptoms or behaviors that "remain" after such treatment are addressed according to the following priorities: a. Effort s ar e made to determine if symptoms or behaviors have a cognitive or psychodynamic basis and are worked with accordingly. b. Thos e symptoms and behaviors that are persistent, not currently remediable with somatic treatments, and not available to work within a cognitive, behavioral , o r psychodynami c paradig m ar e clarifie d an d studie d carefully, an d effort s ar e the n mad e t o hel p th e patien t adap t t o thes e limitations (e.g., prefrontal cognitiv e disturbances that impair instrumental role functioning). The preeminent focu s fo r all clinicians, however, mus t be to establis h and maintai n th e treatmen t alliance . Thi s i s a n ongoin g tas k an d ofte n must preced e othe r efforts , particularl y i n th e cas e o f th e "noncom pliant" patient. Among other goals, the treatment philosophy mus t communicate t o th e patien t th e ide a tha t h e o r sh e ca n b e understood ; tha t the "illness " represent s bu t a par t o f hi s o r he r menta l experienc e (al though a dominant an d pervasive influence); that he or she is not utterl y debilitated, helpless, or to blame for what has happened. As clinicians , w e mus t provid e patient s wit h a mode l o f effectiv e coping, whic h assume s thei r participatio n an d contribute s t o thei r self respect. Ou r treatmen t program s shoul d hel p patient s achiev e a n avail able, plausibl e understandin g o f themselves . A t th e sam e time , w e mus t take int o accoun t tha t th e patient's vie w o f hi s o r her psychotic experi ences has been heavily influenced b y the intensity of those events and the patient's perceptio n tha t th e hallucination s o r feeling s o f suspicio n ar e or were accurate. The "truth" is indeed never so simple as "our way" or "their way. " The patient' s renditio n o f realit y mus t b e respecte d a s th e most accurat e representatio n o f hi s o r her inne r experience , and , there fore, a s a crucial source of dat a for teaching us about the patient's fram e of reference , which is a necessary first step in establishing an alliance. Many treatmen t program s ar e limite d i n effec t becaus e the y d o no t address thes e concerns . The schizophreni c patien t i s to o ofte n give n

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prescriptions, whether for medication, rehabilitative treatments, or other therapies, withou t a concomitan t effor t t o hel p hi m o r he r understan d why o r ho w th e treatmen t wil l hel p an d withou t placin g th e "prescrip tion" within the context of the patient's subjective experience. Clinician s are inhibite d i n thi s regar d b y thei r uncertaint y o f th e mos t effectiv e means of copin g with the patient's denia l or delusional convictions . The matter i s to o ofte n resolve d b y attemptin g t o convinc e th e patien t tha t his or her perceptions or beliefs are simply wrong and that the clinician's view must be accepted. Conflicts , noncompliance , o r passive complianc e characteristically aris e from suc h confrontations. The treatment allianc e is furthe r straine d when , i n th e fac e o f seriou s impairmen t i n som e aspects of the patient's cognitive functioning, a s well as dejection, resentment, an d consequen t withdrawal , th e clinicia n o r therapeuti c staf f as sume that the patient is globally impaire d and beyond help. Therapeuti c despair i s then not uncommo n an d often unavoidabl y communicate d t o the patien t throug h th e clinician' s withdrawa l o r avoidanc e o r throug h an expressio n o f resentmen t towar d th e patien t fo r rejectin g hi s o r he r efforts. In any treatment, a s we attemp t t o establis h a basis for collaboratio n and t o educat e th e patien t abou t himsel f o r herself , w e wil l encounte r several obstacles . The patient may, under the influence o f overwhelmin g paranoid attitudes , mistrust our intentions. What we are describing may represent a n unacceptabl e narcissisti c injury . T o th e degre e tha t schizo phrenic individual s ar e awar e o f thei r inabilit y t o contro l thei r menta l life, our confronting the m with this fact may occasion feelings o f horror, humiliation, an d hopelessness . An y treatmen t experienc e i s potentiall y quite difficul t fo r th e schizophreni c individual , wh o ma y manifes t dis tress throug h increase d paranoia , oppositionality , o r withdrawa l rathe r than over t acknowledgmen t o f sadnes s o r fea r o f wha t i s happening. I t is als o tru e tha t th e patient ma y experienc e relie f tha t someon e appear s willing t o openl y confron t wha t h e o r she , an d others , hav e sough t t o conceal o r avoid. Much o f wha t w e discus s will b e relevant to th e work o f psychother apists attemptin g t o interes t an d maintai n schizophreni c individual s i n treatment. Bu t w e chos e t o writ e thi s boo k abou t treatmen t allianc e because we fel t it to be a crucial, yet often unappreciated , componen t o f all treatmen t paradigms . Psychotherap y ma y hav e a n important , eve n pivotal, rol e i n the maintenance o f th e treatment allianc e with th e chroni c

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schizophrenic individual , bu t al l therapie s requir e a treatmen t alliance , and clinician s o f ever y disciplin e fac e th e sam e stresse s an d obstacle s i n working wit h thi s patien t group . Multidisciplinar y treatmen t represent s the onl y possibl e approac h t o th e treatmen t o f schizophrenia—n o singl e therapy ca n addres s al l o f th e problem s pose d b y thi s illness . I t i s therefore criticall y importan t tha t practitioner s hav e availabl e a mode l of th e disorde r an d o f th e treatmen t philosoph y an d goal s an d under stand th e basi c working s o f th e treatmen t allianc e s o tha t consisten t treatment effort s ca n b e applied .

UNDERSTANDING TH E CRISIS IN THE TREATMENT ALLIANCE Treatment o f the schizophrenic individua l usuall y begin s with th e assessment an d pharmacologica l amelioratio n o f suc h symptom s a s hallucina tions, agitation , an d disorganization . Late r stage s o f treatmen t focu s o n the patient' s difficultie s i n socia l an d occupationa l functioning . Poo r outcome, o r noncompliance , i s usuall y see n t o b e th e consequenc e o f "positive" symptom s tha t ar e too-little responsiv e t o medication s o r th e debilitating effec t o f sever e "negative" or "deficit " symptoms . While thi s formulation may , i n som e cases , b e true , w e hav e foun d i n ou r ow n work tha t outcom e an d complianc e ar e mor e dependen t o n th e natur e of th e treatmen t allianc e tha n o n an y othe r singl e variable . Thi s is , to a degree, a conceptua l distinction , becaus e th e natur e o f th e treatmen t alliance is certainly influenced b y the prevailing symptomatology an d th e severity o f th e illness ' manifestations ; however , th e distinctio n i s no t a facile on e becaus e disturbance s i n th e treatmen t allianc e implicat e psy chological mechanism s tha t ar e als o distinc t fro m "positive " o r "nega tive" symptoms. In addition, althoug h attentio n ha s recently, and appro priately, bee n focuse d o n th e "negative " sympto m syndrome , failur e t o appreciate th e importanc e o f th e treatmen t allianc e wil l hampe r clini cians' attempt s t o engag e thes e patient s i n rehabilitativ e o r othe r treat ment strategies . The treatmen t allianc e i s especiall y trouble d b y th e persistenc e o f delusionality o r irrationa l denia l (whic h ar e often associated) . Clinician s struggle t o cop e wit h thes e phenomena tha t ofte n limi t th e effectivenes s of th e treatmen t process . What seem s mos t troublesom e i s the difficult y in persuadin g patient s t o reconside r thei r firmly hel d views . Patients ca n

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often hol d apparentl y contradictor y position s (e.g. , "M y problems wer e caused b y people wh o wer e torturin g m e becaus e I was evil, " an d "I' m afraid there' s n o cur e fo r me") , yet stil l resis t acknowledgin g th e utilit y of medications , th e valu e o f hospitalization , o r of after-car e treatments . One facto r explainin g th e intensity wit h which delusiona l idea s ar e held may b e the natur e o f th e physiological-perceptua l experience , suc h tha t the individua l experience s thes e distorte d "facts " an d "events " a s real . Irrational (sometime s delusional ) denial , however , reflect s no t onl y dis torted perception bu t the fear of profound narcissisti c injury. In our experience, virtually al l patients who present with a delusional view o f themselve s an d their experienc e o r with dense , irrationa l denia l are als o unabl e t o relinquis h thei r convictions , t o chang e thei r poin t o f view, a t th e star t o f a treatment program . Som e patient s wil l persis t i n their distorte d vie w o f th e worl d throughou t thei r treatment ; bu t suc h patients, thoug h no t al l perhaps , ca n nonetheles s develo p a workabl e treatment allianc e an d participat e effectivel y i n treatment . T o accom plish this , clinician s mus t b e abl e t o identif y th e obstacle s t o th e treat ment alliance and have in mind strategies for engaging the patient, either despite th e obstacle s o r sometime s b y usin g thes e apparen t barrier s t o our and the patient's advantage. d Three broa d pattern s o f maladaptatio n characteriz e trouble d treat ment alliances . Thes e ma y represen t a n individual' s maladaptiv e re sponses t o th e illness rathe r than symptom s o f th e illness itself . W e wil l note them here and discuss them in greater length: 1. Maladaptiv e Resentment or Grandiosity a. nee d to blame others for plight, often coupled with rage and envy toward the world , whic h combin e t o successfull y kee p potentia l helper s a t a distance; unrealistic estimatio n o f abilit y t o manag e sel f an d symptoms (e.g., ' I ca n sto p m y symptom s i f I want" ; " I choos e t o retrea t int o fantasy"; or "I am above earthly matters") 2. Delusiona l Conviction or Denial a. persisten t belie f i n a view o f event s tha t precludes, in whole o r in part, participation in treatment [e.g., "I am already dead"] 3. Demoralizatio n a. apathy , amotivation, withdrawal As we note d earlier, these represent responses to the symptoms o f th e illness, which hav e a direct and significant impac t on the patient's inter personal functionin g an d on his or her attitude toward treatment efforts . Although eac h behavioral o r cognitive pattern is influenced b y the char-

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acteristics o f th e illness , these complex phenomen a hav e significan t psy chodynamic components . To facilitate our consideration of these concepts, we will present three vignettes o f patient s wh o manifes t symptom s o r behavior s tha t presen t challenges t o th e formation o f a treatment alliance . Eac h cas e i s slightl y different an d suggest s uniqu e problem s an d differen t solutions . Al l ar e drawn fro m ou r experience s i n workin g wit h schizophreni c individual s in supportive psychotherapy .

Case A: A Dialogue fro m Two Perspectives A woman i n her early thirtie s presented wit h a ten-year histor y o f psychotic symptoms , frequen t suicida l ideation , an d poo r treat ment compliance . Neurolepti c medication s wer e abl e t o brin g abou t only partia l remissio n o f he r symptom s an d ha d no t affecte d he r suicidal intent . Antidepressan t trial s were equall y limite d i n effect . She ha d no t previousl y bee n see n regularl y b y an y clinician , no r was sh e ever engaged in psychotherapy. Sh e was bright and articulate an d ha d a mil d though t disorde r tha t di d no t significantl y impair he r communicatio n skills . Nevertheless , he r lif e ha d bee n seriously disrupte d by her illness. At th e tim e sh e first bega n t o experienc e symptoms , sh e wa s married an d considerin g graduat e schoo l wit h a n ey e towar d a future caree r i n academics . A t tha t time , whil e separate d fro m home b y man y thousand s o f mile s an d facin g th e strain s o f a ne w marriage an d some financial difficulties, sh e began to experienc e a sense o f mistrust , a feeling o f bein g watched, a s well a s disturbin g premonitions tha t suggeste d sh e ha d som e foreknowledg e o f im portant world events. She gradually became convinced that she had powers of prophetic perception and that she possessed informatio n that could affect th e course of world events. She began to interpre t statements made on the radio and television as containing message s to he r fro m internationa l agencies . A s sh e remembers , thes e state ments mad e ove r th e medi a wer e unambiguousl y directe d a t her . She subsequently becam e convinced tha t her home was unde r electronic surveillanc e becaus e thes e agencie s wer e desperat e t o kno w what she knew. Her marriag e deteriorate d i n par t becaus e he r husban d wa s

A Model for Understanding Schizophrenia 2 troubled, eve n angered , b y he r suspiciou s concern s an d als o be cause sh e becam e anxiou s an d withdrawn , uncertai n an d sociall y uncomfortable. Sh e wa s divorce d soo n after , wa s o n he r own , terrified an d desponden t fo r a time , the n live d wit h he r parent s until th e tim e o f admission . Sh e ha d a few prio r hospitalizations , precipitated b y suicide attempts or threats. Despite her intelligenc e and educationa l background , sh e wa s abl e t o wor k onl y whe n i n settings wher e th e expectation s woul d rarel y threate n her . Sh e found tha t sh e becam e extremely , unmanageabl y anxiou s whe n supervisors wer e critica l o r impatient . Whe n working s a s a sale s person, irritabl e o r difficult customer s woul d provok e similar , disabling anxiety. I f faced with a problem for which she had no ready answer, she was terribly frustrated to find that she could not reason out a solution. I t was a s i f sh e wer e quit e stupid , thoug h sh e wa s not. Sh e fel t helples s an d confused , frightene d tha t sh e seeme d unable to use her intelligence. She said she felt tortured all the time and was intensely mistrustful. Sh e hoped there might be an answer, a way t o stop the torture. At times she wondered if she were crazy, but the n fel t convince d tha t he r perceptions ha d bee n accurat e al l along. Sh e di d believ e sh e wa s losin g he r mind , bu t a s a conse quence of perpetual menta l torture rather than mental illness. On admissio n t o th e unit, sh e described thi s past history a s if i t had happene d t o someon e else . However , whe n sh e spok e o f th e early days of her marriage and of her initial happiness and sense of peace, sh e becam e sa d an d sai d tha t sh e fel t angr y a t hersel f fo r having le t al l o f tha t happe n t o herself . Sh e sai d thi s despit e th e fact tha t i n th e sam e intervie w sh e acknowledge d tha t sh e stil l believed that these events (he r premonitions, the electronic surveillance, etc. ) ha d reall y happened . The interviewe r a t tha t tim e di d not ask her to try to resolv e the incongruity betwee n her statement that sh e wa s responsibl e fo r he r pligh t an d he r convictio n tha t those event s had reall y happened t o her . Believing tha t the patien t could not , a t tha t time , reflec t o n he r (unconscious ) uncertaint y about th e veracity o f he r delusions , h e chos e t o begi n b y focusin g on he r tendenc y t o blam e hersel f fo r event s tha t wer e clearl y no t under her control. Sh e acknowledged tha t this had bee n a lifelon g characteristic an d had first appeared in the context o f he r relationship with her mother.

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Several week s later , th e patien t aske d th e therapis t ho w h e understood wha t ha d happene d t o her . H e tol d th e patien t that , based o n he r statement s an d hi s ongoin g observation , h e though t she ha d suffere d a prolonge d psychoti c episode . Thi s woul d b e hard fo r he r t o acknowledge , h e wen t o n t o note , fo r a variet y o f reasons, on e bein g tha t acceptanc e o f he r illnes s woul d mak e i t harder fo r he r t o blam e herself . "You' d rathe r thin k o f yoursel f a s bad tha n ill . That way you ca n continu e to beat up o n yourself. " On hearing this, the patient was initially distraught, not the leas t because, onc e again , sh e ha d bee n unabl e t o find someon e wh o would suppor t he r vie w tha t sh e wa s persecuted . Fo r som e time , her treatmen t focuse d o n he r nee d t o blam e hersel f an d he r ange r at her therapis t fo r acceptin g rather tha n punishin g her. Gradually , though no t endorsin g th e "illness " model , th e patien t bega n t o demonstrate interes t i n th e copin g strategie s presente d t o he r an d listened whil e he r therapis t describe d ho w feelin g suspiciou s o r experiencing troublesom e menta l event s (hallucinations , premoni tions) nee d not paralyz e her . She learned abou t managin g anxiety an d stres s with medication s as wel l a s throug h othe r techniques . Th e staf f presente d thei r un derstanding o f wh y i t wa s har d fo r he r t o solv e problem s b y pointing ou t th e rol e of anxiet y an d demoralizatio n an d suggestin g that i t was possible t o find a way aroun d thes e impairments an d t o find job s tha t di d no t lea d he r t o confron t the m a s often. Sh e als o began t o conside r tha t he r suspiciou s view s o f other s migh t b e based o n distortio n an d tha t others ' behavior s coul d b e explaine d by les s malignan t motive s tha n thos e sh e ha d imagined . Sh e an d her therapis t devise d "tests " tha t coul d hel p he r t o evaluat e peo ple's motives , t o se e whethe r a les s suspiciou s attitud e brough t about bette r relationship s an d bette r predicted people' s behavior . Case B : An Agreement t o Disagree , an d Ye t Wor k A man i n his late twenties had bee n ill for severa l years and, despit e a numbe r o f hospitalizations , ha d no t bee n abl e t o recove r an y meaningful involvemen t i n socia l relationship s o r i n work. H e ha d several times bee n treated i n day programs an d halfwa y house s bu t usually droppe d ou t afte r a fe w months . H e woul d the n liv e i n a n

A Model for Understanding Schizophrenia 2 apartment alon e o r with a friend fo r severa l month s withou t pur poseful activity , subsistin g o n welfar e unti l h e manifeste d a worsening i n hi s symptom s tha t woul d requir e hi s rehospitalization . Most people workin g with him had given up and described him as a "burnt out schizophrenic. " A clinician began to work with this young man in an attempt t o help him realize his potential an d make use of his evident persona l attributes, whic h include d a remarkabl e warmth , generosity , an d persistent fait h i n himsel f an d other s despit e al l o f hi s difficulties . After on e yea r i n once-a-wee k outpatien t supportiv e psychother apy, h e presente d a complain t abou t someon e wh o ha d insulte d him in public. At the time of the session, the patient had been living in a half-way hous e an d engage d i n a da y progra m fo r on e year . He had recently decided to look into obtaining training in a field in which he had had prior experience. Throughout th e year , th e patien t an d hi s therapis t ha d ha d many discussion s regardin g how the y migh t separately understan d the patient's experiences . Thes e include d recurren t auditor y hallu cinations, idea s o f reference , an d delusion s tha t durin g slee p h e had lef t hi s ow n bod y an d performe d variou s crimina l act s abou t which h e no w fel t guilty . I t was no t withou t precedent , therefore , that o n thi s instanc e th e patient aske d the therapis t how h e ough t to respon d whe n a strange r i n a departmen t stor e sai d t o hi m without provocation , "Yo u helped 'So n o f Sam ' perform al l thos e killings." The patient had considered confronting , eve n assaulting , his accuse r o r callin g th e police—th e latte r ide a leas t favore d be cause he was afraid they might believe the other man. The patient had previously accepted as a possibility the idea that sometimes h e hear d thing s tha t wer e a produc t o f hi s ow n min d and that , i n particular , hi s experience s o f movin g outsid e o f hi s own bod y might not actually have happened. Nevertheless, on this occasion, whe n th e therapis t suggeste d thi s possibilit y t o him , h e became defensive an d said that it was impossible that he had made up what wa s sai d to him . The therapis t pointed ou t tha t having a hallucination di d not mean that one "mad e up" the experience fo r it woul d certainl y see m a s i f i t ha d actuall y happened . The y dis cussed way s o f understandin g ho w hallucination s occu r an d ho w they are perceived. Nevertheless, the patient insisted that the event

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28 Working with the Person with Schizophrenia actually too k place . Th e clinicia n acknowledge d tha t h e coul d neither convince the patient nor prove what had happened, and so he asked the patient how he could be of further help. The patient said h e wa s trouble d b y th e implicatio n tha t h e wa s evil . Th e therapist reviewe d thei r histor y together , emphasizin g th e therapist's experienc e o f th e patien t a s a caring an d generou s perso n who, althoug h capabl e o f ange r an d resentment , ha d show n n o evidence of the outrageous tendencies of which others appeared to be accusing him and, indeed, of which he appeared to be accusing himself. Th e patient agreed , tentatively, tha t thi s view wa s mor e accurate than the one presented by the stranger in the department store. H e di d no t fee l h e ha d consciousl y don e anythin g terribl e nor tha t an y action s performe d whil e h e wa s i n contro l o f hi s behavior had ever resembled the crimes he worried he might have committed whil e "asleep. " The patient was slowly abl e to accept his therapist's recommendations. Although he might disagree with the therapis t abou t what ha d happened i n the departmen t store , the socially acceptable and, in the end, most comfortable recourse for him would b e to ignor e suc h insults, althoug h h e might continue t o worr y abou t thei r meaning . H e accepte d th e fac t tha t confronting strangers in the way he had contemplated might create embarrassing situations for him. At the conclusion of that session, the patient continued to insist that the therapist was wrong in not "believing" his account of the actions of the accuser, but he acknowledged: "What you say about me not being as bad as he said I was seems to make sense. So I can see your point about not doing or saying things that would get me into trouble, like hitting him or calling the cops." Note that the patient and therapist agreed to disagree about the "facts." The therapist' s decisio n t o conduc t th e intervie w i n this manner demonstrated respec t an d allowe d th e patien t t o partici pate while confronting the presumed distortion. In turn, the patient was abl e to conside r mor e appropriate behaviors. Had the therapist insiste d o n hi s positio n (i.e. , "th e accuser' s word s wer e a hallucination"), he and the patient would have become locked in a struggle. Th e patien t wa s no t read y t o conside r th e delusiona l nature o f hi s perceptions . B y sayin g wha t h e did , th e therapis t presented a rational view of the events and coping strategies, while

A Model for Understanding Schizophrenia 2 implicitly recognizin g that , ove r time , th e par t o f th e patien t tha t questioned hi s delusiona l belief s woul d graduall y b e abl e t o iden tify wit h th e therapist an d hi s views. Case G : A Common Rout e o f Avoidanc e A 35-year-ol d woma n wa s readmitte d t o th e hospita l afte r havin g lived fo r th e previous thre e years o n th e street s o f Ne w Yor k City . She ha d bee n briefl y hospitalize d tw o year s previousl y becaus e o f paranoid delusion s an d deteriorate d health . Thi s time , sh e wa s hospitalized followin g th e effort s o f a communit y crisi s team , whic h picked he r u p i n a confused , debilitated , an d battere d condition . The patien t requeste d transfe r fro m a cit y hospita l t o th e privat e institution wher e sh e ha d bee n treate d severa l year s before . Tha t prior treatmen t ha d include d tw o year s o n a long-ter m uni t fo r schizophrenic patients . Whe n sh e arrived , sh e tol d th e docto r wit h whom sh e had worke d i n the past that sh e was frightened, tha t he r life ha d bee n horribl e ove r th e pas t thre e year s sinc e sh e ha d see n him, an d tha t sh e wishe d no w t o participat e i n treatmen t an d would accep t referra l t o a halfwa y hous e an d da y program , a pla n that ha d bee n suggeste d severa l year s befor e bu t turne d dow n b y the patient becaus e it conflicted wit h he r principles . The patien t believe d tha t sh e was th e subjec t o f a mind-contro l experiment performe d b y th e CI A an d tha t he r on e missio n i n lif e was t o expos e thi s corruptio n an d t o brin g he r tormentor s t o justice. Sh e was hampered , sh e maintained , b y th e fac t tha t i n he r view this plot involve d everyon e whom sh e met . In he r prio r hospita l treatment , th e patien t ha d attempte d t o enlist he r therapis t an d othe r staf f i n he r struggle , t o hav e the m support an d champio n he r cause . When sh e returned t o th e hospi tal o n thi s occasion , sh e agai n renewe d he r plea , askin g tha t th e therapist mak e specia l effort s t o hel p her . Thi s include d he r de mand tha t staf f cal l th e CI A t o insis t tha t the y releas e informatio n on her . She was admitte d t o a general inpatien t unit , populated b y me n and wome n primaril y i n thei r thir d an d fourt h decade s o f life . Most o f the m suffered fro m schizophreni a o r othe r seriou s psychi atric illnesses. Despite thi s fact , thi s patien t stoo d ou t amongs t th e

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30 Working with the Person with Schizophrenia group as clearly bearing the ravages of chroni c illness and a hard life o n th e street s o f Ne w York . Sh e wa s sociall y withdrawn , anxious, dresse d bizarrel y wit h excessiv e layer s o f clothing , an d walked about the unit with furtiveness an d mistrust that was disturbing t o others . I n additio n t o he r belie f i n th e mind-contro l conspiracy, th e patien t als o ha d com e t o believ e tha t sh e ha d a religious mission in life and reported frequent visual hallucinations of th e bod y o f Christ , which ha d appeared t o he r while sh e was praying in church. Her physica l conditio n improve d durin g th e thre e week s sh e was in the hospital. Although she became less overtly disorganized and anxious, it was clear that the minimal demands for socialization, maintenanc e o f persona l hygiene , an d participation i n some therapeutic activitie s produce d anxiet y an d insecurity . Sh e wa s confronted wit h ho w sever e he r impairmen t i n rol e functionin g was. Task s tha t wer e difficul t fo r he r wer e mor e easil y accom plished by other people, in particular tasks related to relationshipbuilding. W e d o no t kno w ho w consciousl y sh e perceive d thes e difficulties. I t was perhap s fo r thi s reaso n that , despit e he r early evidence of commitmen t to seeking a different lif e for herself, the patient left the hospital and when last heard from had returned to her life o n the streets, seeking refuge i n churches and shelters fo r the homeless. Each of thes e patients shar e common responses: denial; intermittent compliance with treatment; a conviction about a certain way of viewing their experience that is at odds with how we understand their symptoms and what is happening to them; and feelings of despair and futility. And yet, eac h o f thes e individual s present s a very differen t story . Thei r involvement in or withdrawal from treatment follows patterns related to, but not wholly determined by , either their character or the nature and severity o f th e illnes s fro m whic h the y suffer . W e see k t o understan d what ca n accoun t fo r thei r symptom s and , i n particular , ho w thei r attitudes about their symptoms dispose them towards treatment. We speculate, although we do not know, that there may be physiological factor s tha t produce suc h symptom s a s denia l an d the convictio n that one's perceptions are accurate and that others are mistaken. We do not as yet have a model for understanding such denial as a consequence

A Model for Understanding Schizophrenia 3

1

of organi c factors , bu t we ma y discove r tha t thi s disturbanc e i s a t leas t instrumental t o th e developmen t o f schizophrenia . D o thes e patient s prefer t o believ e i n thei r vie w o f themselves , o r ar e the y utterl y con vinced o f tha t vie w a s a consequenc e o f th e working s o f thei r ow n perceptive apparatus? 6 Bein g utterl y convince d o f one' s vie w o f th e world ma y b e a consequenc e o f th e wa y i n whic h th e min d evaluate s what i t experiences . Yet , w e ma y conside r tha t thes e patient s maintai n their delusiona l view s becaus e t o d o otherwis e woul d requir e the m t o acknowledge thei r experience o f th e world t o b e a disordered o r unreli able one. Perhaps thi s explain s why , i n th e secon d example , th e patien t wh o had previousl y bee n abl e t o acknowledg e hallucination s late r resiste d that assertion. His original endorsement of his 'hallucinations" may have been partia l o r tentative . H e ma y hav e remaine d skeptica l ye t hopeful , the hope fueled by the knowledge that his treatment had been associate d with improved functioning an d a pronounced reduction in the frequenc y of hi s hallucinations . Ha d h e bee n harborin g a hop e tha t thos e experiences woul d sto p a s a resul t o f th e har d effor t h e ha d pu t int o hi s treatment? Hi s disappointmen t i n th e unanticipate d recurrenc e o f hi s hallucinations i n th e absenc e o f an y apparent , externa l precipitatin g event may have bee n enough t o brin g about the denial an d contentious ness tha t marke d th e beginnin g o f tha t session . Thi s stat e nonetheles s yielded t o th e clinician' s assertio n tha t th e patien t wa s a goo d an d worthwhile perso n wh o still , despit e difficulties , coul d manag e t o cop e with his life and secure happiness for himself . This is not to say that the patient was helped simply by the therapist's asserting, "Yo u ar e a good fellow. " Rather , the intervention too k place , necessarily, as a series of steps. First, the therapist defined the boundaries of wha t he could an d could not do regardin g the patient's experienc e o f an even t happenin g outsid e th e office . Th e therapis t mad e clea r hi s inability t o "prove " t o th e patien t tha t th e even t h e fel t ha d occurre d (the referenc e t o "So n o f Sam" ) di d no t occur . However , base d o n al l the therapis t knew , h e wa s convince d tha t th e even t di d no t happe n a s reported, and he communicated this to the patient—though h e acknowl edged tha t h e lacke d th e abilit y t o convinc e th e patien t o f thi s point o f view. Second, there is an area wherein the therapist had direct experience of th e patient: tha t is, in the office, i n their treatment sessions . Fro m his direct observatio n an d experience , th e therapis t coul d indee d dra w ac -

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curate conclusion s abou t the patient: "Sinc e I wasn't there, I can't, with absolute certainly , sa y tha t n o on e sai d thos e words . However , give n everything tha t I know bot h abou t yo u an d ho w th e res t o f th e worl d operates, I' m 9 9 percen t sur e tha t n o on e othe r tha n yoursel f accuse d you." Third, whe n thes e conclusion s (suc h a s tha t th e patien t i s no t evil ) refuted o r wer e i n conflic t wit h th e patient' s vie w o f himsel f o r others , the therapist coul d then, with authority , challeng e th e patient's assump tions. T o facilitat e th e patient' s abilit y t o liste n t o thi s alternativ e poin t of view , i t wa s helpfu l t o firs t identif y wit h th e patien t th e adaptiv e aspect o f hi s perceptions : " I coul d certainl y understan d you r wis h t o place th e blam e outsid e yourself . I f I thought I migh t hav e committe d terrible crimes , I coul d imagin e tha t feelin g other s wer e blamin g m e might even be a kind of relief. " The patient' s denia l ma y hav e bee n a resul t o f som e featur e o f hi s underlying disorde r or a psychological mechanis m tha t attempts t o shu t out painful realities ; but in neither case can we simply assault misperceptions. Th e patien t wh o hold s a distorte d vie w o f himsel f an d other s i s suffering a deep sense of isolation and struggling to maintain self-esteem . We als o assum e (an d i n tim e find) th e "denying " patien t i n som e wa y aware of hi s distortion. To assum e otherwise i s to take the unwarrante d position tha t the patient i s capable of destroyin g reality ! The exercise o f denial implie s th e individual's recurrin g confrontation wit h th e stress of truth. The evidenc e tha t delusiona l conviction s ca n b e supporte d b y th e need t o protec t self-esteem , o r maintai n a particular vie w o f th e self , i s represented i n th e clinica l observatio n tha t som e patients , lik e th e firs t two describe d here, can reconsider their delusional views an d admit that they ma y no t b e accurat e whe n psychologica l concern s relate d t o th e patient's necessity to maintain these delusions ar e addressed. In the first case, the patient's overwhelming sense of rage and helplessness, both a t not bein g abl e to functio n an d because o f he r persecution, was empathicall y appreciate d b y th e therapist . Thereafte r cam e a n un derstanding of how the patient characteristically tended to blame herself, thus turning the rage inward. Note that the understanding, to this point, was independen t o f th e patient' s delusiona l system . I t wa s th e stuf f o f everyday life that concerned her and with which we must empathize; but it i s th e stuf f that , fo r her , becam e th e mediu m i n which th e delusiona l

A Model for Understanding Schizophrenia 3 3 system incubated . Th e nee d t o punis h onesel f i s troubling but , i n con trast t o th e experienc e o f bein g pursue d b y governmen t agents , no t extraordinary. B y translating the bizarre into the usual, we connect th e patient with the rest of us, and ourselves with the patient. From this example we can see how, in order to help the schizophrenic individual, the clinician must have a good understanding of the patient's ideas about herself an d the world—that is, the patient's subjective experience. We cannot create meaningful goal s until we understand what the patient desires and how she perceives her difficulties. An d we must learn how to make use of the patient's perspective in formulating a treatment strategy.

BUILDING TH E TREATMEN T ALLIANC E

A treatmen t allianc e shoul d b e base d o n a n agreemen t betwee n th e patient an d th e clinicia n concernin g th e goals an d mean s o f treatment . This doe s no t mea n tha t patien t an d clinicia n agre e full y abou t al l aspects of the treatment or about all of the goals. There is, however, no basis for meaningful wor k if there is no common ground or no common goal. Thi s tas k first require s exploratio n o f th e patient' s vie w o f self , illness, an d treatmen t an d explicatio n b y th e clinicia n o f hi s o r he r observations, conceptual framework , treatmen t proposals, and expectations. Both of these tasks require a good understanding o f the nature of the illness and how it affects th e individual. We wish here to review the conceptual mode l o f schizophreni a wit h which w e work an d whic h we ultimately seek to present to the patient. The relevance of explainin g our thinkin g to the patient i s not gener ally appreciated ; no r i s th e tas k easy . I n particular , becaus e o f th e complexity an d subtlet y inheren t i n th e treatments , i t i s important fo r clinicians t o translat e int o comprehensibl e analogie s o r t o reduc e t o essentials th e principle s an d mode s o f actio n o f treatments . Thi s i s especially critical in work with innately mistrustful patients , who tend to attribute malevolen t intention s t o th e environment , particularl y whe n they are confused o r threatened. Further, the likelihood tha t mos t delusional patient s canno t b e persuaded t o renounc e o r abando n thei r misperceptions make s i t incumben t o n an y clinicia n t o lear n innovativ e

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techniques t o mak e ou r knowledg e an d method s availabl e and , wher e possible, acceptable to the schizophrenic patient . Making wha t w e d o an d ho w w e d o i t visibl e t o th e patien t i s a n important earl y step . Fo r example , a patient wh o wa s give n t o magica l thinking, especiall y relate d t o fantasie s o f merge r wit h hi s therapis t ( a common phenomenon i n work with schizophrenic patients, representing a wished-fo r unio n wit h another , tha t ma y b e partl y eroti c a s wel l a s dependent, reflecting helplessness and a need for strength, angry, jealous, and consumptive , an d usually highl y dereistic) , expressed th e belief tha t previous therapists had been able to read his mind. The therapist, alerte d by this statement, mad e a n observation, carefu l t o detai l th e constituen t data of his conclusion: Dr.: Becaus e I see you fidgeting in your chair , an d not e ho w muc h yo u are sweating—o n a rathe r coo l day—an d ca n hea r you r voic e sounding higher than usual, I conclude that you are anxious; about what I do not know, but if I am right, perhaps we can explore wh y this might be so. This interventio n exemplifie s th e principl e o f careful , patient , detaile d explication, whic h i s crucia l t o th e metho d w e present . Althoug h no t presenting a complicated physiologica l o r psychological mode l here , the clinician i s sharing with th e patient detail s tha t illuminat e th e mean s b y which th e clinicia n make s conclusions , ho w h e o r sh e goe s abou t th e job. Th e ver y persistenc e an d equanimity require d fo r an d communi cated by this style ar e often helpfu l i n reducing a schizophrenic patient' s anxiety an d mistrust. Many clinician s hav e difficult y formulatin g a model o f schizophreni a that bot h adhere s t o wha t i s know n abou t th e illnes s an d allow s fo r communication wit h patients and families. In part, this is a consequence of th e welter of theorie s i n the schizophrenia literature . I n part, it is due to th e heterogeneity o f schizophreni c syndromes . Schizophreni a i s not a uniform disorder ; no r i s outcome easil y predictable . To o frequentl y th e strains in the treatment allianc e with th e patient or family ar e a result of the clinician' s assumptio n o f a n attitud e o f certaint y (abou t prognosis , severity o f course , etc. ) wher e n o certaint y exists . I n attempt s t o b e frank, t o hel p prepar e familie s fo r often-predictabl e stresse s an d disap pointments, clinician s (unfortunately ) see m t o th e familie s t o scatte r hopes, t o obscur e uniqueness , an d t o sugges t a kin d o f knowledg e an d

A Model for Understanding Schizophrenia 3 5 authority we do not possess. We should resolve, at the outset, to abjure false certaintie s an d present the science we have as clearly a s we may, acknowledging its limitations and our own. It is important to begin with a discussion of our understanding of the nature of th e illness with whic h these patients struggle, to defin e what serious an d significan t problem s the y mus t fac e a s well t o delimi t th e boundaries of the illness and the boundaries of our information. We will proceed with the task we initiated above, which is to discern among the symptoms of th e disorder those that may be primary to the illness and those whic h may , i n whol e o r i n part , reflec t th e patient' s effort s t o adapt to his or her condition. We have noted that the common current distinction between positive and negative symptoms, or positive and negative syndromes, in schizophrenia i s i n itsel f confusin g an d limiting . I t has arisen , i n part , fro m nineteenth-century phenomenological description s of schizophrenia (which were heavily influenced b y the assumption that schizophrenia was etiologically related to "other dementias")—ideas that, although challenged by Bleuler and others, continue to persuade some in the field, and color clinical depictions of the disorder (consider the persistence of the image of "irreversible , progressiv e deterioration " man y stil l associat e wit h schizophrenia, despite evidence that this picture is not accurate for most schizophrenic patients) (21). The reasons for the prevailing conceptual bia s regarding schizophrenia ar e complex an d unclear . Althoug h Jackson (6 ) first proposed th e notion of "positive " and "negative" syndromes, the roots of this model lie even further in the past. The works of Kraepelin and Bleuler (22-23) have eac h contribute d t o thes e developments . Kraepelin , i n particular, linked schizophrenia to the dementias and rigidly to a disease model that did no t describ e a rol e fo r psychologica l adaptiv e functionin g i n th e production of "symptoms." Bleuler's nosologic contributions have inadvertantly focuse d attentio n o n th e mos t noticeabl e symptom s o f th e disorder, as they have dominated clinical descriptions of the illness. We must no w direc t ou r attentio n bac k t o other , subtle r aspect s o f th e schizophrenia illness process, including the disturbances in ego functioning also addressed by Bleuler. In doing so, the conceptual limitation s o f th e neo-Kraepelinian perspective on negative symptoms are immediately evident. While we must acknowledge the role of brain pathology, the complexities of the psycho-

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logical presentatio n o f th e individual wit h schizophreni a ar e also appar ent. Nevertheless , writer s suc h a s Brenne r (24) , whil e makin g valuabl e contributions t o our understanding of the cognitive psychology o f schiz ophrenia, virtuall y ignor e th e importanc e o f th e individual' s sens e o f self, experienc e o f th e illnes s o r treatment , an d othe r psychological , psychodynamic variables . I t i s disturbin g tha t thi s bia s (especiall y th e notion tha t negativ e symptom s ar e simpl y expression s o f neurologi c deficits) affect s s o much of the field's current theoretical framework . I t is even more troubling that this attitude contributes to a therapeutic ennui, with clinician s an d familie s feelin g helples s an d discourage d whe n con fronting the chronic, debilitating symptoms of this disorder. We contend that the positive/negative dichotom y ha s contributed to a stagnation i n clinica l researc h an d treatmen t o f schizophrenia . Th e the ory i s ofte n associate d wit h th e presumption tha t "negative " symptom s are uniformly symptom s o f a neurologic "deficit " state (resurrectin g th e assumptions o f th e nineteenth-centur y mode l o f dementi a praecox) . B y compressing a varie d an d variabl e disorde r int o tw o artificiall y nea t "syndromes," the basis for the heterogeneity o f schizophreni a i s lost. In particular , th e ide a tha t th e patient' s psychologica l reactio n an d adaption t o th e disorde r plays a role in th e production o f th e syndrom e is not considered. Coping , improved adaptation, self-understanding, an d self-acceptance ar e extraneous t o thes e descriptions , a s is the likelihoo d that thes e patien t characteristic s migh t influenc e outcome . Patient s an d families, when presented with the "positive/negative" or "flagrant symptom/deficit symptom " model , coul d wel l b e expecte d t o experienc e dis couragement an d resignatio n tha t ma y preclud e mor e effectiv e adapta tion. We hav e a way o f thinkin g abou t th e disorde r that , whil e consisten t with wha t i s known, doe s no t needlessl y discourag e u s nor ou r patient s and thei r families . Thi s mode l include s way s o f breakin g dow n ofte n confusing symptomati c pictures into categories that help us to see which symptoms ma y b e treate d appropriatel y wit h medica l intervention s o r rehabilitative intervention s a s well a s which treatmen t wil l bes t addres s the profound disturbance s i n self-esteem an d the burden of despai r with which these individuals struggle.

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A MODEL FOR UNDERSTANDING SCHIZOPHRENI C SYMPTOMATOLOG Y In Table 1.1 , w e propos e a categorization o f th e mos t significan t symp toms o f schizophrenia . W e will discus s th e meanin g o f th e specifi c cate gories, bu t on e ca n se e immediatel y tha t ou r approac h recognize s th e complexity o f schizophreni a an d the likelihood tha t a number o f differ ent processes ar e at work. We specifically oppos e th e lumping of schizo phrenic symptoms int o either positive or negative groups alone ; and our method reflects our theoretical bias, thus differentiating thi s system fro m the undiscriminating "laundr y list" in DSM III-R. Under sectio n I , we describ e wha t w e currentl y understan d t o b e th e physiological substrat e o f schizophrenia . W e labe l thes e "primary " disturbances becaus e currentl y availabl e literatur e indicate s tha t thes e symptoms see m mos t closel y relate d to th e principal underlyin g physio logical disturbance. In support of this argument, we would like to briefl y explore curren t knowledg e regardin g th e physiologica l component s o f this disorder. This discussion is based on a reading of a n eclectic body of literature, some of which is referenced in our bibliography. In particular, we find suppor t fo r ou r view s i n a recen t pape r writte n b y Dr . Danie l Weinberger (25) . He has reviewed a great deal of literature as well as his own experienc e i n studyin g schizophreni c individual s an d propose d a conceptual organizatio n o f the disorder that may accoun t fo r its confus ing presentation . Wha t w e offe r her e i s a n integratio n o f ou r thinking , his work, an d the work o f other theoreticians an d scientists. Most reader s wil l b e familia r wit h th e basi c concept s regardin g th e neurophysiology o f schizophrenia ; t o thos e wh o ar e not , w e strongl y recommend a revie w o f thi s topic . Ther e i s a n excellen t overvie w i n Psychiatry, edite d b y Michels an d Cavena r (26) , and a thorough exami nation of the research literature by Noll an d Davis in Schizophrenia and Affective Disorders, edite d b y Rifki n (27) . Bot h text s ar e highl y usefu l and clear. Professionals wh o find these references to o medically oriente d are recommende d t o Andreasen' s summar y o f recen t advance s i n th e field (28). Researchers hav e lon g believe d tha t man y cor e schizophreni c symp toms were based on a dopamine-excess condition , principally becaus e of the purported sit e o f actio n o f neuroleptics , a s post-synaptic dopamine -

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Table 1. 1 I. "Primary " Disturbance s i n Schizophrenia (Physiologica l Substrate ) A. Limbi c Dysfunctio n (Mesolimbic Pathways ) 1. Perceptua l Disturbance s a. Hallucination s b. Illusions , ideas of referenc e (se e below ) c. Dej a v u experiences, "Epiphanies," Anwesenheit 2. Suspiciousness , paranoi a a. Ide a o f reference , overvalue d idea s (consistin g o f distorte d attri bution o f meaning ) 3. Anxiety , agitatio n a. Disturbance s i n self-object differentiatio n ("eg o boundaries" ) b. Depersonalization , derealizatio n c. Agitation , excitemen t 4. Irritabilit y a. Hostility , aggressivenes s (als o "disinhibited " behaviors ) 5. Othe r affectiv e experiences , including grandiosity, elation, etc. B. Subcortical , Cortica l Dysfunctio n (Subcortical Nuclei , Prefrontal Cortex , Mesocortica l Pathways ) 1. Cognitiv e Impairmen t in : a. Proble m assessment , analysis , plannin g b. Stimulu s discriminatio n (fronta l lobe ) c. Retrieva l o f store d pattern s o f respons e t o stres s (thalami c dys function) 2. Consequen t disturbance s i n integrative capacitie s and i n instrumenta l role functionin g C. Uncertain , but probabl y Organi c Etiolog y 1. Amotivation , apathy , avolitio n (se e below ) 2. Restricte d affect , narro w ideatio n (se e below ) 3. Neuroleptic-responsiv e affectiv e symptom s (Hirsc h e t al. ) [40 ] D. Though t disorde r ( ? 2° to prefrontal cortica l disorder ) II. Secondar y Disturbances , with Physiologica l Basi s A. Depression , an d Othe r Moo d Disturbance s 1. Majo r Depressio n (frequentl y misdiagnosed ) 2. Subaffectiv e Syndrome s B. Iatrogeni c Symptom s 1. Parkinsonia n Syndrome : Psychomoto r retardation ; povert y o f con tent of though t 2. Medicatio n toxicit y resultin g in cognitiv e impairmen t C. Disinhibite d affects , behavio r III. Psychologica l Response s t o Illnes s A. Effort s t o Achieve Safety an d Decreas e Stres s 1. Commo n behaviors : socia l withdrawal , denia l o f painfu l realitie s

A Model for Understanding Schizophrenia 3 9 Table 1. 1 (continued ) about illness , cognitiv e avoidance , persistenc e i n unrealistic plans , delusions, idiosyncratic solutions 2. Goal s of these behaviors: decreasing anxiety or confusion associated with social interactions; aiding in self-object differentiation; avoiding experiences that confront the patient with impairment in psychological continuit y an d clarity; increase sense of autonomy an d control (however unrealistic); defense against acknowledgement of loss; de fending self against perceived threats from the environment. B. Maladaptiv e or Dysfunctional Patterns 1. Resentmen t or Grandiosity a. Predominan t anger, resentment, oppositionality; undermining efforts at helping b. Unrealisti c view of control 2. Delusiona l Conviction or Denial a. Effort s to explain experience, under influence of abnormal mental states (especially physiologically induced suspiciousness) b. Resistanc e to self-examination becaus e of narcissistic injury c. Maladaptiv e consequences denied or ignored 3. Demoralizatio n and Withdrawal a. No t having "model" that suggests ways to help self, improve selfesteem, and exert meaningful control (internal locus of control) b. Socia l and emotional withdrawal, both adaptive (decreases stress) and maladaptive (dysfunctional) c. Excessiv e self-reproach IV. Symptom s of Uncertain or Mixed Etiology A. Amotivation , Avolition, Apathy B. Restricte d Affect , Narro w Ideation , Anhedonia , Decrease d Curiosity , Decreased Sense of Purpose C. Lac k of Insight 1. ? Cognitive component receptor blockers . Recen t literatur e (29-30 ) ha s pointed ou t the limitations inheren t i n th e theory . Dopamin e activit y ma y b e relate d t o th e flagrant symptoms of schizophrenia (hallucinations , delusions), but these may alternativel y b e associated wit h serotonergi c neuro n hyperactivity . It is noted that there are two classes of dopamine receptors , with th e D2 receptor apparently being most closely associate d with neuroleptic activity. Whethe r blockad e o f th e D 2 receptor i n fact explain s antipsychoti c activity is uncertain, though mos t investigators fee l thi s is so. Noradrenergic neuron metabolism may be correlated with anxiet y state s and thus implicated i n th e genesi s o f schizophreni c symptomatology . Th e rele -

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Figure 1. 1

Source: E . Richelson , "Schizophrenia : Treatment, " i n Psychiatry, ed . R . Michel s an d J . O . Cav enar, Jr., vol . 1 (Ne w York : Basi c Books , 1987) , 15 . Reprinte d b y permissio n o f J . B . Lippincot t Co . and th e author .

vance an d clinica l o r phenomenologica l significanc e o f anatomica l ab normalities, such a s ventricular enlargemen t an d decreased cerebra l mas s found i n som e schizophreni c populations , i s als o uncertain , althoug h this dat a ha s bee n presumptivel y linke d t o th e "deficit " theorie s o f schizophrenic cognitive disturbance. Whether th e symptoms, which mos t investigators no w labe l "negativ e symptoms, " ar e du e t o cholinergi c deficiency state s or other physiologic disturbances ha s also been debated . Weinberger's mode l postulate s tha t th e primary , o r inciting , lesio n i n schizophrenic individual s i s a disturbanc e i n th e functionin g o f dopami nergic neuron s i n th e prefonta l corte x (se e Figur e 1.1) . I n fact , th e localization o f a n "incitin g lesion " i s not crucia l t o ou r model . Whethe r this hypothesi s i s later substantiated , a s Weinberger ha s se t i t forth , th e elements essentia l t o ou r discussio n hav e t o d o wit h th e propose d neu rophysiological an d phenomenologica l distinction s betwee n classe s o f symptoms. These distinction s ca n b e made whethe r o r no t th e anatomi c relationships discusse d b y Weinberger ar e true . Ou r interes t i s in differ entiating th e kinds o f symptom s experience d b y schizophrenic patients . The prefronta l an d subcortica l region s o f th e brai n hav e bee n associ ated wit h abnorma l functio n i n schizophreni c patient s (13 , 31) . Th e abnormality i s particularl y apparen t whe n schizophreni c patient s ar e asking to do psychological test s (e.g. , the Wisconsin Car d Sort ) requirin g integrative, organizationa l cognitiv e functions . Thes e latte r ar e menta l operations tha t hel p th e individua l determin e ho w t o approac h menta l

A Model for Understanding Schizophrenia 4 1 tasks efficiently, analyzin g tasks , prioritizing, an d utilizing experientia l information. Thi s specifi c cognitiv e abnormalit y i s correlate d wit h decreased activit y i n th e dorso-latera l prefronta l corte x (DLPFC) , whe n brain-imaging studies (PET scans) are done during test-taking. Studies don e o n rat s (32 ) sugges t tha t th e DLPF C is significan t be cause i t ma y exer t a toni c modulator y effec t o n subcortica l catechol amine systems (i.e. , nerve pathways using the neurotransmitters norepinephrine, epinephrine , dopamine , an d s o forth) . A s show n b y a large body of research, the subcortical region of the brain, is vitally important to cognitive functioning (33-34) . Disturbances such as those postulated here impair the individual's capacity to organize or process stimuli from the environment; to make use of learned patterns of thinking or behavior in coping with stress or challenging tasks; to evaluate and respond to the subtleties an d complexitie s o f socia l interactions , whic h requir e extensive use of stored, instinctive coping strategies. Abnormalities i n thes e anatomi c pathway s may , implicitly , var y i n severity amon g schizophreni c patients . Thi s ma y accoun t i n par t fo r heterogeneous presentations. In addition, variable degrees of impairment also provide a n explanation fo r th e effect o f stres s on symptoms . The impairment represents a diathesis, so that certain stresses (psychological and physiological) may cause variable degrees of disturbance and different consequences . Thi s variability ma y als o accoun t fo r difference s i n age of onset of schizophrenia, a topic about which Weinberger presents a stimulating hypothesis; however, that discussion is beyond the scope of our current task. The cortical disturbance in the prefrontal cortex , often referred to as a syndrome of "hypofrontality," and the subcortical dysfunction, which may be a consequence of thi s disturbance, have other ramifications. As Weinberger describe s i n his paper, thes e regiona l dopamin e deficienc y states may stimulate excessive, compensatory activity in the midbrain, a critical regulatory center (se e Figure 1.2) . Decrease d activity i n the mesocortical pathways (involvin g the DLPFC and subcortical regions ) signals the midbrain to produce more dopamine, according to Weinberger's hypothesis. Bu t th e mesocortica l pathway s ar e damage d o r dysfunc tional, an d canno t utiliz e th e dopamin e neurotransmitte r or , perhaps, deliver it where it is needed. The increased levels of dopamine may "spill over" int o th e mesolimbi c system , whic h i s a nerv e pathwa y leadin g from th e midbrai n t o brai n structure s involve d i n th e integratio n an d

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Figure 1. 2 Effect of Prefronta l Dopamin e Differentiatio n

Normal Stat e

Source: D . R . Weinberger , "Implication s o f Norma l Brai n Developmen t fo r th e Pathogenesi s o f Schiz ophrenia," Archives of General Psychiatry 4 4 (Jul y 1987) : 665. Reprinte d b y permission .

modulation o f emotiona l experienc e an d perceptio n (i.e. , th e limbi c system). We know tha t individuals with disturbance s i n the limbic system (e.g. , epileptics wh o hav e seizure s tha t affec t thi s are a exclusively ) experienc e perceptual disturbance s (hallucinations) , anxiety , confusion , paranoi d states (feelin g watched , threatened ) an d othe r phenomen a (35—36) . Drugs that overstimulat e thi s regio n ca n produc e psychosis . The inappropriat e and incidenta l (o r secondary ) stimulatio n o f thes e pathway s ma y thu s account fo r th e flagrant o r "positive " symptom s o f schizophrenia . Neu roleptics, b y "blocking " dopamin e activit y i n th e mesolimbi c system , decrease thes e distressin g symptoms . Ironically , thes e medication s ma y worsen th e defici t i n th e mesocortica l pathways , perhap s accountin g fo r the findings o f cognitiv e impairmen t i n som e schizophreni c patient s treated wit h hig h dos e neurolepti c regimens , impairmen t tha t remit s when medicatio n dose s ar e lowere d an d th e patient s becom e les s "Par kinsonian" (37-38) . This theory , incorporatin g Weinberger' s semina l contribution , offer s the possibility o f constructin g a hierarchy o f symptoms , such a s we hav e outlined i n Tabl e 1.1 . Th e disturbance s i n th e limbi c syste m ma y b e correlated wit h thos e symptom s tha t ar e mos t neuroleptic-responsiv e

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Table 1. 2 "Negative" Symptom s I. Du e to Subcortical or Prefrontal Cortex Dysfunction II. Expression s of Psychological Response to Core Illness III. Symptom s of Unclear or Mixed Etiology IV. Iatrogeni c V. Misdiagnose d Symptoms of Superimposed Depression and that have been called "positive" symptoms by others, as noted under section LA . Mos t importantly , thi s theor y allow s u s t o mak e a crucia l distinction betwee n thos e othe r manifestation s o f th e disorder , ofte n described as "negative" symptoms, identifying thos e that are directly, or secondarily, a consequenc e o f disturbance s i n th e prefronta l corte x o r subcortical regio n (involvin g th e mesocortical pathways ) an d those tha t may b e du e t o othe r causes . Indeed , Weinberger' s hypothesi s point s t o the essentia l erro r i n groupin g al l so-calle d "negative " symptom s to gether. The disorder s caused b y abnormalities i n mesocortical pathway s lea d to marke d impairment s i n cognitiv e functionin g (14 ) an d thu s t o de creased "instrumenta l rol e functioning" (performanc e i n tasks, interpersonal situations) . These disturbance s ca n accoun t fo r much o f wha t ha s been calle d th e "negative " symptom syndrome , bu t not all . Phenomen a such as social withdrawal, amotivation , and lack of interes t in treatment are comple x behaviors , whic h mus t represen t mor e tha n th e result s o f discrete cognitiv e disruptions . W e wis h t o distinguish , amongs t thos e symptoms whic h hav e bee n variously considere d par t of th e "negative " symptom syndrome , thos e tha t ar e clearl y a direct o r proximate conse quence o f th e prefronta l o r subcortica l disturbance s note d above , an d those whic h ma y hav e othe r causes . I n Tabl e 1.2 , w e hav e delineate d these a s follows: symptom s du e to subcortica l o r prefrontal corte x dys function; symptom s tha t represent psychological response s t o th e disor der (including , i n man y patients , socia l withdrawal) ; symptom s havin g an unclea r o r "mixed " etiology , perhap s representin g interaction s o f physiological an d psychologica l processe s (includin g th e syndrom e o f amotivation, avolition , an d apathy) ; "negative " symptom s tha t are , i n fact, iatrogenic , du e t o neurolepti c administratio n i n man y case s ("Par kinsonism"; psychomoto r retardation ; povert y o f conten t o f thought) ; and those symptoms tha t are due to the often overlooke d coincidenc e o f

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a depressiv e syndrom e superimpose d o n a n acut e o r chroni c schizo phrenic illness (39) . This analysis of "negative " symptoms i s reflected i n the structure of Table 1.1 . Each of these categories can be found unde r a heading that most closely reflects ou r thinking about etiology . It i s importan t t o not e tha t w e ar e no t denyin g th e existenc e o f th e symptoms tha t som e investigator s hav e studie d a s part o f th e "negativ e symptom syndromes" ; rather, we ar e questioning the validity an d utility of tha t conceptua l groupin g o f symptoms . The analysi s w e hav e pre sented abov e appear s to us to b e concordant with the available researc h data. It has the further advantage of clarifying wha t has been an obscure situation. Treatmen t an d treatmen t researc h hav e bee n limite d b y th e assumption tha t th e negativ e sympto m syndrom e ha s a unified etiolog y and that al l aspect s o f th e "syndrome " might be expected t o respon d t o the same, though a s yet unavailable, treatment . In a recen t review , Hirsc h (40 ) describe s ho w man y o f wha t ar e commonly considere d "negativ e symptoms" may be neuroleptic-respon sive whe n the y appea r a s par t o f th e prodrom e t o decompensation , o r recurrence o f a n acut e psychoti c episode . Indeed , Dochert y e t al . (41 ) presented a schema, with experimental support , suggesting that the early phases o f relaps e wer e marke d b y psychologica l (an d physiological? ) overload o r "overextension, " whic h coul d produc e symptom s suc h a s withdrawal, narrowe d attentio n an d ideation , alienation , "feelin g over stimulated," anxiety , an d irritability , progressin g t o mor e over t symp toms o r psychosis. These behavior s ma y represen t attempt s b y the indi vidual t o "compensate " fo r wha t i s happenin g psychologicall y (e.g. , avoidance o r restriction o f distressin g stimuli , thoughts , an d socia l con tacts; obsessional thought s an d behavior s a s responses t o anxiety) . Thi s "compensation" i s no t necessaril y willful , fo r i t ma y b e mediate d b y cognitive processe s influence d b y th e physiologica l disturbance . Never theless, these psychological state s may be partly controllable through the patient's activ e effort . These phenomen a poin t t o th e comple x natur e o f symptom s tha t result fro m a n interactio n o f psycholog y an d physiology . Socia l with drawal o r narrowed ideatio n ar e provoked b y a physiologic disturbanc e and, a s Hirsc h points out , ca n improv e i f th e physiologic disturbanc e i s treated. Bu t thes e phenomen a ar e behaviors, o r cognitiv e patterns , tha t the individua l ma y b e abl e t o recogniz e an d influence . The y ma y b e adaptive i f the y reduce anxiet y o r stress; or maladaptive i f the y increas e

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dejection, demoralization , anxiet y o r ineffectiv e coping . The y ma y b e approached, then , in the sam e way tha t cognitive maladaptation s ar e in the treatment of depression . In th e treatmen t o f th e schizophreni c individual , i t i s importan t t o realize tha t th e patient' s effort s t o cop e ca n b e helpful i n recovery . I t is equally importan t fo r th e patien t t o acknowledg e this . A convictio n o f helplessness support s paranoi d o r delusiona l interpretation s o f event s and contribute s t o demoralization , whic h wil l surel y worse n th e cours e of the illness and preclude collaboration an d more effective adaptation . We d o no t intend t o outlin e her e a rationale fo r th e role o f cognitiv e therapy i n th e treatmen t o f acut e schizophrenia . B y thi s discussion , w e hope t o convinc e th e reade r o f th e validit y o f ou r assertion : tha t phy chological response s t o th e physiologica l disturbance s i n schizophreni a exist an d ar e important i n th e conceptualizatio n o f th e disorde r an d it s treatment. Th e social withdrawa l tha t appears in the acute prodrome o f schizophrenic decompensation i s a psychological, behavioral response t o "unseen" disturbances . Similarly , socia l withdrawa l i n chroni c schizo phrenia i s a n adaptatio n t o tha t stat e an d t o th e physiologica l an d psychological event s at work within the individual. Items II and III in Table 1. 2 (an d corresponding sections in Table 1.1 ) represent those areas of th e symptomatic presentation of chroni c schizophrenia wher e th e subtl e interactio n o f physiologica l disturbanc e (an d its sequelae ) an d psychologica l respons e i s mos t active . Certai n behav iors an d cognitiv e pattern s see m t o u s mor e clearl y adaptiv e (and/o r maladaptive) tha n others : Thes e ar e liste d i n sectio n II I o f Tabl e 1.1 . Behaviors suc h a s avolition , amotivation , an d apath y appea r t o hav e a strong physiologi c componen t an d perhap s a n undiscovere d organi c etiology. Bu t i t i s als o possibl e tha t the y ca n b e influence d throug h th e active effor t o f th e patient—that the y represen t psychologica l reaction s that can be altered. These latter behaviors are noted in section I of Tabl e 1.1 an d agai n i n sectio n IV , reflectin g ou r hig h inde x o f suspicio n regarding th e importan t rol e o f organi c factor s i n th e productio n o f these particular symptoms. Also i n sectio n I o f Tabl e 1.1 , w e not e tha t th e though t disorder , which i s quit e prevalent (thoug h no t uniform ) i n chroni c schizophreni c patients, has a primarily organic, or physiological, etiology . Researcher s (15-16) poin t ou t tha t thi s syndrom e i s mor e properl y considere d a disorder of speech production. Schizophrenic individuals are impaired in

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their capacit y t o organiz e speec h a s well a s in other aspect s o f linguisti c activity. I t seems, intuitively, tha t this disturbance is linked t o th e disorders in the mesolimbic pathways in schizophrenia, bu t this remains to be elucidated. On e important corollary of linguisti c research i n schizophre nia, however , i s tha t whil e speec h productio n i s ofte n quit e impaired , speech comprehensio n i s no t equivalentl y limited . Comprehensio n o f conversational speec h b y schizophreni c patient s i s no t infrequentl y un impaired, despit e th e presenc e o f a "though t disorder, " althoug h th e attribution o f meanin g t o wha t ha s bee n sai d i s frequentl y subjec t t o delusional distortion . Of particular importance wit h respec t to th e focus o f thi s book i s the material containe d i n sectio n II I of Tabl e 1. 1 (we will pas s ove r sectio n II, whic h i s self-explanatory ; thes e issue s hav e i n an y cas e previousl y been addressed). Here we outline the conceptual cor e of this book i n the assertion that certain aspects of schizophrenic symptomatology represen t "psychological" response s t o th e illnes s itsel f an d furthe r tha t thes e responses may be altered. We ter m thes e "psychological " reactions becaus e the y have identifia ble cognitiv e an d psychodynamic significanc e and , importantly, becaus e they ar e responsiv e t o interpersona l therapie s an d t o th e actio n o f th e patient's own psychological developmen t an d will. The mind, in a sense, demands thes e responses—whic h ca n b e bot h adaptiv e (b y decreasin g stress o r anxiety ) an d maladaptive—tha t satisf y interna l psychologica l priorities. These priorities, as we shal l endeavo r to illustrate, grow fro m the centra l experience s o f mistrust , inefficacy , desperatio n an d loss , whic h typify th e schizophrenic person's experience . With our, albeit rudimentary, knowledge of the cognitive and psychological disturbance s visite d upo n schizophreni c patients , w e ma y appre ciate how demanding and disappointing is their everyday life. In addition to disturbe d perceptions , suc h a s hallucinations , whic h ar e mos t ofte n frightening o r confusin g (althoug h man y patient s repor t gratifyin g an d reassuring hallucination s tha t themselve s pos e uniqu e challenge s t o th e clinician), thes e patient s frequentl y hav e idea s o r conviction s tha t ar e refuted o r labelle d a s "crazy " b y famil y an d others . Th e disheartenin g consequences o f suc h inevitabl e alienation , th e frustration s associate d with bein g unable t o convinc e other s o f one' s beliefs , i n additio n t o th e other disturbin g manifestation s o f th e illness , combin e t o undermin e

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self-esteem i n the schizophrenic individual an d serve to bolster maladaptive cognitive and behavioral responses . Because o f th e subtl e cognitiv e impairment s experience d b y mos t (i f not all) schizophrenic patients, as well as the fundamental disturbanc e in trust, interpersonal relation s are commonly fel t to be extremely stressful . The demand s tha t suc h interaction s plac e o n u s all—fo r vulnerability , empathy, reflection , an d spontaneity—challeng e o r threate n th e schizo phrenic individual' s existin g adaptiv e functions . The schizophreni c per sons's acces s t o learne d pattern s o f socia l copin g i s limite d b y th e pre frontal an d subcortica l deficit s delineate d previously . W e mus t ofte n carry o n a n effor t a t understandin g withou t th e patient' s activ e assis tance, for frequently th e patient is either uncertain as to the nature of his or he r difficult y i n relationship s o r mistrustfu l o f revealin g wha t h e o r she knows . I n interaction s wit h ou r patients , w e ma y observ e thei r responses t o socia l demand s an d wonder : Wha t doe s thi s encounte r evoke and require? How a m I being experienced ? We can describe behaviors that reflect this quandary and the patient's efforts t o cope with stress . Most apparen t is social withdrawal, a central feature of schizophrenia. This behavior may have complex origins, as we shall discus s a t later points i n our argument , bu t it can first be seen a s a simple maneuve r t o decreas e th e stres s associate d wit h socia l interac tions. Often , withdrawa l i s complicate d b y feeling s o f demoralizatio n and futility , b y resentmen t an d a wis h t o punis h other s throug h self negation, o r b y grandios e delusion s o f omnipotenc e an d control . Thes e latter represent , i n part , psychologica l reaction s t o th e illnes s tha t rein force th e stress-reducin g behavio r o f withdrawal . I f w e see k t o chang e this patter n becaus e o f it s deleteriou s consequence s t o self-estee m an d social functioning , w e mus t bea r in mind tha t thi s withdrawa l serve s a t least one important purpose. The patient's searc h for an explanation o f hi s state of min d confront s him wit h threatenin g questions . Fe w patient s ar e abl e t o acknowledg e they hav e symptom s tha t distor t thei r thinking . Tha t thes e patient s s o often manifes t denia l o f thei r conditio n ma y b e du e t o obscur e physio logical factor s tha t affec t judgemen t a s well a s cognition . I t is als o tru e that denial i s a ubiquitous an d predictable psychological respons e t o th e mental state s we hav e described. Therefore, i t is not remarkable tha t w e confront denia l i n attemptin g t o establis h a treatment allianc e wit h th e

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chronic schizophreni c individual . Whe n ou r patient s d o develo p th e capacity fo r acknowledgmen t o f thei r conditio n an d a commitmen t t o seeking an d acceptin g help , it is testimony t o thei r endurance an d courage. Fo r thos e no t ye t abl e t o mee t th e psychologica l demand s o f suc h acknowledgment, denia l serve s a s a barrie r (althoug h alway s a perme able one) to the intolerable. A closel y relate d phenomeno n i s on e w e hav e dubbe d "cognitiv e avoidance," by which w e mea n th e effor t t o obscur e o r frustrat e mean ing, to bloc k inquiry , to refus e t o take seriously th e significance o f one' s behaviors an d statements . Whil e mos t schizophreni c patient s demon strate som e degre e o f though t disorde r (whic h ma y b e roote d i n a physiological disturbance) , man y patients striv e to mak e themselves ob scure. Wha t w e refe r t o goe s beyon d straightforwar d denia l o r simpl e avoidance: I t represent s th e willingnes s o f som e patient s t o us e thei r communication difficultie s a s a screen, t o appea r mor e debilitate d tha n they are . The ai m may b e to avoi d th e stress of scrutin y o r the threat of change tha t understanding an d help migh t offer. Suc h patients ma y als o be obliquel y expressin g resentmen t abou t thei r conditio n an d uncon sciously actin g out self-punitive impulses . Like denial , persistenc e i n unrealisti c plan s ma y represen t a n uncon scious wis h no t t o acknowledg e th e disturbin g realitie s o f a situatio n marked b y dyscontrol an d shame. The intensit y o f thes e patients' assertions an d thei r durabilit y i n th e fac e o f logi c an d concer n ofte n inspir e frustration i n others . A degre e o f grandiosit y ofte n color s thi s persis tence, a s wel l a s th e fantas y tha t th e individua l ca n contro l events , people, o r hi s o r he r ow n psychoti c symptoms , a s i n th e followin g illustration: A young ma n wa s hospitalize d thre e time s within tw o year s o n an inpatient unit. Despite clear evidence of symptomatic recurrence on discontinuatio n o f hi s medication , h e insiste d tha t thi s tim e h e would b e abl e t o sto p hi s neurolepti c wit h impunity . Whe n chal lenged wit h th e bal d fact s o f hi s history , h e woul d triumphantl y assert tha t h e no w understoo d wh y h e ha d becom e ill . H e woul d then offer a s explanation a reminiscence abou t a n interaction wit h his family that he had allowed to get the better of him, occasionally invoke hi s marijuan a us e (eve n i f temporall y dissociated) , an d maintain tha t he coul d tel l th e differenc e betwee n "real " thought s

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and psychoti c ones , thu s ascribin g hi s readmissio n t o th e conse quences o f fatigue , misunderstanding , o r th e maliciousnes s o f hi s parents. H e state d once , whe n particularl y pressed , tha t h e coul d make himsel f hav e psychoti c thoughts , tha t thes e wer e entirel y voluntary, an d tha t the y coul d b e stoppe d a t will . I f h e ha d no t stopped the m i n th e past, i t was becaus e h e wa s angr y o r tire d o r sad. Delusions represen t a challengin g an d confusin g proble m i n th e as sessment o f schizophreni c symptomatology . The y ar e ubiquitous , frus trating t o clinicians , an d polymath i n thei r psychological functions . Thes e phenomena surel y hav e a basi s i n th e physiologica l disturbanc e tha t typifies thi s disorder, bu t they are also complex phenomen a tha t require cognitive elaboration , defense , an d suppor t wit h logi c an d rationaliza tion an d that, a s we have previously seen , can change. Delusions, i n our view, ar e an elaboration o f primary mental events , such as illusions an d misperceptions, int o a framewor k tha t rationalize s thes e event s t o th e schizophrenic individual . Becaus e thi s proces s o f elaboratio n implicate s the actio n o f unconsciou s psychologica l an d cognitiv e forces , th e delu sion als o inform s u s abou t th e individual' s subjectiv e experienc e o f hi s or her illness. The delusio n i s an effort a t creating coherence, a t defend ing the self from the disturbing implications of disordered mental events, and a depictio n o f th e inne r psychologica l stat e o f th e schizophreni c individual. In writing hi s luci d an d moving cas e history o f hi s patient, who m h e called Aimee , afte r th e heroin e o f th e patient' s tragi c novel , Jacque s Lacan said: Organic psychiatrists tend to regard a delusional system as the intellectual elaboration of organically-determined phenomena. Its structure, according to them , is of littl e importance . W e cannot accep t thi s formulation. We believe tha t th e primitiv e phenomen a discusse d abov e (oneiroi d state , incomplete perceptions , misinterpretations , illusion s o f memory ) canno t explain how a delusional system can become established or account for its particular organization. In our view the crucial factor lies in the personality o f th e subject , an d thi s allow s u s t o regar d th e developmen t o f th e psychosis as a process disorder. (42) In his argument , Laca n link s tw o assumption s tha t ar e relevan t t o ou r conceptualization o f delusions : first, tha t organi c psychiatrist s regar d delusions a s the elaboratio n o f organicall y determine d phenomena ; an d

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second, tha t those sam e psychiatrists vie w th e structure of th e delusion s as unimportant . W e agre e wit h th e ide a tha t delusion s ar e elaboration s of primar y phenomena ; bu t w e als o assert , alon g wit h Lacan , tha t th e structure of th e delusion i s relevant an d meaningful an d that it is unique in eac h patien t becaus e eac h schizophreni c patient' s personalit y i s unique . It i s the personality , th e unconsciou s menta l lif e togethe r wit h th e indi vidual's characteristi c cognitiv e patterns , tha t lend s specificit y t o th e delusional constructions . The delusion , lik e denia l o r grandiosity , ca n protec t th e individua l from stress , hel p hi m avoi d threatenin g experiences , an d fen d off , t o a degree, th e narcissisti c injur y associate d wit h th e illness . Thi s latte r function ma y hel p t o explai n wh y delusion s ar e persisten t eve n whe n patients ar e otherwise symptomaticall y improved . Relinquishin g th e delusion would occasion a crisis in the individual's self-perception. A s with any psychologica l defense , th e delusio n wil l no t chang e a s lon g a s a significant motiv e (e.g. , protection fro m narcissisti c injury ) remains . W e can se e fro m ou r biologica l mode l tha t delusions canno t b e expected t o respond t o neuroleptics . The primar y menta l event s (illusions , halluci nations, a mental stat e of suspiciousness , o r irritability, etc.) tha t underlie th e delusio n ma y b e decrease d i n frequenc y o r intensit y alon g wit h other mesolimbi c phenomena ; bu t th e delusio n represent s integrated , global cerebra l activity , whic h i s reinforce d i n memor y an d become s a deeply embedded component of the individual's self-view. We can "eradicate" delusions onl y by over-medicating ou r patients to the point where they canno t think ; o r w e ca n communicat e t o ou r patient s tha t i t i s unhealthy o r unacceptabl e t o hol d delusiona l views—an d ca n then b e assured that we will hear nothing further of them. Delusions ma y serv e othe r function s a s well , includin g (a s w e hav e noted) function s tha t actuall y suppor t mor e effectiv e functioning . Fo r example: A 29-year-ol d mal e schizophreni c wa s tol d b y hi s halfwa y hous e counsellor tha t i f h e continue d t o sta y i n be d rathe r tha n g o t o work, h e woul d hav e t o leave . Th e patien t the n develope d th e delusion tha t h e wa s bein g drugge d an d tha t h e neede d t o resist . To d o s o require d hi m t o "b e u p an d abou t an d productive. " Shortly thereafter, h e resumed working.

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These psychologica l response s mee t certai n needs , som e o f whic h w e have listed in Table 1.1 , section III. A.2. These psychological factor s are a windo w int o th e subjectiv e experienc e o f th e schizophreni c patient . Our abilit y t o understan d tha t experienc e wil l greatl y determin e th e success of our treatment alliance. Many o f thes e psychologica l goal s hav e bee n discusse d above : th e effort t o decrease stress, threat or anxiety, whethe r in the form o f socia l interactions; confrontation s wit h experience s tha t migh t caus e injur y to self-esteem; o r conflic t brough t abou t b y paranoi d interpretation s o f motives o r events. We also note some concepts that we will elaborat e in the next chapter: the need to stabilize one's sense of self; to experience a sense of separateness fro m others; to see oneself a s effective an d capable of controllin g oneself an d one's environment a s opposed to feeling helpless, controlle d (perhap s b y delusiona l forces) , an d ineffective; an d the need t o cop e wit h th e intens e experienc e o f variou s form s o f loss—o f abilities, of hopes, of a sense of continuity with a "past self," of relationships, jobs, and other social structures. In Tabl e 1.1 , we als o lis t (sectio n III.B ) thre e importan t pattern s o f behavior that might be described as syndromal since they are frequently observed t o b e characteristi c response s i n schizophreni c patient s (al though an y given patien t ma y demonstrate aspect s o f eac h o r som e o f these categories) . Thes e categorie s ar e useful i n helping u s organize our thinking abou t symptom s an d behavior s tha t ar e traditionall y see n a s disorganized, purposeless, maladaptive, or dysfunctional. We note , however , tha t thes e behaviors , whe n studie d closely , ca n often b e see n t o hav e importan t function s an d sometimes t o assis t th e patient in meeting social demands or support other useful adaptations . Our discussio n shoul d mak e clea r th e potential fo r the developmen t of frustratio n an d resentment i n schizophrenic patients . This ange r may be obvious, appearin g in the form o f an outright hostile stanc e (perhap s reinforced b y feelings o f mistrust, misperception, or misinterpretation of motive). Thi s hostilit y itsel f ma y direc t patient s towar d a mor e delu sional vie w o f sel f an d environment , i n tha t th e delusio n ma y offe r a means to avoid conscious acknowledgment of pain, disappointment, and loss an d may support unrealisti c feeling s o f powe r an d control, whic h are gratifying despit e their lack of substance. Anger directed at caregivers may spill over into attacks on others of whom patients are envious, who

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may b e see n a s th e author s o f thei r tormen t (throug h a delusio n o f persecution), o r whos e expectation s ma y b e threatening . Concurrentl y patients may act out a tragedy of self-denial an d self-punishment becaus e of unconscious anger and blame they direct at themselves. Their hostility may exacerbat e symptom s an d mos t assuredl y wil l preclud e effectiv e recovery. The connectio n betwee n unconsciou s ange r an d ange r directe d a t others ma y als o b e expresse d mor e subtl y i n patient s wh o ma y see m superficially complian t and placid, but who manifest their anger through private disregar d fo r th e hel p offere d them , throug h a kin d o f quie t rebellion o f conscience , i n whic h schizophreni c individual s se e them selves a s prisoners i n a corrupt world wher e the y must be careful no t t o reveal thei r sacre d disavowa l o f th e notio n tha t the y ar e ill . Words , intentions ma y b e attacke d i n secret , a s i n thi s cas e o f a schizophreni c young man: The patien t wa s well-like d o n th e ward , an d see n a s dutiful , eager to please, an d "devoted" to hi s therapist. I n one session , the patient complained tha t he had trouble remembering , o r taking in, what his therapist said . When aske d to describe what happened a s he listene d t o hi s therapist , h e spok e o f th e word s "no t gettin g through." Exploratio n b y th e therapis t yielde d th e patient' s ac knowledgment tha t h e like d th e session s fo r th e opportunit y t o talk himsel f an d hav e hi s therapis t listen ; bu t whe n th e therapis t spoke, the patient, although outwardl y pleasant and attentive, would silently thin k "bullshit , bullshit , . . . " an d repea t thi s a s lon g a s his therapist spoke. H e acknowledge d tha t his behavior was partly related t o longstandin g resentmen t abou t feelin g ignore d b y hi s parents, bu t tha t i t wa s largel y a consequenc e o f hi s fea r tha t hi s therapist might have contradictory thoughts or introduce ideas that would threate n hi s vie w o f himself . Tha t self-view , h e revealed , was tenuousl y constructe d o n th e optimisti c premis e tha t nothin g was wron g wit h hi m an d tha t th e disturbin g psychoti c episod e from which he had recently recovered was reall y misinterpreted b y his family an d the unit staff. Many patients , o f course , ar e les s resentfu l tha n this ; i f the y resis t help, the y d o s o i n less flagrant ways . On e commo n manifestatio n o f subtle resentmen t is an unrealistic view o f contro l over one's symptoms .

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Patients, commonl y i n discussing their medications, will asser t that they can prevent themselve s fro m becomin g "psychotic " if the y choose . Thi s statement i s supporte d b y thei r renderin g o f wha t recentl y occurre d o r had occurre d o n previou s occasion s whe n the y becam e dysfunctional . Patients usually describ e these episodes a s having been associated with a state of awareness : "I knew what was happening" or " I could see that I wasn't makin g sense. " Sometimes the y will imput e a psychological mo tive to their failure t o take control: " I was angr y at my parents," "I was depressed, I didn't fee l lik e doin g anything, " o r " I wanted t o ge t ou t o f where I was living." Many of these explanations seem implausible, if not frankly irrational . Sometimes , patient s wil l propos e idiosyncrati c o r bi zarre rationale s tha t ar e colored b y thei r delusiona l preoccupation s bu t that share the theme of lapsed control that can be reasserted. This unrealisti c vie w o f contro l i s damagin g i n severa l respects . I t is clearly motivate d b y the wish t o avoi d injur y to self-esteem , bu t it ofte n leads t o noncompliance . Further , i t i s a n unreasonable positio n tha t implicitly and unfairly assigns blame to the patient, blame for not having acted t o preven t th e psychoti c disruption . Patient s ma y b e willin g t o accept thi s assignmen t o f responsibilit y i n retur n fo r avoidin g th e ac knowledgment o f thei r impairmen t an d thei r limitation s i n managin g it. Clinician s ma y vie w thi s a s simpl y dysfunctiona l o r a s a n irritatin g obstacle t o th e treatment alliance . I t does also , however, consciousl y o r unconsciously, resonat e wit h th e emotiona l experienc e o f self-blaming , self-revulsion, an d despai r tha t suffuse s th e schizophreni c individual' s psyche. Thi s sham e i s a crucial aspec t o f patients ' distress, abou t whic h they hav e grea t difficult y talkin g an d which , further , the y d o no t allo w themselves to see. That phenomenon o f denial , a s well a s the closely associate d pattern s of delusiona l convictio n abou t oneself o r others, is yet another maladaptive psychological respons e t o th e illness experience , an d the nex t poin t in Tabl e 1.1 , sectio n III.B.2 . Ou r understandin g o f delusion s fuse s a physiological an d psychologica l perspective : Delusion s originat e i n dis turbed perception s an d represen t a psychologica l proces s tha t aim s a t organizing disordere d experiences , whil e simultaneousl y respondin g t o the emotiona l demand s o f th e psyche . Mos t particularly , delusion s ar e an effort t o arriv e a t an explanation o f experienc e tha t protects patient s from th e threa t pose d b y thei r feeling s o f loss , anger , an d self-blame . Denial, a s it is commonly manifeste d i n schizophrenic patients, may also

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have a physiological basis , bu t this i s as yet an unsubstantiated notion . Whatever the etiology of these phenomena, they are usually not resolved by medication s an d mus t b e respecte d a s redoubtabl e feature s o f th e patient's psychological constitution . This patter n o f defensiv e behavio r i s pervasiv e i n schizophreni c pa tients—and s o intens e i n man y tha t w e canno t fai l t o b e impresse d b y the severity of the threat to the self, agains t which these mechanisms are engaged. The resistance t o self-examinatio n no t only bedevil s th e clinician i n his or her efforts t o promot e a treatmen t alliance , bu t in effec t prescribes behavior s fo r th e patien t tha t lea d t o damagin g an d self defeating consequences , whic h ar e themselves ignore d o r denied . Con sider the following: A youn g ma n who had a several-year histor y o f recurren t psy chotic decompensations associate d with noncomplianc e (an d rapid recrudescence o f symptom s afte r medicatio n withdrawal ) insiste d that he was "fine" and planned to resume work a s a tennis professional afte r leavin g th e hospital. H e maintained tha t his symptoms were lie s fabricate d b y his family becaus e the y di d not approve of his lifestyle . A s a consequenc e o f hi s illness , exacerbate d b y hi s denial an d noncompliance, th e patient ha d not worked i n severa l years an d playe d tenni s irregularly . Althoug h i t wa s no t clea r whether wit h treatmen t h e could functio n i n this role , th e patient had clearl y damage d himsel f b y his persistent avoidanc e o f treat ment. Whe n ill , he could not , and would not , practice tennis . His physical conditio n an d his reflexe s ha d deteriorate d t o th e poin t where h e was not able t o play competitively . H e complained tha t medications impaire d his ability to play; but his denial and refusal of treatment had plainly racked his physical an d emotional health . Because this problem of defensiveness an d resistance to self-examinatio n is s o intimatel y associate d wit h th e wor k o f treatmen t allianc e forma tion, i t wil l b e a majo r focu s o f ou r discussio n ove r th e nex t severa l chapters. We com e no w t o th e thir d o f ou r maladaptiv e paradigms , tha t o f demoralization (se e Table 1.1 , sectio n III.B.3) . Muc h o f wha t w e hav e presented speak s t o thi s them e i n th e menta l lif e o f ou r patients. Th e trauma an d conflic t tha t inspir e discouragemen t o r despai r ar e readil y understandable. Bu t ther e ar e specifi c aspect s o f th e conditio n and ,

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unfortunately, o f man y treatment s tha t predispos e t o demoralization , and it is to these that we mus t direct our analysis. We must also look t o what w e kno w abou t demoralization , a s i t ha s bee n studie d an d de scribed in other settings. Fear communicatio n theor y (43—44) , whic h ha s recentl y bee n a n important componen t o f publi c health plannin g i n relation t o th e AID S epidemic, i s draw n fro m studie s o f som e populations' response s t o pre sentation o f vita l an d disturbin g healt h information . Researc h ha s bee n done o n th e mos t effectiv e method s o f educatin g th e publi c abou t th e dangers o f cigarett e smokin g o r othe r behavior s associate d wit h healt h risk. Th e conclusion s o f thes e investigation s hav e a commonsensica l character: The y stat e that , wit h regar d t o an y potentiall y dangerou s behavior, ther e i s a critica l amoun t o f informatio n tha t mus t b e pre sented i n order to promote chang e in at least a significant proportio n o f the population. Ther e i s also , however, a point a t which suc h a presentation, b y virtu e o f bein g to o intense , inflammatory , o r doom-ridden , becomes overwhelmin g an d actuall y discourage s change . If , i n th e process o f tellin g people abou t th e danger s o f smoking , you exaggerat e th e health consequences , even in the interest of healthfu l persuasion , peopl e are likely eithe r to ignore the argument (considerin g it shrill an d unrealistic) o r resig n themselve s t o smokin g i f the y conclud e tha t thei r bodie s are already irrevocabl y damaged . I f in warning people abou t th e ris k o f AIDS, yo u alar m the m s o muc h tha t the y fee l tha t the y an d everyon e else ar e doomed t o ge t the diseas e eventually, regardles s o f precautions , then thos e person s wil l no t tak e appropriat e measure s t o protec t thei r health. What i s essentia l fo r effectiv e participatio n i n a health progra m an d for collaboration wit h health professionals is , researchers say, an appropriate but not excessive degree of concern about oneself and a conviction that reasonabl e measure s tha t wil l protec t o r promot e healt h ar e pos sible. The individual mus t feel that it is within his or her power t o effec t change an d that the goals ar e comprehensible, attainable , an d desirable. Few o f u s woul d adher e t o a thoroughl y blan d an d colorles s diet , fo r instance, regardless of our concern about cholesterol an d fat. These issue s overla p anothe r are a of researc h concerne d wit h patien t attitudes tha t affec t recover y fro m illnes s a s wel l a s acceptanc e o f an d compliance wit h medica l treatments . Investigator s hav e note d tha t a n experience o f contro l i s crucia l t o recover y fro m illnes s an d a goo d

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predictor of complianc e (45-48) . On e study looked at people recoverin g from a hear t attack . Individual s wer e studie d i n th e IC U shortl y afte r admission an d rate d wit h respec t t o thei r attitude s abou t wha t ha d happened t o them . Predictably , patient s wh o denie d the y wer e a t al l seriously il l an d wh o lef t th e hospita l abruptl y o r di d no t retur n fo r follow-up ha d th e poores t outcome . The y coul d no t consciousl y accep t the ide a tha t the y wer e vulnerabl e an d ill , an d thei r health , no t simpl y their compliance , suffered . Surprisingly , patient s wh o frankl y admitte d they were ill, who frette d an d were cautious, afraid to stress themselves, reluctant t o push themselve s bac k int o life , als o di d poorly . The y wer e more compliant i n the sense that they passively submitte d to treatments . But the y wer e no t activ e collaborator s i n thei r treatment s an d pursue d an overl y conservativ e an d dependen t styl e o f adaptation . Thei r healt h suffered, too . Th e patient s wh o ha d th e bes t outcome , i n al l respects , were thos e wh o accepte d thei r vulnerability, admitte d the y wer e ill , bu t were convince d tha t the y woul d recover . The y wer e determine d t o be come healthy an d active again and saw that they could reasonabl y enac t changes i n thei r habit s an d lifestyle s tha t woul d produc e meaningfu l health benefits . Thes e patients, of course , were th e best collaborators i n treatment an d ha d wha t w e migh t cal l th e bes t treatmen t allianc e wit h their physicians. Theorists refe r t o thi s conviction (tha t one ha s a role to play i n one' s own recovery and that individual actions can result in significant change s that ca n b e describe d an d appea r attainable ) a s a n interna l locu s o f control. Rotter (49) developed a locus of control scale to study the extent to whic h individual s perceiv e th e event s followin g thei r behavio r a s resulting fro m thei r ow n effort s o r a s externall y controlled . Accordin g to Rotter , a belief i n a n internal locu s o f contro l mean s tha t th e perso n perceives a n event to b e "contingen t upo n hi s own behavio r o r his ow n relatively permanen t characteristics " (p . 1) . I n contrast , attributin g th e same event s to fat e o r malevolent other s would reflec t a n external locu s of control . The concep t ha s als o bee n studie d wit h regar d t o healt h habits an d i s easily applicabl e t o ou r population: Th e ide a tha t one ha s a rol e t o play i n one' s ow n recover y an d tha t individua l action s ca n result in significant chang e allows for the best treatment alliance. We see that patient s wit h a n interna l locu s o f contro l enjo y a bette r prognosi s and course o f illnes s than those who d o not. Indeed, individuals who d o not believ e the y ca n exer t meaningfu l contro l over thei r illnesse s ar e

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prone not only to poor compliance and poor prognoses, as in the cardiac studies, but to the emotional state s of depression and hopelessness. Schizophrenic individual s suffe r fro m a n illness tha t assaults th e very faculty throug h whic h we reaso n and perceive. The mind's active effort s are require d t o cop e wit h seriou s illness , a s w e hav e seen ; bu t i n th e schizophrenic patien t th e capacit y t o objectivel y regar d the illnes s a s an illness is impaired. What th e person experience s an d feels t o b e true has often alread y bee n distorte d b y th e illnes s proces s itself . Havin g a n internal locu s o f contro l i s dependen t o n th e individual' s abilit y t o circumscribe th e illness, to se e it as a part of him- or herself, bu t not the whole. I t is necessary t o objectify th e illness, to se e its limits an d effects , and to imagine oneself coping with, remediating, and surmounting them. Schizophrenia i s a condition that is limited in effect, thoug h that effect i s broad. Its particular quality, however, is that it involves an intimate part of th e experienc e o f th e self, tha t th e illness, in a sense, stand s betwee n the individual an d his or her perception o f self , o f others , an d indeed o f the illness process. Though ther e ar e aspect s o f menta l lif e untouche d b y th e illnes s experience, th e disruptio n i n functionin g lead s t o a n overwhelmin g de gree o f frustratio n an d t o a sens e o f havin g bee n severel y traumatized . The essentia l characte r o f th e schizophreni c condition , includin g it s chronicity, predispose s th e individua l t o a stat e o f demoralization . Th e adaptive eg o function s tha t migh t b e calle d int o servic e i n copin g wit h serious illnes s ar e confounded , thoug h no t eliminated , b y th e illnes s process. Withdrawal , tha t i s t o say , isolatio n an d alienation , an d th e associated phenomena of amotivation , apathy , and anhedonia ar e partly a manifestation o f this demoralized condition. Indeed, much of what has been describe d a s th e "negativ e sympto m syndrome " i s attributabl e t o demoralization an d it s sequelae . Schizophreni c individual s d o no t i n most case s posses s a n accurat e locu s o f contro l wit h respec t t o thei r illness (othe r tha n a delusiona l concep t o f control) . I n addition , thei r condition i s chronic , debilitating , an d associate d wit h frequen t disturb ing menta l events . Th e helplessnes s tha t schizophreni c patient s feel , consciously o r unconsciously , i s a s comprehensibl e a s i t i s clearl y dam aging to their capacity to manage the symptoms of the illness. We hav e note d tha t i n presentin g a treatmen t mode l an d pla n t o a patient, clinicians should emphasize the seriousness of the condition, but not presen t s o muc h informatio n an d i n such a way tha t w e contribut e

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to whateve r feelin g alread y exist s i n patient s tha t the y hav e n o rol e i n their recover y o r tha t meaningfu l chang e canno t occur . Yet , inadver tently, thi s i s precisel y wha t schizophreni c patient s experienc e i n man y treatment settings . Treatmen t plan s ar e presented wit h a n emphasi s o n illness an d debilit y an d often wit h abrup t confrontations , suc h as : "Don' t you se e tha t your thinkin g i s crazy—no on e agree s with you, " or "Yo u have a serious illness , a brain imbalanc e . . . " O n hearin g this , patient s are effectively , an d expectedly , overwhelmed , i f the y hav e no t bee n already—where d o yo u begi n buildin g a lif e i f yo u begi n wit h th e ide a that your brain is diseased? Preserved menta l functioning , talents , an d asset s ar e no t routinel y presented alon g wit h th e confrontation s abou t dysfunctio n o r debility . This i s a goo d reaso n fo r extensiv e evaluation , includin g personalit y and cognitiv e testing . Thos e asset s tha t ar e note d ar e no t typicall y linked to potential in relationships or work. Recover y is not emphasized. If we kne w tha t schizophreni c patient s coul d no t recover , w e shoul d o f course b e frank . Bu t i s ou r historica l vie w o f schizophrenia , o f th e "natural history " o f th e disorder , tantamoun t t o knowledge , o n whic h we can base a firm prognosis? Recen t work, suc h as the Vermont Longi tudinal Stud y b y Hardin g e t al . (21) , seriousl y challenge s th e assump tions of previous studies , which, for the most part, were carried on in an era prio r t o refinemen t i n diagnosti c an d researc h practice s an d befor e the intervention o f th e few availabl e moder n treatment s (pharmacologi c and rehabilitative). I t seems to us that sober realism tempered with hop e and support is the least our patients are due. The poin t o f thi s argumen t is , i n part , tha t th e caus e o f som e o f th e maladaptation i n chroni c schizophreni c patient s i s th e metho d throug h which thei r treatmen t an d its goals ar e presented. W e a s clinicians hav e contributed t o th e distorte d defensiv e posture s o f som e schizophreni c patients b y overwhelmin g the m i n ou r communication s o f ou r impres sions an d plan s an d b y failin g t o provid e th e patient s wit h a model fo r recovery tha t als o incorporate s th e ide a tha t the y coul d manag e o r control som e aspects of their illness. For man y reasons , patients d o no t fee l the y ar e being presented wit h treatment option s fo r whic h the y hav e responsibilit y an d over whic h they hav e som e contro l o r choice . Thi s i s obviousl y no t possibl e wit h dangerous patients , bu t man y schizophreni c individual s ar e treate d thi s way whethe r o r no t the y ar e seriousl y a threat t o themselve s o r others .

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Their desire s an d opinion s ar e mor e ofte n dismisse d o r criticize d tha n worked with , an d thei r rol e i n treatmen t i s viewe d b y bot h partie s a s largely passive—acceptin g prescribe d modalities . Becaus e o f thei r ten dency t o grandiosit y an d denial , patients ' comment s an d goals o r plan s may b e viewe d b y clinician s wit h exasperatio n an d see n a s bu t a treatment obstacle . I n consequence, a genuine treatmen t allianc e i s no t pos sible, an d potentiall y dysfunctiona l alliance s (passive , resentful , etc. ) more likely. Clinicians must learn how better to work with schizophreni c patients' difficult behavio r in order to develop collaboration . Importantly, schizophrenic individual s must be helped to understand , as far as they are able, how the illness affects perceptio n an d thinking as well a s what i t doe s no t affect . Tha t ther e i s preservation o f normativ e ego functioning shoul d be emphasized, so that patients can consider ho w to us e thei r mind s t o understan d themselves . The illnes s process ca n b e demystified: Hallucination s ca n b e viewe d a s a n "anxiety " o r "stress " response that can be met with various coping strategies, both psychological and pharmacological. Psychologica l maladaptatio n can be describe d and understood , an d strategie s develope d fo r alternativ e method s o f coping. Functiona l deficit s ca n b e approache d throug h model s o f adap tive social functioning . It i s vitall y importan t tha t psychologica l maladaptatio n no t b e con fused with the illness process. Yet this tendency is quite common. I n our view, this is a primary reason for the failure of man y treatment alliance s with schizophrenic patients. This conceptual erro r exaggerates the scop e of th e illness, contributes t o the patients' experience of dyscontrol , help lessness an d demoralization , an d preclude s th e developmen t o f mor e effective psychologica l adaptation . This issu e canno t b e more clear than i n our approach t o understand ing th e socia l an d emotiona l withdrawal , th e associate d anhedoni a an d disinterest, an d th e often-associate d denial , delusionality , an d idiosyn cratic relatedness , whic h ar e the hallmarks o f th e schizophreni c clinica l "syndrome." W e mus t unhesitatingl y pursu e psychologica l antecedent s to thes e various behaviors , se e meaning i n their for m an d function , an d assume tha t th e schizophreni c individua l ha s bot h som e awarenes s o f and some innate capacity to cope with them. That there are "biological" antecedents w e als o readil y acknowledge . I n turnin g ou r attentio n t o psychological factors , w e ar e placin g ou r trus t i n th e individual' s re sources o f min d an d spirit and seeking to draw what availabl e potentia l

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we ma y from ou r patient. Even in the fac e of suc h a serious disturbanc e in mental functioning , inheren t adaptive capacities may be identified an d supported. One specifi c psychologica l paradig m tha t contribute s greatl y t o th e experience o f defeat , futility , an d the self-abusive alienatio n fro m potential hel p i s tha t o f excessiv e self-reproach . W e hav e allude d t o thi s phenomenon earlie r in the chapter, but it is worthwhile t o underscore i t because of its prevalence and maladaptive potential. This state represents the consequenc e o f th e patient' s failur e t o satisf y th e expectation s tha t he o r sh e associate s wit h a n "idealize d self " and that ar e demanded b y his superego . The individua l experiences , predominantl y unconsciously , intense disapprova l o f him - o r herself . Som e patient s wil l repor t suc h feelings a s part o f thei r consciou s experience , represente d b y comment s such a s " I a m t o blam e fo r m y illness, " o r the y wil l identif y wit h frequently repeate d criticism s of thei r behavior by agreeing that they ar e simply lazy or arrogant. Patients themselves will often avoi d understanding wh y the y ma y appea r "lazy " or "arrogant " an d wil l no t reflec t o n their confusion , uncertainty , o r perceive d nee d t o defen d themselve s through haughtiness or derogation. They accep t a superficial assessmen t of characte r functioning , perhap s becaus e the y hav e difficult y compre hending psychologica l motivatio n or , mor e probably , becaus e thei r dy namic conflic t abou t self-acceptanc e i s playe d ou t i n thei r self-abusiv e willingness t o accep t a distorted characterization. Thi s unconscious self reproach can , o f course , b e expresse d i n mor e patentl y self-damagin g behaviors. Finally, i n Table 1.1 , sectio n IV , we not e thos e aspect s o f th e schizo phrenic syndrom e (alon g wit h other s w e hav e no t listed ) fo r whic h w e have n o clea r etiologica l formulation . Amotivatio n an d s o fort h hav e been associate d wit h demoralizatio n an d ma y stan d a s prototype s fo r behaviors tha t hav e mixe d etiolog y an d ar e a "final commo n pathway " of symptomati c expression . Other s ma y hav e mor e clearl y organi c o r psychological etiology . Thi s category , bu t a smal l par t o f wha t w e d o not understan d abou t schizophrenia , symbolize s th e necessity fo r a flexible and readily curious approach by the clinician. At the beginning of thi s chapter, we proposed t o outline a conceptua l model o f schizophreni a tha t i s clinically useful , rational , an d conduciv e to a soun d treatmen t alliance . W e hav e presente d a mode l tha t divide s

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schizophrenic phenomenolog y int o five principa l categories , whic h ca n be abstracted and reviewed with patients and their families: 1. Mesolimbic Disturbances ar e a manifestatio n o f abnorma l brai n function. I t is most importan t t o emphasiz e tha t the patient experience s the consequen t menta l event s a s real . The y constitut e distorte d percep tions (hallucinations , etc. ) o r menta l state s (e.g. , irritability , suspicious ness). Althoug h th e caus e i s som e disturbanc e i n neurologica l function ing, thes e problem s ca n b e worsene d b y stres s an d ca n b e likene d t o states of extreme anxiety . 2. Subcortical, Prefrontal Abnormalities ma y be hard to describe, but they ca n b e likene d t o learnin g disabilitie s (cognitiv e impairment s tha t limit the individual' s effectiveness) , whil e no t implyin g necessary los s o f intellect. Thes e ar e subtl e an d seriou s problems , and , becaus e o f ou r limited knowledge , the y ar e usuall y th e mos t difficul t t o treat . Patient s are no t consciou s o f thes e problem s an d merel y experienc e frustratio n and ineffectiveness abou t tasks. Families can be helped to empathize with this aspec t o f th e disorde r an d t o understan d ho w problem s her e ca n provoke worsening of other symptoms. 3. Secondary Physiological Disturbances, suc h as depression or iatrogenic Parkinsonism, can also be described and treatments recommended . Assessing treatment efficacy require s informed collaboration amon g clinical staff, patient , family , an d others in the patient's immediate environ ment. 4. Psychological Responses ar e crucia l t o a n understandin g o f th e patient an d ar e inherently par t of an y interpersonal modality , includin g family work . I t i s her e tha t empath y ca n b e especiall y facilitate d an d here as well that the treatment alliance is placed in context. 5. Symptoms of Uncertain Etiology represen t th e mas s o f wha t w e do not know about the disorder and provide a useful basi s for discussing the limitation s o f ou r treatment s bu t als o th e potential withi n th e indi vidual patient for meaningful recovery . This mode l i s comprehensible , althoug h th e amoun t o f informatio n is, fro m th e perspectiv e o f ou r patient s an d thei r families , unavoidabl y overwhelming. The advantage of thi s model, i n addition t o it s verisimilitude, i s it s clarity . Althoug h man y problem s an d complication s ar e addressed, implicitly, a t each step, there is a framework fo r understand ing how a problem ma y b e helped. The possibilit y o f improve d adapta -

62 Working with the Person with Schizophrenia tion, and , indeed , o f recover y o f usefu l functionin g i s rationall y sup ported. W e ca n reliabl y lin k thi s mode l o f schizophreni a t o a plan of treatment and to the maintenance of hope. The issue of the "negative symptom syndrome" has not been laid to rest by our discussion. Bu t we hope that we have enlivened the debate and suggested fresh investigative approaches. Most importantly the presentation t o this point should have provided the clinician with insights into th e illnes s process , th e psychologica l event s whic h develo p i n an effort t o cop e wit h tha t process , an d th e subjectiv e experienc e o f th e schizophrenic individual. It is this emphasis on the internal experience of the individual who is ill that is crucial to our method and will form the basis fo r furthe r discussio n o f th e techniqu e o f treatmen t allianc e for mation.

2 Understanding the Subjective Experience of the Person with Schizophrenia

Jtsychological response s reflec t a n individual' s uniqu e experienc e a s well a s th e skill s an d limitation s o f hi s o r he r innat e menta l capacities . These response s ar e product s o f a n orga n tha t operate s accordin g t o natural laws, depends on physiological functions , and organizes its activity with discernable and predictable patterns. When an individual, whether schizophrenic or not, meets a challenge, he or she utilizes past experience to deploy behavior s and make decisions. If that past experience doe s no t provide usefu l strategie s o r if , i n th e near-instantaneou s processin g o f memories an d imagine d options , debilitatin g association s impai r effec tive responses , th e perso n falters . Ou r accumulate d reflection s o n ou r efforts t o manag e ou r live s contribut e t o ou r self-image , whic h i n tur n helps o r hinder s ou r progress . Clearly , fo r schizophreni c individuals , there i s n o meaningful , othe r tha n conceptual , distinctio n betwee n bio logical an d psychologica l perspective s o f thei r experience , an d n o mor e important issue than that of their experience of themselve s in the world. The discussion i n this chapter is organized according to the outline i n Table 2.1 . Ou r inquir y int o th e schizophreni c individual' s subjectiv e experience (1—7 ) begin s wit h a them e tha t ha s bee n emphasize d i n th e last chapter: If patients an d clinicians ar e to establish a useful treatmen t alliance, i t is essentia l tha t clinician s see k a n understandin g o f patients ' views o f themselve s includin g ho w the y understan d thei r symptoms ; their "explanations " o f events , interna l an d external , whic h other s se e to b e th e produc t o f thei r illness ; an d thei r vie w o f others ' complicity , ignorance, o r othe r response s t o wha t ha s happene d t o them . Thi s i s done i n a spirit of empathy , wit h th e immediate goa l o f comprehendin g how patient s experienc e thei r treatment , s o tha t clinician s may , wher e reasonable, adap t thei r approac h t o th e patients . Usin g thi s outlin e t o 65

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Table 2. 1 The Subjectiv e Experienc e o f th e Schizophreni c Perso n I. Literal , Stated Understanding of: A. Symptom s B. Illnes s Process C. Rol e of Others in Relation to Illness D. Treatmen t Process II. Subjectiv e Experience: Themes A. Patient' s Interaction with the Environment 1. Attitude s toward relatedness 2. Manifes t communications B. Qualit y of Patient's Experience 1. Self-objec t differentiatio n 2. Sustainin g experiences 3. Psychologica l experience of continuity and clarity C. Concern s 1. Autonom y and control 2. Los s 3. Safet y III. Priorities , Flexibility, Demands A. Hierarch y of Priorities 1. Conflict s among priorities B. Flexibilit y and Limitations 1. Availabilit y to treatment, to requirements of environments, to change 2. Wha t patient can and can't do at this time C. Demand s Patient Makes on Environment 1. Ca n treatment setting and caregivers meet the patient's expectations, and with what consequences? 2. Feasibilit y of treatment alliance obtain informatio n tha t wil l simpl y b e presente d i n th e for m o f a con frontation, t o convince th e patients o f th e irrationality o f thei r views, o r to pressur e the m int o acknowledgmen t o f thei r illness i s a misuse o f th e concept o f treatment allianc e and will b e unproductive. Section I of Tabl e 2. 1 direct s th e clinicia n t o thes e primar y themes , which are , appropriately , th e focu s o f ou r initia l contact s wit h th e patient. Whil e reviewin g symptoms , performin g menta l statu s exams , and organizin g th e histor y o f th e patient' s illness , w e als o asses s th e patient's psychological respons e to the illness, both his understanding o f what is happening to him and his attempts to cope. How di d he construe the onse t o f auditor y hallucinations ? Ha s h e worke d ou t a mechanis m

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to explai n wh y h e hear s voices o r a rationale supportin g hi s convictio n that he is being persecuted? Has he found an y maneuvers to decrease his anxiety? Such questions will not only inform our approach to the patient but will inestimabl y promot e ou r rappor t wit h hi m b y showin g respec t for his views, even where those views conflict with ours. The impac t o f thi s inquir y o n th e ambienc e o f th e treatmen t canno t be overestimated . I n chapte r 4 , w e presen t a detaile d accoun t o f a n initial intervie w wit h a schizophreni c man , wher e th e clinician' s explo ration of the patient's subjective experience yields insights of evident and crucial importanc e t o hi s treatment . Th e patient' s vie w o f "wha t ha s happened" was bizarre, so it is not surprising that prior treatment effort s encountered poo r compliance . Mor e importantly , th e patient' s human ity, hi s struggl e wit h pai n an d isolation , ha d bee n obscure d b y th e disjunction betwee n th e competing perspective s o f hi s illness. The inter viewer's patience an d curiosity intrigue d th e patient an d fostered condi tional bu t significan t trust . A s a consequence , a riche r appreciatio n o f the patient's personality becam e possible. The rol e o f other s i n relatio n t o "illness " is a theme tha t remind s u s that in work with schizophreni c individuals: 1. N o on e is presumed innocent, and 2. Simpl e reassurance is not effective . Since mos t peopl e and , mos t importantly , famil y an d friends , find i t difficult t o endorse the schizophrenic person's views, daily life confront s her with contradiction an d disagreement. Th e patient must then explain, to herself, why other s dispute her ideas, why they do not help her in the way sh e wants, or why they insist on her taking medications when she is not persuade d o f th e medicine' s effectiveness . Thes e conflict s ar e com monly resolve d throug h delusiona l devices . N o famil y membe r no r cli nician o r othe r caregive r ca n b e assume d t o b e exclude d fro m involve ment i n delusiona l systems . Indeed , th e mor e importan t th e person' s approval, th e mor e likel y tha t his or her action s will b e incorporated i n the patient's delusional constructio n of experience . Reassurance, statement s assertin g one' s ignoranc e o f persecutor y plots , and s o fort h ca n b e o f littl e use , considerin g th e force s supportin g delusions. The patien t mus t arriv e a t a constructio n o f he r experienc e that protects he r from th e injury o f self-estee m associate d wit h thinkin g

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that sh e i s il l an d tha t satisfie s he r wish fo r contro l o r safety . T o th e extent that her delusional system fosters these ends, there is an intensity to these distorted perceptions that convinces the patient of their "truthfulness." Reassurance ma y be offered, a s in the following example , but must be linked to an awareness an d often a statement to the patient of our understanding of the incompleteness of this effort: A young schizophrenic woman told a staff membe r on an inpatient unit of he r concern that the CIA had planted minute microphones i n he r eyeglasses . Th e staf f member , i n a well-meanin g gesture, suggeste d tha t th e patient coul d g o t o a n eyeglass store , purchase ne w frames , an d watch the m pu t th e frame s together . The patient said she would think about doing just that. Later, the staff membe r was offended t o lear n that the patient had told her doctor that she suspected the staff membe r of having taken her glasses during the night in order to give them to the CIA so that the microphone could be installed. We can only speculat e a s to why th e staf f membe r was include d in the delusiona l syste m i n thi s way . Perhap s th e directnes s o f th e staf f member's suggestion reminde d the patient of ho w disturbingl y deviou s was her own experience of peopl e an d events. The patient ma y as well have been angry that the staff member , like her family an d her doctor, would no t offe r t o writ e t o th e CI A o n he r behalf , abou t whic h th e patient had repeatedly importuned her caregivers. That the staff member was offended, however, is an indication of that person's misunderstanding of the patient's subjective experience. The staff membe r might have added, afte r offerin g th e advic e abou t ne w eyeglas s frames , th e state ment: "But I understand that this suggestion may not be helpful t o you, for you ma y not trust my motives. I suppose you could com e up with reasons why my advice would not be helpful. I am sure others have given you such advice, but it has apparently not solved your problem. I n fact , th e onl y "solution " I can se e i s base d o n m y understanding that your belief is a symptom of the mistrust that is a resul t o f you r illness . Bu t I also kno w tha t w e disagre e abou t whether you are ill."3

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This respons e migh t no t hav e altere d th e patient' s receptio n o f th e staff member' s statement s o r preclude d th e staf f member' s inclusio n i n the patient' s delusion . I t would, however , hav e give n th e patien t paus e to reflec t o n pas t experienc e an d it s implication s fo r thi s an d othe r current relationships , an d i t woul d hav e len t consistenc y t o th e staf f member's interaction s wit h tha t patient . Furthermore , i n makin g thi s statement, th e staff membe r would hav e bee n protecting him - or herself from disappointmen t o r anger on hearing the patient's response . Under standing th e mode l o f th e patient' s psycholog y woul d allo w th e staf f member to understand the patient's distortions an d consider other interventions. This vignett e als o illustrate s ho w th e totalit y o f th e patient' s subjec tive experience, including but not limited to delusional interpretation s of events, affect s th e treatmen t process . Th e patien t describe d her e mani fested a patter n o f tireles s plea s t o caregiver s an d other s t o hel p he r uncover th e plot agains t her happiness an d her safety. I t was importan t for clinician s workin g wit h he r t o appreciat e th e significanc e o f thi s behavior, fo r i t mean t that , a t thi s time , he r participation i n treatmen t was alway s considere d i n ligh t o f he r conscious , ultimat e aim : th e un masking o f he r CI A persecutors . Sh e agree d t o treatments , sh e said , because b y bein g a "good " patient—tha t is , b y bein g complian t an d agreeable—she though t sh e might have a better chanc e o f obtainin g he r clinicians' support i n he r dogge d crusade . Althoug h w e imagin e he r unconscious motivatio n t o b e complex, he r avowed attitud e towar d her treatment informs our understanding of her responses to treatment interventions. Assessment o f thes e component s o f subjectiv e experienc e ca n an d should b e part of ou r initial evaluation of schizophreni c patients. Learning about the patient's perspective require s time and the development o f some trust , bu t thi s perspectiv e i s mor e readil y accessibl e tha n mos t clinicians assume . A n understandin g o f th e patient' s consciou s experience o f th e treatmen t process , i n particular , i s a crucia l step , an d a prelude to the evaluation of more complex psychological themes . In Table 2.1 , sectio n II , we lis t thre e furthe r aspect s o f th e patient' s subjective experience: (1 ) the patient's interaction with the environment , (2) qualities o f th e patient' s experience , an d (3 ) centra l concern s o f th e patient. Th e item s liste d beneat h thes e thre e heading s represen t aspect s of behavio r or of psychological functionin g tha t can serve as foci fo r our

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detailed inquir y int o th e patient' s subjectiv e experience . The y ar e indic ative o f clinica l theme s tha t recu r wit h regularit y in , an d ar e relativel y unique to , schizophreni c individuals . Sinc e the y ar e no t typicall y con sidered i n nosologi c o r descriptiv e account s o f schizophrenia , thes e as pects o f th e schizophreni c person' s experienc e ar e ofte n overlooke d o r poorly understood . The y shoul d not , however , b e interprete d a s a n exhaustive vie w of th e individual's psychologica l life .

PATIENTS' INTERACTIONS WITH THE ENVIRONMENT Like everyon e else , schizophreni c individual s mus t cop e wit h th e insis tent stresse s o f th e environment . Th e environmen t i s represented princi pally b y people , wit h who m the y d o o r d o no t wis h t o interact , a s wel l as b y th e physica l environment , mad e u p o f objects , spaces , an d events . It i s importan t t o b e ope n an d flexibl e i n observin g ho w schizophreni c individuals experienc e tha t environmen t an d ho w the y adap t t o it . W e will b e interested i n ho w patient s respon d t o people an d wha t behavior s are associate d wit h socialization . In som e patients , i t ma y b e equall y important t o observ e ho w the y relat e t o pet s o r othe r animat e o r inani mate objects tha t ma y b e psychologically significant . W e suggest that th e clinician pa y particula r attentio n t o tw o areas : (1 ) attitude s towar d relatedness an d (2 ) the manifest communication s o f th e patient. W e wil l discuss these a t length below . Attitudes Towar d Relatednes s By relatedness , w e refe r t o th e man y an d ofte n peculia r way s i n whic h schizophrenic individual s thin k abou t an d relat e t o thei r environment . Relatedness take s o n a variet y o f form s an d i s evidentl y influence d b y abnormal perceptions , affects , an d delusiona l ideation . Th e schizo phrenic person ma y treat people with who m h e has contact a s if they ar e impostors, agent s o f som e hostil e force , wh o ma y pos e danger s t o him . Or, he may trea t people a s if they have no uniqu e characteristic s an d ar e robots programme d b y som e centra l forc e wit h whic h h e doe s battle . Less pathologica l example s includ e experiencin g peopl e a s unvaryingl y critical o f hi s aspirations, suc h a s his wish t o be a professional athlet e o r a religiou s advocate . Suc h a patien t migh t complai n tha t al l doctor s o r

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mental healt h professional s ar e united i n a n effor t t o obstruc t him . H e might believ e tha t h e ha s receive d a direct messag e fro m Go d i n whic h he ha s understoo d th e meanin g o f existenc e an d bee n tol d h e mus t convert others . Anyon e disagreein g wit h hi s poin t o f view , especiall y those who try to tell him he has an illness, are seen as unbelievers whos e efforts represen t th e temptation s o f th e devil . Sinc e thei r ai m i s t o distract him from his God-given task, they must be resisted. The manne r i n which a patient pursues relationships an d his attitud e toward the m i s clearl y a reflection o f hi s subjectiv e experience . W e ca n learn about his psychological lif e b y observing, an d inquiring about , th e behavioral pattern s associated with relatedness . These have a significan t impact o n th e way s i n whic h h e interact s wit h peopl e i n treatmen t situations a s wel l a s i n everyda y contacts . The patien t wh o believe s himself a prophet may have difficulty wit h informal interaction s becaus e his religious convictions intrude. Consequently, he may find people want to avoi d him because they find interactions with him uncomfortable an d unrewarding, which results, in turn, in the patient's isolation . Schizophrenic individual s ma y desir e mor e interaction s bu t b e dis suaded b y psychologica l consequences . Fo r example , th e patien t wh o believes he is a prophet ma y derive comfort fro m socia l interaction s bu t deny himsel f pleasur e becaus e o f th e perceive d primac y o f hi s spiritua l responsibilities. This fervo r ma y b e dictated b y unconscious psychologi cal priorities. To others he will appea r dogmatic, intrusive, and opinionated. To himself, h e says he is fulfilling hi s mission; should he be scorned in his view, he will accept this as suffering i n service of th e Lord. There ar e man y schizophreni c patient s whos e wis h fo r relatednes s i s difficult t o discer n sinc e i t i s satisfie d throug h subde , idiosyncrati c means . Consider th e regresse d patient , who , becaus e h e refuse s t o bathe , i s assigned a staf f membe r t o assis t hi m wit h hi s persona l hygiene . Suc h behavior ma y b e see n a s a consequenc e o f sever e cognitiv e disturbanc e or apathy an d avolition . The patient may , however , b e capabl e o f thes e tasks but avoid them for secondary gain. Interacting with a staff membe r in this limite d manne r ma y provide th e patient wit h th e onl y saf e inter personal contact he can tolerate. In that sense, not bathing is his medium of negotiatin g contac t wit h th e world . A t th e sam e time , poo r hygien e generally assure s tha t mos t peopl e wil l kee p thei r distance , whic h ma y satisfy th e patient's need to regulate stressful interactions . Such consideration s mus t b e entertaine d i n assessin g th e behavio r o f

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any schizophrenic individual les t we write off som e patients, erroneousl y assuming tha t the y ar e utterl y indifferen t t o huma n contact . Further more, imaginin g tha t th e huma n nee d fo r intimac y reside s i n eve n th e most withdraw n patient s allow s fo r potentiall y creativ e an d rewardin g treatment intervention s wit h person s wh o migh t otherwis e see m hope less an d unengageable . Suc h effort s increas e th e possibilit y o f empathy . They ar e equall y importan t wit h patient s whos e leve l o f disturbanc e i s less severe but who may have significant difficult y i n social functioning . Clarifying th e patient' s patter n o f relatin g t o a significan t figure (o r figures) in his life is often critica l in developing an understanding of wha t priorities h e hold s an d wha t typifie s hi s psychologica l life . W e wil l illustrate this point by briefly describing some aspects of a psychotherapy that on e o f th e author s undertoo k wit h a severel y disturbe d youn g schizophrenic man , focusin g particularl y o n hi s relationshi p wit h hi s father. Sergio, a 19-year-ol d Italia n male , ha d bee n summone d t o th e United State s b y hi s father , wh o ha d emigrate d th e previou s year . The understandin g withi n th e famil y wa s tha t th e fathe r woul d establish himsel f i n Boston an d then woul d sen d fo r his son. Thei r combined income s woul d b e use d t o bu y passag e fo r th e youn g man's mother and sister, who remaine d in Italy. After severa l month s o f workin g lon g hour s i n a pizz a parlo r and livin g a n extremel y fruga l existence , th e so n discovere d tha t his fathe r wa s spendin g thei r savings o n a girlfriend. I t was a t this point tha t th e so n bega n hearin g th e devil' s voice , an d h e wa s admitted t o th e hospita l wher e h e staye d fo r fou r months . Th e father describe d hi s so n a s havin g bee n quit e clos e t o hi s mothe r and, apar t fro m her , h e ha d no t socialize d muc h whil e livin g i n Italy. The father also felt that, as a child, the patient had been afraid of him. Shortly afte r admissio n t o the hospital, th e patient cut his wrist, dripping hi s bloo d o n Time magazine' s cove r o f th e just-slai n President Kennedy . Thoug h th e patien t a t tha t tim e spok e littl e English, he was heard to mutter over and over, "My father. Dead." He believe d tha t h e wa s th e so n o f th e slai n president , tha t th e devil wa s responsibl e fo r th e assassination , an d tha t Le e Oswal d was a disguis e th e devi l ha d used . I n late r versions , Oswal d wa s

Understanding the Subjective Experience 7 3 described as one of two human forms the devil took, the patient's biological father being the other. During hi s firs t tw o year s o f treatment , th e patien t furiousl y insisted that the assassinatio n ha d made him an orphan an d that he wished to dedicate his life to the pursuit of his father's murderer. Frequently durin g thes e tirades , th e voic e o f th e devi l (wh o wa s described in a way that suggested his father) woul d become more and more intense and threaten him. In the third year, Sergio began to discus s hi s sens e o f sorro w a t bein g orphane d and , concomi tantly, h e graduall y gav e u p hi s wis h t o aveng e hi s "father's " death. On several occasions, he indicated displeasure at JFK's having left him and once announced that being a President's son had its limitations. After months of mourning, he no longer heard the devil's voice and , for th e first time, acknowledged th e identity of his biologica l fathe r an d his disappointmen t wit h him . Unti l thi s point, th e patien t ha d refuse d t o mee t wit h hi s father , initiall y voicing fear of being in a room with the devil and later falling into sullen silence whenever the issue of his father's visiting was raised. Now he expressed a wish to see his father. The patient spoke with him about his disappointment an d how furiou s h e was with him for having misused their funds. On several occasions during these discussions wit h hi s father , th e patient experience d th e retur n of his belief that he was JFK's son and that the man he was addressing was not his father but rather his father's murderer, Lee Oswald. At such time s th e famil y sessio n woul d en d an d th e patien t woul d then revie w th e experienc e wit h hi s therapist. Gradually , h e was able t o confron t hi s fathe r withou t feelin g h e wa s turnin g int o someone else. When this occurred, he announced to his therapist, "I'm not an orphan after all. I do have a father. But now, when I have nice thoughts toward him, I think of m y mother, get angry, and worry about the devil's voice returning." The patient's relationship with his father included his actual relationship with his biological father, consisting of experience and expectation; his delusiona l image s o f hi s father , constitute d fro m distorte d an d intense perceptions, organized into a bizarre but meaningful framework ; and his adaptation to these perceptions in both interpersonal and intrapsychic terms. Sergio's relationship to his father, or, more accurately, his

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various relationship s wit h hi s father , ca n b e groupe d int o thre e phases . During th e first tw o years , th e patien t angril y declare d himsel f t o b e fatherless, centered his life on avenging his "father's" death, and personified hi s biologica l fathe r a s th e devil . Clearly , b y bot h aggressivel y denying hi s father' s actua l identit y an d representin g hi m a s evi l incar nate, Sergio was, in a psychological sense , indicating his intense involve ment wit h hi s father . The qualit y o f hi s "actual " relationshi p wa s poo r in tha t i t wa s totall y denied . H e provide d himsel f wit h a n idealized , though slain , fathe r substitut e (JFK) , whil e maintainin g a n angr y an d fearful representatio n o f hi s fathe r a s th e devil . Sergi o converte d hi s helplessness int o actio n b y vowin g t o aveng e hi s father' s deat h and , i n this way, retaine d a n intense, hostile involvemen t wit h hi s actual father . Note tha t he retained a n appreciation o f his biological father' s authorit y over hi m b y makin g hi m a figure of tremendou s power , th e devil . The patient wa s tryin g t o maintai n interna l homeostasi s b y concealing fro m himself hi s rage toward hi s own fathe r an d providing himself th e bittersweet comfor t o f havin g bee n fathere d b y a goo d an d powerful , albei t slain, individual . Hi s delusio n allowe d hi m t o organiz e hi s existenc e around a specific task : avengin g hi s murdere d father . The delusio n als o allowed Sergi o a n explanatio n fo r event s tha t wer e frightenin g an d frustratingly uncontrollable , thu s insulatin g hi m fro m th e sadnes s an d helplessness that he later experienced and expressed through his mourning. When, durin g hi s thir d yea r o f treatment , Sergi o acknowledge d th e "loss" of hi s fantasized , idealize d father , h e too k th e essentia l first ste p toward facing his tangled relationship with this actual father. Decreasin g his aggressiv e stanc e towar d th e assassi n wa s a further indicatio n o f hi s wish fo r rapprochement . It' s a s i f h e wer e saying , "There' s mor e tha t I need for myself tha n the cold comfort o f retaliation. " This change in the character of his relationship t o his father (bot h th e delusional image and the real) paralleled his acknowledgement o f loss in relation to the illness that had damaged him. The delusional fathe r (JFK) was constructe d t o explai n th e distorted event s h e bega n t o experience ; we have described this process as an unconscious psychological respons e to th e overwhelmin g conditio n o f psychosis . The fantas y o f th e delu sional fathe r a t the sam e tim e containe d th e conflicte d an d als o uncon scious elements of his relationship with his real father. As Sergio became less mistrustful , a s hi s illnes s lessene d i n severity , th e psychologica l requirement fo r th e delusio n als o lessened . H e the n began , eve n uncon -

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sciously, to confront the evidence of his illness, of what had happened t o him, i n hi s everyda y life . H e mourne d no t onl y th e los s o f a n idealize d father bu t unconsciousl y als o th e los s o f a n idealize d self . H e then ha d to cope with the realities of his limitations. This youn g man' s progress throug h hi s illnes s illustrate s severa l points . In reality, hi s mourning , hi s improvemen t i n communicatio n an d relat edness, an d th e chang e i n hi s delusion s parallele d no t onl y gradua l improvement i n hi s illnes s bu t hi s increase d capacit y fo r trus t i n hi s therapist. Th e therapist' s capacit y t o explor e an d understan d Sergio' s experience o f hi s father was crucia l t o thes e changes. Equally importan t was th e therapist' s determinatio n t o lear n wh y Sergi o ha d forme d thi s particular delusion. As Sergio's acut e psychotic disturbanc e improved , s o di d his capacit y for socia l interaction . H e coul d tak e mor e risk s an d trus t mor e safely . He develope d a n increased tolerance fo r vulnerability, whic h mad e possible his touching expressions o f sadness . That tolerance o f vulnerabilit y was composed o f lessened anxiety and mistrust, a reduction in psychotic stimuli, an d th e experience s derive d from hi s relationship wit h hi s ther apist. The delusiona l relationshi p t o JF K wa s no t th e onl y idiosyncrati c relationship observe d durin g tha t treatment . The therapeuti c relation ship itself was "idiosyncratic" in that the therapist explored the delusion and di d no t attemp t t o argu e i t awa y o r discourag e th e patien t fro m discussing it . I n fact , the y spen t a grea t dea l o f tim e talkin g abou t Sergio's delusion . I f th e therapis t attempte d t o discus s matter s mor e psychologically familia r (suc h a s t o broac h th e matte r o f hi s illnes s o r hospitalization), th e patien t woul d becom e silent . Hi s delusio n wa s th e medium fo r contact , th e wa y i n whic h Sergi o coul d tolerat e lookin g a t and talkin g abou t hi s experience . A s Sergio' s psychologica l necessitie s and prioritie s changed , h e mor e directl y elaborate d th e theme s tha t th e therapist ha d understoo d (fro m hi s assessmen t o f th e natur e o f th e delusion and of Sergio' s relatedness) t o have always been present. We se e her e severa l crucia l aspect s o f relatedness : (1 ) th e patient' s predisposition t o imbu e object s wit h bizarr e interpretation s o f identit y or motives ; (2 ) hi s tendenc y t o avoi d an y consideratio n o f particula r qualities o f th e objec t (eve n misperceptions ) i n favo r o f categorizin g objects accordin g t o predetermined , interna l standards ; (3 ) th e observ er's difficult y i n discernin g th e patient' s ofte n intens e interes t i n th e

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object becaus e o f th e subtle o r unusual way s i n which h e manifested hi s interests; an d (4 ) th e importanc e o f understandin g pas t attachment s i n order to make sense of curren t relationships. Whenever th e clinician become s awar e o f a pattern o f relatedness , h e needs t o asses s th e patient' s flexibility fo r considerin g othe r base s fo r interaction. The clinicia n test s thi s b y invitin g th e patien t t o conside r alternatives t o th e positio n h e currentl y holds . Conside r a patien t wh o related tha t al l of hi s forme r doctor s wer e par t of a conspiracy wit h hi s mother. Accordingly , h e refuse d t o "incriminate " himsel f wit h hi s ne w doctor an d avoide d discussio n o f hi s past . Nevertheless , h e an d hi s therapist had lively discussions abou t baseball an d found they supporte d the sam e team . Thei r interaction s wer e war m an d friendl y unti l th e therapist brough t u p a ' 'psychiatric" issue , whereupo n th e patien t be came cooll y hostile . Simila r patterns wer e eviden t wit h othe r clinicians . The therapis t pose d th e followin g questions : I s the patien t abl e t o con sider that his caregivers migh t not b e in league with his mother? I s there anything i n hi s ow n experienc e o f th e therapis t o r other s tha t run s counter t o his belief? What of th e intimacy h e has shared with them , a n intimacy that seems to belie the adversarial position ? The patient' s response s wil l tel l u s ho w rigidl y an d sterotypicall y h e views hi s relationship s an d ho w readil y h e ma y conside r a particula r individual differen t fro m others. This consideration is important becaus e the patient' s willingnes s t o suspen d hi s prejudices , howeve r transiently , is ofte n th e firs t ste p towar d a positio n o f trust . The patien t ca n b e helped i n thi s proces s b y th e clinician' s indicatin g t o th e patien t thos e instances whe n hi s action s sugges t h e i s no t full y committe d t o hi s position o f mistrust . However , man y patients are not availabl e t o reflec tive discussion s o f thi s sort , i n particula r thos e wh o ar e to o threatene d by bein g mad e awar e o f thei r difficulties . Suc h wa s th e cas e i n th e experience of a woman describe d below : A woman i n her mid-thirties , wh o wa s a n inpatient wit h a tenyear histor y o f progressivel y worsenin g schizophreni c symptoms , angrily deride d staf f an d othe r patient s i n grou p an d communit y meetings. She vehemently accused others of "actin g stupid," saying "I don' t lik e i t on e bit. " Althoug h a colleg e graduate , th e patien t maintained that "a high school educatio n i s enough."

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As a consequence o f he r illness, the patient manifeste d a sever e thought disorder . Sh e was , i n addition , quit e delusional . Related ness, a s wel l a s th e performanc e o f mor e organize d socia l an d occupational tasks , wa s greatl y disturbed . Tha t other s wer e "act ing stupid" was th e patient's explanatio n fo r why other s appeare d not t o b e abl e t o understan d her . A hig h schoo l educatio n wa s "enough" becaus e sh e ha d los t a grea t dea l o f he r intellectua l ability—though sh e remembere d disparat e facts , muse d abou t mathematics an d ciphers , an d ha d a goo d (thoug h seldo m seen ) sense of humor . When aske d abou t her goals in life, sh e affected a disinterested pose : "Wh o need s work ? I' m fine ; I don't nee d any thing else." The patien t displaye d a unique , thoug h constricted , for m o f relatedness. A few staf f member s were allowe d t o spen d time wit h her, th e interaction s consistin g principall y o f he r digression s o n idiosyncratic philosophica l themes , which , thoug h disorganized , consistently spelle d ou t he r cynical , isolate d vie w o f th e world' s incompetence, deceit , an d needles s pursui t o f knowledg e an d achievement. She treated the staff member s as if they were students at her lecture . He r relianc e o n thes e interaction s wa s indicate d b y her predictabl e irritabilit y an d withdrawa l whe n thos e "trusted " staff member s were not available. Such patients pose striking challenges for caregivers. But the discovery of thi s woman' s uniqu e demand s fo r relatednes s an d the staff' s adapta tion t o the m allowe d he r t o b e mor e involve d i n th e uni t community . These didacti c interaction s migh t b e promote d i n orde r t o increas e th e patient's toleranc e fo r socia l interactions . Eventually , effort s migh t b e made t o direc t th e patient' s attentio n t o usefu l activities , lik e ridin g public transportation , whil e engagin g he r b y acceptin g he r nee d t o b e instructional an d arrogant. The vignette s presente d her e illustrat e th e principl e tha t pattern s o f relatedness an d attitude s abou t interaction s wit h th e environmen t in form clinician s abou t th e schizophrenic individual' s psychologica l expe rience. Thi s information , i n turn , help s u s t o understan d th e patient' s limitations an d potential an d can often sugges t strategie s fo r planning a treatment. Mos t often , understandin g thes e issue s wil l hel p clinician s

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appreciate ho w difficul t i t is fo r th e schizophreni c individua l t o tolerat e change, challenge , o r self-awareness an d will dictat e a patient approac h to the fashioning o f treatmen t interventions.

Manifest Communicatio n When evaluating schizophrenic patients, we continually com e up against their ambivalenc e abou t receivin g help , thei r defensiveness , thei r ofte n arcane perspective , an d thei r disturbed communication . I t behooves th e clinician t o carefull y conside r al l o f th e patient' s behavio r an d othe r communications wit h regar d t o it s potential contributio n t o ou r insight about his or her psychological state . All that the patient says or does can be seen a s a manifestation, o r a manifest communication , o f psychologi cal needs. In this way, appreciation of the meaning of obscure or severely disturbed behavior s ca n yiel d a fulle r understandin g o f th e patient' s subjective experience . Clinicians ordinaril y find littl e difficult y i n inferrin g th e significanc e of familia r behaviors , such as friendly invitation s to caregivers, cooperation i n treatmen t plans , o r helpfulness . W e use d th e ter m "manifest, " however, rathe r tha n "apparent " o r "outward, " t o underscor e ou r ex perience i n assessin g th e comple x intention s o f schizophreni c individu als' actions. That communications ar e manifest doe s mean that they ca n be appreciate d b y an observer ; i t means tha t speculatio n abou t motive s or psychological principle s require s inferenc e fro m thi s data. Th e us e o f the ter m "manifes t communications " shoul d furthe r aler t th e clinicia n to th e differenc e betwee n a behavior' s apparen t purpos e an d wha t i t actually accomplishe s o r indicates . Thi s distinctio n i s critica l i n wor k with schizophrenic persons because of the complexity of their psychological response s t o th e illness , in particular, a s well a s the critical effec t o f the illnes s o n communicatio n an d behavior . Curiosit y an d suspicio n o f easy formulation s ar e th e greates t aid s t o clinician s involve d i n thi s aspect of evaluation . The followin g vignett e illustrate s ho w certai n behavior s ca n hav e other than apparent significance : A schizophrenic man in his late thirties had been ill for all of hi s adult life . H e had difficult y bein g wit h othe r people, ofte n becom ing anxious and coughing, sometimes so hard that he would vomit .

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His functiona l abilitie s wer e quit e limited . Prio r t o hi s admissio n to the hospital, he had lived at home, inactive, for three years. During hi s first wee k o n th e unit , th e patien t wa s withdraw n and confused. Late r he participated in meetings and attended som e basic activities , thoug h h e remaine d isolate d an d demonstrate d limited capacitie s fo r independen t functioning . Hi s manne r wa s always deferential . H e sometime s coyl y pleade d wit h th e nursin g staff t o giv e him more cigarette s (the y had bee n restricted becaus e he otherwis e smoke d thre e o r fou r pack s a day ) bu t wa s neve r disagreeable. H e seeme d wounded , friendless , bu t approachable . The staf f though t o f hi m fondly , despit e hi s poo r hygien e an d severe thinkin g disturbance , an d som e fel t h e ha d becom e a uni t "mascot." I n a staf f meeting , th e uni t chie f pointe d ou t tha t thi s 35-year-old ma n wa s bein g treate d lik e a child . H e raise d th e question o f whether , behin d thei r "kindness, " th e staf f wa s ex pressing their anger at him by refusing to acknowledge an y level of mature development . In a family session, the patient became agitated when his mother was effusivel y complimentar y abou t hi s havin g ha d a haircut. H e mumbled t o himsel f an d turne d awa y fro m her . Whe n th e socia l worker—therapist inquire d abou t hi s reaction , h e bitterl y com plained: "Th e staf f won' t le t me have my cigarettes ; they trea t m e like a child , lik e I' m stupi d o r somethin g . . . the y smil e a t m e because they'r e makin g fu n o f me , an d I have to smil e bac k t o ge t more cigarettes." The patient' s complaint s abou t th e staf f wer e i n part a displacemen t of hi s ange r a t hi s mother' s patronizin g attitude. H e doubtlessl y fel t some warmt h fro m an d fo r th e staff , bu t hi s concomitan t resentmen t could no t hav e bee n discerne d fro m hi s statement s an d gesture s o n th e unit. Hi s behavio r ha d bee n apparentl y cooperative . Bu t th e manifes t communication o f hi s behavio r coul d hav e bee n see n t o hav e been , i n fact, more complicated an d painful. Although delusiona l an d seriousl y disturbed , h e wa s no t demented . He observe d hi s environmen t an d hi s plac e i n i t an d kne w tha t h e wa s different, tha t h e di d no t hav e th e responsibilit y an d independenc e o f most me n hi s age . Bu t thoug h h e migh t se e tha t hi s behavio r wa s self debasing, h e acte d thu s a s a consequenc e o f complicate d needs . Hi s

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cigarettes helped, he felt , t o decreas e hi s constant , disablin g anxiety . H e was no t abl e t o si t and convers e wit h others , s o th e manipulativ e inter actions around his cigarette smoking provided some of th e few opportu nities h e ha d t o engag e people , t o hav e the m smil e wit h hi m fo r an y reason. Hi s behavio r mad e him appea r pitiable, reducin g others ' expectations o f him , their expectations, an d his own, makin g him fee l threat ened (lik e the patient who said "a high school educatio n is enough"). The patient' s interactiv e pattern s wer e reinforce d b y his achievemen t of a kind of homeostasis, although at a cost of which he was periodicall y aware. The manifes t communicatio n o f hi s behavio r was : " I a m dis abled; expec t littl e o f me , bu t sta y involved : don' t deser t me , bu t don' t make me look a t what hurts me about myself." His apparentl y coopera tive, playful attitud e communicated , i n fact, a great deal more , once th e observer looke d closely . The ke y to understandin g hi s behavio r was th e patient's lac k o f contentmen t despit e occasiona l display s o f amiability . To understan d th e patient' s experience , w e mus t loo k a t behavior s i n situ, not isolate them. This assessmen t provide s u s wit h a n appreciatio n o f thi s man' s poi gnant inne r life . Hi s subjectiv e experienc e i s no w mor e readil y imagin able: hi s isolation , disappointment , self-blame , an d self-revulsion , a s well a s hi s nee d fo r people . Ou r analysi s suggest s a simpl e schem a fo r evaluating th e component s o f thes e behavior s tha t communicat e t o u s the schizophrenic individual's subjective experience : 1. Physiologica l factors , fo r example , primar y state s o f anxiety , aggres sion, o r stress , lea d t o secondar y compensator y behaviors . Often , especially i f th e adaptatio n i s effective , onl y th e latte r wil l b e ap parent. 2. The patient' s relationshi p t o th e environment , hi s o r he r nee d fo r human contact or wish to avoid it, fashions the behaviors we observ e as manifest communication s o f hi s or her subjective experience . 3. Intrapsychi c concerns , directl y o r indirectly relate d to self-imag e an d self-esteem, suc h a s th e wis h t o decreas e others ' expectations , als o have an impact on the behaviors clinicians must evaluate. These thre e rudimentar y distinction s ca n provid e clinician s wit h a basis fo r organizing their evaluation o f thes e behaviors. The significanc e of a give n "communication " ca n generall y b e understoo d withi n th e

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framework o f on e o f thes e categories , thereb y allowin g fo r greate r in sight into actions and words that may seem meaningless. A delusio n i s a manifest communication , expresse d i n words . Denia l similarly informs u s about the patient's psychological response s to his or her illness . Whe n w e spea k abou t manifes t communications , however , we mos t ofte n refe r t o behaviors , suc h a s those describe d above . Othe r examples include: • apparentl y off-puttin g behavio r tha t actuall y function s a s a wa y o f keeping people involved, though in a controllable wa y • a n unwillingnes s t o mak e him - o r hersel f clear , a s a manifestatio n o f the patient's fear of bein g understoo d • physical , repulsiv e actions , such a s aggressive behavior , inattentio n t o hygiene, noncompliance with rules or expectations, or surliness, which are ofte n expression s o f th e patient's experienc e o f feelin g threatene d or out of contro l • effort s t o contro l other s throug h manipulation , insistenc e o n discuss ing prescribe d topic s (suc h a s religious delusions) , o r demandin g tha t others join in specific tasks , such as uncovering a persecutory plot. As note d before , thes e behavior s ar e multipl y determined . W e mus t acknowledge th e contributio n mad e b y disturbances i n ego functioning , while considerin g whethe r suc h conduc t ma y exis t i n orde r t o accom plish particula r goals . The behavior s describe d i n th e precedin g para graph distanc e other s o r creat e a feeling o f futility , discouragin g effort s to remai n involve d wit h th e schizophreni c individual . Th e patien t ma y unconsciously maintai n suc h behavior s becaus e increase d interactio n might b e intolerable . I t is importan t t o conside r th e possibilit y tha t th e patient i s makin g a n activ e effor t t o kee p peopl e awa y an d t o contro l her environment . Thi s activit y i s ofte n a consequenc e o f th e patient' s fantasies abou t others , a s i n th e fantas y tha t the y ar e attemptin g t o influence o r control him, which stimulates efforts t o protect himself. The increased stress from interpersona l interaction s can thus be seen to aris e from th e schizophreni c individual' s nee d t o asses s whethe r ther e ar e hidden intent s behin d others ' actions . A commo n concer n i s tha t othe r people will attemp t to convince her that she is ill. Treatment then can be effectively directe d a t examining thos e attitude s abou t other people tha t concern the patient. These interventions ma y well reduc e anxiet y an d in effect hel p the patient to acquire adaptive behaviors.

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The place to begin the investigation i s not at the level o f th e patient' s belief tha t th e clinicia n i s intereste d i n convincin g he r o f he r illnes s bu t rather why th e clinician ha s this desire. The patient ma y then revea l he r belief tha t th e clinicia n i s envious o f th e patient's freedom , angr y a t the patient's stubbornness , unabl e t o functio n unles s h e or sh e i s in a superior position ( I am well ; yo u ar e sick) , an d s o on . Ove r time , then , th e patient i s give n a n opportunit y t o compar e thi s a prior i vie w o f th e clinician with her ongoing, actua l experienc e of that caregiver. An additiona l componen t o f th e schizophreni c individual' s effor t t o distance an d contro l other s i s he r resentmen t towar d peopl e holdin g expectations o f her . Patient s resen t th e expectatio n tha t the y find way s to cop e wit h thei r disturbances , sometime s favorin g th e magica l expec tation tha t someone o r something will radically change their life, that all will be as it was "before." This dynamic is evident in those patients who, as a requirement for interaction, insist that the other person join them in their idiosyncratic endeavors, such as personal crusades. We can see that patients' insistence o n involvemen t solel y o n thei r terms represents thei r fear tha t participatin g i n treatment , fo r example , woul d requir e ac knowledging their difficulties. Consider , for example, the following : A 23-year-ol d schizophreni c ma n ha d becom e reclusiv e followin g a n unsuccessful attemp t a t a sexua l relationship . B y th e tim e o f admis sion t o th e hospital , h e wa s refusin g t o g o ou t o f th e house . H e informed hi s therapist that he would like him to collaborate with him in "purifyin g th e world o f th e sins of th e body." The patient refuse d to discus s an y othe r matters , mos t particularl y anythin g t o d o wit h difficulties h e migh t b e experiencing . H e proclaime d tha t onl y whe n the purificatio n effor t wa s successfull y complete d woul d h e resum e association with others. Our goal i s a more thoroug h understandin g o f patients ' unique way s of viewin g thei r environment, a s wel l a s th e effort s the y mak e t o adap t to an d modify tha t environment in order to mee t their internal, psycho logical needs. By observing what they think about people, how they treat them, whethe r or not the y show a n interest in interactions an d on wha t basis, w e lear n wha t peopl e mea n t o the m withi n th e contex t o f thei r own psychologica l worlds . W e als o deriv e som e understandin g o f thei r difficulties wit h relationship s an d thei r limitation s i n interactin g wit h others.

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The followin g brie f vignett e illustrate s som e aspect s o f on e schizo phrenic individual' s effort s t o appea r disintereste d whil e remainin g re lated o n he r terms . Onl y whe n absolutel y necessar y di d sh e revea l he r need for the therapist. Despite th e fac t tha t he r therapis t ha d give n th e patien t a writte n schedule of thei r appointment times, the therapist always had to seek the patient ou t when i t came time fo r he r session. The patient stare d blankly a t th e therapis t whe n sh e reminde d th e patien t tha t th e schedule wa s poste d o n he r wall . However , th e patien t eagerl y ac companied the therapist to her office, wher e she would throw hersel f on th e couch , facin g awa y fro m th e therapist . Sh e wa s attentiv e t o what th e therapis t said , registerin g agreemen t o r disagreemen t b y nodding he r hea d an d uncertaint y b y shruggin g he r shoulders . Sh e never lef t a sessio n early , an d whe n th e therapis t woul d announc e that sh e woul d mis s a session , th e patien t communicated , throug h discussion wit h a nursin g staf f member , he r wis h fo r a "make-u p session." The patient' s sullennes s wa s balance d b y evidenc e o f he r interes t i n her relationship wit h th e therapist . He r ambivalenc e communicate d he r desire fo r understandin g an d intimacy , a s wel l a s he r commitmen t t o controlling he r relationship s an d concealin g tha t desire . Awarenes s o f this paradigm guided the clinician in predicting the patient's tolerance of a give n interventio n an d suggeste d intervention s fo r improvin g th e pa tient's self-estee m an d broadenin g he r socia l skills . I t would hav e bee n unwise, fo r instance , t o challeng e th e patient abou t her "feigned" disinterest, for she used that stance to protect her self-esteem an d to feel more in control : I t i s likel y tha t "exposure " o f he r dependenc y woul d hav e been humiliatin g an d migh t als o hav e frightene d th e patien t i f sh e ha d delusions o f bein g controlle d b y others . Socia l rehabilitatio n interven tions thus focused o n providing the patient with experiences wherein she felt "i n charge, " supervisin g others , perhaps , whil e attemptin g t o in crease he r toleranc e o f vulnerabilit y throug h modelin g o f interaction s between, say , manager s an d employee s i n a wor k setting . Fo r a lon g period o f time , th e therapis t woul d simpl y schedul e a make-u p sessio n whenever possible . Sh e woul d d o thi s matte r o f factl y and , gradually , mention tha t i t wa s importan t t o maintai n continuity . Stil l later , sh e would commen t o n th e patient's request, sayin g "I' m glad I was abl e t o

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make u p th e time , especiall y sinc e yo u ha d requeste d it. " Onl y muc h later coul d th e therapist explor e wit h th e patient why sh e had t o concea l her desires . This perspective o n th e patient's interpersona l an d socia l presentatio n increases ou r understandin g o f th e patient . Th e technique s describe d above wil l als o foste r th e treatmen t allianc e an d increas e th e specificit y of ou r clinica l interventions .

THE QUALITY OF THE PATIENTS SUBJECTIV E EXPERIENC E Qualitative assessment s o f th e patient' s psychologica l experienc e focu s on describin g interna l state s rathe r tha n o n determinin g th e significanc e of behavior s a s w e hav e jus t don e above . However , informatio n abou t these issue s ca n certainl y b e inferre d fro m th e schizophreni c person' s actions; a s w e hav e delineate d above , ther e ar e numerou s route s t o a n understanding o f th e patient' s subjectiv e experience . W e mea n her e t o describe suc h state s a s havin g difficult y experiencin g onesel f a s physi cally o r psychologicall y separat e fro m others ; sustainin g one' s hope , happiness, o r wil l t o live , throug h us e o f certai n fantasies , myths , o r other cognitiv e devices ; an d disturbance s i n one' s sens e o f tempora l o r physical continuity , o f self , or of others . Self-Other Differentiatio n Most peopl e d o no t hav e difficult y i n experiencin g themselve s a s sepa rate fro m othe r people . In normativ e psychologica l experiences , peopl e can retai n a sens e o f individualit y whil e als o bein g abl e t o "identif y with" othe r people—tha t is , se e similaritie s betwee n themselve s an d others o r empathiz e wit h someon e else . Fo r schizophreni c individuals , this sens e o f self-integrit y i s no t necessaril y immediat e o r reliable , fo r they ofte n describ e feelin g a s if there is no boundar y betwee n themselve s and other s (8-9) . As described b y schizophrenic individuals , the experienc e o f th e self' s losing a sens e o f integrit y suggest s a t leas t tw o mechanisms . Th e first i s analogous t o th e reports o f depersonalizatio n o r derealizatio n b y peopl e who hav e experience d extrem e state s o f anxiety . Depersonalizatio n an d derealization ar e often see n in individuals with sever e character disorder s

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during states of stres s or anxiety bu t can also be experienced b y psychologically health y individual s durin g periods o f extrem e stres s or organi c mental disturbance . I t is possibl e tha t th e schizophreni c perso n experiences such states even more frequently, i f not at times continuously, suc h that hi s o r he r sens e o f bein g separat e an d uniqu e i s consequentl y impaired. Concern ove r self-objec t boundarie s ma y als o resul t fro m th e schizophrenic person' s experienc e o f intrusiv e thoughts , though t withdrawal , delusions o f bein g controlled , o r othe r simila r menta l disturbances . Pa tients ofte n repor t feelin g a s if thei r thoughts ar e not thei r own o r hav e been take n awa y o r a s i f thei r action s ar e controlle d b y outsid e forces . The accumulation o f thes e events understandably undermine s a sense of self an d self-competence. Asid e from developing delusional explanation s for thes e experiences , th e schizophreni c individua l mus t conten d wit h the profoun d demoralizatio n an d anxiet y tha t atten d thes e psychoti c phenomena. The disturbance in self-object boundar y ca n then be seen to have tw o components: physiologica l factor s tha t produce abnorma l menta l state s and a psychologica l representatio n o f th e sel f a s permeable , o r uncon trolled, stemming from the experience of those abnormal events. In general, patients see k t o resolv e thi s distressing stat e b y increasin g their sens e o f wholeness . The y accomplis h thi s i n a variet y o f ways . Social isolation may decrease stress and so reduce disturbing experience s of anxiet y an d associate d depersonalization ; isolatio n als o allow s pa tients the psychological experienc e o f privacy , which ma y b e difficult t o achieve given their recurrent feelings o f bein g watched, of havin g thought s imposed o n them , an d of numbin g amotivatio n tha t arises , confusingly , from n o though t o r event . Rigi d categorizatio n o f people , stereotyping , and treating al l persons a s if they shared common motive s an d psychol ogy o r ar e a commo n fo e ar e als o mean s o f increasin g a sens e o f differentiation betwee n th e patient and all others. Aggression is particularly useful becaus e it implicitly defines people (aggressor s versus victims or objects of hostility) an d creates distance through fear and resentment. Some patients exhibit ambivalence towar d resolving problems of self object differentiation . The y ma y fantasiz e abou t "merging " (10 ) wit h another object (person , in most cases), becoming on e with someon e els e and thu s resolvin g th e proble m o f isolation , threat , an d inefficacy . The other person is frequently see n as capable of helping the patient cope, of

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gratifying hi s o r he r wis h fo r successfu l intimacy . The othe r perso n i s seen as untroubled by the patient's concerns and is thus also an object of envy. Patient s ma y seek fulfillmen t o f tha t wish i n annihilatio n o f them selves, with th e underlyin g fantas y tha t the y wil l the n find comfort i n a greater onenes s wit h th e objec t o f thei r wis h fo r merger . Wishe s fo r merger ca n als o reflec t a patient' s yearnin g fo r broade r obliteration , symbolized a s a desir e fo r th e en d o f th e world . Th e merge r coul d b e fantasized a s a perfected union, even marriage, between the persons. Yet man y patient s fea r thi s fantas y o f merger , includin g som e wh o also actively entertain the wish for it. The expression of this ambivalenc e is graphically illustrated in the following vignette : A chronic schizophrenic patient became so enamored of th e film The Invasion of the Body Snatchers tha t sh e purchased i t a s soo n as i t cam e ou t o n cassette . Fo r her , th e plo t o f th e film, i n whic h extraterrestrial invader s "tak e over" people i n such a way that the invaders and the earthlings become merged, was most significant . After viewin g th e cassett e fo r severa l day s th e patien t obeye d her compulsio n t o destro y it . Sh e reporte d tha t sh e coul d no t understand ho w sh e ha d eve r enjoye d th e film sinc e i t no w ap peared to her as the "scariest movie I have ever seen." The fea r o f los s o f self-objec t differentiatio n ma y b e expresse d a s a n intense wis h t o isolat e onesel f t o preserv e a sens e o f separateness . Th e threat o f los s o f sel f ma y b e directe d a t others , a s i n schizophreni c individuals' depictio n o f peopl e a s controller s o r invader s seekin g t o overwhelm the m an d eradicat e thei r individuality . Thi s fea r o f bein g overwhelmed ma y lea d t o effort s t o distanc e other s an d form s anothe r component o f suc h behaviors as we have discussed previously. Patients als o manifes t difficultie s wit h self-objec t boundarie s i n thei r failure t o clarify thei r interests, goals, or limitations. These efforts migh t be understoo d a s expressin g a wish t o resis t definin g themselves , fo r t o do s o woul d implicitl y reinforc e thei r separatenes s b y identifyin g wha t makes the m differen t fro m othe r people. Suc h separatenes s coul d repre sent a threat to their wish for merger with a stronger, comforting object , signaling th e los s o f th e fantasie d resolutio n t o thei r predicament . Pa tients' wishes to eliminate themselves in favor of merge r may be stronger than thei r fear s o f th e consequence s o f self-annihilation . Th e followin g example illustrates this point.

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A schizophreni c patien t believe d tha t h e coul d obtai n safet y through submergin g himsel f i n a higher power, "Korax. " To gai n Korax's protection , h e wa s require d t o cu t himsel f of f fro m al l prior connections , renounc e hi s presen t self , an d devot e himsel f completely. I n thi s context , th e patien t becam e activel y suicidal , informing hi s family , "Eithe r wa y I ma y die , bu t thi s wa y I a m more powerful. " Other patient s migh t attemp t t o coerc e anothe r person , perhap s a therapist, int o collaboratin g i n a wa y tha t separate d th e tw o o f the m from th e res t of th e environment, thi s "special " relationship bein g simi lar to a fantasized merger . I n hospital setting s a s well a s i n othe r treat ment environments, suc h behavio r ofte n excite s resentmen t an d env y i n other patient s an d staf f members . I n part , thi s result s fro m shared , instinctive env y a t seein g exclusiv e relationships . I t is als o frequentl y a response t o th e patient' s subtl e hostilit y towar d others , whic h furthe r serves t o isolat e th e patien t an d th e patient' s chose n object , a s i n th e example below : In on e case , a hospita l staf f membe r fel t s o draw n int o th e struggles an d sufferin g o f a youn g schizophreni c ma n tha t sh e arranged t o mee t wit h hi m i n th e communit y afte r th e patient' s discharge despit e her ethical concerns . The patient initially seeme d glad of th e attention, but felt disappointed that his psychiatrist still seemed aloof , refusing , fo r instance , t o visi t him a t home. Eventu ally, he became angry and resentful an d reported suicidal thoughts, necessitating rehospitalization , a t whic h tim e h e insiste d tha t hi s hospital psychiatris t resume treating him. The schizophreni c person' s difficult y wit h definin g self-boundaries , even when stemming from a physiological disturbance , comes to assum e an importan t rol e i n th e patient' s psychologica l lif e becaus e i t offer s a fantasied resolutio n t o stressfu l experienc e an d rekindle s unconsciou s wishes fo r a n en d t o th e isolatio n tha t i s a centra l aspec t o f hi s o r he r psychic life. Understanding th e patient' s experienc e o f self-objec t differentiatio n greatly enhance s th e clinician' s awarenes s o f ho w th e patien t interpret s aspects o f th e treatmen t situation . Chang e itsel f ma y b e frightening , representing th e threa t o f furthe r los s o f control . Advice , effort s t o

88 Working with the Person with Schizophrenia educate, insight s ma y al l b e felt t o b e foreig n intrusions . A t times , the mere presence of the clinician may activate the patient's concerns abou t self-object differentiation . I f thes e concern s ar e prominen t i n a give n patient, specific treatment interventions may be indicated. In the patient who ha s intens e fea r o f other s an d a wis h t o maintai n a sens e o f separateness, efforts ma y b e made both verball y an d physically t o reinforce to that patient his or her sense of integrity. Consider the following: A schizophrenic patien t wh o share d a roo m wit h a fello w pa tient kept moving his roommate's name from the door while failing to put u p a sign with hi s name on it. He believed that there could only be "one soul" in the room and, whoever that was, that "soul" would tak e over the other. The staff helpe d hi m find a temporar y solution by suggesting that three signs could be put up: His roommate's name , his name, and on e directly unde r his stating that h e was not his roommate. The patient accepte d this with one modifi cation—that the negation precede his name. Thus, the signs read: 1. Joh n Jones 2. No t John Jones but Steven Smith. Several weeks later the patient removed the "Not John Jones" part, remarking he could not understand why he had felt that necessary. Such clarification s ma y eve n exten d t o reinforcemen t o f a sens e o f physical integrity , becaus e some patients describ e feeling s o unreal tha t they canno t distinguis h part s o f thei r bod y fro m othe r object s clos e t o them i n th e environment . Suc h a patient coul d b e helped b y becomin g engaged i n exercise s tha t woul d promot e awarenes s of hi s or he r bod y and a sens e o f contro l ove r bodil y movemen t an d functioning . Fo r example, a patien t wh o fel t hi s arm s wer e no t par t o f hi s bod y wa s helped throug h playin g poo l t o appreciat e tha t th e forc e o f hi s arm s applied to the cue stick determined where the ball went. A patien t wh o feare d th e influenc e o f others ' thought s migh t b e approached b y hospital staff member s with a routinized introductio n i n which th e staf f membe r acknowledge d th e patient' s anxiet y abou t th e interaction an d reassured th e patient that h e or she could terminate th e discussion a t an y point . Fea r o f merge r ca n als o be helped b y insistin g on one' s separatenes s fro m th e patient. On e catatonic patient, whe n h e

Understanding the Subjective Experience 8 9 began to speak, announced that the thing that had made him feel most safe about his therapist was overhearing him tell a colleague that he was going awa y fo r th e weekend . Fo r th e first time, th e patien t fel t th e therapist wa s no t intereste d i n mergin g wit h him . Thi s an d simila r interventions might be specifically oriente d towards problems with selfobject differentiation while at the same time addressing other concerns.

Sustaining Experiences or Expectations A second important aspect of the inner experience of the schizophrenic individual is an appreciation of which aspects of his life he conceives of as psychologically sustaining. All of us characteristically think of certain categories, suc h a s life goal s an d important relationships, a s being important t o ou r mental well-being . W e recognize tha t ongoin g pleasan t interactions an d events help us cope with the stresses and uncertainties in our lives. The schizophrenic individual often has a paucity of experiences that would b e considered sustaining b y ordinary standards . Certainly, the situation of th e individual who experiences frequent perceptual disturbances, uncomfortable state s of anxiety , cognitive disruptio n and multiple difficulties wit h relationships and effective socia l functioning is one of limited opportunities for gratifying experiences. At the same time, it becomes extremely important for him or her to findsome aspects of experienc e tha t ar e sustainin g i n orde r t o tolerat e th e difficultie s inherent in that experience. For some schizophrenic individuals, effective socia l adaptation, when it is possible, allows for satisfying interpersonal experiences that contribute to self-esteem. For many patients whose difficulties limit involvement in work or intimate relationships fantasy ma y function a s their psychological sustenance, especially in the development of compensator y idiosyncratic behaviors or thoughts. In our experience, this is not an infrequent caus e fo r patients ' refusing t o tak e antipsychoti c medication . A 43-year-old schizophreni c woman , fo r instance , wh o wa s profoundl y upset b y he r childlessness , believe d hersel f whe n delusiona l t o b e th e "old woman in the shoe," surrounded by imaginary children. She steadfastly refused treatments that had in the past "taken my children away." Some individuals findmajor gratification through maintaining contact with people, and yet the way they go about it makes their object-seeking difficult t o recognize. An example might be the patient who takes plea-

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sure i n disappointin g peopl e wh o attemp t t o hel p him . Fo r someon e whose sens e of pleasure is restricted an d who experience s intense resentment about that limitation, th e perverse pleasure of frustratin g th e helpful efforts o f others may become a critical motivation fo r survival. Othe r patients ma y b e unabl e t o consciousl y acknowledg e a wish fo r interac tion wit h other s becaus e o f conflict s abou t intimacy . Fo r some , t o ex press a desir e fo r intimac y woul d overtl y challeng e thei r nee d t o se e themselves as self-sufficient. Stil l others may behave helplessly or obnoxiously, i n ways tha t require others t o spen d time with them , even i f tha t time is often colore d by antagonism. In all these examples, the sustaining experience i s th e interactio n whic h i s conducte d alon g line s tha t simul taneously affor d th e patient a sense o f safet y whil e gratifyin g hi s or he r particular desires. It i s ofte n har d t o obtai n a statemen t abou t sustainin g experience s from schizophreni c individual s becaus e the y ma y fee l tha t thos e experi ences canno t b e shared withou t ris k o f losin g them . They ma y fea r tha t others will tr y to take away anythin g that is identified a s pleasing. Som e patients ar e so threatene d b y their ill-understood an d capricious uncon scious, whose effect s the y ma y attribute t o a n external source , that the y may vaguely experience part of themselves as dangerous and so not wish to assert what is important to them. The patient who must believe in her perfection wil l experienc e an y yearnin g fo r greate r fulfillmen t a s inimi cal. Suc h a patien t als o need s t o deny , eve n t o herself , tha t ther e ar e things tha t ar e importan t t o her . I t is a s i f sh e wil l betra y hersel f i f sh e speaks. "I t wanted something . I t had to b e taught that there is nothing I cannot provid e fo r myself . Otherwis e I would no t b e th e daughte r o f Zeus." The abilit y t o identif y sustainin g aspect s o f th e patient' s experienc e allows the clinician to begin to fashion the treatment in a way tha t takes advantage o f tha t information . I n th e cas e o f th e patien t wh o sustain s himself b y frustrating treatment interventions, the treatment would hav e to begi n wit h a n effor t t o modif y thi s situation . Ongoin g inquir y an d interaction woul d b e require d t o attemp t t o hel p th e patien t find som e way in which other aspects of his experience could become sustaining s o that the wish to sabotage helpfulness woul d assum e a less central role. Often th e clu e t o resolvin g situation s lik e thi s come s fro m th e meth ods th e patien t employ s t o effec t sabotage . Fo r example , a young mal e schizophrenic repeatedl y frustrate d staf f members ' effort s t o communi -

Understanding the Subjective Experience 9 1 cate with him by talking over them and reciting verses from the Bible. The patien t wa s therefor e encourage d t o star t a Bible clas s fo r othe r patients. The class would begin with his delivering a formal reading and would be followed b y a discussion. Although th e patient had difficult y with th e exercise , h e graduall y demonstrate d increase d toleranc e fo r others' views about the readings. He simultaneously developed a source of self-esteem and tolerance for some social vulnerability. For th e patien t fo r who m socia l interactio n i s importan t bu t wh o cannot acknowledg e tha t need , th e clinicia n coul d structur e activitie s allowing indirect or compulsory socialization, being careful not to force upon the patient the awareness that this is important to him or her. The patient coul d b e encouraged first to observ e activitie s tha t di d not require his participation. Dependin g on the patient's tolerance of socialization, a jo b coul d b e devise d tha t closel y matche d hi s abilitie s an d limitations: deliverin g book s o r mail t o othe r patients i n the hospital ; answering a telephone; working as a receptionist. Compulsory activities would b e a n alternative fo r th e resolutely withdraw n patient . Contac t with staf f member s could initiall y b e prescribed. The rationale fo r the interactions woul d b e clearly state d i n terms reflecting onl y th e staff' s interests: "We must meet with you to obtain information necessar y for our work. " Thi s migh t reliev e th e patient' s unconsciou s fea r tha t hi s interest in such contacts would be uncovered. The aim of the treatment interventions would be specific: increasing the patient's ability to tolerate socialization whil e helping him to understand and cope with his anxieties or other psychological reactions to those experiences. A list of sustaining experiences might well read as a catalog of human desire. Developing a compendium of such items is thus an unapproachable task. I n work wit h schizophrenia persons , however, crucia l issue s do recur in our assessment of what is important to and motivates them. These issues, not surprisingly, are related to themes such as sense of selfintegrity and self-esteem; psychological continuity; and safety, avoidance of loss , an d preservatio n o f autonomy . Thes e ar e th e aspect s o f th e patient's subjective experience we treat here; they are of central psychological importance.

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PSYCHOLOGICAL CONTINUIT Y AND CLARIT Y

We describe d earlie r th e schizophreni c individual' s experienc e o f pro found, repeated , an d ofte n persisten t perceptua l an d cognitiv e disrup tion. These difficulties creat e a psychological experienc e of discontinuity . The physiological basi s for thi s state may b e ameliorated b y medications , but ther e ma y remai n significan t disturbanc e i n th e qualitativ e psycho logical experience. It behooves the clinician to mak e a careful assessmen t of th e patient' s psychologica l experienc e o f continuit y an d clarit y (11 ) because thi s aspec t o f menta l functionin g ha s significan t impor t whe n the clinicia n attempt s t o asses s the patient's handlin g o f treatmen t inter ventions. Most schizophreni c patient s experienc e treatmen t intervention s (in cluding interviews , presentations o f th e treatmen t plan , an d som e tasks ) as a significan t challeng e t o thei r cognitiv e functioning . I n thi s respect , care mus t b e take n t o determine , withou t insultin g patients , tha t the y have bee n abl e t o atten d t o th e tas k a t hand , tha t the y ar e abl e t o concentrate o n wha t i s expecte d o f them , an d tha t th e particula r tas k does no t excee d thei r presen t abilities . Sensitivit y t o patients ' state s o f anxiety, a s well a s to thei r potentia l frustratio n o r discouragement , i s a n important attribut e o f th e empathi c clinician . B y th e sam e token , i t i s also apparen t fro m th e researc h literatur e that , althoug h schizophreni c individuals hav e difficultie s wit h som e aspect s o f cognitiv e performance , these problem s ar e no t globa l o r uniform . A schizophreni c patien t wh o was dubbed "J o e y Slowey " by his fellow patient s because of his slownes s of thinkin g wa s note d on e da y t o b e arguin g with a TV sport s announc er's comment s abou t a basebal l player's pas t performance. A n aler t staf f member note d thi s an d engage d hi m i n discussio n abou t th e merit s o f this particular player . From this chance event, Joey was found t o posses s an encyclopedi c knowledg e o f basebal l record s goin g bac k decades , a s well a s a kee n appreciatio n o f th e curren t gam e an d it s strategies . H e soon becam e recognize d a s a n authorit y i n thi s are a an d hel d cour t during an d afte r games . Clinical experienc e inform s u s tha t w e canno t assum e tha t a patien t who i s gravel y impaire d i n som e respect s doe s no t posses s area s o f competence (12—14) . This ver y stat e o f affairs , however , illustrate s on e aspect o f discontinuity : th e disparit y i n cognitiv e an d othe r psychologi -

Understanding the Subjective Experience 9 3 cal functioning within the same individual. What is more, schizophrenic patients ar e ofte n perplexe d an d frustrate d b y thei r limitations , no t infrequently becomin g self-critica l an d imaginin g tha t the y ar e lazy , stupid, or demented. Individuals with schizophrenia often repor t experiences that indicate distorted perceptions o f identity . A patient ma y not recognize tha t the staff membe r who is holding out a cup to her is the same person whom she had just asked for water. This may represent more than a deficit in memory function. A patient who says in a family meeting, "These aren't my parents, they're impostors," has experienced a dramatic and disturbing disruption in his ability to identify objects and a sense of continuity of thos e object s ove r time . Simila r phenomena hav e bee n describe d in the neurological literature , including persons who ar e unable to recognize faces , despit e having intact memories (fo r th e well-known cas e of "the man who mistook hi s wife fo r a hat," see Oliver Sacks's book by this title). This discontinuity can also affect complex cognitive and emotional experiences. Motivation, desire, commitment, and persistence, all of which have a temporal dimension, may be elusive because of psychological discontinuity, as the following illustrates: A woman i n her thirtie s ha d suffere d a severe an d prolonge d psychotic episode three years before. Although partially recovered, she continued t o have ideas of referenc e an d occasional auditor y hallucinations. He r psychoti c symptom s reiterate d he r delusio n that her ex-husband , wh o wa s a police office r an d of Italia n descent, had contracted with the Mafia t o have her killed or driven to suicide by mental torment. Whenever sh e becam e involve d i n activities , sh e woul d pre dictably becom e anxiou s (becaus e sh e wa s afrai d sh e ha d los t her intellectua l abilitie s an d becaus e task s wer e ofte n difficult ) and would soo n repor t hearin g taunt s promptin g he r t o suicide . She woul d the n becom e discourage d an d withdraw n an d ceas e working. When describing these experiences, the patient would say, "When I hear thos e voices , it s just like I' m bac k i n that hel l thre e years ago. I can't function, I forget wher e I am, what I' m doing, an d I just want to die." Feeling, like Sisyphus, repeatedly defeated, thrown back, sh e was unable t o muste r desire fo r mor e effective adapta -

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tions, wa s amotivated , an d convince d o f he r inabilit y t o wor k persistently toward s meaningful goals . Like al l individuals , schizophreni c person s hav e psychologica l mech anisms tha t ca n repres s awarenes s o f painful , confusing , conflictua l as pects o f thei r lif e (14-16) . A s on e woul d expect , muc h i n th e schizo phrenic person' s menta l lif e i s subjec t t o defensiv e eliminatio n fro m consciousness. Thes e operation s als o contribut e t o th e patient' s igno rance of interna l consistency . Some patients, particularly those who have long been ill, seek throug h fantasy t o eradicat e empt y years . They avoi d awarenes s o f suffering , a s well th e sense of los s due to the passing of opportunities . They ofte n ac t as if no time has passed at all, as in the case of the man described below . A ma n wh o wa s i n a professiona l schoo l i n hi s earl y twentie s developed symptom s o f hi s first acut e psychoti c episode . H e wa s able t o retur n t o professiona l schoo l onl y briefl y an d the n ha d t o leave schoo l an d retur n home . Ove r th e ensuin g te n years, h e ha d lived at home without working, tied to the fantasy that he was stil l working activel y towar d his professional degre e an d that opportunities wer e imminent . Whe n h e wa s i n hi s thirties , thi s patien t spoke abou t hi s experience o f professiona l schoo l a s if it were bu t a few month s ag o an d asserte d tha t h e woul d b e abl e t o tak e u p his caree r a t an y tim e a s soo n a s h e coul d wor k ou t som e forma l issues regarding applications fo r more schooling . This man , wh o ha d suffere d fo r a numbe r o f year s an d coul d ac knowledge th e emptines s o f tha t tim e ha d sough t hop e (throug h a sustaining fantasy ) an d relie f fro m despair . Hi s unconsciou s provide d a kind o f hop e throug h hi s delusiona l treatmen t o f time , bu t th e conse quences fo r hi s life an d his treatment were debilitating. Copin g with th e symptoms o f hi s illnes s an d scalin g dow n hi s expectation s wer e no t a t issue, give n hi s insistenc e o n returnin g t o work h e coul d i n fac t no t reasonably resume . Other individual s ac t a s i f tim e wer e no t movin g o r a s i f thei r live s were unending. The y maintain the y have no need to change, t o compen sate, t o revise goals, or to thin k abou t the future. The y awai t somethin g that will change them, relieve them of the responsibility of acceptin g and coping with thei r illness and circumstances.

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One suc h patient , wh o wa s verba l an d intelligen t bu t functionall y impaired, spen t severa l year s i n a hospita l setting , maintainin g al l th e while tha t h e had n o nee d t o engag e i n therapeuti c work , rehabilitativ e efforts, o r activitie s tha t woul d promot e hi s independenc e an d auton omy. H e planne d t o retur n hom e an d liv e wit h hi s famil y bu t sai d h e would wait until his family relente d in their insistence that he not return home. Faced with resolute noncompliance, th e staff transferre d hi m to a state hospital, fro m which his family eventually extricate d him. Many schizophreni c individual s als o experienc e discontinuit y wit h their former habit s an d abilities , despairin g abou t regaining an y aspect s of tha t pas t self . The y find themselve s unabl e t o reclai m copin g skills , frustrated b y difficult y accomplishin g once-simpl e tasks , an d feelin g s o different abou t themselve s an d thei r goal s tha t the y believ e the y hav e been irrevocabl y changed , becom e differen t persons . Thi s i s wha t hap pened to a young woman in her twenties. This youn g woma n ha d bee n a superio r studen t i n hig h schoo l and wa s activ e i n extracurricula r activities . A t tha t time , sh e wa s full of hope and promise and planned a career in photography. Sh e had troubl e i n college , first manifes t a s socia l awkwardnes s an d some difficulty carryin g through school assignments . She nevertheless completed al l bu t one semester of college , bu t just prior to her final exams i n he r senio r year , sh e experience d he r first psychotic episode. Sh e endure d si x year s o f sever e an d persisten t paranoi d psychotic symptoms an d several hospitalizations . When, i n he r twenties , sh e wa s encourage d t o reminisc e abou t her past , sh e showe d picture s o f hersel f receivin g award s durin g that halcyo n hig h schoo l period . Sh e spok e poignantl y abou t tha t person a s if she were dead, as if there were no connection betwee n who sh e wa s no w an d tha t person te n year s before . No t onl y di d she fee l sh e ha d los t a grea t deal , bu t sh e denie d retainin g an y o f her pas t qualities . I t appeare d tha t acknowledgin g th e persistenc e of prio r traits , abilities , ideals , o r value s i n hersel f woul d indicat e that sh e reall y ha d changed . Thi s absolut e disconnectednes s al lowed he r t o maintai n tha t he r curren t stat e o f min d wa s tempo rary and not real. She attribute d he r cognitiv e disturbance s t o brai n experiment s performed b y th e CIA . He r single-minde d goa l wa s t o determin e

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some wa y t o pu t a n en d t o thi s experimen t s o a s t o b e abl e t o return to the state of min d she possessed a t the end of hig h school , to retur n t o tha t poin t whe n sh e coul d stil l imagin e dream s an d goals an d th e possibilit y o f survival . Sh e wante d onl y t o discove r her punisher s s o a s t o recove r al l tha t ha d bee n take n fro m her . Her pas t sel f wa s lik e som e perfectl y preserve d relic , froze n bu t ready to spring back to life. This disconnectednes s wa s severel y maladaptiv e becaus e i t con tributed t o he r refusa l t o engag e i n treatment . Sh e resiste d recognizin g her residua l abilities , whic h sh e coul d otherwis e hav e pu t t o goo d use , for t o recogniz e the m mean t acceptanc e an d compromis e fo r her . Sh e clearly needed help in several areas : to mourn her loss of prior function ing; t o contai n th e anxiet y tha t woul d b e brough t abou t b y effort s a t adaptation (whic h woul d inevitabl y remin d he r of he r past accomplish ments); an d to reestablis h link s wit h whateve r skill s remaine d an d t o build on these. How coul d thi s b e don e whil e he r manifes t goa l wa s stoppin g th e brain experiments ? Th e patien t ha d first t o b e persuade d tha t othe r activities migh t b e of us e to her. When the staff planne d a rehabilitation or resocialization program , the patient would b e interested in work onl y if i t helpe d he r achiev e he r single-minde d goal . He r stubbornnes s wa s also fel t t o b e a resistanc e t o assumin g responsibilitie s a t whic h sh e might fail . Th e staf f chos e t o focu s o n a highl y learne d an d relativel y preserved skil l an d interest, photography. The activit y that came closes t to tha t was a volunteer positio n i n the hospital's radiolog y department . Although he r wor k woul d b e largel y physica l (transportin g patients , etc.), sh e woul d b e abl e t o observ e th e functionin g o f th e departmen t and its equipment. Th e staff presente d th e rationale, but the patient wa s encouraged t o thin k i t ove r hersel f an d determin e i f sh e coul d find an y reason wh y thi s wor k migh t appea l t o her . The patien t agree d t o tak e the job , sayin g tha t he r interes t i n mind-contro l experiment s le d he r t o want to learn more about neuroradiology techniques . Appreciating a patient' s uniqu e psychologica l experienc e allow s fo r greater empathy with the patient's instinctive coping efforts. Som e treatments nee d to b e modified becaus e o f specifi c disturbance s i n the clarit y of menta l experience—tha t is , i n condition s wherei n perception s ar e

Understanding the Subjective Experience 9 7 regularly distorted and marked impairment in basic cognitive functions, including orientation an d attention, is noted. These patients also manifest the phenomenon of discontinuity because of the marked disruption of menta l life. Patient s who have difficulties wit h cognitive clarity may benefit fro m environmenta l suppor t tha t emphasize s consistenc y an d some degree of routine and structure but also opportunities for activity, challenge, and newness tempered by staff support. It would be a mistake to assum e tha t patients with cognitive difficult y nee d only a n environment tha t i s stabl e an d routinized . Suc h individuals , lik e anyon e else , also benefit fro m meeting and mastering new experiences. They require help i n greetin g thes e ne w experience s an d i n devisin g compensator y strategies to cope with them. Therapeutic staff who have an understanding of th e psychological experienc e of suc h patients may be better able to suggest creative strategies for coping with new circumstances, as they did in the example described below. An inpatient in a hospital that had a rather labyrinthine structure continually foun d hersel f gettin g lost a s she tried to find her way fro m on e activit y to another. Sh e had considerable difficult y orienting hersel f becaus e sh e was unabl e t o remembe r significan t landmarks along the way. The occupational therapist accompanied her fro m th e uni t t o th e occupationa l therap y department . The y then discussed making a map to enable her to get to various places. The patient chose first to learn the route to her therapist's office , which was a considerable distance from the unit. Rather than sit in the activitie s departmen t an d construct th e map from memory , a concept whic h woul d hav e maximall y stresse d th e patien t an d characteristically led her to withdraw and/or to turn over the entire task t o th e activitie s person , th e therapis t decide d t o wal k th e patient through the experience. They began on the unit and, in the course of going from there to the therapist's office, noted along the way all structures that were familiar to the patient. They then went back to the activities department an d constructed a map utilizing the information gained from their walk together. Treatment o f cognitiv e disturbance s ma y b e ease d b y linkin g th e patient's present experienc e t o previous one s an d implicitly addressin g underlying discontinuities. For example, a staff member working with a

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schizophrenic individual , suc h a s th e woma n describe d above , migh t approach he r an d say , "W e ar e goin g t o g o fo r a wal k toda y a s w e discussed two days ago in our last treatment planning meeting. Ou r plan was t o wal k int o tow n an d d o som e researc h o n bu s routes . That' s something yo u sai d wa s importan t t o yo u a t you r las t treatmen t plan ning meeting. " The importan t issu e i n th e staf f member' s communica tion t o th e patien t i s th e supportiv e emphasi s o n wha t th e patien t ha d expressed a s he r desires , interests , an d goals , a n emphasi s tha t encour ages a sens e o f continuit y and , i t i s hoped , increase s th e patient' s sens e of competence . I t als o decrease s he r tendenc y t o experienc e other s a s making decision s fo r he r becaus e o f he r difficult y i n maintainin g a n awareness of th e continuity o f her own interest . Patients ca n b e helpe d t o se e tha t recoverin g aspect s o f a past sel f i s not a s threatenin g a s the y fea r an d ma y b e crucia l t o thei r curren t survival. Th e tendenc y o f suc h patient s t o eradicat e time , t o ac t a s i f there i s n o nee d fo r the m t o addres s thei r difficultie s i n th e here-and now, t o maintai n tha t thei r onl y hop e i s a complet e retur n t o thei r premorbid stat e mus t b e presented wit h th e blea k consequence s o f tha t stance. A patient whose psychological dispositio n indicate s disinterest in any outcom e othe r tha n on e tha t remove s al l o f th e rea l difficultie s hi s or he r illnes s impose s i s no t prepare d t o engag e i n a useful therapeuti c alliance. Suc h a n attitude i s an ultimatum tha t al l mus t be put right an d indicates tha t the patient abdicates responsibility fo r coping with reality . This attitude, though ofte n superficiall y optimistic , is infused wit h hope lessness, anger , an d despair . Clinician s mus t evok e awarenes s o f tha t demoralization an d hel p th e patien t t o a mor e tractabl e position . Con frontation abou t thi s issu e wil l predictabl y lea d t o expressio n o f dee p sadness and resentment, a s the following illustrates . A onc e quit e successfu l actress , wh o ha d spen t th e majorit y o f her las t te n year s unemploye d an d i n an d ou t o f hospitals , infuri ated the treatment staf f b y insisting that the only thin g sh e neede d to do fo r herself wa s t o call her agent (wh o no longer returned her calls). Sh e insisted tha t whe n th e righ t part cam e along , h e woul d arrange an audition for her. She also insisted that, given this opportunity, she would the n make the most of it . "Whe n I get the part," she woul d say , "th e res t of m y lif e wil l fal l int o place. " Until tha t

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time, sh e wa s conten t t o spen d he r day s o n th e couc h i n th e da y room vociferously protestin g any efforts t o get her to move. The patient' s therapis t bega n t o poin t ou t variou s residua l tal ents hinted at in her present behavior, such as the fact that she had good voca l presenc e eve n thoug h he r remarks wer e generall y cur t and off-putting, an d that her persuasive abilities were considerable, even whe n complainin g o f ho w unjus t peopl e wer e i n demandin g things of her . But he also pointed out to her how sh e was allowin g these skill s t o stagnate . H e predicte d tha t he r socia l skill s woul d continue to deteriorate unless she decided to accept help. The patient wa s trouble d b y this line of argumen t an d began t o refuse he r sessions . Sh e seeme d t o clin g t o th e sof a eve n mor e desperately. Sh e als o becam e mor e withdrawn , stiflin g he r com plaints about the staff, a s if repressing all evidence of her vocal an d interpersonal skills . I t was a s though fo r her to acknowledg e thes e remaining talent s wa s als o t o acknowledg e he r infirmit y an d he r difficulty usin g thes e skill s a s effectivel y a s before . Sh e wa s fortu nate i n tha t he r cognitiv e skill s wer e relativel y preserved , s o tha t she wa s abl e t o find work , afte r hospita l discharge , thoug h i n a clerical positio n an d no t th e theater . Sh e was ofte n noncomplian t with her treatment and resentful towar d those helping her. Nevertheless, sh e an d he r therapis t persiste d i n explorin g he r sadness an d resentmen t an d he r experienc e o f discontinuit y wit h her past self. I t was mor e than a year before sh e was agai n abl e t o express hersel f wit h th e vitalit y sh e ha d displaye d i n the hospital . At first, thi s vitalit y wa s see n i n he r outburst s o f ange r an d deri sion. Gradually , sh e coul d b e see n t o posses s mor e emotiona l depth, and , concomitantly , he r lif e an d treatmen t becam e mor e stable. Experiencing discontinuity wit h one's past self is not wholly arbitrar y nor imaginary . I n many instances , schizophreni c patient s d o los e skills , relationships, careers , an d som e dreams . The therapeuti c goal , whethe r in supportiv e psychotherapy , rehabilitativ e interventions , o r othe r mo dalities, i s t o hel p th e patien t identif y part s o f hi s o r he r curren t sel f (skills, relationships , potentials ) tha t ar e link s t o th e past , whil e als o helping the patient to forge links to a feasible an d desirable future .

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CONCERNS The thir d are a t o which w e direct our attention i n gathering dat a o n the patient's subjectiv e experienc e is one we have designated "concerns. " By this we mean emotiona l issue s that ar e of overriding importanc e to mos t schizophrenic individuals . Th e three w e hav e liste d her e ar e not exclu sive, but in our judgment, the y ar e nearly ubiquitou s feature s o f schizo phrenic patients ' psychologica l lives . Thes e theme s overla p wit h on e another an d wit h aspect s o f th e subjectiv e experienc e tha t w e hav e discussed above . Autonomy Autonomy i s a concept tha t connote s suc h varie d idea s as independence, control, integrit y o f the self (tha t is , wholeness o r oneness), and respon sibility. Intac t self-objec t differentiatio n an d a capacit y fo r intimac y without fea r o f merge r ar e psychological function s characteristi c o f autonomous individuals . Fo r schizophreni c patients , thi s issu e present s great difficulty . Fo r them , independenc e i s bot h hel d a s a goa l an d resisted becaus e of its frightening implications . Intimacy is highly conflic tual insofa r a s it requires managemen t o f interpersona l relatednes s a t a sustained, intens e level that many schizophreni c patients find threatenin g and overwhelming . The sense of identity o r wholeness o f the self, whic h is closel y relate d t o th e concep t o f self-objec t differentiation , i s als o impaired, perhap s primaril y becaus e o f physiologica l dysfunctio n bu t also as a consequence o f their uniqu e psychological experience . In ou r discussion o f self-objec t differentiation , w e made th e observa tion tha t schizophreni c individuals are ambivalently dispose d a s to whether they prefe r a stat e o f individualit y o r merge r wit h anothe r perso n o r object. Schizophreni c patients ' struggl e wit h autonom y i s over whethe r and ho w to pursu e it , how to delimi t th e boundaries o f th e self, wher e to insis t on their authority , an d where to rely on the hope tha t another' s actions, anothe r sel f ma y provide the m wit h suppor t an d safety. Man y schizophrenic individual s op t fo r a stat e o f relativ e isolatio n becaus e closeness t o peopl e i s fraught wit h stres s an d uncertaint y an d th e nee d to exercis e disturbe d interpersona l skills . Fo r man y patients , however , that isolatio n i s a renunciation o f a fantasied unio n wit h anothe r perso n

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that woul d provid e the m wit h securit y an d relief fro m stress . Movemen t toward autonom y i s a conflictua l compromis e betwee n th e desired end s of self-integrit y an d th e contrastin g goa l o f closeness . Bot h goal s carr y risks an d are associated wit h uniqu e stresses . Ofte n th e patient, suc h a s the on e describe d below , oscillate s fo r a considerabl e perio d o f tim e between pola r opposites , a s i f protestin g an y possibilit y o f integratin g these two positions. A youn g woma n describe d oneiroi d (dreamlike ) state s wherei n she "retreated " t o a privat e "planet, " a worl d withou t violence . She relate d he r fantas y tha t on e da y sh e would g o ther e forever , because people were too cruel. Alternatively, th e patien t describe d a delusio n tha t entaile d a much mor e publi c an d activ e imag e o f herself . Sh e believe d sh e could predic t th e futur e an d fel t a n urg e t o communicat e he r premonitions abou t tragedies , natura l an d political , t o govern ments an d the media. Sh e had, in fact , o n a numbe r o f occasion s reported he r premonitions t o authorities, on one occasion prompt ing a call back fro m a police agency , which frightene d her . Her publi c "self " wa s assertiv e an d impatient . Whe n sh e dis cussed her wishes, she related high expectations and a strong desir e for love , intimacy , an d commitment . Thes e discussion s woul d b e predictably followe d b y a period o f withdrawal, marke d b y bitte r reminiscences about past lovers who had hurt her and then descrip tions of her private world o f peace. Although th e patient referre d t o her withdrawal a s a voluntar y "retreat," th e staf f workin g wit h he r sa w thi s a s a respons e t o anxiety, intens e sadness , and resentment. Th e oneiroid stat e was a physiological consequenc e o f th e stres s o f relatednes s an d desire . Her predictio n o f a n ultimat e retrea t wa s linked t o he r recurren t and seriou s suicidal ideation . Control—Its Relatio n t o Autonom y It is apparent tha t in addition t o autonomy, th e schizophrenic individua l is concerned wit h issue s related to control, such a s the control of bound aries o f th e self, o f objects i n the environment, o r his or her mood. The schizophrenic person' s interes t i n autonom y reflect s a wis h fo r control .

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This arise s ou t o f hi s o r he r frustration , awarenes s o f limitations , an d the unresponsivenes s o f object s i n wha t i s t o thi s individua l a n insuffi cient environment . Some patient s manifes t a fantas y o f contro l i n whic h the y imagine , like th e youn g woma n i n th e precedin g vignette , the y ca n contro l thei r symptoms, tha t psychoti c state s ar e i n whol e o r i n par t volitional . Thi s patient ha d fantasize d tha t sh e coul d retrea t fro m he r problem s t o a private world . Suc h belief s ar e maladaptiv e i n tha t the y usuall y caus e patients t o argu e agains t reasonabl e treatmen t interventions , a s i s see n most frequently i n persons who decline medication an d relat e the fantas y that the y ca n contro l th e appearanc e o f thei r hallucinations . Whe n hal lucinations d o appear , the y explai n tha t fo r som e reaso n the y "d o no t choose" to contro l the m now . They avoi d th e nee d t o acknowledg e tha t they have a n illnes s with whic h the y must cope . When w e challeng e suc h fantasie s o f control , o r denia l o r delusions , it i s importan t tha t w e als o infor m patient s abou t ou r expectation s fo r their collaboration an d how we see them being able to assert meaningful , realistic contro l ove r thei r symptoms . Patient s ca n lear n t o identif y prodromal symptom s o f decompensatio n an d t o us e medicatio n appro priately t o avoi d relapses . Cognitiv e an d behaviora l intervention s di rected a t decreasin g socia l isolatio n o r stres s ca n hel p t o trea t sadnes s and anxiety , whethe r thes e occu r a s par t o f a n illnes s recurrenc e o r a s the psychological reactio n to that illness. Insight, self-understanding, an d familiarity wit h characteristi c copin g pattern s ca n assis t schizophreni c patients i n achieving a healthier adaptatio n t o their condition . Control i n Relationship s Social stresses , the demand s o f interaction s wit h people , also stimulat e a wish fo r control . Various behaviors , adaptations, resul t fro m th e schizo phrenic individual' s effort s t o cop e wit h thes e demands . A fea r o f th e consequences o f closenes s ofte n drive s th e patien t towar d isolation , which i s relativel y les s stressfu l becaus e ther e ar e fewe r stimul i an d les s demand fo r performanc e tha t ma y b e unrewarding. Ye t such isolatio n i s not consoling . Th e lonelines s an d inabilit y t o b e involve d i n gratifyin g activities, includin g interaction s wit h others , an d th e lac k o f assistanc e and suppor t o f other s ar e damaging . The schizophreni c perso n ma y the n see k a wa y t o obtai n th e value s

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of relationship s withou t feelin g threatened . T o accomplis h thi s sh e ma y seek a relationshi p i n whic h sh e i s i n contro l o f wha t th e othe r think s and feels. From the patient's perspective, any object may possibly undermine he r self-esteem b y threatenin g he r view o f herself . Object s ma y b e made saf e onl y whe n subjugated . Thi s contro l ma y b e enacte d throug h engrossment in fantasy o r by manipulation of the relationship. When workin g wit h schizophreni c patients , man y clinician s discove r that the y fee l restraine d an d deskilled. Thi s ma y resul t fro m th e schizophrenic individual's subtle attempts to undermine the effectiveness o f the clinician's psychological reasoning , objectiveness, and attention to external standards . Th e treatmen t contrac t ma y b e challenged . Th e patien t may attemp t t o convinc e th e clinicia n tha t rea l hel p wil l occu r outsid e the treatment framework , throug h a "special" relationship. B y enlistin g the clinicia n i n specia l work , suc h a s uncoverin g th e perpetration s o f a persecutor, th e patien t i s demonstratin g he r wis h fo r contro l ove r th e clinician's thoughts . The patien t ma y ofte n b e persuasive , offerin g th e person helping her the fantasy tha t she, the patient, ca n be cured if onl y someone wil l trus t and liste n t o her . She may blatantl y ignor e th e clini cian's presence , trea t th e clinicia n a s a n incompetent , o r threate n th e clinician wit h unleashe d aggressio n t o creat e distanc e whe n necessary . The patient may becom e preoccupied wit h fantasie s o f merge r such tha t the clinicia n direct s hi s o r he r effort s t o gettin g extricate d fro m a n entangled dyad rather than attending to the patient's symptoms or debility; or more subtly, the patient may refuse to acknowledge the therapist's actual qualities through idealization . The patient ma y tr y to straight-jacke t th e clinician b y restricting hi m or he r wit h regar d t o th e kind s o f question s an d area s o f inquir y tha t may b e initiated. The clinicia n ma y find that he or she is abl e to engag e the patien t onl y withi n a limite d range , tha t th e patien t allow s onl y certain kinds of inquiry . On e patient, upo n meeting her therapist for the first time, announced , "You r job i s to tak e car e of m y bod y fluids—see to i t tha t I' m fe d an d watered . The onl y thin g yo u ar e t o tal k t o m e about, apar t fro m m y health , i s ho w yo u ca n protec t m e fro m m y enemies." A mor e blatan t exampl e o f contro l occur s whe n th e patien t trie s t o undermine th e meanin g o f th e clinician' s word s an d understanding . Many patient s stat e that they objec t t o th e clinician' s reachin g indepen dent conclusions . Tha t is , th e patien t question s th e clinician' s righ t t o

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use insight , judgment , an d reasonin g t o evaluat e th e patient' s situation . Such a patient might say, "Those were not m y words. You can't sa y tha t because I didn't sa y it," or "Don' t pu t words in my mouth. You'r e tryin g to pu t thought s int o m y head." Th e ne t effec t o f thes e effort s i s to leav e the clinicia n feelin g incapabl e o f usin g hi s o r he r ow n reaso n t o under stand th e patient o r t o hel p th e patient se e him- o r herself . The patient' s efforts ar e aime d a t maintainin g isolatio n an d safet y becaus e words tha t impute insigh t o r awarenes s o f painful circumstance s ar e felt a s a threat . The for m o f contro l mos t difficul t t o manag e involve s th e patient' s attempt t o engag e someon e i n th e specia l relationship , describe d above , that exclude s other s an d promise s a unique an d privilege d status . Throug h an elemen t o f seductiveness , th e schizophreni c individua l ma y limi t th e clinician's activit y b y prescribin g th e condition s unde r whic h th e rela tionship mus t tak e place : Th e patien t ma y insis t tha t thei r relationshi p remain secre t (and , therefore , no t share d wit h othe r treaters , i n tur n preventing th e clinicia n fro m obtainin g valuabl e informatio n fro m col leagues an d deprivin g the m o f wha t h e o r sh e knows) ; th e clinician , o r other migh t b e proscribe d fro m raisin g concern s tha t hav e t o d o wit h the patient' s "illness " o r directin g attentio n t o lif e problems . Th e pre scription i s typically fo r th e object, b e it a clinician o r other , t o abando n interest i n treatmen t o r attentio n t o th e patient' s disabilities . Ther e is , further, a n effor t t o caus e th e clinicia n o r othe r t o se e th e patient' s symptoms a s les s pathologica l an d mos t strongl y t o identif y wit h th e patient's expresse d wis h fo r freedo m fro m treatment , supervision , o r other restrictions . Summarizing th e Aulonomy/Gontro l Dilemm a Coupled wit h th e desir e fo r contro l i s th e patient' s simultaneou s wis h for autonomy . Autonomy ma y be desired because it is socially acceptabl e to b e independen t an d self-sufficient , an d ther e ma y als o b e a n innat e wish fo r competenc e an d effectivenes s tha t ca n onl y b e associate d wit h autonomy. However , independenc e i s frightenin g an d i n som e respect s unrewarding. Autonom y ma y b e associate d wit h isolation . Th e pai n i n looking forwar d t o a lif e seemingl y filled wit h challenge s t o self-estee m and disappointmen t i s a dauntin g prospect . Th e schizophreni c perso n often yearn s fo r partnershi p wit h anothe r s o tha t lif e ca n becom e les s painful, les s lonely, and mor e bearable .

Understanding the Subjective Experience 10 5 Yet thi s nee d fo r contac t i s conflictua l becaus e o f th e anxiet y an d frustration experience d i n interpersona l relatedness . Nevertheless , tha t intimate contact is desired because, if it can be controlled and managed, it promises a degree of support and safety that the patient cannot otherwise experience . Th e patien t wil l attemp t t o balanc e thi s nee d fo r a relationship wit h hi s fea r o f it s consequence s throug h maneuver s tha t titrate intimac y accordin g t o hi s toleranc e an d reassur e hi m tha t th e partner in the relationship i s not uncontrollable , no t threatenin g overwhelming involvemen t no r sudden rejection an d abandonment. Corre spondingly, the clinician often experiences anxiety about loss of control when working with such patients. The intense, unconscious demands on the clinician provoke sometimes startling countertransference events. For example: A psychiatris t i n trainin g foun d i t difficul t t o spea k wit h hi s supervisor about his work with a young schizophrenic patient. The young doctor explained, "He [the patient] and I have such a special thing going; it's hard to explai n to anyon e else." Several month s later, the therapist, while waiting for the elevator in his apartment building, ha d th e distinc t fantasy , accompanie d b y a feelin g o f anxiety an d anger, that the patient (wh o was in fact on a locked unit twent y mile s away ) ha d followe d hi m home , ru n u p t o hi s apartment, and would get out of the elevator just as the therapist entered it. At that point, the doctor began to discuss his interaction with th e patient, beginnin g with hi s belie f (a s exemplified b y the story), tha t th e patien t wa s takin g ove r hi s life . Th e therapist' s reaction was to want to stop treating the patient. Loss The theme of autonomy is closely related to experiences or anticipation of los s (17) . The illness process itself robs the individual o f a degree of autonomous menta l experience . Furthermore , th e intens e ambivalenc e associated wit h trus t and relatedness presents the patient with alternatives implyin g differen t bu t constan t loss : I f th e schizophreni c perso n opts for vulnerability by trusting another and allowing for intimacy, he or she relinquishes some control. As noted, some patients who fantasize about tyrannica l contro l ove r other s woul d experienc e suc h a los s a s

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extremely threatening . Alternatively , choosin g t o remai n aloo f o r with drawn necessitate s los s o f suppor t an d understanding , impoverishmen t of emotiona l life . Thes e ar e not always consciou s "choices " and may b e dictated b y physiologica l o r unconsciou s factors , bu t th e experienc e o f loss is abiding and real, as was the case for the woman describe d below : A 46-year-ol d femal e schizophreni c entere d treatmen t wit h th e belief tha t sh e wa s a distan t relativ e o f "th e ol d woma n i n th e shoe." She claimed t o hav e twenty-nine children , an d in the initia l interview, th e therapist was prohibited fro m sitting in many differ ent chairs , lest h e inadvertentl y "crush " one o f th e children , al l o f whom wer e tin y an d invisibl e t o anyon e bu t th e patient . Withi n the first eighteen months of treatment, twenty-eight children "died"— through acciden t o r illness . Th e patient' s moo d remaine d bland. Two year s later , amids t muc h wor k an d change , includin g explo ration o f th e psychological significanc e o f he r last remaining "child " (and the underlying issu e of thi s patient's actua l childlessness) , th e child wa s "killed " i n a ca r acciden t th e patien t insiste d wa s he r fault. Sh e then became depressed, but allowed clinicians to support her, and was able to be more vulnerable an d genuine. The loss of functiona l capacitie s is a common an d devastating featur e of schizophrenia . Pas t skill s o r persona l qualitie s a s wel l a s moo d an d outlook ma y b e dramaticall y altered . Patient s ma y i n fac t hav e los t relationships, supports , and jobs, as well a s opportunities. Perhap s mos t importantly, the y hav e los t a self-image tha t wa s associate d wit h thos e goals and skills. One patient, a previously successful artist , felt that, as punishment fo r her accomplishments, her talents were "stripped" from her and that now she wa s no t fit t o dra w anythin g mor e tha n stic k figures. Sh e woul d become angr y at the occupational therapist' s urging her to draw, declaring, "That person is no more!" For many patients , thi s profound los s produces utte r discouragemen t and a tendenc y t o se e pas t capabilitie s a s unavailable . Thi s attitud e precludes recruitment of usefu l aspect s of potential ego functioning sinc e those aspect s o f themselve s ar e viewed a s dea d o r distant . Th e anxiet y that a schizophreni c patien t experience s i n socia l situation s migh t b e helped b y his o r her abilit y t o recal l a sense o f competenc e fro m earlie r social experiences , bu t very frequentl y tha t capacit y i s compromise d b y

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the profoun d sens e o f helplessnes s tha t i s associate d wit h th e sens e o f loss of th e old self. In clinica l experience , thi s sens e o f los s i s particularl y acut e wit h respect t o los s o f time , o f opportunities , an d o f relationships . Man y patients, however , ar e no t abl e t o consciousl y acknowledg e th e natur e of thei r loss . Typically, the y experienc e los s a s something tha t has happened t o the m a s a resul t o f outsid e forces . Th e schizophreni c patien t who has lost friendships o r a career will delusionally maintain that these things hav e bee n take n away . A patient wh o perceive s hersel f t o b e th e subject of persecution ma y clai m that the losses sh e has experienced ar e only a resul t o f he r persecutor' s effort s t o tur n friend s agains t her , convince employer s t o kick her out of a job, and so on. The psychologi cal force s favorin g thes e delusiona l interpretation s ar e evident: The los s is mor e tolerabl e i f denie d o r distorted. The delusion s i n tur n have tw o intriguing characteristics: 1. Th e delusio n suggest s a potentia l resolutio n fo r thes e losses . Th e persecutor could stop, or be persuaded to stop, or a cure could be foun d for th e damagin g effect s o f min d contro l experiment s an d th e like . Although th e possibility o f suc h a resolution ma y b e remote, i t offer s a magical hop e o f restitutio n t o th e patient an d often prompt s hi m o r her to enlist others in bringing about this release. 2. Unfortunately , th e delusions als o promote passivity . Copin g i s no t possible. The patien t experience s him - o r hersel f a s a victi m an d see s change a s a n externa l event , i f i t i s possibl e a t all . No t onl y doe s th e delusion see m t o preclude effectiv e adaptatio n an d treatment collabora tion, i t als o further s a disablin g psychologica l stat e o f helplessness , which predisposes th e patient to depression, futility, an d symptom exac erbation. Consider the following : A youn g man , wh o ha d bee n il l fo r severa l year s since hi s las t year in high school, reported the delusion that he had had electrical devices plante d i n his brai n a t the tim e o f hi s first hospitalization. These devices included a computer that told him what to think and occasionally mad e hi m hav e disturbin g sexua l thoughts . Thes e devices, he said, were implanted by psychiatrists, who were punishing him for having been rebellious toward his parents. Although initiall y angr y a t al l menta l healt h professionals , th e

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patient ha d ove r th e year s modifie d hi s views . H e ha d com e t o accept th e ide a tha t h e ha d disease d brai n tissu e an d tha t thi s i s what cause d hi s schizophrenia , whic h wa s responsibl e fo r hi s ag gressiveness. H e no w believe d tha t th e compute r i n hi s brai n wa s steadily, carefull y "zapping " the diseased parts of hi s brain, killing the schizophreni c parts . H e believe d tha t ultimatel y h e woul d b e cured and that then the computer could safely b e removed. Though a likeable young man, he was characteristically resistan t to participatio n i n treatmen t programs , unmotivate d fo r rehabili tative work, listless, and without goals for his future. Though ofte n superficially compliant , h e typicall y avoide d productiv e wor k a t home, becomin g progressivel y mor e reclusive , the n irritable , an d finally paranoi d an d disorganize d b y th e tim e h e inevitabl y re quired rehospitalization . His treatmen t wa s eventuall y furthere d whe n clinicians , takin g into accoun t hi s psychologica l experience , suggeste d tha t partici pating i n a n activit y progra m woul d promot e healthie r menta l functioning. The patien t cam e t o believ e tha t ne w brai n tissu e might grow a s a result of his work, an d this delusion helped him to increase his consistency an d motivation a t work. The defens e agains t acknowledgmen t i s suc h a ubiquitous featur e o f schizophrenia tha t i t ma y b e a source o f discouragemen t fo r clinicians . In this regard it is important to recall that this denial is in part a product of unconsciou s conflic t an d thu s a consequence o f th e patient' s psychi c distress. Los s i n it s polymat h form s i s vigorousl y defende d against , a s are memories of past selves or dreams that threaten to reveal the burdens of th e present. This defens e ca n tak e man y forms . Patient s ma y destro y picture s o f themselves, den y thei r name , alte r thei r dress , posture, bod y habit s (b y gaining o r losin g significan t amount s o f weight) , mutilat e themselves , and so forth. On e patient, when shown his high school yearbook pictur e from a year ago asked, "Do I look lik e him?" If one look s bac k a t the person on e was som e years ago, one remem bers old interests, values, and abilities and reflects o n how an d why the y have change d ove r time . Tha t proces s o f chang e woul d b e see n a s a result o f experience , reflection , decision , growth . Ther e ma y stil l b e a sense of loss , perhaps a loss of innocenc e o r newness, but the nature and

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process o f th e chang e ca n ordinaril y b e understood . Thi s experienc e o f continuity i s directly subverted by the illness experience in schizophreni c persons and represents yet another perspective on the dimension of thei r loss.

Safety We may begi n t o loo k a t the issue o f safet y b y reviewing wha t i t is tha t makes schizophreni c person s fee l unsafe : disturbance s i n self-object dif ferentiation; stres s associated with interpersonal relatednes s (du e to cognitive an d emotiona l demands) ; threa t t o self-estee m b y anyon e wh o may challenge th e patients' (ofte n delusional ) vie w o f themselve s and/o r their illness; delusions o f bein g controlled b y others; states o f paranoia , including fear s o f bodily , spiritual , o r menta l harm ; intense , disruptiv e states o f anxiety , producin g discontinuity ; fear s o f helplessness ; an d interminable emptiness . The concer n fo r safet y represent s th e patient' s wish t o contro l thes e phenomena o r someho w t o creat e a haven secur e against these threats. We have observed many behaviors whose principal ai m appears to be the maintenanc e o f a feelin g o f safet y (18) . Som e ar e particularl y rele vant t o th e situatio n o f th e treatmen t alliance . I n mos t instances , th e most threatenin g aspec t o f a therapeuti c encounte r i s th e clinician' s capacity t o observe , reflect , an d pose question s t o th e patient, a process that inevitably force s th e patient to confron t on e o r another face t o f hi s or her liabilities or defenses agains t acknowledging them . Some patient s mus t contro l al l inquiry : Ever y tim e he r doctor bega n to speak , on e patien t place d he r hands firml y ove r he r ears. After som e months o f this , sh e brough t i n a frame d pictur e o f herself , thre w i t o n the therapist's desk, and, pointing to the cracked frame, declared, "Can't you se e th e glu e isn' t holding ? It' s becaus e peopl e ar e tryin g t o loo k a t the picture , an d I can't alway s sto p them. " The patien t explaine d that , whenever anyon e cam e int o he r room , sh e woul d tur n th e pictur e fac e down bu t tha t sh e wasn' t "fas t enoug h sometimes. " The therapis t sug gested ther e wa s a paralle l betwee n th e pictur e an d th e patient . Th e patient fel t othe r people's looking was destructiv e t o th e frame an d that the therapist' s word s wer e someho w dangerou s t o her . "Perhaps, " th e therapist suggested , "you'r e afrai d i f yo u tak e you r arm s awa y fro m

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your ears , you'l l crack . But, " h e added , " I tak e you r showin g m e th e picture as a sign that you want me to know somethin g about you." Another patient , wh o participate d complacentl y i n hi s activit y pro gram a t th e da y hospital , wa s routinel y pleasan t unti l hi s cas e manage r attempted t o discus s treatmen t goal s wit h him . H e woul d the n predict ably becom e belligeren t an d accus e he r o f tryin g t o seduc e o r castrat e him. Althoug h apparentl y willin g t o coexis t peacefull y an d indefinitel y in th e da y program , h e intensel y resiste d an y effort s t o brin g hi m t o consider change, hi s future , o r eve n th e notio n o f fulle r recover y fro m his severe psychotic disorder. Patients diffe r i n th e degre e t o whic h the y exclud e part s o f thei r lif e from inclusio n i n the treatmen t process . The degre e o f symptomatolog y bears littl e relationshi p t o th e breadt h o f scrutin y deeme d permissible . This i s importan t sinc e to o ofte n prognosi s i s base d simpl y o n th e intensity o f patholog y rathe r tha n o n th e limitation s th e patien t place s upon wha t ca n an d canno t b e explored . On e patien t tolerate d he r rela tionship wit h he r therapis t an d thei r wor k togethe r exceedingl y well , except whe n aske d abou t he r sexua l life . A t thos e times , th e patien t would fee l "possessed " b y th e spiri t o f he r dea d grandmother , becom e verbally an d physicall y abusive , an d appeare d t o hallucinate . Thoug h quite delusional , th e patien t allowe d broa d exploratio n o f he r lif e an d behavior an d benefitte d fro m treatment . A secon d patien t wa s alway s stiffly polit e wit h hi s therapist , punctua l fo r meetings , an d neve r mani fested loud , dramatic , o r unmanageabl e symptomatology . However , h e constantly insiste d tha t his lif e wa s nobody' s busines s bu t his own , tha t he ha d ever y righ t t o liv e i t a s unconventionall y a s h e wanted . Thi s translated int o hi s refusa l t o revie w hi s maladaptiv e behaviors , despit e the fact that, at 37, he had spent nearly half of his adult life in hospitals. In their desperate efforts t o establish an atmosphere of safety, patient s may b e force d t o exclud e mos t form s o f intimacy , wit h a resultin g impoverishment in their social experiences (19) . A patient who could not tolerate an y acknowledgmen t o f he r illness could maintai n relationship s with peopl e onl y unde r stric t circumstances . Sh e woul d insis t tha t on e and al l tak e a n "oath " statin g thei r belie f tha t he r trouble s wer e th e result o f mistreatmen t b y he r doctors . He r conversation s wit h he r few intimates wer e limite d t o repeate d harangue s abou t th e injustice s don e to her. Such a rigid posture dramaticall y limit s the range and effectiveness o f

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the individual' s experienc e wit h other s (20 , 21) . I n a globa l sense , th e motive for such rigidification i s the patient's perception that such drasti c measures ar e require d fo r a sens e o f safety . A s w e hav e alread y dis cussed, thes e measure s als o mee t othe r needs , suc h a s improvemen t o r resolution o f difficultie s wit h self-objec t differentiation , resolvin g con cerns abou t autonom y an d control , an d perhap s mor e psychologica l continuity. A patient in a day hospital who experienced thinking as "unsafe" was encouraged in patient government meetings to formulate position papers or uniqu e perspective s o n topic s tha t differentiate d hi s thinkin g fro m others. Thes e experience s wer e the n reviewe d wit h th e patien t an d em phasis place d o n pointin g ou t th e uniquenes s o f th e patient' s thinkin g and how i t differed fro m others' as well a s on how the patient may have been abl e t o influenc e othe r people' s thinkin g an d reviewin g wit h hi m how thi s proces s ordinaril y happens . I n thi s way , th e clinicia n emphasized the patient's autonomy , contro l ove r his thinking, an d his unique ness a s well a s providing a model fo r th e patient abou t ho w peopl e ca n be influence d b y others ' thought s withou t tha t bein g a malignan t o r damaging process. The issu e o f safet y return s u s t o th e concept s tha t bega n ou r discus sion o f th e subjectiv e experienc e becaus e i t remind s u s tha t ther e ar e powerful reason s fo r an y schizophrenic individual's adoptin g the copin g mechanisms h e o r sh e no w manifest s t o th e clinician . Behavior s an d thoughts represen t multimoda l attempt s t o cop e wit h th e schizophreni c experience. Amon g al l th e aspect s o f tha t subjectiv e experience , safet y and the wish to avoid feeling overwhelmed or threatened or experiencing a fragmentation o f one's sense of self remain major concerns that modif y the patient' s abilit y t o cop e and , especially , t o engag e i n a treatmen t alliance (22) . Aspects of the patients' subjective experiences, such as concerns abou t control, loss, and safety, may be manifest in their behavior and thinking, or the y ma y b e inferre d throug h carefu l clinica l observation . I n eithe r case, we ar e ultimately intereste d i n the internal psychologica l prioritie s that motivat e th e patient . On e patien t ma y manifes t concer n abou t safety b y sayin g overtly , " I don't trus t people here . Peopl e ar e trying t o hurt me." Another patient migh t not discus s feelin g unsaf e fo r fea r tha t by acknowledgin g hi s concer n h e would compromis e th e efficac y o f hi s efforts t o protec t himself . Tha t patien t ma y nonetheles s exhibi t behav -

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iors from which we ca n infer a concern abou t safety, a s in the case for a patient wh o avoid s discussin g ange r i n famil y therap y sessions . Thi s patient ma y den y tha t ange r exists , despit e report s o f fighting i n th e home. Therapeuti c exploratio n o f th e relationship s i n th e hom e migh t be a threat to his efforts t o fight for his place there. Inference abou t aspect s o f th e subjectiv e experienc e ca n assis t th e strengthening o f th e treatmen t alliance . B y decipherin g th e meanin g o f obtuse behaviors , an d bein g prepare d wit h ou r understandin g o f th e critical psychologica l issue s concernin g th e schizophreni c patient , w e may ac t t o facilitat e th e patient' s adaptation , whethe r o r no t h e o r sh e participates wit h insight . Whe n w e perceiv e tha t a patient feel s unsafe , for exampl e an d have a n idea abou t wha t threaten s hi m o r her, we ca n structure ou r interaction s s o a s to increas e a feeling o f competenc e an d security. This was done for the man in the following example : A 31-year-old schizophreni c patien t appeare d t o defen d himsel f against an y affectiv e experienc e o f loss . H e develope d a ritua l o f tearing the obituary colum n out of the newspaper as soon a s it was delivered t o th e unit , proclaimin g h e di d thi s "t o protec t th e pa tients fro m th e lying , Jewish press. " This behavio r wa s on e mani festation o f a n intricat e delusiona l syste m i n which n o on e "reall y died" but, instead , fals e report s o f thei r death s wer e circulate d b y Jews a s part of thei r plan t o tak e ove r th e world. Thus, i t was fel t helpful t o engag e th e patient in som e benig n activit y i n which los s might occu r a s par t o f th e dail y routine , bu t i n a manne r suffi ciently nonthreatenin g s o that , ove r time , th e patien t coul d begi n to examine it. Since he had expressed a n interest in botany, he was encourage d to work i n th e garden . Th e first approac h emphasize d activit y without discussion . That is , the patient would prun e branches, cut away dea d leaves , an d s o on , an d n o commen t woul d b e made . Gradually, th e activitie s therapis t bega n t o commen t abou t wha t the patien t wa s doing , alway s stayin g a t th e concret e leve l o f th e gardening activity, saying , fo r example , " I notice d yo u cu t awa y those dead leaves." Over time, in his individual therapy, the patient began t o discus s th e cycl e o f lif e an d deat h a s evidence d i n th e garden and , from there , to explore th e themes o f deat h an d loss i n looking at other people an d their experiences.

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In thi s case , th e natur e o f th e gardenin g activit y ha d t o b e clearl y described t o the patient i n advance. What was not initiall y discusse d wa s the relationshi p betwee n thi s interventio n an d interna l psychologica l concerns tha t th e clinicia n sa w t o b e relevan t t o th e patient' s recovery . This strateg y i s analogou s t o th e withholdin g o f a n interpretatio n i n psychotherapy unti l the patient i s able to hear i t and us e it productively . The categories we have described represen t commo n theme s that hav e been apparen t t o u s i n ou r wor k wit h chroni c schizophreni c patients . That i s no t t o sa y tha t the y ar e unvaryingl y presen t o r tha t al l patient s will b e adequatel y serve d simpl y b y attendin g t o thes e themes . Rather , they provide a starting point an d a structure throug h whic h th e clinicia n can orde r hi s o r he r work . Th e clinicia n mus t activel y explor e schizo phrenic patients' experience s of themselves and , in that process, generat e hypotheses tha t reflec t a tentativ e understandin g o f thos e patients . Suc h hypotheses lea d t o idea s abou t treatmen t interventions , th e result s o f which woul d hel p to infor m th e clinician a s to whethe r o r no t hi s or he r hypotheses wer e accurate . Th e mor e th e clinicia n i s expose d t o an d aware o f th e kind s o f psychologica l response s tha t characteriz e th e schizophrenic patients ' adaptatio n t o thei r illness , th e mor e likel y tha t his or her treatmen t intervention s will be relevant t o that give n patient .

PRIORITIES AND FLEXIBILITY Finally, w e com e t o ou r las t perspectiv e o n th e subjectiv e experienc e o f the schizophreni c individual . I n Tabl e 2.1 , sectio n III , w e direc t th e clinician's attentio n t o issue s tha t reflec t th e integratio n o f patients ' psychological reaction s t o thei r illness. Until thi s point, i t may have bee n possible t o conside r th e themes , concerns , an d categorie s o f th e subjec tive experience i n isolation . Thi s clearl y doe s no t mirro r th e psychologi cal lif e o f th e patient . Coinciden t an d eve n conflictin g concern s ca n occupy schizophreni c person s an d caus e comple x compensator y behav iors to arise . We have allude d t o th e ambivalen t natur e o f th e patient's menta l life , particularly wit h regar d t o importan t issue s suc h a s loss, autonomy an d self-esteem. Th e ide a tha t th e patien t possesse s a n implici t hierarch y o f priorities, which determine s t o wha t degre e an d ho w a given psycholog ical concer n i s handled , i s a n abstractio n o f a common-sens e principle .

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It conceptualize s a question w e naturall y begi n t o ask : Ho w d o schizo phrenic individual s experienc e al l o f thes e aspect s o f th e subjectiv e ex perience a s thes e aspect s interac t withi n themselves ? Whe n considerin g the patient' s characteristi c managemen t o f a give n issue , suc h a s self object differentiation , w e mus t wonde r ho w importan t thi s matte r i s t o him o r her , compare d t o concern s abou t safety . Ho w doe s tha t issu e influence self-vie w an d world-view ? Ho w doe s i t alte r th e confirmatio n of hi s o r he r delusions ? Whe n d o som e psychologica l prioritie s conflic t with others, and how doe s the patient resolve them? Given th e comple x demand s o n th e patient' s psyche , ho w effectivel y does h e o r sh e rende r thes e conflict s settled ? Ca n w e imagin e that , because o f intensel y conflictin g priorities , th e patien t i s hemme d in , restrained, in his or her ability to effect satisfactor y relatednes s or gainful functioning? W e can then conceptualize th e patient's flexibility, which i s a measure of how beset by rigid demands is the patient's ego. A patient who mus t struggle t o mee t too man y priorities tha t conflic t too muc h i s les s abl e t o conside r change . Becaus e thes e issue s affec t character functioning an d relatedness, this state may be said to affect th e patient's availabilit y t o treatment . Ca n th e patien t tolerat e th e ide a o f change or accept inquiry and/or intimacy ? The patient' s availabilit y ca n b e assesse d o n a numbe r o f differen t levels. On e coul d asses s the schizophrenic patient' s willingness an d ability t o participat e i n a psychosocia l treatmen t paradigm . On e migh t consider th e patient' s abilit y t o b e involve d i n a medication trial . Fro m all th e relevan t clinica l data , includin g th e assessmen t o f subjectiv e ex perience, the treatment team or a given clinician can construct an assessment of th e patient's ability to participate directly in a given task . Constructing a hierarch y o f prioritie s help s u s understan d ho w th e patient goe s abou t resolvin g th e requirement s impose d o n hi m b y hi s illness. Th e subjectiv e experienc e inform s u s abou t th e origi n o f priori ties. The patient' s behavior , thinking , an d mode s o f adaptatio n tel l u s about ho w h e seek s t o resolv e thos e priorities . Thi s awarenes s o f th e patient's effort s t o balanc e hi s competin g need s allow s fo r mor e em pathic an d creativ e treatmen t planning . Thi s approac h create s i n th e clinician a sensitivity t o th e patient's experience , t o ho w th e patient wil l receive a particula r treatmen t interventio n an d contribut e t o th e clini cian's assessmen t o f ho w t o promot e th e treatmen t allianc e an d ho w best to revise the treatment plan.

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The consideratio n w e hav e give n t o th e subjectiv e experienc e i n thi s phase o f ou r clinica l assessmen t allow s u s t o mak e judgment s an d predictions abou t tw o importan t area s o f ou r wor k wit h patients . A s w e have discussed , we lear n first about what patients ca n an d cannot d o a t this time , an d second , wha t patient s reques t o r deman d o f us . I n th e latter instance , w e ar e evaluatin g wha t message s patient s giv e t o th e environment, ho w the y communicat e thei r toleranc e fo r an d interes t i n relatedness or other aspects of social functioning. The patient who insist s that no one mention or discuss with him that he has an illness, refuses t o participate i n psychosocia l treatments , o r avoid s takin g medication s poses differen t challenge s tha n th e patien t wh o i s complian t i n som e respects but who believe s that her illness is a just punishment from God . Such a patient might insist that the clinician agree there is no justificatio n for an y attempt s a t promoting he r recover y an d deman d tha t th e clini cian collaborat e i n he r remainin g chronicall y disfunctional , belo w he r potential. Bot h suc h patients manifes t differen t form s o f maladaptatio n that impose different requirement s on the environment. Treatment plannin g take s int o accoun t thes e patient-authore d de mands by clinicians' first understanding the priorities that these demands reflect. Thi s aspec t o f ou r experienc e o f th e patien t i s ofte n th e mos t intense an d difficul t par t o f ou r work . Befor e w e begi n t o explor e th e patient's subjectiv e experience , w e ar e i n man y case s acutel y awar e o f the patient' s effec t o n us . Ou r countertransferenc e t o th e schizophreni c patient is in this way extremely informative, especiall y regardin g critica l aspects o f th e patient' s psychologica l functioning . Thos e prioritie s tha t are most importan t ar e usually, i f no t always , manifes t i n th e demand s the patien t make s o f us . Fo r thi s reason , th e prioritie s associate d wit h this critical aspec t of th e patient's behavio r are most important for us to address i n th e treatmen t plan . Appreciatio n o f thi s clinica l issu e thu s provides u s wit h som e guideline s abou t wha t t o addres s first o r mos t urgently. I t is likely, also , that thes e priorities wil l requir e th e mos t tac t and creativit y i n presentin g a treatmen t pla n tha t doe s no t overwhel m the patients ; tha t doe s no t stres s the m beyon d thei r capacities ; tha t begins where they are able to begin.

3 From Understanding to Action: The Alliance and the Treatment Program

Uur goa l i n emphasizin g th e natur e o f th e treatmen t allianc e wit h schizophrenic patients is to bring about the patients' increased collaboration i n an d commitment t o treatment an d thus promote thei r effectiv e coping wit h thei r illnes s (1-6) . Thes e aim s ar e reflecte d i n th e first section o f Tabl e 3.1 , which outline s th e goals o f treatment . Particula r attention is given to the attitudes communicated to patients and to the understanding patients derive from the work. I n this sense, these treatment goals are particular to our interest in the treatment alliance and its place in the implementation of any therapeutic modality. A recurrent theme is our emphasis on collaboration rather than compliance, a theme that distinguishes ou r treatment approach fro m those that do not actively consider the patient's complicated role in accepting and effectively usin g help. Most importantly, w e acknowledge tha t the patient's activ e participation i s a prerequisite t o the treatment process. Without suc h collaboration , th e patient wil l b e a t best passively compliant. A patient who merely consents to be in a treatment setting cannot effectively cop e with his or her illness. We prefer to see compliance as a natural consequenc e o f understandin g an d collaboration rathe r than a goal in itself. When reviewing the psychological consequence s of the schizophrenic illness process, we have noted the dominance of patients' experience of diminished self-estee m (7—8) . Man y realitie s imping e upo n patients ' experience of efficacy an d satisfaction. They are unavoidably confronted with evidence of often-denied or controverted vulnerabilities. Self-acceptance requires acknowledgment of those vulnerabilities and of an image of th e self representin g som e diminished capacities ; it also requires intense experiences of loss and discontinuity. In order to accept participa119

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Table 3. 1 I. Goal s of Treatment A. Increase d Collaboration (versu s "Compliance") B. Increase d Self-Estee m C. Understandin g and Management of Symptoms D. Copin g with Psychological Responses to Illness E. Developin g Effective Cognitiv e and Behavioral Responses II. Treatmen t Frame A. Establishin g the Clinician's "Presence" 1. Separateness , Uniqueness, Limitations, Fallibility, Empathy, and Hope B. Presentin g Model of the Illness 1. Construc t Acceptable to Patient; Timing C. Treatmen t Tasks D. Patient' s Goals and Treatment Goals III. Treatmen t Alliance Techniques A. Genera l Principles 1. Reexploratio n of Subjective Experience 2. Reinforcemen t o f Treatment Frame; Limitations 3. Ton e B. Th e Parallel Dialogue C. Th e "Resigned" Patient D. Countertransferenc e tion i n rehabilitation , medicatio n administration , o r othe r treatments , the patient mus t be able to tolerate some acknowledgement o f a need fo r help an d o f th e limitation s tha t thi s implies . Th e followin g exampl e illustrates thi s issue. A 28-year-ol d woman , wit h a twelve-yea r histor y o f chroni c schizophrenia, tol d he r psychiatrist, i n his office, tha t someon e wa s listening t o he r throug h th e wall s o f he r bedroom . Sh e als o sai d that sh e ha d hear d peopl e discussin g he r o n th e stree t outsid e he r home. She ha d begu n t o complai n o f feeling s o f mistrustfulnes s som e three week s before . Sh e had continue d t o atten d he r da y program , but woul d no t ea t lunc h i n th e hospita l cafeteri a becaus e "peopl e there laug h abou t m e whe n I wal k in. " Sh e ha d agree d t o a n increase i n he r neuroleptic , whic h serve d t o decreas e th e intensit y of thes e experiences . However, he r improvemen t le d to he r t o sto p the medication afte r on e week .

From Understanding to Action 12 1 The patient ha d previously bee n abl e t o discus s he r psychotic symptoms wit h th e psychiatrist an d th e rational e fo r medicatio n use, while still maintaining that "these things that happened to me may be true; I think I can tell the difference between hallucinations and real events." Her strongest reason to doubt the reality of her symptoms prove d t o b e he r religiosity . A s i t develope d i n he r treatment, th e most ego-dystoni c aspec t of he r delusions wa s the fear tha t sh e migh t b e o r becom e possesse d b y th e devil . Th e psychiatrist helped the patient to contrast this irrational fea r with the multiple evidences of her kindness, scrupulosity, and adherence to her religious beliefs. In th e week s an d month s prio r t o thi s decompensation , th e patient had been frustrated by her lack of progress and particularly by her difficulty i n working (sh e had withdrawn from two volunteer jobs arranged by her day program). She found social demands quite stressful and became easily discouraged if her responsibilities or performance did not meet her own high expectations. She complained bitterl y tha t famil y an d day progra m staf f di d no t "support" her when sh e discussed ambitiou s plans for full-tim e wor k or school. On th e da y sh e presente d he r paranoi d concer n abou t eaves dropping, th e patien t wa s uncharacteristicall y insisten t tha t he r psychiatrist accept these symptoms as true. When he demurred, she stormed out of his office saying, "You don't support me either! No one does!" The psychiatrist wondere d i f sh e would b e safe an d contacted her supervised residence . Late r that night, the patient called . She had been unable to sleep and related terrifying experiences: feeling paralysed; vivid visua l hallucinations ; a sensation lik e th e to p of her head being lifted off; premonitory dread; and the fear that her body was being taken over by the devil. In contrast to her attitude in her earlier session , th e patient allowe d he r psychiatrist t o empathize with her fear and confusion without insisting on his acceptance of these experiences as evidence of demonic possession. She asked the psychiatrist if anything might help her sleep. He noted that these symptoms could be due to anxiety , a s he understood these phenomena. They discussed increasing her neuroleptic

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and addin g a mino r tranquilize r fo r sedation . Th e psychiatris t reminded th e patien t o f he r previous successfu l effort s i n titratin g medication to control he r acute symptoms. This interactio n wa s mad e possibl e b y th e patient' s allowin g herself t o be vulnerable, letting her psychiatrist help her in the way he could—althoug h tha t required he r acknowledging tha t she wa s not managin g wel l enoug h o n he r own . The patien t migh t stil l wonder abou t th e "reality " o f he r symptoms , bu t sh e truste d he r psychiatrist's capacit y to help her. That trus t i n tur n wa s buil t o n th e treatmen t alliance , wit h it s model o f th e patien t a s a good an d spirituall y correc t perso n an d the implied mode l o f th e illness and treatment presented fairl y an d openly, withou t embellishmen t o r exaggeration . Becaus e th e psy chiatrist stood consistentl y fo r a compassionate an d reasoned vie w of he r and her illness, the patient was abl e to return for help whe n that proved necessary . Our formulatio n o f a workin g treatmen t allianc e proceed s towar d this goal an d offers strategie s fo r achievin g it . We will recapitulat e thes e points, bu t t o som e exten t the y suffus e al l o f wha t w e say . Understand ing the patient's difficult y i n tolerating self-awareness underlie s our conceptualization o f th e disorder and its manifestations. Thi s understandin g is a cornerston e o f ou r thoughtfu l treatmen t o f delusion s an d ou r vie w of thei r importance t o the schizophrenic individual. I t is also reflected i n our recognizin g ho w frequentl y schizophreni c person s ar e critica l o f themselves. The y blam e themselves unfairl y fo r their illness, for relapse s and failures , an d especiall y fo r failin g t o satisf y thei r ow n o r thei r families' expectations . The y als o suffe r fro m thei r inability t o formulat e realistic expectation s o r b e satisfie d wit h them , sinc e suc h formulation s often impl y temperin g grandios e demands . I n these issues ar e containe d the sources of patients' sadness and demoralization . The goal s o f ou r work , a s liste d i n Tabl e 3.1 , ma y eve n see m self evident, give n th e discussio n i n th e precedin g tw o chapters . Increase d collaboration an d improve d self-estee m hav e bee n th e clario n motif s o f this presentation . I n sectio n I.C , "Understandin g an d Managemen t o f Symptoms," we present an issue derived fro m principles se t forth earlie r in the book. We have proposed that the conceptual mode l of schizophre nia w e outline d i n chapte r 1 ca n b e an d shoul d b e presente d t o th e

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patient whe n an d to th e degre e h e o r sh e i s abl e t o us e th e informatio n productively. W e ca n sometime s depen d o n th e patient' s curiosit y t o help us know ho w muc h to say. The creative and empathic introductio n of thi s materia l i s nevertheles s crucial . Althoug h i t ma y b e stressfu l fo r the patient , a rationa l understandin g o f hi s o r he r illnes s ca n hel p t o resolve self-blame , confusion , an d irrational fear s abou t the future. Thi s knowledge i s fa r fro m bein g a panacea , bu t i t i s a n asse t i f i t ca n b e accepted. We als o recommen d th e patient' s activ e inclusio n i n treatmen t deci sion-making an d particularly i n the selection o f treatmen t options . Thi s can b e a troublesom e issu e becaus e i t require s th e clinicia n t o tolerat e relinquishing some of his or her authority. More importantly, it demands discretion and judgment in determining both how to make opportunitie s for the patient's participatio n availabl e an d when th e clinician's author ity mus t b e appropriatel y asserted . Thes e issue s ar e exemplie d i n th e following: A patien t wa s discussin g he r treatmen t goal s i n a patient-staf f treatment plannin g meeting . I n additio n t o goal s o f reducin g sui cidality, copin g wit h he r delusiona l interpretation s o f events , an d family stresses , th e patien t brough t u p he r difficult y toleratin g aggression i n others. This had caused her considerable difficult y i n the past , i n particula r i n wor k settings . Whe n runnin g a cas h register, she would frequentl y becom e anxious an d disorganized i n response to irritated and critical customers . The patien t wondere d abou t joinin g a n activit y tha t woul d al low her to role-play and learn techniques for coping with and using assertiveness. Her therapeutic activities coordinator was noticeabl y uncomfortable whe n thi s wa s mentioned . Th e coordinato r note d that th e patien t ha d bee n reticen t i n challengin g hersel f i n othe r activities an d ha d generall y worke d belo w he r potential . Fo r thi s reason, th e coordinato r sai d th e patien t woul d probabl y find th e role-playing activit y too stressful , particularl y becaus e that activit y required toleranc e o f observatio n an d criticis m b y othe r patient s and staff. Th e coordinator ende d by saying, "I just don't want you to try something and fail a t it." a The staf f discusse d thi s interactio n a t a late r meetin g an d de cided to allo w the patient to choose whether or not she would joi n

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the role-playin g activit y afte r receivin g recommendation s fro m th e activity coordinator . I t wa s fel t tha t th e patien t wa s capabl e o f assessing th e coordinator' s advic e an d the n freel y deciding . I f sh e "failed" a t th e activity, i t would b e uncriticall y viewe d a s a learning experience. The activity coordinato r was urge d to collec t her impressions o f the patien t an d presen t the m i n th e contex t o f he r exper t assess ment, includin g recommendation s base d o n th e activit y coordina tor's experience . I n this way , th e patient wa s give n a consultatio n but retained , appropriately , th e righ t t o tak e o n a challenge . N o serious harm would hav e eventuated fro m he r "failing," and "fail ure" itself wa s no t certain , thoug h ver y possible. Th e patient electe d to follo w th e coordinator' s advic e an d delaye d enrollment i n tha t activity for a few weeks. Physicians certainl y retai n a crucia l authorit y ove r th e accurat e use s of medications . Bu t within thi s domain, there are many occasions wher e choices amon g reasonable alternative s ca n be made in consultation wit h the patient. The simple exercise of prerogative can meaningfully suppor t a patient' s self-esteem . Whe n a specific treatmen t i s indicated, th e rationale fo r thi s decisio n shoul d b e plainl y presented . Thes e ar e common sense principle s tha t ar e nevertheles s neglecte d du e t o th e mistake n assumption tha t the patient is utterly apathetic or unable to comprehen d what w e wis h t o present . Thoug h disturbance s i n communicatio n an d relatedness ma y b e present , regardin g th e patien t a s a n unconcerned , unthinking entity is hopelessly detrimenta l t o the treatment alliance . The ac t o f explainin g implicitl y introduce s an d late r maintain s a model fo r comprehendin g illnes s an d subjectiv e experienc e apar t fro m the patient' s autochthonou s view . W e hav e referre d t o thi s proces s a s demystifying bot h illnes s an d treatmen t becaus e th e clinician' s mode l presents reaso n an d clarit y tha t th e patien t ma y over tim e revie w an d accept. A t best, the clinician's understandin g o f th e patient is organized, hopeful, realistic , an d fre e fro m unreasonabl e expectations , hars h judg ments, o r guilt . The patien t ma y reconcil e himsel f t o tha t mode l over time becaus e i t instill s i n hi m a feelin g o f contro l (a n interna l locu s o f control) mor e satisfyin g an d effectiv e tha n hi s illusions o f mastery . Du e to limitations impose d b y his illness and his psychological respons e to it,

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each patien t differ s i n hi s relativ e capacit y t o accep t hel p an d informa tion. Thi s mean s tha t treatmen t plan s wil l necessaril y b e individualize d and require creativity even in the method of their presentation. Indeed, on e o f ou r mos t importan t task s i s t o enlighte n patient s regarding th e existenc e i n the m o f psychologica l reaction s t o a n illnes s they ma y o r ma y no t acknowledge—reaction s tha t ar e usually no t con sciously understoo d bu t tha t d o determin e a grea t dea l o f th e patient' s affective lif e an d behavior s an d thu s ar e a not inconsiderabl e sourc e o f frustration an d uncertainty . Schizophreni c patients , lik e othe r people , are often unawar e of self-defeating pattern s or of the practical price they pay fo r avoidin g conflic t o r confrontatio n i n a n are a o f vulnerability . Exaggerated fear s o f menta l incompetenc e an d mystificatio n over th e causes of impairments in relatedness are among the common antecedent s of suc h maladaptiv e response s a s socia l withdrawa l an d avoidanc e o f challenges in the service of avoiding confrontation wit h cognitive limitations. Clinicians ca n us e a n educativ e paradigm , talkin g abou t schizophre nia and the common psychological response s to the disorder, or they can rely o n traditiona l modalities , suc h a s supportive psychotherapy , milie u therapy, and rehabilitative treatments, to inculcate principles and convey pragmatic recommendations . Al l interpersona l therapeuti c modalitie s offer opportunitie s fo r reflectio n o n th e cognitiv e an d behaviora l pat terns that manifest th e patient's psychological adaptation . The five goals noted in Table 3.1, section I, encompass the breadth of change that is the desired outcome of any successful treatment . Althoug h we have chosen to focu s o n the treatment alliance, it is clear that a wellfunctioning, maintaine d treatmen t alliance will b e accompanied b y positive psychologica l an d behaviora l change . Indeed , thes e goal s ma y b e seen a s genera l treatmen t goal s themselves . W e realize , however , tha t work wit h schizophreni c individual s i s ofte n no t reducibl e t o th e con cerns we present. Attention to environmental conditions , to physical an d psychological complications , an d t o sever e o r debilitatin g symptom s may predominate treatmen t planning. I n such cases, the goals specific t o the treatmen t allianc e will , i n ou r view , stil l b e critica l bu t a s on e face t of a n integrated, complicated task .

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THE TREATMENT FRAME When clinician s identif y concern s abou t th e treatmen t allianc e wit h a given patient , the y mus t the n organiz e thei r effort s t o achiev e th e goal s we hav e outline d above . Th e remainde r o f thi s chapte r wil l sugges t a plan t o effec t th e principle s w e hav e se t forth . W e wil l orien t ou r presentation largely from the perspective of the individual clinician working to establis h a treatmen t allianc e wit h a schizophreni c individual . Thi s outline is appropriate to any treatment modality and useful regardles s of the clinician's discipline. The plan can also be part of a multidisciplinary treatment effort, fo r what we learn about the patient's subjective experience an d other psychological concern s will b e relevant an d adaptabl e t o the work o f al l members of a treatment team . The reader can follow th e discussion usin g the outline in Table 3.1, sections II and III. In an y treatmen t setting , w e begi n b y definin g wha t th e treatmen t i s and what it is not, the roles or expectations of both clinician and patient, and th e goal s o f th e work . I n psychoanalyti c writing , thi s i s ofte n re ferred to as the process of setting the treatment "frame." Although man y times, throug h habitua l oversigh t o r ignorance , thi s crucia l exercis e i s neglected, it s theoretica l an d practica l importanc e i s well-established . Selzer (9 ) ha s emphasize d th e importanc e o f a treatmen t contract — essentially th e proces s w e ar e describin g here—i n wor k wit h borderlin e patients. Th e rol e o f th e treatmen t fram e i n wor k wit h schizophreni c individuals i s n o les s centra l no r les s critica l wit h respec t t o outcome . Patients wh o ar e mistrustfu l an d ofte n misperceiv e others ' action s re quire a clear an d consisten t structur e withi n whic h thei r treatmen t ma y occur. Even at the beginning of their relationship, the clinician is often force d by the patient's behavior or importuning to define for both of them what responses ar e and are not possible. In initial contact s with schizophreni c patients, many clinicians have had experiences i n which the y ar e prematurely asked for their "diagnostic impressions." Or they are made to fee l that if they proceed with their work, they will lose the patient's trust and goodwill because , fo r example , th e patien t ha s state d tha t sh e i s no t il l but i s bein g treate d unfairly . No t uncommonly , th e patien t urge s th e clinician t o defen d o r champion he r or his cause in opposition t o other s who hav e bee n punitiv e an d prejudiced . A s w e hav e discusse d previ -

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ously, the psychological motive s for these behaviors are complex, but no less comple x i s th e predicamen t i n whic h well-meanin g clinician s ca n soon find themselves. Our approach to the beginning of the treatment is based on principles we delineate d i n chapte r 2 . W e mus t first tak e car e no t t o commi t ourselves t o promise s o r conceptual position s i n the earl y phases o f ou r work. Whe n a patient barrage s u s with demands , we mus t insist on ou r right—like th e patient's—to tak e time to reflect before makin g decision s or agreein g t o a poin t o f view . Thi s i s especiall y importan t whe n w e discuss th e patient' s "diagnosis. " Ho w frequentl y th e patien t states , provocatively o r defiantly , " I suppos e yo u thin k I' m crazy , too. " The appropriate response , in the earl y part of treatments, is for th e clinicia n to recoun t wha t h e ha s bee n tol d abou t th e patient , whil e confrontin g the patient' s insistenc e tha t h e mus t kno w abou t he r befor e h e ha s experienced her. This latter point will likely lead into a discussion of th e patient's experienc e o f th e clinicia n a s "jus t lik e al l th e others, " having the sam e thought s a s prior clinicians , an d therefore no t uniqu e o r indi vidual (fo r an excellent example of such an interaction, see chapter 4). It is also fair for the clinician to tell the patient that he respects the source s of informatio n abou t th e patient , bu t tha t h e wil l reserv e th e righ t t o make his own conclusion s afte r h e has come to know th e patient better . It is als o importan t fo r th e clinicia n t o not e whe n som e o f th e patient' s assertions, particularly delusions , see m implausible , whil e addin g that it is not possible fo r the clinicia n t o prove o r disprove them . The clinicia n can amplify o n his criteria for plausibility base d on his experience of th e world a s a place where, for example, people ar e not whimsically single d out fo r unremittin g an d fantasti c tortur e b y intelligenc e agencie s o r supernatural forces . The clinician' s impression s d o no t preclud e th e reality of th e patient's, but are the basis for the clinician's own subjectiv e experience. B y presentin g them , th e clinicia n emphasize s hi s separate ness. Th e clinicia n als o begin s t o le t th e patient kno w ho w hi s analyse s and opinions ar e formed. Whenever possible, it is best to defer extende d discussion of thi s issue until the treatment alliance has been better established. The reaso n fo r thi s cautiou s deferenc e t o th e patient' s paranoi a i s simple: Patient s ar e threatene d b y th e prospect o f scrutin y an d change . They ar e consequentl y mistrustfu l o n severa l accounts , an d no t merel y because o f thei r perceptua l suspicion . Patient s ma y unconsciousl y loo k

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for a reaso n no t t o liste n t o wha t wil l unavoidabl y b e har d lesson s i n self-understanding. Th e therapeuti c allianc e mus t b e mor e firmly base d so tha t patients ' prematur e dismissa l o f clinician s ca n b e avoided . I n particular, tim e an d carefu l work ca n allo w th e patient s t o integrat e perceptions of clinicians' honesty, integrity, consistency, and compassion. Then patient s ma y b e bette r abl e t o listen . Ou r guidin g principl e i s ou r respect for patients' limitations an d our resolve not to expect patients t o do more than they can do at a given time. What w e propos e i s i n fac t nothin g mor e tha n bein g fran k wit h patients. Our first impressions are often base d on unproven assumptions. We ma y b e abl e t o diagnos e a though t disorder , excitement , activ e hallucinations (bu t not their cause), or a mistrustful, guarde d stance. We can explor e th e unreasonablenes s o r maladaptiv e implication s o f som e of th e patient's belief s o r statements. Bu t we canno t kno w th e patient i s delusional withou t proof ! Obviously, certai n views ar e implausible. I t is enough to note our curiosity, confusion, or incredulity and, when appropriate, t o poin t ou t wha t w e se e an d searc h fo r plausibl e explanations . In this, w e ca n sometime s enlis t th e patient' s capacit y t o reaso n an d b e reasonable. I f we are , on th e contrary, prematurel y dogmati c o r author itarian, w e ris k actin g no t o n principl e o r theory , bu t o n th e ange r an d resentment, th e countertransference , evoke d i n u s b y th e difficult , de valuing, an d paranoid patient . It is mor e meaningfu l t o poin t ou t th e activ e intrusio n o f symptom s of the illness than to debate the significance o f past events. Some patients prefer anchorin g thei r attentio n an d th e clinician' s i n a revie w o f th e past rathe r tha n confrontin g harsh , presen t challenges . I t i s als o mor e relevant t o describ e ho w a patient use s delusiona l concern s o r th e pas t to avoid acknowledging the truth about current difficulties. Fo r example, schizophrenic patient s wh o confron t cognitiv e limitation s subtl y affect ing socia l performanc e o r aspect s o f wor k skill s wil l avoi d situation s that s o stres s these limitations, while maintainin g tha t their inactivity o r withdrawal ha s som e othe r cause , typicall y on e w e se e t o b e delusiona l or a t leas t irrational . Suc h explanation s includ e assertion s o f min d con trol; o f pas t brai n damag e fro m medications ; supernaturall y ordaine d restrictions o n activity; or lack of interes t in any other than the patients' focused concerns , which , typically , the y cannQ t pursu e withou t bein g free of treatment, especially medications. Although it is a long-term goal, it i s inherentl y therapeuti c t o hel p suc h patient s se e th e psychologica l

From Understanding to Action 12 9 function of their delusion, for example, and to explore alternative means of copin g with thei r problem. This kind of wor k i s not possible, however, i f th e discussio n become s mire d i n a pointles s attemp t t o wi n patients' disavowal of their beliefs. Once th e clinicia n ha s establishe d a firmer base fo r th e therapeuti c alliance, it is also possible to begin pointing out behaviors and cognitions that have occurred in meetings with the patient, events that both parties have witnessed, and to use these as data on which to base diagnosis and treatment recommendations. Common experiences are better sources of information an d can lead to a discussion of trus t and differing perception, which is essential for the progress of the treatment alliance. Suggestions fo r treatment plans arising from these observations ar e less likely to be experienced as prejudicial. It is essential that, in looking for evidence of 'symptoms' in the present interaction with the patient, we broaden our view of schizophrenia in a manner consisten t wit h th e mode l w e presente d i n chapte r 1 . I f w e persist in "diagnosing" schizophrenia b y considering delusions, hallucinations, an d though t disorde r th e mos t importan t symptoms , ou r approach to the patient will be similarly skewed. The search for symptoms in the here and now mus t follow th e thrust of ou r model, wherein the patient's principal concerns are seen as: 1. Perceptual , attentional, and mood disturbances 2. Mistrustfulnes s 3. Cognitiv e limitations 4. Psychologica l maladaptations and low self-esteem In ou r day-to-da y interaction s wit h th e patient , i n an y treatmen t modality o r setting , w e ca n find evidence fo r disturbance s i n eac h o f these four areas. Patients who meet DSM III-R criteria for schizophrenia will hav e disturbance s i n thes e areas ; th e revers e i s als o true . Bu t i n organizing ou r thinking in this way, w e focu s ou r concern an d have a useful way of focusing our treatment interventions. We can discuss some of thes e impairment s withou t havin g t o directl y addres s th e patient' s delusional views—for these must be dealt with patiently and over time. Patients can begin work on problems in these areas while still grappling with thei r uncertaint y ove r why thi s has happened t o the m o r what it means to them. Importantly, we can help to combat their demoralization

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by showin g the m tha t wor k ca n g o o n despit e delusiona l o r irrationa l concerns.

ESTABLISHING TH E THERAPISTS "PRESENCE " These variou s issue s implicitl y differentiat e th e clinician' s perspectiv e from th e patient's . While thi s distinctio n ma y b e assumed , i t i s not saf e to assum e tha t th e patien t accept s o r appreciate s it . A s w e note d i n discussing th e natur e o f th e patient' s subjectiv e experienc e i n chapte r 2 , the schizophreni c individua l ma y no t experienc e th e clinicia n a s a sepa rate person . H e o r sh e ma y entertai n fantasie s o f merge r wit h th e clini cian or have expectations abou t th e clinician's role that represent uncon scious projections. When we speak of establishing the clinician's "presence " (10-11), w e refe r t o th e complicate d tas k o f definin g th e clinician' s rol e and responsibilitie s i n ligh t o f th e schizophreni c patient' s typica l con cerns. This is , of course , a crucial par t o f th e treatment frame . The clinicia n mus t asser t hi s o r he r uniquenes s an d separatenes s without conveyin g disregar d fo r th e psychologica l basi s o f th e patient' s tendency t o trea t th e clinicia n a s no t separate , no t unique , o r subordi nate. W e mus t remembe r th e profoundl y troublin g disturbance s i n self object differentiatio n tha t ma y lea d th e patien t t o assum e th e clinicia n can rea d hi s o r he r mind , tha t th e patient' s thought s ar e create d o r controlled b y th e clinician , o r tha t th e relationshi p wit h th e clinicia n must b e spurne d i n orde r t o alleviat e anxiet y consequen t t o intimacy . When patient s attemp t t o blu r th e clinician' s uniquenes s ("You'r e lik e all the othe r nurses") , our respons e mus t b e dictate d b y our understand ing o f th e potentia l perceptua l disturbance s accountin g fo r thes e phe nomena, a s wel l a s thei r defensiv e function : I f th e patien t nee d no t consider th e clinician' s uniqueness , h e or sh e is required t o d o les s wor k in integratin g th e clinician' s varie d behavior s an d statements . Th e pa tient als o characteristicall y devalue s whateve r change-provokin g obser vations th e clinician the n makes . Disturbance i n self-objec t differentiatio n (12) , as well a s experiencin g lack o f contro l an d concer n abou t safety , ofte n lead s to defensiv e effort s to contro l th e clinician b y extorting promises, seducing th e clinician int o a "special " allianc e o r deviatio n fro m standar d practice , o r contemp tuously demeanin g th e clinician' s capacities . Thes e psychologica l mech -

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anisms o f defense , o r adaptation , frequentl y complicat e th e clinician' s efforts t o establis h a treatment frame . Al l ca n be deal t with, i n part, b y the clinician's careful delineatio n of his or her role, understanding o f th e nature of th e patient's difficulties, an d proposals for their work. How doe s th e clinician defin e hi m or herself a s separate an d unique ? First, we mus t note when patients make assertion s tha t imply th e opposite. A patient's statemen t "You'r e jus t lik e al l th e rest " (se e chapte r 4 , as note d previously , fo r a n extende d discussio n o f thi s theme ) i s a n obscuring of uniqueness. When patients maintain that clinicians can read their thoughts , ther e is a n implicit blurrin g o f separatenes s (whic h ma y be th e consequenc e o f abnorma l perceptions) . Mor e subtl e ar e th e cir cumstances whe n patient s ar e inordinately passive , invitin g clinician s t o take control , mak e decisions , o r organiz e prioritie s fo r them . I n thes e cases, ther e ha s bee n a d e fact o los s o f separatenes s that , whe n recog nized, mus t b e confronte d b y al l parties . The clinicia n mus t resolve t o distinguish betwee n genuine , empathic , professiona l hel p an d makin g choices o r settin g priorities , task s fo r whic h th e individua l mus t i n al l events, barrin g predictable dange r t o sel f o r others , assum e responsibility. In the cases of a characterization stereotype , a clinician may respond by pointing ou t i n the first instance ho w h e o r she is different , sinc e w e are al l i n som e respect s unique . The clinicia n ca n the n hel p th e patien t to se e tha t obscurin g uniquenes s lead s t o a "deadening " o f experienc e and difficulty predictin g the behavior of individuals, who do not respond uniformly t o mos t challenge s an d stimuli . I n the cas e o f accusation s o f mind-reading o r mind-controlling capacities , repeate d denial s wil l b e o f limited avail . Rather , over time , th e patien t ma y com e t o instinctivel y appreciate the differences i n thinking processes, between himself an d the clinician, if the clinician take s care to elucidate how h e thinks. This task is also aided when the clinician takes opportunities t o point out how th e patient's reasonin g differ s fro m hi s o r he r own , a s i n th e followin g situation: When a patient in the hospital complained about a staff membe r who ha d made what th e patient interprete d to b e a condescendin g gesture, the clinician, who was a nurse, said the following : "I see why you thought that, but I looked at it differently. Whe n I see someon e gestur e lik e tha t [ a wave o f th e hand] , I think tha t person i s tryin g t o b e playful an d friendly , an d i n m y experience ,

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that's usuall y true . Besides , I kno w tha t staf f member , an d sh e often act s lik e that , bu t she's neve r condescending—though I realize w e ma y vie w he r differently . Also , rathe r tha n bein g conde scending, I think, fro m wha t you tol d m e about your conversatio n with her just before, tha t she was worried you were angry with her and wa s tryin g t o ge t throug h t o you , t o le t yo u kno w tha t sh e wasn't put off b y your irritation with her." This approac h als o require s franknes s i f i t i s t o b e successful , whic h means ou r acknowledgin g th e fac t tha t w e do ge t angry a t patients an d sometimes expres s this in our behavior. This candor also commands ou r eschewing defensivenes s whe n reviewin g wit h th e patien t th e behavio r of colleagues , a process tha t i s applicable whe n treatmen t take s place i n a hospital, day-hospital , o r rehabilitative progra m setting . Conside r thi s situation: A schizophreni c man , i n hi s mid-thirties, wa s angr y a t a day hospital staf f membe r who m h e accuse d o f bein g arrogan t an d condescending. Anothe r staf f membe r reviewe d th e relationship o f the patient with the "arrogant" clinician, and remarked: "You know , C [th e "arrogant " clinician ] an d yo u hav e th e same problem . You'r e bot h sensitiv e t o rejection , an d yo u bot h pull away to protect yourselves when you feel hurt. I've talked with C, wh o feel s yo u don' t respec t her , tha t yo u don' t thin k sh e can hel p you . I kno w tha t whe n C feel s tha t way , sh e rarel y shows it. Instead she is removed, even aloof. Bu t inside, she's quite disappointed tha t th e tw o o f yo u hav e no t foun d a wa y t o wor k together." Although the patient and "arrogant" clinician continued to have difficulty, th e patient learne d a great deal abou t his own characte r from this process. Throughout th e cours e o f treatment , clinician s mus t presen t them selves a s limite d (i n th e sens e o f bein g huma n an d imperfect) , fallible , and vulnerable. Schizophrenic individuals have understandable difficult y with empath y an d will b e hostile in an environment where the clinician s present themselves a s authorities, unapproachable, an d "different" fro m patients an d wher e fallibilit y o r humannes s ar e no t activel y acknowl edged. A t th e sam e time , clinician s mus t als o comfortabl y asser t thei r

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expertise and, where relevant, their objectivity. Patients certainly wish t o believe the y ar e in competent hands . Competenc y wil l no t b e communi cated throug h unnecessar y authorit y o r force . I s no t th e impruden t o r pointless use of suc h authority rathe r the work o f insecurit y an d incertitude? Ou r sur e understandin g o f th e disorder , ou r idea s abou t ho w w e can help , an d ou r fran k acknowledgemen t o f wha t w e d o no t kno w o r cannot surely help constitute the framework o f our expertise. The acknowledgmen t o f th e fundamenta l rol e o f th e schizophreni c patient's psychologica l adaptatio n t o hi s o r her illness implicitl y define s any clinician' s rol e a s tha t o f a consultant. Th e treatmen t canno t wor k until th e patien t i s a n activ e participant . Th e crucia l firs t ste p o f th e treatment, whic h i s th e establishmen t o f th e treatmen t alliance , i s th e very proces s o f eliciting interest , conviction , an d hope . Th e clinicia n i s not responsibl e fo r th e patient's improvemen t an d cannot thin k so . Th e patient i s responsible ; th e clinicia n provide s knowledge , observationa l skills, and a plan. It is, i n thi s sense , dangerou s t o wan t th e patien t t o becom e well , t o base professiona l estee m o n obtainin g a desire d respons e fro m a give n patient. Clinicians must focus on technique, the refinement of knowledg e and experience , an d o n th e stead y applicatio n o f th e treatmen t model . Of cours e clinician s would soo n despai r if their efforts di d not generall y meet wit h success . I t mus t b e enoug h fo r u s t o kno w that , i n general , our principles an d methods ar e valid and valuable. I t is not counterther apeutic t o hop e fo r a given patient' s recovery . Bu t we mus t ofte n pres s on, faithful t o our conceptualization o f the disorder and our work, whil e the patient resists or avoids or passively complie s with the treatment. The rational e fo r thi s admonitio n i s threefold. First , work wit h thes e individuals i s intense , provocative , an d complicated . I f ou r spirit s an d esteem depen d o n th e patient' s apparen t improvement , w e wil l soo n become dispirited , demoralized , an d ineffective . Second , schizophreni c persons' psychologica l stat e i s complicate d b y intens e self-blam e an d deeply unconsciou s anger . The y vie w carin g an d helpful intention s am bivalently an d bot h desir e an d resis t intimacy . The patients ' perceptio n that clinicians want their improvement, indeed need it for their own selfesteem, offer s a n unfortunat e mediu m i n whic h patient s ma y ac t ou t anger and envy as well a s self-destructiveness i n demoralizing or alienating a potentia l caregiver . Third , clinicians ' dependenc e o n a patients ' clinical improvemen t put s thei r objectivit y a t risk. Treatmen t decisions ,

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even unconscious decision s abou t what o r what no t to say , ma y then b e influenced b y countertransferenc e rathe r tha n theor y an d experience. I n such circumstances , i t is quite commo n t o se e clinicians actin g out thei r own frustratio n an d resentmen t throug h us e o f clouded , eve n preju diced treatment rationales. As clinicians , w e mus t hav e i n min d th e mode l o f th e consultant , regardless o f eac h o f ou r disciplines , an d accept th e fact o f th e patient' s ultimate contro l an d responsibilit y (13) . I n so doing , w e concentrat e o n what w e understan d abou t th e patient' s behavio r o r symptom s an d communicate tha t understandin g togethe r wit h a pla n fo r copin g wit h the problems presented. When the patient does not utilize what we offer , we resor t t o ou r technique s o f understandin g th e patient's resistanc e t o treatment. W e explor e th e patient' s subjectiv e experience , conside r th e psychological function s o f denial , an d asses s th e patient's psychologica l adaptation an d how i t might be influenced b y his or her participation i n the treatmen t intervention . I t i s crucial , abov e all , t o remembe r tha t psychologically motivate d denial , resistance , an d unconsciou s ange r ste m from lo w self-estee m an d fear of th e humiliation o r disappointment tha t might follow effort s a t change. The onl y antidote s t o unrealisti c expectation s ar e education an d self examination. Clinician s mus t expec t th e slo w rat e o f chang e o f th e schizophrenic patient . Bu t the y shoul d als o fee l tha t the y understan d why, an d wh y thei r effort s ma y b e helpful eve n without immediat e an d observable alteration s i n symptom s o r psychologica l adaptation . I f a clinician repeatedl y struggle s wit h expectation s fo r wor k tha t ar e ulti mately self-defeating an d limiting, it is perhaps appropriate for the clinician to reflect why this is so. Part of ou r presence a s clinicians i s expressed i n the highly individua l ways in which we communicate empathy and hope. Indeed, our personal commitment t o endur e ou r schizophreni c patients ' despair , doubt , an d rage i s th e mos t importan t communicatio n o f hope . Although , a t present, w e ca n offe r n o cure s an d mus t frankl y acknowledg e th e rea l an d persistent difficultie s wit h which ou r patients struggle , perhaps through out thei r lives , understandin g an d compassio n ma y creat e a bon d tha t can suppor t schizophreni c individual s i n thei r struggle s wit h sufferin g and frustration . Tha t w e als o offe r a pla n fo r copin g tha t challenge s demoralization i s added reason for hope that schizophrenic persons may

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develop greater self-understanding, self-acceptance , an d improved adaptation to their illness.

PRESENTING THE MODEL OF THE ILLNESS As w e discusse d i n chapter s 1 an d 2 , i t i s inherentl y difficul t fo r th e schizophrenic perso n t o appreciat e th e disturbance s i n hi s perceptio n and thinking . Correspondingly , i t ma y tak e hi m quit e som e tim e t o accept the fact he is ill (i f he ever fully does) . He may not want to hear a description of his illness or a delineation of the symptoms that reflect th e disorder's influenc e o n hi s psychologica l state . Nevertheless , whe n an d to th e degree the patient i s able, education abou t the model w e outline d in chapter 1 is a central element in setting our treatment frame. This tas k i s centra l precisel y becaus e i t define s ou r functio n an d th e theory tha t inform s ou r plans . Furthermore , insofa r a s th e mode l i s logical an d consisten t (whil e no t complete) , i t generates predictions an d assessments tha t suppor t it s reasonableness . Althoug h thi s doe s no t insure the patient's acceptance , suc h reliability ca n appeal t o th e schizophrenic individua l wh o i s awas h i n feeling s o f discomfort , uncertainty , and futility. Fo r example: A man in his late twenties reported incessant wordless "chatter ing" in his head for the past year. It was distracting, discouraging , and associate d wit h tensio n an d irritability . Th e patien t believe d this nois e wa s cause d b y "transmissions " fro m a n unspecifie d de vice controlle d b y confederate s o f a n apparentl y well-to-d o ma n whom h e ha d see n a t a distanc e o n a plane, bu t who, th e patien t imagined, resente d hi m fo r havin g ha d enviou s thought s an d fo r being attracted to the man's wife. The patient als o manifested, bu t did no t acknowledge , significan t cognitiv e an d behaviora l impair ments, including difficult y assessin g affec t i n others ; trouble whe n trying t o prioritiz e tasks ; difficult y assimilatin g ne w information ; facial grimacing ; and social withdrawal . The patient initiall y di d not accep t neuroleptic medications . H e was quit e mistrustful , eve n hostile , sayin g h e wante d t o sto p th e

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perpetrators of his torment and did not think his psychiatrist coul d be of an y help, yet he continued to attend sessions. The psychiatris t recommende d a neurolepti c regimen , an d ex plained his rationale. The patient showed interes t in the neurologi cal issues , so th e psychiatrist dre w som e explanator y figures. They reviewed how the medications would work according to the theory (concentrating o n th e mechanisms responsibl e fo r producing anxi ety and hallucinations). The psychiatrist emphasized that he understood tha t th e patien t migh t b e convince d o f th e realit y o f hi s perception o f th e "chattering " (i.e. , tha t i t cam e fro m a n externa l source) an d described in psychological term s why this would be so. The psychiatrist concluded b y saying: "You maintai n tha t th e 'chattering ' i s cause d b y transmissions . The trouble is , you don' t know ho w o r why this is happening, an d there i s n o apparen t way , yo u tel l me , fo r yo u t o sto p it . Thi s causes you frustration an d discouragement . "I believe , fo r th e reason s I have stated , tha t you r experience s are symptom s o f thi s illness , a s I'v e described . I f I am correct , th e medication I' m prescribing will help , although gradually . The anxiety, tension, an d hallucinations wil l get better over the course of a few weeks ; i f w e ca n find th e righ t dos e an d i f th e medicin e works—and i t doe s mos t o f th e time . I t ma y no t remov e al l you r symptoms, bu t i t shoul d mak e thos e tha t remai n mor e tolerable . My plan suggest s tha t yo u wil l fee l bette r soon . Th e pla n offer s you a way t o d o somethin g tha t wil l produc e results ; you tel l m e that otherwise you're helpless. I hope you'll consider this treatment plan, becaus e I think you'l l b e less frustrate d i f yo u se e tha t yo u can have some control over these experiences." After som e furthe r clarificatio n o f side effects, respons e charac teristics, an d prognosis, th e patient agree d t o tak e th e medication , although h e said, " I don't quit e bu y the idea tha t this is an illness, but I figure maybe th e medication wil l hel p decrease m y sensitivit y to the transmissions." It is necessary to think about when to present the model of the illness. Timing ha s importan t implication s fo r th e treatmen t alliance . I f pre sented to o soo n o r with to o muc h urgency , th e model ma y b e perceive d

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as threatening, which can lead to a rupture of the treatment alliance. Yet some allusio n t o th e clinician' s rational e an d theoretica l approac h i s necessary earl y in the treatment: i f a clinician i s offering someon e treat ment, i t i s presumabl y becaus e tha t perso n ha s a mental illness . A s w e stated above , th e clinician' s uniquenes s i s a n importan t par t o f th e treatment frame ; th e clinicia n canno t abando n hi s o r he r practic e o r theoretical approac h eve n i f i t is with th e intentio n o f rescuin g a failin g treatment alliance . W e begi n wit h som e statemen t o f ho w w e d o ou r work, ho w w e evaluate an d recommend. We agree to respect the schizophrenic individual' s viewpoin t an d difference s an d indee d affir m ou r interest i n hi s o r her ideas an d subjective experienc e o f self , illness , an d treatment. Wit h thi s approach , w e hop e t o reac h a n agreemen t fo r patient and clinician to work an d learn together. Although we cannot standardize this intervention, we can recommend that the clinicia n begi n with a n overview o f hi s or her understanding o f the illnes s mode l an d as k i f th e patien t i s intereste d i n mor e detail , particularly a s i t i s relevan t t o th e clinician' s treatmen t modality . Th e patient's curiosit y ma y then be a guide. In the presentation, the clinicia n should mak e libera l referenc e t o th e patient' s model—tha t is , t o th e patient's subjectiv e experienc e o f hi s illness , whic h ofte n include s delu sional elements . Commonalitie s an d difference s ma y b e described , a s well a s implication s fo r treatment . Thi s las t guidelin e assume s tha t be fore presentin g th e mode l t o th e patient, th e clinicia n wil l hav e mad e a diagnostic evaluation and explored the patient's subjective experience. If there is diagnostic uncertainty , bu t enough certitud e t o begi n som e treatment, thi s uncertaint y ma y b e appende d t o th e discussio n o f th e model a s outlined near the end of chapte r 1 . To recapitulate, the illness' primary an d secondar y manifestation s ca n generall y b e presented usin g these categories: 1. Perceptual , attentional, an d mood disturbance s 2. Mistrustfulnes s 3. Cognitiv e limitation s 4. Psychologica l adaptio n to illness and low self-estee m The delineation o f symptom s ma y the n lead into a discussion o f ho w these variou s problem s ma y b e addresse d throug h specifi c treatmen t modalities.

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TREATMENT TASKS Although thi s chapte r canno t encompas s a multidisciplinar y treatmen t manual, w e will briefl y describ e th e principa l menta l healt h treatmen t modalities an d wha t specifi c aspect s o f schizophreni a eac h ma y address . In settin g the treatmen t frame , th e clinicia n mus t kno w wha t eac h treat ment modalit y ma y accomplis h an d ho w i t will d o so . This understand ing shoul d b e imparte d t o th e patien t i n som e detai l a s par t o f th e process o f clarificatio n an d demystificatio n o n whic h ou r pla n fo r th e treatment allianc e is based . Psychotherapy The practic e o f psychotherap y ha s endure d a n uncertai n and , recently , much maligne d reputatio n i n th e treatmen t o f schizophreni a (14-17) . The surroundin g controvers y i s too complicate d t o addres s here , but w e do not e ou r convictio n tha t psychotherap y ha s no t enjoye d genera l success or suppor t becaus e ther e has no t yet bee n a plausible psycholog ical mode l o f schizophreni a o r o f th e rol e o f psychotherap y i n treatin g the disorder . W e presen t a mode l tha t clearl y suggest s a rol e fo r a kin d of psychotherapy . W e hop e i n late r work s t o amplif y o n th e theme s w e will outlin e here . Mos t generally , th e task s o f psychotherap y fo r th e schizophrenic individua l include : reviewin g an d clarifyin g th e patient' s subjective experience ; understandin g th e dynamic s o f self-esteem , self acceptance, and experience of his or her illness; and, importantly, achievin g an increase d understandin g o f th e patient' s psychologica l response s t o the illness , while guidin g th e patien t t o bette r adaptiv e functioning . W e list belo w severa l conceptua l categorie s tha t organiz e ou r psychothera peutic work wit h schizophreni c patients : Information The first rol e o f th e psychotherapis t i s t o provid e information , i n a considerate an d thoughtfu l fashion , regardin g th e scientifi c knowledg e about schizophreni a tha t ma y b e pertinent t o th e patient. Thi s tas k ma y be share d b y othe r menta l healt h professional s i n a multidisciplinar y treatment setting . A s discusse d above , thi s informatio n migh t includ e

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scientific evidenc e an d theorie s (note d t o b e theories , rathe r tha n facts ) regarding th e productio n o f symptoms ; th e action s o f medication ; th e nature o f cognitiv e disturbance s i n schizophrenia ; an d strategie s fo r coping wit h symptoms . We ten d t o emphasiz e th e importanc e o f cogni tive an d behaviora l strategie s (suc h a s structurin g daytim e activities , setting achievabl e goals , experiencin g succes s an d praise ) tha t comba t demoralization an d socia l withdrawa l an d t o bas e thes e recommenda tions o n researc h i n rehabilitativ e psychiatry . I t i s als o importan t t o outline rationally , usin g availabl e data , th e risk s an d prognosi s fo r schizophrenic patients an d t o reassure them tha t mental incompetenc e i s not a n inevitabl e outcome , whil e bein g fran k abou t th e limitation s o f treatment an d ou r limite d capacit y to predict outcome . The amoun t o f informatio n eac h individua l ca n tolerat e varies . A given patien t ma y nee d time , improve d self-esteem , greate r trust , an d a stronger treatmen t allianc e t o accep t th e fact s an d theorie s w e presen t them. W e hav e foun d tha t thi s exercis e ca n b e attempte d eve n earl y i n the work , an d tha t th e patien t wil l typicall y indicat e intoleranc e b y becoming angry or withdrawing. In this case, we pause and try to discus s the material later , particularly a t a juncture when the information woul d be valuabl e t o th e patient . I t ma y b e opportun e t o discus s sympto m generation an d cognitiv e copin g strategie s a t a tim e whe n th e patien t i s experiencing a mil d recrudescenc e o f symptoms . I n thi s context , th e information migh t provid e th e patien t wit h usefu l mean s t o reasser t some contro l ove r hi s o r he r thinkin g an d thu s reduc e anxiety . We hav e found tha t suc h a discussio n doe s no t alienat e patients , unles s th e pre sentation i s mad e thoughtlessly , i n servic e o f th e clinician' s anxiety , insecurity, o r frustration , a s i n th e cas e o f a clinicia n wh o remarke d t o schizophrenic patient s manifestin g denia l o f thei r illness , "Don' t yo u realize you'r e crazy , tha t yo u hav e a brai n disease ? Doesn' t tha t worr y you?" Ou r understandin g o f schizophreni c individuals ' psychologica l reaction t o thei r illnes s woul d lea d u s t o conside r suc h a n interventio n fruitless an d potentiall y abusive . Exploring Subjective Experience We hav e take n som e pain s t o emphasiz e th e importanc e o f thi s tas k i n the establishmen t o f th e treatment alliance : it is furthermore essentia l t o the conduc t o f psychotherap y (18-19) . I n dealin g wit h delusiona l pa -

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tients, this task is central. It requires, in addition to data-gathering abou t the patient' s experienc e o f th e illness an d o f treatment , astut e effort s t o establish a dialogue , wherei n th e patient' s an d psychotherapist' s view s are evaluated . W e wil l discus s thi s proces s i n detai l below , whe n w e refer t o th e "paralle l dialogue. " These theme s ca n the n b e availabl e fo r psychotherapeutic work .

Support The psychologica l experienc e o f th e schizophreni c person—th e feeling s of vulnerability , lac k o f control , an d futility , i n particular—generate s defenses an d a narrowin g o f awareness , whic h handica p cognitiv e an d behavioral adaptation . The psychotherapist mus t function, in part, as an auxiliary eg o (2) , helpin g th e patien t t o construc t alternativ e copin g strategies an d usin g th e patient's prioritie s t o d o so . I n this process, th e therapist doe s no t assum e tha t h e o r sh e know s bette r tha n th e patien t how to make choices, resolve conflicts, or make judgments. The therapist does acknowledg e th e patient' s relativ e limitations , a t thi s time ; thes e may b e psychologica l (i.e. , th e narrowin g o f "perspective " tha t i s a consequence o f unresolve d conflic t withi n th e psyche ) o r cognitiv e (un certainty cause d b y intens e anxiet y o r ambivalenc e tha t i s primaril y physiologically mediated ; o r prefronta l subcortica l cognitiv e impair ments a s describe d i n chapte r 1) . The therapist' s tas k i n thi s aspec t o f the work i s to fashio n alternativ e copin g strategie s tha t th e patient ma y then elec t t o use ; th e matte r o f choic e an d settin g prioritie s i s appro priately left to the patient. Two specifi c eg o function s ar e commonl y modele d b y psychothera pists working with chroni c schizophrenic patients: a sense of psycholog ical coherenc e an d continuit y ove r tim e an d th e tas k o f decipherin g th e emotional conten t o f interaction s o r th e psychologica l motivation s o f others. Th e first o f thes e i s accomplished , ofte n unconsciously , a s a consequence o f th e therapist's innat e capacit y t o reason , remember, an d organize hi s o r he r experienc e o f th e world . Thes e psychologica l func tions ca n b e impaire d i n som e schizophreni c persons , a s we elaborate d in chapter 2. The therapist can consciously addres s this problem, if he or she perceives it to be significant, b y taking opportunities, especially when a patien t i s anxious , disorganized , o r mistrustful , t o recal l pas t conver sations an d remin d th e patient o f feeling s o r convictions th e patient ha s

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previously espoused . The psychotherapist i n a sense contains a coherent and continuou s (thoug h incomplete ) imag e o f th e patient ; th e ac t o f remembering aid s the patient in experiencing a desired but elusive conti nuity with his or her past. The latte r o f thes e eg o function s i s on e tha t ca n als o b e modeled , though th e tas k i s comple x an d canno t b e treate d thoroughl y here . A s we noted above, this aspect of the work i s far from the therapist's tellin g the patient what to do or what to think. The therapist assists the patient in clarifying distortions , noting patterns in the way th e patient respond s to certai n people o r events; presenting th e patient with alternativ e way s of looking at an interaction; and suggesting different cognitiv e or behavioral responses , whic h ma y depen d o n a differen t assessmen t o f th e situational challeng e i n th e environment . S o fa r i n thi s book , w e hav e given a number o f example s o f thi s kin d o f modelin g tha t illustrat e th e principles noted here, as does the following vignette : A 29-year-ol d woma n wh o wa s diagnose d a s sufferin g fro m chronic schizophreni a wa s transferre d fro m a n inpatien t uni t t o a long-term, residentia l treatmen t facilit y becaus e o f sever e an d persistent paranoia , suicida l ideation , an d impairment s i n socia l an d other rol e functioning . Despit e thes e difficulties , th e patien t ha d the capacit y t o engag e an d interes t others , wa s personable , eve n charming when not mistrustful, an d had made a good many friend s among staff an d other patients on the inpatient unit. A wee k afte r he r transfer , sh e calle d a staf f membe r fro m th e inpatient uni t t o sa y tha t sh e fel t unsaf e a t th e ne w treatmen t facility. Sh e believe d th e staf f ther e wante d t o punis h he r an d "drive me crazy" because the y knew tha t she had filed suit agains t a psychiatris t wh o ha d treate d he r when sh e was a teenager. (Th e patient had in fact complained t o the State Medical Revie w Boar d about allege d abus e b y a forme r therapist , complaint s tha t wer e plausible an d bein g dul y investigated) . Th e patient fel t th e staf f a t the residential facilit y wer e connected t o thi s former therapist . Sh e accused th e inpatien t uni t staf f membe r an d th e othe r staf f mem bers ther e o f deliberatel y sendin g he r t o a place wher e sh e woul d be tortured . Despit e reassurance , sh e insiste d tha t th e inpatien t staff wer e angr y at her because of he r suicidality an d her inability, or refusal, t o get better for them.

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The staf f membe r firs t reminde d th e patien t o f ho w sh e had fel t when sh e first cam e t o th e inpatien t unit . Together , the y recalle d many incident s i n whic h th e patien t experience d th e sam e kin d o f mistrust an d hostilit y towar d th e inpatien t staf f tha t sh e no w fel t for th e staf f a t th e new treatmen t setting . They the n reviewe d ho w th e patien t ha d graduall y change d he r view o f th e inpatien t staff . Specifi c encounter s wer e remembered . The patien t wa s encourage d t o tr y again , a s sh e ha d s o success fully before , t o tak e risks , t o giv e peopl e aroun d he r a chanc e t o know her . The staf f membe r the n explore d th e patient' s awarenes s o f he r own behavio r a t th e ne w facility . Th e patien t grudgingl y admitte d that sh e ha d bee n withdraw n an d irritable . Sh e recounte d severa l incidents sinc e he r arriva l tha t convince d he r o f th e ne w staff' s malevolence. Th e inpatien t staf f membe r note d tha t th e patient' s impressions coul d no t b e disproved, especiall y since the staff mem ber ha d no t bee n ther e t o witnes s th e incidents . Th e patien t wa s given alternativ e construction s o f th e events , however, whic h wer e presented a s hypotheses . Th e patien t wa s the n give n idea s abou t how t o test these hypotheses: for example , that sh e could approac h one perso n a t th e facility , who , sh e was convinced , hate d her , an d discuss thei r recen t interaction . Th e patient' s capacit y t o tolerat e such vulnerabilit y wa s reviewe d i n th e contex t o f pas t simila r efforts tha t bot h remembered . Suggestion s wer e mad e abou t ho w to evaluate th e other person's possibl e responses . The phon e cal l ende d wit h th e staf f membe r continuin g t o re mind th e patien t o f he r abilit y t o wor k throug h obstacle s wit h people, a s sh e ha d i n th e past , an d th e patien t remainin g ambiva lent and mistrustful . Nevertheless , a few month s later, the inpatien t staff membe r receive d a larg e decorate d thank-yo u not e fro m th e patient, announcin g tha t sh e ha d settle d i n a t th e residentia l pro gram. Dynamic Psychotherapy Those involve d i n psychodynamicall y oriente d wor k wit h th e chroni c schizophrenic perso n mus t conside r tha t th e physiolog y an d psycholog y of th e disorde r i s to o comple x fo r precis e identificatio n o f exac t cause s

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of sympto m exacerbation . Whil e i t i s importan t t o explor e theorie s about psychological stressors , room must be left for an unavoidable lac k of certitude . The tas k o f th e psychotherapis t i s t o hel p th e schizophreni c perso n achieve the broadest, richest possible understanding of his or her psyche. The tasks we have outlined above are oriented toward this goal. So, too, is dynamic psychotherapy, whic h can be a part of what might be seen as an educative , thoug h no t didactic , exercise . Dynami c psychotherap y i s distinguished b y it s attentio n t o transferenc e an d it s persisten t effor t t o explore motivatio n an d elucidat e th e mechanism s o f psychologica l de fenses. Transference is certainly important, though often not studied, in work with schizophrenic individuals. In a sense, the "subjective experience" of the schizophreni c patien t i s relate d bu t no t limite d t o th e concep t o f transference. Ho w th e patient "sees " or "hears " the therapis t i s impor tant to the treatment allianc e an d to therapy. Exploration o f th e subjective experience an d of th e transference wil l yiel d important informatio n about dynami c themes, particularly a s they relate to issue s o f trust , selfesteem, supereg o pressure s o r expectations , an d disposition s towar d intimacy an d vulnerability. Additionally, a s we hav e note d before , on e o f th e goal s o f treatmen t is t o increas e th e patient' s understandin g o f hi s o r he r psychologica l responses t o th e illnes s process , whic h mean s understanding , amon g other things , hi s o r he r unconsciou s an d psychologica l mechanism s o f defense. A s w e describe d i n detai l i n chapte r 2 , th e rage , despair , an d confusion associate d with the schizophrenic illness demand coping strategies tha t ar e often maladaptive . T o b e able t o loo k a t an d revis e thos e maladaptive strategies , th e schizophrenic individua l mus t b e confronte d with th e affect s an d thought s tha t motivat e hi m o r her . Ne w strategie s must take into account the patient's concerns in order to be effective an d desirable. Findin g mor e adaptiv e way s t o experienc e a sens e o f contro l than maladativ e withdrawa l o r contro l throug h fantas y wil l b e helpfu l where mere confrontation abou t disturbed behavior will not . We ca n consider , thoug h withou t proof , tha t thi s kin d o f dynami c work ma y no t b e appropriate fo r som e patients. Those individual s wh o respond mor e readil y t o cognitiv e an d behaviora l tecnique s ma y als o find dynamic therapy too threatenin g to self-esteem . Thi s kind of explo ration i s helpfu l whe n maladaptiv e behavior s an d cognition s interfer e

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with th e progres s o f recover y an d i n a way tha t suggest s that th e patien t must b e helpe d t o confron t intolerabl e interna l affect s o r conflict s i n order t o permi t change . Bu t th e patient' s limit s o f toleranc e fo r self knowledge wil l determin e whethe r h e o r sh e persist s i n thi s par t o f treatment. Rehabilitative Strategie s The specifi c task s o f rehabilitativ e clinician s (20—22 ) requir e a thought ful integratio n o f psychologica l understanding , includin g th e principle s used b y psychotherapist s a s describe d above , an d knowledg e abou t so cial skill s learning , behaviora l techniques , an d motivationa l strategies . The rehabilitatio n therapis t mus t identif y impairment s i n instrumenta l role functionin g an d the n discer n thei r causes . We have seen that schizo phrenic person s hav e impairment s i n cognitiv e functionin g (especiall y subtle prefrontal , frontal , an d subcortica l disturbances ) tha t ma y pro duce suc h problem s a s impersistence , difficult y initiatin g tasks , o r trou ble workin g independentl y wit h directions . Thes e sam e cognitiv e dis turbances ma y als o explai n th e schizophreni c person' s struggle s wit h interpersonal relatedness . We hav e als o described , however , th e rol e playe d b y th e individual' s psychological reactio n an d adaptatio n t o th e illness . Th e rehabilitatio n therapist mus t tak e thes e concern s int o accoun t whe n devisin g interven tions an d mus t hav e a s clea r a n understandin g o f th e patient' s psycho logical determinant s a s th e psychotherapis t an d othe r treatmen t tea m members. On e canno t trea t tas k avoidanc e o r socia l withdrawal withou t a "psychologica l diagnosis. " Thi s ste p i s crucia l t o treatmen t plannin g as well a s to th e treatment alliance . Rehabilitation intervention s provid e patient s wit h opportunitie s t o experience competenc e an d improve d self-esteem . Fro m th e perspectiv e of cognitiv e treatmen t theory , this i s vitally importan t t o recovery . Wha t rehabilitation therapist s mus t no t do , i n ou r view , i s se e themselve s a s simply teachers . Th e schizophreni c individual' s inabilit y t o carr y ou t a task i s du e t o a we b o f factors , includin g cognitiv e impairment s (whic h are no t altere d b y teaching) , experientia l deficit s (fo r whic h teachin g may b e appropriate) , an d psychologica l adaptation s tha t ma y impai r performance. B y providing th e schizophrenic patient wit h wor k o r inter -

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actional paradigms , w e giv e the m opportunitie s t o discove r improve d skills fo r copin g wit h thei r impairments , thoug h w e canno t ofte n teac h those skill s (becaus e the y involv e preconsciou s subcortica l processes) . These paradigm s suc h a s involvemen t i n a work-lik e settin g a s par t o f treatment, ar e par t o f a n ongoin g evaluativ e process , whic h teache s th e clinical team abou t th e schizophreni c person's cognitiv e an d psychologi cal qualities . Rehabilitatio n intervention s ca n b e bette r devise d whe n these various perspectives ar e integrated . Nursing Intervention s Like rehabilitativ e paradigms , nursin g activities , whic h a t thi s tim e ar e most ofte n limite d t o inpatien t settings , provide opportunitie s fo r obser vation o f a patient' s cognitiv e an d interpersona l functioning . Nursin g staff o n a psychiatric unit have a special role that i s a consequence o f th e incidental intimac y tha t exist s betwee n the m an d thei r patients . The y may stud y th e cognitio n an d behavio r o f patient s i n a natura l socia l paradigm (albei t no t natura l i n th e sens e th e inpatien t uni t i s a uniqu e community), bu t onl y i f the y understan d th e psycholog y o f schizophre nia. Thi s require s a n appreciatio n o f th e effect s o f physiologi c distur bances a s wel l a s th e psychologica l concern s an d adaptiv e strategie s characteristic o f th e schizophrenic individual . Not onl y d o nursin g staf f hav e a particular perspective , but the y hav e opportunities t o help patients adap t b y modeling interpersonal o r cogni tive copin g strategies . This tas k fall s betwee n th e psychotherapist' s rol e in elucidatin g th e patient' s conscious , cognitiv e appreciatio n o f hi s o r her psychology, an d th e rehabilitatio n therapist' s focu s o n specifi c socia l or wor k skills . Relationships , a s w e hav e noted , ar e vexin g an d compli cated fo r th e schizophrenic individual, and they are only partly and ofte n not practicall y deal t wit h i n eithe r psychotherap y o r rehabilitatio n ther apy. Nursin g ca n involv e a uniqu e adjunctiv e role , assistin g patient s i n practicing relatedness . This practice nee d not , indee d bes t not , occu r formally . Nursin g staf f have th e advantag e o f intimac y an d immediacy . Usin g wha t the y kno w about th e patient' s psychology , nursin g staf f ca n "model " i n eithe r o f the following ways : 1. The y ca n respon d t o anger , mistrust , o r othe r disposition s i n pa -

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tients b y carefu l reflectio n o n events , impressions , an d patients ' distor tions. Nursin g staf f ca n detai l ho w the y understoo d o r reaso n abou t a n event, presentin g thi s a s a n alternativ e mode l t o patient s (no t tryin g t o convince th e patients o f "th e truth " but offerin g anothe r wa y o f under standing tha t ma y b e mor e consisten t an d usefu l an d providin g mor e direction regardin g interpersona l copin g strategies) . Furthe r discussion s about a n even t (e.g. , a n argumen t wit h anothe r staf f member ) coul d include review of different behaviors , responses, that might have worked better. 2. When a patient demonstrates persisten t maladaptiv e patterns , suc h as intrusiveness , socia l withdrawal , o r bizarr e behavior , a pla n ca n b e organized tha t will: a. hel p the patient understand why he or she acts in certain way; b. provid e opportunities fo r more useful, esteem-buildin g functioning ; c. reinforc e o r discourage certain behaviors through a behavioristic paradigm emphasizing positive reinforcemen t o f suc h a plan. The following vignett e outlines the formulation o f suc h a plan. A 25-year-ol d woma n wa s hospitalize d fo r worsenin g o f para noid symptom s tha t ha d bee n present , wit h varyin g severity , fo r approximately fou r years . Whil e activel y hallucinatin g an d delu sional o n admission , sh e too k grea t car e with he r appearanc e an d was flirtatious with mal e staff member s an d patients. Sh e had als o been suicida l prio r t o admission , bu t thes e feeling s ha d abruptl y submerged. The patien t ha d a history o f self-abusiv e sexua l liaisons—ofte n with violen t men—prio r t o admission . O n th e unit , sh e wa s sex ually provocative , frequentl y touchin g variou s men , talkin g abou t her "nee d fo r sex, " an d o n severa l occasion s wa s foun d i n som e male patients' rooms. Her poise , he r polishe d appearance , an d he r affectatio n o f a kind o f haught y denia l o f illnes s o r vulnerabilit y wer e quit e dis turbing. Nursin g staf f fel t protectiv e o f her , especially wit h regar d to he r potential fo r sexua l behavio r tha t coul d b e humiliating an d self-destructive, an d were frequently angr y with her because of he r arrogant demeanor an d her indifference t o their concerns.

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A pla n wa s devise d t o hel p patient s an d staf f cop e wit h thes e problems an d t o mode l differen t interactions . Whe n th e patien t was foun d t o b e sexuall y inappropriat e o r intrusive , nursin g staf f would tak e he r asid e an d rea d fro m a prepared outlin e o n whic h the reade r woul d amplify . The outlin e wa s use d t o insur e consis tency, to reinforce the interventions through repetition, and to help staff cop e wit h thei r tendenc y t o ge t irritate d wit h her . Th e inter vention wa s als o a mil d "negative " reinforcemen t i n tha t i t wa s difficult fo r the patient to hear. When discussed by the nursing staff member, usin g th e outline, th e intervention woul d typicall y soun d like this: "We are concerned about your behavior because of the possibility tha t yo u wil l humiliat e yourself—yo u hav e tol d u s wha t hap pened whe n yo u wer e a t home an d acte d lik e this—o r b e hur t b y verbal o r even physical rejection—some people , as you've foun d i n the past, don't like your advances. "We thin k tha t thi s behavio r come s fro m feeling s o f lo w self esteem. Yo u hav e tol d u s how sa d you were befor e yo u cam e here and tha t yo u wer e als o suicidal . W e thin k tha t yo u fee l sexua l attractiveness i s your only asset—s o muc h so , that you mus t forc e sexual intimacy because you feel ba d about yourself . "We're no t tryin g t o contro l you r se x life . You'r e a n adul t an d free t o d o wha t yo u choose . Bu t i f yo u wan t t o continu e i n treat ment here, control o f you r sexual impulse s is part of th e treatmen t we prescribe , becaus e w e ar e convince d thi s i s a n importan t self esteem issue. "We also prescribe other activities that we think you can accomplish an d that will hel p your self-esteem. Let' s hope you don' t giv e up o n wha t i s certai n t o b e a slow , frustrating , bu t potentiall y rewarding course." Of course , th e nursin g staf f membe r als o implicitl y model s throug h his o r he r character . Peopl e lear n i n par t throug h thei r experience s o f others. The behavio r o f nursin g staf f members , thei r relativ e tolerance , openness, an d benevolenc e o r impatience, disdain , an d criticism, hav e a qualitative effec t o n th e patient s wit h who m the y work , an d o n th e milieu o n th e treatmen t unit . Rathe r tha n seekin g ourselve s simpl y a s

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natural models , however , w e ma y striv e t o shar e ou r thinking , ou r emotional experience , whil e providin g mor e i n th e for m o f integratin g psychological constructions , as in the following vignette : A 3 5-year-old ma n wh o ha d bee n il l fo r severa l year s an d wh o was als o quite brigh t had begun a successful caree r as an architec t before th e onset of hi s schizophrenic disorder . He was hospitalize d most recentl y fo r a n exacerbatio n o f hi s symptoms . On e o f hi s principal difficultie s wa s hi s persisten t noncomplianc e wit h medi cations. He approache d a nursin g staf f membe r t o hav e a talk . The y spoke fo r abou t twent y minutes , whe n th e nurs e ha d t o leave . A t this tim e th e patient, wh o ha d bee n attentiv e an d ope n durin g th e discussion, said , "Wha t you'v e tol d me—I'v e hear d i t al l before . It's nothing new. " The nursing staff membe r responded instinctively , saying , "Yo u know, tha t make s m e fee l lik e shit , tha t afte r talkin g wit h yo u fo r twenty minutes , yo u jus t sa y 'I'v e hear d i t before. ' " The y sa t i n silence fo r a moment, afte r whic h th e patient smirked , althoug h i t was no t a gleeful smile . H e appeare d anxious , th e nurs e thought , because the smile was so awkward, so out of place. "I als o think, " th e nurs e wen t on , "tha t yo u sai d tha t becaus e you ar e to o prou d t o admi t I ma y hav e helpe d yo u o r tha t jus t talking i s helpfu l eve n i f th e thing s w e sa y aren' t new ; an d that' s sad, becaus e w e al l nee d hel p t o learn , to hav e someon e shar e ou r troubles. I do it everyday wit h other staf f an d with m y friends an d family. I hop e yo u ca n le t peopl e hel p yo u an d no t push the m away, a s you jus t tried to pus h m e away , becaus e otherwis e you'l l be very alone." Later tha t day , th e patient , wh o ha d sai d nothin g furthe r afte r the nurse' s statement , cam e u p t o he r an d sai d tentatively , " I apologize fo r wha t I said earlier. " H e stoo d there , unabl e t o sa y more. Th e nursin g staf f membe r thanke d him , apologize d a s wel l for he r earlie r heate d tone , an d mad e arrangement s t o tal k wit h him when she was next on duty. This mixture of directness , openness, and reflection, which make s use of wha t w e kno w abou t th e patient an d abou t psychological principles , is i n ou r vie w extremel y valuabl e an d appropriate . Th e mode l easil y

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conforms t o th e kin d o f wor k practice d b y nursin g staf f an d t o th e circumstances o f thei r practice . Th e onl y cautio n w e woul d ad d i s t o note that this model ca n be abused if it is simply an excuse to tell patients that the y ar e offensiv e an d thu s gratif y ou r offende d sensibilities . With out compassio n an d understanding , mer e franknes s wil l b e o f littl e benefit. We woul d not e tha t th e developin g practic e o f cas e management , sometimes performed i n th e communit y b y nursing professionals, share s many o f th e feature s o f nursin g practic e a s w e hav e describe d it . Th e same combinatio n o f directnes s an d insigh t i n modelin g interpersona l relatedness ma y b e an importan t componen t o f cas e managers' work , i n addition t o their supportive , practical interventions . Family Therap y The literatur e ampl y document s th e importanc e o f th e famil y syste m i n our understandin g an d treatmen t o f th e schizophreni c individua l ( 2 6 27). Researc h int o th e rol e o f expresse d emotio n i n familie s o f schizo phrenic person s ha s le d t o intervention s th e efficac y o f whic h ha s bee n documented. I t i s likely tha t hig h level s of expresse d emotio n ar e stress ful becaus e the y represen t a n interpersona l situationa l deman d tha t (1 ) taxes subtl e cognitiv e function s involvin g subcortica l neura l activity , a s described i n chapte r 1 ; (2 ) reinforce s schizophreni c persons ' lo w self esteem b y communicatin g criticis m fo r behavior s no t entirel y i n thei r control o r fo r failur e t o mee t thei r families ' expectations ; an d (3 ) chal lenges certai n adaptiv e behaviors , suc h a s socia l withdrawal , denial , o r fantasies o f control . In the languag e o f ou r model , expressed emotio n confront s aspect s of the cor e physiologi c disturbanc e a s i t affect s cognitiv e functioning , a s well as conflicting wit h th e patient's effort s a t psychological adaptation . We encourag e famil y therapist s t o integrat e thei r clinica l an d treat ment model s wit h th e mode l w e presen t i n chapte r 1 , a s w e hav e don e here with respec t to the expressed emotio n paradigm. We present furthe r thoughts o n famil y treatmen t concept s i n chapte r 8 , wher e a clinica l example i s also provided. I t is our convictio n tha t the concepts presente d here can facilitat e mos t famil y treatmen t interventions . Our mode l ha s particula r relevanc e t o th e psychoeducational compo nent o f famil y wor k (28—32) . Some famil y therapist s favo r a mode l o f

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schizophrenia tha t utilize s th e dualisti c conceptualizatio n w e criticize d in chapte r 1 . Many specificall y refe r t o negativ e symptom s a s deficit s i n neurological functionin g an d describ e n o rol e fo r th e psychologica l re sponses w e hav e characterized . A s w e note d i n chapte r 1 , w e fee l tha t this understandin g o f th e disorde r i s unacceptabl y reductionisti c an d needlessly pessimistic . W e suggest , als o i n chapte r 1 , tha t th e mode l there ca n b e presente d t o families . I n ou r experience , understandin g i t has facilitate d thei r effort s t o cop e wit h th e schizophreni c famil y mem ber. W e hav e note d a significan t reductio n i n blamin g an d angr y o r guilty response s t o provocativ e symptom s an d improve d copin g behav iors i n famil y a s a consequenc e o f instructio n i n ou r mode l o f th e disorder. Muc h o f th e discussio n oriente d t o helpin g clinicians ' under stand thei r reaction s t o schizophreni c patient s ca n b e translate d t o hel p families understan d thei r psychologica l responses . In thi s way , th e psy choeducational wor k ca n assis t in elucidating psychodynamic theme s fo r use in insight-oriented famil y therapies . Other Modalitie s It is, we hope , apparen t tha t an y treatmen t modalit y ma y b e augmente d by consideratio n o f th e principle s outline d i n thes e thre e chapters . Eve n the practice o f psychopharmacolog y (23-25 ) must , i n our view , adopt a broader perspectiv e i f it is to b e done thoughtfully. I t is no simple matte r to decid e whethe r a sympto m i s a produc t o f disturbe d physiolog y o r a manifestation o f psychologica l adaptatio n (goo d o r ill) . Nor ca n w e b e presumptive i n assessin g th e implication s o f a treatmen t response . I t i s necessary t o understan d an d us e psychologica l principle s becaus e ou r knowledge o f physiolog y i s limited an d becaus e pharmacotherapeutics i s itself a blunt instrument . Moreover , w e can se e that an y mind , includin g that o f a schizophrenic person, has innate capacities availabl e to psycho logical treatments . Unti l scienc e permit s u s t o prun e inappropriat e syn apses an d regulat e th e appearanc e an d sensitivit y o f specifi c membran e receptors, w e mus t us e interpersonal , experientia l treatment , th e ver y conditions tha t contribut e t o th e developmen t o f eac h individual' s anat omy, physiology, and , thus , psychology . We close this section on the treatment fram e b y noting the importanc e of definin g an d elaboratin g th e patient' s goal s fo r th e treatment . A s w e

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have discussed , thes e ma y b e quit e differen t fro m thos e o f th e clinicia n or treatment team . Nevertheless , th e treatmen t allianc e shoul d no t proceed unless these discrepancies an d conflicts ar e first acknowledged. I t is difficult enoug h to pursue a treatment where the patient understands th e process very differently fro m the clinician, as in the vignette of the young man wh o though t neuroleptic s migh t decreas e hi s menta l sensitivit y t o the occult transmission s tha t caused "chattering " in his head. I t is mor e difficult stil l t o imagin e tha t th e clinicia n an d a patient ar e workin g i n concert only to find that the patient's later treatment avoidance is due to unknown an d unresolve d difference s betwee n th e clinicia n an d th e pa tient's conceptualization o f the treatment's purpose. Exploring an d acknowledgin g suc h difference s allo w th e clinicia n t o make bette r prognoses , anticipat e crises , an d bette r understan d th e pa tient's participation and response. The knowledge of the patient's subjective experienc e ma y als o lea d t o creativ e strategie s t o dea l wit h delu sions, a s w e hav e discussed . Identifyin g an d talkin g abou t th e patient' s treatment goals are specific aspects of our inquiry into his or her psychological view. Insofa r a s this exercise als o communicates respect , interest , and a collaborative, non-authoritarian stance on the part of the clinician, it furthe r recommend s itsel f a s a n essentia l ste p i n beginnin g th e treat ment alliance. As we pursue the various measures describe d here in connection wit h setting th e treatmen t frame , w e wil l implicitl y communicat e ou r view s on th e treatmen t goals . B y discussin g ou r limitation s wit h th e patient , we wil l defin e i n par t wha t w e thin k w e ca n an d canno t accomplish . Presenting ou r model , ou r conceptualizatio n o f patients ' symptoms an d their struggles , w e mak e referenc e t o wha t i s disturbe d an d wha t ma y change. Describin g specifi c treatments , thei r tasks , an d ho w the y ma y work, w e canno t avoi d introducing ou r thoughts abou t where the treatment is headed. Therefore, althoug h a formal statemen t about treatmen t goals is useful, th e process of beginnin g the treatment alliance b y setting the treatment frame reinforces th e clinician's unique and specific view of his or her capacity to help. It i s als o importan t t o construct , t o whateve r exten t possible , treat ment goal s tha t ar e meaningful t o th e patient. W e ma y se e tha t a give n patient would d o best working, for example, as an assistant in a medical laboratory; bu t i f hi s drea m i s t o becom e a physicia n an d medica l

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researcher, ou r goal s ar e useless . When conflict s suc h a s thes e arise , w e must ste p bac k an d conside r othe r approache s an d othe r goal s tha t wil l enlist th e patient's motivationa l capacity , however trammelle d i t is. When w e presen t treatmen t goal s i t als o help s t o indicat e ho w thes e goals wil l assis t th e patien t i n developin g self-estee m an d confidenc e i n specific skills . Th e discussion s abou t goal s ar e no t perfunctor y ex changes; the y ar e par t o f th e proces s o f formin g th e treatmen t alliance . This par t o f th e wor k ca n an d mus t communicat e ou r appreciatio n o f the patient' s anticipator y anxiety , fea r o f humiliation , an d avoidanc e o f achievement tha t wil l lea d t o furthe r feare d demands , a s wel l a s th e importance o f settin g and achievin g goals in order t o avoi d isolatio n an d discouragement.

TREATMENT ALLIANCE TECHNIQUES We wis h t o clos e thi s chapte r wit h comment s o n th e conduc t o f ou r interaction wit h schizophreni c patient s i n th e process of formin g a treat ment alliance . In doin g so , we emphasiz e th e primac y o f th e allianc e i n the treatmen t experience . Repeate d evaluatio n o f th e statu s o f th e treat ment contrac t an d th e patient' s understandin g o f an d respec t fo r th e treatment fram e a s wel l a s compariso n o f th e patient' s psychologica l model wit h tha t o f th e clinicia n ar e critica l an d basi c technique s i n practice. The y ar e a s muc h a par t o f th e wor k wit h schizophreni c indi viduals a s repeated forma l menta l statu s an d traditiona l diagnosti c eval uation. In particular , reexploratio n o f th e subjectiv e experienc e provide s a n invaluable too l to our understanding . I n the manner describe d i n chapte r 2, questionin g th e patien t abou t hi s o r he r psychologica l perspectiv e i s qualitatively, an d ofte n practically , useful , a s in the following example : A schizophrenic ma n i n his late twenties was bein g treated a s a n outpatient fo r a recen t exacerbatio n o f hi s symptom s o f mistrust fulness an d persisten t auditor y hallucinations . Hi s neurolepti c ha d recently bee n change d becaus e of hi s complaints o f extrapyramida l side effects . Th e patient' s fathe r ha d called , relatin g hi s concer n about th e patient' s irritabilit y an d hostil e threat s towar d others .

From Understanding to Action 15 The fathe r als o note d hi s uncertaint y abou t th e patient' s compli ance with the prescribed neuroleptic regimen. In the session , th e clinicia n aske d th e patien t ho w h e currentl y felt abou t th e medicatio n an d whethe r h e though t i t woul d help . The patient said, " I don't think it is helping. And, anyway, I' m not so sure it will h e l p . . . . I mean I'm pretty convinced tha t this thing [i.e., th e hallucinations ] i s external . I wish I could believ e i t wa s internal, 'caus e it' s b e a lo t easier . . . . I' d b e calme r i f I knew i t was internal . A s i t is , I ge t prett y frustrate d . . . infuriate d . . . thinking that somebody's trying to control my mind." The clinicia n explore d th e issu e further , attemptin g t o discove r how ambivalent , i f at all consciously, th e patient was regarding the etiology o f hi s menta l experience . I t was apparen t tha t th e patien t was consciousl y convince d tha t h e wa s no t il l an d tha t whateve r uncertainty reside d i n hi s mind , i t wa s no t a t tha t tim e available , being, presumably , deepl y represse d (eithe r becaus e i t woul d no t be easie r t o thin k h e wa s ill , a s th e patien t suggested , o r becaus e the experience of his symptoms was so intensely convincing that he felt doubts to be spurious). Although i t was possibl e tha t th e medicatio n wa s no t effective , it was mor e likely, give n the tone of hi s subjective experience, tha t the patient was no t takin g the medication a s prescribed. The clini cian informe d th e patient' s famil y o f hi s concerns , an d o f hi s impression tha t the patient would probably requir e hospitalizatio n in the near future. The patien t i n fac t argue d wit h hi s parent s tha t night , becam e hostile an d withdrawn , an d was admitte d t o th e hospital th e nex t day. The patient' s fathe r remarke d tha t th e argumen t leadin g t o admission fel t strang e t o him , a s i f th e patien t wa s forcin g hi s family's hand , makin g the m hospitaliz e hi m becaus e h e coul d no t consciously accep t his need for help. In ligh t o f th e patient' s sayin g tha t i t woul d b e "easier " i f h e believed he were ill, the clinician told the patient's father it was not hard t o imagin e tha t th e patien t migh t hav e a n unconsciou s wis h to find help. His own efforts t o understand and manage his mental experience ha d bee n futil e an d frustrating . H e ha d state d i n th e past that the model o f his illness and treatment as presented b y his clinician, wer e sensibl e an d suggeste d hop e an d a mean s o f cop -

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ing—though h e added that despite these advantages he was unabl e to accept the model then . This patient's frustratio n wit h hi s ow n inefficac y an d confusio n ma y offer a beginnin g fo r a fruitfu l treatmen t alliance , althoug h th e charac teristics o f th e patient' s denia l als o sugges t tha t i t ma y tak e som e tim e for hi m t o acknowledg e hi s wis h fo r treatment , eve n i n part. Neverthe less, reexploration o f hi s subjective experience gav e a clear picture of hi s attitude abou t treatment , allowe d th e clinicia n t o counse l th e famil y about th e inevitabilit y o f hospitalization , an d mad e clea r tha t furthe r education an d exhortation woul d b e inconsequential a t that time. Equally necessar y i s th e periodic , unavoidabl e tas k o f reinforcemen t of th e treatment frame . This is often don e in concert with exploration o f the subjectiv e experienc e an d involve s assessin g th e schizophreni c indi vidual's expectation s o f th e clinician . Unrealisti c demand s an d resent ment o f th e clinician' s limitation s ar e ofte n symptom s o f anxiet y abou t the ris k inheren t i n treatment. Dependin g o n th e schizophreni c persons ' specific subjectiv e experience , sh e ma y anticipat e failure , criticism , o r even betrayal i f she commits herself t o the proposed work . A schizophreni c woma n i n he r mid-thirtie s wa s hospitalize d principally becaus e o f a histor y o f repeate d suicid e gesture s an d attempts. Sh e ha d mad e progres s i n he r treatment , whic h ha d helped he r confron t he r necessar y choic e betwee n deat h an d th e risks of acceptin g that she was ill and needed help. Nevertheless, sh e continue d t o hav e episodi c bout s o f paranoi d ideation an d maintained , i n he r words , "o n th e bac k burner, " a delusion regardin g he r persecutio n b y a malevolen t organization . She frequentl y questione d others ' motive s an d worrie d tha t he r treatment itsel f wa s a hoax, t o b e followe d eventuall y b y betraya l and destruction. She ha d develope d a habi t o f askin g he r psychotherapis t an d some nursin g staf f abou t statement s mad e i n individua l discus sions. Sh e would, fo r example , approac h he r psychotherapist out side session s inquiringl y and , a t times , accusingly , saying , "Wha t did you mean when you said .. . ?" As sh e approache d th e tim e fo r he r discharge, he r psychotherapist note d a n increas e i n thes e extracurricula r questionings . H e said t o her , "Yo u know , I can't possibl y answe r al l th e question s

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you have . No r ca n othe r people . Whe n you'r e a n outpatien t yo u won't have opportunities t o check ou t your impressions. Yo u hav e to b e abl e t o tolerat e som e uncertaint y o r thi s treatmen t pla n wil l fall apart." The patien t wa s quie t o n hearin g this . Late r tha t day , sh e con fronted he r psychotherapis t i n th e hall , saying , "What' s wron g about m y askin g yo u questions ? You'r e tellin g m e yo u can' t help me." He responded , "It' s no t tha t you r questionin g i s wrong ; I was simply pointin g ou t th e fac t tha t I have limits . I' m talkin g t o yo u now, but I can't be available to you, like this, all the time. I believe I can be of hel p to you, since we've worked together up until now . But I can only d o s o much to reassur e you, and I don't think I can ever reassure you about all your doubts." In her next session, they went on to discuss how he r preoccupation wit h what peopl e "meant " b y thei r statement s no t onl y occurre d du e t o he r ongoing suspiciousnes s bu t migh t als o hav e reflecte d he r heightened anxiety relate d t o discharge . Sh e was quit e afrai d tha t sh e woul d neve r be abl e t o wor k again , tha t he r despai r an d suicidalit y woul d agai n become unmanageable , an d that she would b e friendless, isolate d a s she had been for the past several years. These fear s were present despit e her many achievement s durin g he r hospital stay . He r trepidatio n abou t lif e outside th e hospita l wa s painfu l t o discus s becaus e i t ofte n le d t o he r awareness o f persisten t feeling s o f skepticis m an d hopelessness. I n some respects, sh e agreed , he r ruminatio n abou t incidenta l statement s mad e by staff serve d a s a n unconsciously motivate d distractio n fro m thinkin g about he r discharg e plans . Reinforcin g th e treatmen t frame , whic h in cluded noting the clinician's limitations, then served to facilitate a discussion of th e patient's affectiv e experienc e an d to focu s bot h patient's an d clinician's attention on the difficult task s at hand. It may be said that, generally, perturbations i n the treatment frame or attempts a t such represen t a resistance t o o r avoidance o f som e difficul t aspect of th e work, a s illustrated above . Request s o r demands fo r mor e or somethin g othe r tha n wha t th e clinicia n ha d offere d implicitl y indi cate that the schizophrenic patien t has expectations o f th e clinician tha t go beyon d thei r understandin g abou t wha t th e treatmen t proces s ca n offer. A s such, those incidents that require a restatement of the treatment

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contract shoul d b e explore d fo r the y wil l typicall y revea l psychologica l concerns of direc t consequence to the treatment alliance . Finally, wit h respec t t o genera l technica l principle s i n conductin g interactions wit h schizophreni c patients , w e com e t o th e matte r o f th e tone of the clinician's communications an d its importance to the further ing of th e treatment alliance . We spea k no t o f specifi c intervention s bu t of a n attitude an d philosophy tha t at their best suffuse al l the clinician' s work. I n a sense, this book i s meant to demonstrate that tone. It is most importan t i n our work wit h schizophreni c patient s tha t w e illustrate ou r convictio n tha t the y ca n attai n meaningfu l autonom y an d to provid e the m wit h opportunitie s t o exercis e thi s basi c componen t o f self-esteem i n a healthy fashion. As we have noted before, in most mental health treatmen t settings , patient s ar e treate d a s i f the y wer e unabl e t o make decisions, even when the y possess th e ability t o do so without risk to thei r o r others' safety . Ther e ar e some treatmen t decision s an d man y life decision s i n which th e schizophreni c perso n mus t mak e choice s an d not b e tol d wha t t o do . Eve n thos e patient s wh o ar e seriousl y disable d will benefi t wheneve r thei r abilit y t o decide , an d thu s t o defin e thei r individuality, i s reasonably supported . In general, w e wis h t o exemplif y a n attitud e o f toleranc e an d under standing tha t doe s no t yiel d t o imprecis e thinkin g o r a dilutio n o f ou r professional roles . Self-respec t an d rationa l hopefulnes s ca n b e modele d by clinicians . The clinicia n alway s serve s a s a mode l fo r th e observin g ego tha t i s ofte n unde r sieg e i n th e schizophreni c individual . I n this w e emphasize th e value of rationa l assessmen t an d reflection i n understanding the psychology o f ourselves an d others. As note d a t th e beginnin g o f thi s chapter , w e se e th e patien t a s a n active participan t i n th e treatmen t proces s an d no t merel y passivel y compliant. Whil e acknowledgin g th e schizophreni c patient' s man y diffi culties i n contemplatin g change , rangin g fro m anxiet y t o bitte r resent ment, w e identif y i n the m th e capacit y fo r improve d adaptation , th e possibility tha t chang e ca n occur , thoug h perhap s slowly . I n helpin g them, w e poin t ou t th e destructiv e rol e o f unrealisti c expectation s tha t contribute t o thei r self-condemnation . Thi s proces s require s a rationa l examination o f plans , goals , an d th e unrealisti c fantasie s tha t serv e t o defend agains t an at times oppressive reality .

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THE PARALLE L DIALOGU E

It is difficult t o maintain a balanced ton e when working with mistrustful , delusional schizophreni c patients. Particularly difficul t ar e those patient s who persis t i n consciousl y endorsin g a distorte d vie w o f peopl e an d events, especiall y insofa r a s the y relat e t o thei r illnes s an d othe r object s of treatment . A s exemplifie d b y severa l vignette s i n thi s text , clinica l work ca n g o o n wit h suc h patient s bu t onl y whe n th e distortion s an d differences ar e understoo d an d whe n som e basi s fo r continue d collab oration ha s bee n established—eve n i f i t i s onl y th e patient' s curiosit y about wha t w e think . Th e clinicia n mus t b e prepare d t o tolerat e th e tension inheren t i n this kind o f work . What w e mean b y a "parallel dialogue " is a modification o f techniqu e necessitated b y continuall y interpretin g event s i n an d aroun d treatmen t through tw o frame s o f reference : tha t is , the clinician' s an d th e patient' s ways o f viewin g events . Th e dialogu e i s "parallel" becaus e th e clinicia n must mak e frequen t referenc e t o th e patient's wa y o f interpretin g event s (as she understand s it ) i n contras t t o he r own . Severa l specifi c measure s are indicated . First, th e clinicia n mus t no t focu s o n gainin g th e patient' s agreemen t about th e litera l o r consensua l "truth " o f events . Treatmen t wil l no t progress i f we try t o mak e a delusiona l patien t admi t h e i s ill, produce a confession, o r prove the falsity o f a delusion. Truth i s in all events alway s partly subjective . Second, th e clinicia n mus t direc t th e treatmen t towar d mutua l goal s that wil l hel p th e patien t t o fee l effectiv e an d t o experienc e improve d self-esteem. Thes e kind s o f goal s ar e mor e likel y t o wi n th e patient' s support, i n th e fac e o f th e patient' s delusionalit y an d denial , an d ar e thus importan t i n servin g a tenuou s treatmen t alliance . Th e clinicia n must als o tr y t o identif y ego-dystoni c aspect s o f th e patient' s delusiona l views: What i s it abou t th e patient's explanatio n o f event s tha t i s unsat isfactory, tha t cause s th e patient discomfor t o r anxiety ? Identifyin g theme s such as loneliness, fatigue ove r a protracted, isolate d struggle, and sham e or frustratio n abou t observe d ineffectivenes s o r failur e ca n b e an impor tant first ste p i n establishin g a treatmen t alliance . Suc h concern s ca n b e used i n decidin g wha t kind s o f treatmen t goal s ma y b e usefu l t o th e patient. Thi s proces s migh t b e sai d t o b e on e o f finding wha t abou t th e

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patient's psychologica l adaptatio n (includin g his understanding o f wha t is happening) t o his illness is ego-dystonic; for the schizophrenic individual i s mor e likel y t o accep t help , a t least initially , wit h a problem tha t produces distress. Third, w e shoul d attemp t t o hel p th e schizophreni c perso n se e his illness clearly—t o see , that is , what symptom s ar e a result o f th e illness and wha t constitute s hi s psychological response s t o that illness . I n psychotherapy, w e mus t hel p hi m to understand th e psychological motive s for maladaptiv e behaviors . Afte r describin g th e variou s feature s o f hi s illness an d his efforts t o cope with it , we try to help him understand the interaction o f these aspect s of his mentation. I n other modalities, we try to hel p hi m understand wh y he has difficulty wit h certai n interpersona l and cognitiv e functions . Finally , w e mus t offe r alternativ e mean s o f coping, suggesting supportiv e intervention s an d assisting th e patient i n discovering wha t kin d o f differen t adaptatio n h e can achieve. Thi s gen eral mode l o f treatmen t shoul d b e presented t o the patient, particularl y in th e contex t o f th e "paralle l dialogue. " Althoug h th e patien t ma y continue t o resis t th e assumption s an d implication s o f treatment , thi s outline offer s a concret e explanatio n o f th e treatment phase s (wit h al l modalities) tha t partially addres s th e mistrustfulness suc h schizophreni c persons manifest . Presentin g thi s mode l als o help s i n tha t delusiona l patients ar e mor e irritabl e an d intractabl e i n setting s characterize d b y ambiguity of purpose. Fourth, w e believ e tha t th e schizophreni c individual' s delusionalit y and denial i s at least in part exacerbated b y his difficulty imaginin g tha t he ca n or will chang e an d his belief tha t copin g wit h th e illness i s futil e and worthless. Accordingly , i n work wit h patient s whose sever e view of self an d illness require s a parallel dialogue , we must repeatedl y describ e the gain s tha t ma y b e possibl e throug h usin g th e treatment , includin g the predictability an d practicality of our model. We must also clarify our realistic expectation s abou t th e cours e o f th e schizophreni c person' s illness an d potentia l recover y t o a positio n o f independenc e an d self esteem whil e copin g wit h hi s symptoms. Importan t component s o f th e psychology o f recover y ar e addressing unrealisti c expectation s an d supporting patients when they avoid change or challenge because of the fear that improvemen t wil l occasio n eventua l expectation s the y canno t pos sibly fulfill, whethe r they imagine such renewed expectations will be selfgenerated or represented in others.

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Conducting a paralle l dialogu e mean s rememberin g tha t th e patien t may b e interpretin g th e clinician' s word s o r action s i n a distorte d wa y and tha t delusiona l expectation s influenc e perceptio n an d reasoning. This kin d o f wor k implie s regularl y havin g t o contras t th e clinician' s point o f vie w wit h on e consisten t wit h th e subjectiv e experienc e articu lated b y th e patient : " I believe tha t wha t happene d wa s a coincidence ; whereas yo u ar e convince d tha t thi s wa s arrange d b y th e peopl e perse cuting you." Such contrasts allo w fo r further clarificatio n b y the patient and serve to identify th e clinician a s a reliable repository o f the patient' s experience, a condition that may enhance trust. Many o f th e clinica l vignette s presente d i n thes e first thre e chapter s have containe d element s o f a paralle l dialogu e an d exemplif y thes e principles. Th e clinica l example s i n chapter s 5 , 6 , an d 7 , wil l als o eluci date thes e themes . Th e ton e o f thes e variou s interaction s wit h patient s demonstrates restrain t an d respec t fo r th e patient' s deepl y hel d delu sional conviction s an d their psychological function . The restraint is particularly manifest in the clinicians' patient expectation of slow and subtle change. The paralle l natur e o f th e clinica l experienc e als o require s th e clini cian t o pursu e the schizophreni c patient' s subjectiv e experienc e throug h repeated inquiry . Patient s wit h intens e delusionalit y ar e mistrustfu l o f revealing thei r tru e dispositions , especiall y abou t thei r treatment . Plan ning o n variou s intervention s ca n ofte n g o awr y whe n thi s concer n i s not addressed. For instance: A schizophreni c man i n hi s twentie s ha d bee n hospitalize d fo r delusional ideation . Althoug h initiall y quit e resistan t t o takin g medications, goin g to activities , or seeing a therapist, he eventuall y cooperated whe n i t was clea r that he would otherwis e b e commit ted t o treatmen t b y th e court . Nevertheless , hi s participatio n i n treatment was unenthusiastic . Discharge plan s wer e readie d b y th e patient' s treatmen t team . Because o f hi s socia l isolatio n an d cognitive impairment s th e tea m recommended referra l t o a residentia l treatmen t facilit y i n a far m setting. The patient sai d little about the plan, which was presente d to hi m a s a "fir m recommendation. " H e sai d h e woul d g o ther e after h e lef t th e hospital , an d hi s famil y tentativel y agree d t o th e plan, for they were surprised at the patient's acquiescence .

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The patien t wa s discharge d hom e an d wa s t o g o t o th e residen tial progra m th e nex t day . Onc e home , however , th e patien t re fused t o g o anywhere . Th e patient' s famil y wa s frustrate d an d helpless becaus e the y woul d no t simpl y thro w hi m int o th e street , despite their concern . When late r speakin g t o hi s outpatien t therapist , wh o inquire d about th e patient' s feelin g abou t treatmen t an d th e residentia l program, th e patient said : "I don' t thin k I' m ill . I've ha d problems , bu t I don't nee d thes e medications. I heard wha t the y tol d m e i n th e hospital—bu t I fee l I've bee n persecute d b y th e FBI , an d I kno w tha t won' t sto p i f I live somewher e else . Goin g t o wor k i s pointless becaus e they [th e FBI] wil l scre w i t u p fo r me . I hav e t o sta y hom e an d pursu e th e truth." It i s apparen t tha t thi s patien t woul d no t the n o r i n th e nea r futur e voluntarily assen t t o th e treatmen t pla n prepare d fo r him . Eventually , his therapis t wa s abl e t o initiat e a treatmen t allianc e wit h hi m b y focus ing o n th e patient' s feeling s o f frustratio n an d acut e discomfor t du e t o his anxiety an d hallucinations. (Anxiet y and hallucination s were the egodystonic feature s o f hi s condition ; hi s ineffectivenes s i n stoppin g th e persecution an d th e associate d frustratio n an d discouragemen t wer e th e ego-dystonic aspect s o f hi s psychologica l adaptation. ) H e slowl y bega n to accep t treatment , includin g medications , a s hi s therapis t helpe d hi m understand th e treatmen t an d illnes s model , describe d wha t medicatio n and othe r intervention s coul d an d coul d no t do , an d suggeste d ho w together the y migh t wor k o n th e othe r problem s h e faced—despit e hi s continuing convictio n tha t wha t h e perceive d t o b e th e cause s o f hi s problems wer e no t du e to a n illness .

THE RESIGNED PATIEN T Some o f th e technique s describe d abov e ca n b e usefu l i n dealin g wit h "resigned," o r withdraw n an d apparentl y hopeless , patients . Indeed , many suc h schizophreni c person s ar e als o delusiona l an d believ e thei r problems hav e a concrete , externa l origin . Bu t befor e thinkin g abou t what t o do with patient s who appea r resigne d t o a n isolated, amotivate d

From Understanding to Action 16 1 life, w e mus t understan d th e variou s reason s fo r patients ' manifestin g this syndrome. We noted i n chapter 1 that symptoms.suc h a s amotivation, disinter est, and resignatio n aris e from unclea r etiologies . We do not know an d have no way of documenting whether a given schizophrenic individual's symptoms o f amotivatio n ar e du e to disturbance s i n fronta l lob e func tioning (th e mos t likel y anatomi c correlate ) o r t o wha t w e refe r t o a s psychological causes . Although the substrate of psychology is the brain, we presume tha t psychologica l disturbance s ar e those that ma y change in response to experience and conscious mental effort (reflection , insight, imagining alternative copin g strategies). Since we do not hav e evidence that a give n schizophreni c patient' s resigne d attitud e ha s a n organi c etiology, we must work to discover and change maladaptive psychological mechanisms tha t ma y also produce or intensify suc h symptoms. We should kee p in mind the putative rol e of fronta l lob e disturbances, and so not badger patients or insinuate where we do not have psychological clues o r evidence . Nevertheless , t o giv e u p o n suc h patients , ascribin g their withdrawa l t o unprove n organi c causes , i s t o abando n huma n beings wh o ma y b e caugh t i n a tra p o f psychologica l self-decei t an d inhibition. What migh t b e th e factor s underlyin g th e psychologica l stat e o f a resigned schizophreni c patient? Th e followin g lis t though probabl y no t exhaustive, indicates those factors: 1. Secondar y Major Depressiv e Illness or other Affective Disorders ; 2. Iatrogeni c Syndrome—due to over-medication and drug-induced Parkinsonism; 3. Discouragement , Demoralization ; 4. Anger , Resentment, Wish to Control—by defeatin g others ' efforts t o help; 5. Delusionality—perceptio n o f ris k i f interes t i s shown , o r certitud e regarding eventual destruction or betrayal; 6. Putativ e Frontal Lobe Syndrome. Obviously, w e mus t first evaluat e th e patien t fo r evidenc e o f a n affective disorde r or iatrongenic Parkinsonism, as we discussed in chapter 1. There is as yet no treatment for frontal lob e disturbances, although we must conside r thei r potentia l contribution . Th e other factor s repre sent form s o f psychologica l adaptatio n tha t ma y b e o f som e limite d

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benefit t o th e patient bu t are associated wit h disablin g consequences . I n particular, socia l withdrawa l ma y hav e a deleterious effec t o n cognitiv e and emotiona l life . Thes e behavior s no t uncommonl y expiat e uncon scious wishes for self-punishment . Once clinician s imagin e tha t psychologica l factor s ma y b e pertinent , they mus t procee d a s w e hav e describe d before : b y first explorin g th e patient's subjectiv e experience . Th e proces s ma y b e difficul t wit h re signed patients, who commonl y deflec t curiosit y throug h apparen t indifference, muteness , obstinacy , o r passiv e compliance . The y ar e typicall y frustrating an d ca n inspir e i n clinician s question s abou t thei r menta l orientation, competence, or relatedness. It may b e useful t o confront patients abou t a demeanor tha t is apparently placi d o r docil e i n th e fac e o f thei r desperat e situation . Thu s on e might say , "Yo u see m no t t o car e wha t happen s t o you , yo u le t other s make decision s fo r you—ye t it' s hard fo r m e t o imagin e yo u ar e in fac t so indifferent." Whe n on e can elicit evidence supporting a psychological motivation fo r th e patient' s resignation , man y othe r intervention s be come possible. The clinician migh t say, for example, "I t is apparent tha t you hav e fel t little genuine contro l ove r your life [perhap s "little contro l over you r menta l experience" ] an d tha t a s a consequenc e yo u hav e expressed your sadness and anger by controlling those who wish t o help you, alternatel y encouragin g the m t o assis t yo u an d then dashin g thei r expectations." Intervention s suc h a s th e latte r ar e mor e elaborate , re quire mor e information , an d ar e appropriat e fo r a patient whos e resig nation i s otherwis e resistan t t o engagement . I n exploring thes e issues , it is importan t tha t w e no t ac t o n ou r countertransferenc e b y makin g merely critica l comments . Confrontationa l intervention s mus t b e thoughtful, an d constructe d s o a s t o b e acceptabl e t o th e par t o f th e patient tha t wishe s t o change , t o th e part o f th e patient's observin g eg o that is aware that her resigned disposition i s damaging to her. In orde r t o engag e th e resigne d patien t i n a treatmen t alliance , on e must discer n an d then elaborat e th e schizophreni c person' s psychologi cal motivatio n fo r thi s uniqu e behaviora l an d cognitive adaptation . I t is useful t o conside r certai n paradigms , suc h a s thos e w e liste d above , although suc h a lis t ca n neve r b e exhaustive . Certainly , ange r play s a n important unconsciou s rol e i n the developmen t o f a resigned attitud e i n many schizophreni c patients . A s w e discusse d i n chapte r 2 , th e man y frustrations o f schizophreni c persons ' externa l an d interna l life , thei r

From Understanding to Action 16 3 sense o f isolation , alienation , an d mistrust , contribut e t o thei r resent ment, envy , an d self-disdain . Thes e psychologica l stresse s ca n b e ex pressed i n a demoralized state , as well as by efforts t o control o r defea t others, eithe r famil y o r menta l healt h practitioners . Ther e ar e als o pa tients with acut e delusiona l concerns , who fea r intimacy , who ar e convinced tha t destructio n ma y com e a t an y moment , o r wh o fea r raisin g their expectation s becaus e o f certai n consequen t betrayal . Fo r some , it may even be dangerous to speak, to let the simplest wish be known. The two vignettes below illustrate these phenomena. A man i n his earl y twentie s ha d a history o f schizophreni a fo r several years. He was hospitalized fo r evaluatio n becaus e of social disfunction, disinterest , apparen t hopelessness , an d treatmen t avoidance. Hi s neuroleptic s wer e firs t decrease d becaus e h e ha d evident iatrongeni c Parkinsonis m an d di d no t otherwis e requir e such high doses. Despite som e enlivenin g o f hi s affect , h e remaine d blan d an d unmotivated. H e was compliant , bu t require d nearl y constan t at tention an d direction . I t was apparent h e had som e cognitive disturbances, bu t hi s tas k performanc e wa s puzzlingl y inconsistent . He wa s playful an d friendl y wit h othe r patients , bu t nearl y mut e when talking to clinicians. When reviewin g th e patient's lif e a t home , the treatmen t tea m learned that the patient's mother was caring but also overweening. She insisted on doing his laundry, making his meals, running to get things fo r him . Sh e had spen t he r lif e a s a caretaker, first for he r mother, the n fo r he r son . When aske d wha t woul d happe n i f th e patient becam e mor e independent , sh e said , " I don' t kno w i f I could tolerate that." The remainde r o f th e patient' s treatmen t i n th e hospita l con sisted of engaging him in rehabilitative programs, which enhance d his self-estee m an d taugh t hi m skills ; famil y wor k aroun d issue s related to autonomy; and the patient's psychotherapy, in which his experience o f hi s illness , and hi s relationshi p t o hi s parents, were explored. His therapist learned that "behind" the patient's apparent indifference and resignation, he was in fact quite demanding and haughty at times . H e considere d man y activitie s t o b e beneat h hi m an d

164 Working with the Person with Schizophrenia scorned much of his treatment. It was clear that this arrogance was defensive, however, in that the patient was also able to discuss his failed expectations , hi s sadness an d sense of loss , an d his intense ambivalence about his relationship with his mother. A part of him was comforted by her solicitude; a part of him was ashamed of his dependency. H e als o worrie d abou t ho w h e woul d surviv e afte r she died. This last theme became the firstfirmbasis for his treatment alliance. A schizophrenic man in his late twenties presented to the hospital after a serious episode of genital self-mutilation. He said he felt he mus t hur t himsel f becaus e "voices " tol d hi m to . H e furthe r stated tha t he had been reincarnated an d that in his past lives he had been sinful. He was convinced that he would be destroyed for his pas t transgressions , tha t ther e wa s n o hop e fo r him , tha t n o one could help; he was simply waiting for the end. When staf f member s offere d help , he wa s uninterested . When asked questions, he often would not respond. Although there was equivocal evidenc e of psychomoto r retardation , h e did not manifest a major depressive syndrome. Through exploration of his subjective experience of his illness— which he felt was a divine punishment, no t a medical entity—th e treatment tea m learne d tha t th e patient wa s actuall y quit e angry and afraid t o le t that show. H e was convince d tha t i f h e "transgressed" in this manner, it would hasten his destruction. Although a part of him was resigned to the inevitability of an early death, a part of hi m was struggling to maintai n a tenuous equilibrium. In the interim , th e treatmen t tea m observe d man y instance s o f hi s behaviors tha t expresse d unconsciou s resentment , envy , an d selfdislike. The latter of thes e two patients was in a desperate condition. His constellation o f psychologica l adaptation s wa s quit e worrisom e an d suggested a prolonged course of treatment before the patient might be at reduced ris k o f furthe r self-mutilatio n o r suicid e (whic h h e ha d at tempted several times). The treatment alliance would take time to evolve and might begi n with th e clinician's exploitin g his conflicting attitude s about th e eventualit y o f imminen t deat h (i.e. , tha t h e wa s helpless ,

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although h e migh t dela y deat h b y containin g hi s anger) . Thi s conflic t might b e see n a s a consequenc e o f unconsciou s ambivalenc e abou t hi s wish t o survive, to accep t his illness, and t o cop e with it . The initia l phas e o f th e treatmen t alliance , however , migh t b e base d on s o sli m a notio n a s hi s uncertaint y abou t th e amoun t o f tim e lef t t o him. I f tha t destructio n wer e t o occu r i n th e distan t future , h e migh t agree that copin g with th e present would b e useful. Otherwise , he woul d be like th e protagonist i n Henr y James's The Beast in the Jungle, await ing a calamit y tha t ha d alread y occurre d within . Fro m there , th e treat ment alliance would requir e finding som e basis through which t o addres s his functiona l impairments . Activitie s tha t coul d suppor t self-estee m would hel p hi m t o tolerat e confrontatio n wit h interpersona l o r tas k paradigms tha t wer e difficult , a s woul d som e conceptua l understandin g of wh y thes e impairment s existe d an d ho w h e migh t lear n t o manag e them.

COUNTERTRANSFERENCE Throughout thes e thre e chapters , w e hav e mad e libera l referenc e t o clinicians' countertransferenc e an d it s relationshi p t o wor k wit h schizo phrenic patients. This subject ha s been effectively treate d i n the literatur e (33—36), an d ou r recognitio n o f it s importanc e i s much indebte d t o th e work o f others . W e conclud e thi s chapte r wit h thi s topi c becaus e w e wish t o leav e the reade r wit h a reminde r a s t o th e importanc e o f critica l self-examination, objectivity , an d reflectio n i n th e treatmen t o f chroni c schizophrenic individuals . The schizophreni c perso n engender s intens e reaction s i n others , in cluding famil y an d menta l healt h practitioners . Thi s ma y b e du e i n par t to th e punitive natur e o f patients ' transferenc e a s well as to th e presenc e of disinhibite d behavior s tha t provok e disturbin g unconsciou s reaction s in observers . I n addition , th e typicall y passiv e and/o r hostil e attitud e o f these persons , thei r help-rejectin g stance , an d th e intractabilit y o f som e of thei r symptoms—whic h expose s th e limitation s o f ou r scientifi c knowledge an d treatments—caus e clinician s t o fee l frustrate d o r ineffec tual. Bein g deprive d o f gratificatio n fro m o r prais e an d thank s fo r thei r work ma y lea d clinician s t o unconsciousl y blam e patient s fo r thei r pro fessional dissatisfaction . Finally , th e characteristic s o f th e disorde r ma y

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disquiet som e clinicians , provokin g reflectio n o n thei r understandin g o f the mind and its too obvious vulnerability . Most disturbin g ar e countertransferenc e response s associate d wit h unconscious guilt . Clinician s ma y b e guilt y abou t th e ange r o r fear , th e wish t o avoi d o r ge t awa y fro m patient s tha t ca n occu r i n thi s work . These feeling s ar e often a consequence o f patients ' efforts t o discourag e others. Perhap s becaus e o f ou r frustration , w e ofte n fee l tha t we shoul d do more , tha t w e ar e no t generou s enough , tha t w e ar e guilt y fo r no t wishing t o giv e more . I n period s o f quie t reflection , w e ma y sa y t o ourselves tha t i f w e wer e bette r a t ou r work , i f w e understoo d more , then w e coul d help . Subtly , unconsciously , w e blam e ourselve s fo r ou r inability t o mak e patients well , t o "ge t through" to thos e wh o mak e u s feel tha t the y woul d respon d i f w e sai d th e righ t thing , mad e th e righ t step, wen t a bit furthe r fo r them . Ironically , w e ofte n fee l w e hav e hur t schizophrenic individual s throug h bein g human , becaus e w e hav e limi tations, make mistakes, respond thoughtlessly, o r fail to comprehend . We must be generous to work with chronic schizophrenic individuals . We mus t als o b e toleran t o f ourselves . W e shoul d striv e t o lear n an d improve, bu t als o t o acknowleg e ou r limitation s t o ou r patient s an d ourselves. Th e schizophreni c perso n experience s grea t nee d an d ofte n a great emptiness ; tha t individua l migh t wel l tak e al l tha t w e coul d give . The tension , th e struggle, fo r th e compassionate clinician , i s in the nee d to recogniz e an d experienc e th e humannes s an d sufferin g o f th e schizo phrenic person , whil e adherin g t o th e principle s an d structur e o f ou r work.

4

The Man with a Bug in His Brain: An Initial Intervie w

1 hi s chapte r present s an d discusse s a n initia l intervie w i n th e assess ment o f a chroni c schizophreni c individua l fo r th e purpos e o f under standing his subjective experienc e s o that a treatment partnershi p ca n b e formed. Peter was interveiwe d b y an attendin g psychiatris t a s part o f a cours e on how to form a n allianc e with a so-called "har d t o reach patient." Th e interviewees, al l inpatients, were selecte d b y the treatment tea m becaus e of thei r difficult y i n makin g contact . Th e patient chose n fo r thi s particu lar sessio n wa s describe d b y bot h hi s therapist an d hea d nurs e a s some one who "refuse d t o participate." Indeed, the staff fel t a t such a loss tha t they wer e considerin g transferrin g hi m t o a stat e hospital . Th e nurs e said, "It' s no t tha t h e doesn' t talk . I n fact , h e talk s a lot , almos t to o much. Bu t it' s suc h craz y tal k tha t there' s n o wa y in. " Th e patient' s therapist sai d tha t th e patient' s chronicit y wa s th e mos t disturbin g fac tor, exemplifie d b y hi s repeate d us e o f th e sam e apparentl y meaningles s "hollow phrases. " Th e therapis t complaine d tha t whe n h e trie d t o ge t the patient t o chang e subjects , th e patien t woul d bombar d th e therapis t with "weir d storie s abou t bein g bugged." The patient's forma l diagnosi s was chroni c schizophrenia .

THE INTERVIE W

The patient , i n hi s mid-thirtie s wa s o f averag e height , somewha t stock y in build , an d dresse d i n ill-fitting, plai d short s an d a Hawaiian shir t tha t hung ou t o f hi s pants . Generally , h e ha d a n amiabl e look , thoug h occasionally h e eyed the interviewer warily . At other times , he stared of f 169

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into space . Periodically , h e tappe d hi s lef t foo t vigorousl y an d seeme d unaware o f hi s behavior . Earl y i n th e interview , h e avoide d th e inter viewer's gaze . A s th e intervie w progressed , h e fixed increasingl y o n th e interviewer, and , b y th e en d o f th e session , th e interviewe r ha d th e feeling tha t th e patient wante d t o si t in his lap. Each patien t ha s a uniqu e voice , a n individua l se t o f image s an d stories (includin g delusions) that reveal his or her experience. The patien t discussed belo w tell s abou t hi s humiliation , pain , an d concern s abou t power i n a stor y abou t bein g bugged . Th e interviewe r start s wit h a serious attemp t t o understan d thi s story a s a message about th e patient' s psychological experienc e an d use s thi s t o demonstrat e tha t th e patien t has a mode l o f himsel f an d hi s problem s tha t ca n b e used b y th e tw o o f them t o begi n a treatment alliance . As w e hav e describe d i n previou s chapters , th e interviewe r i s inter ested i n assessin g th e patient' s subjectiv e experience , th e manne r o f hi s relatedness, what h e is communicating t o others abou t himself , an d ho w he is attempting t o adapt . Sinc e the staf f viewe d th e patient a s inaccessi ble, th e clinicia n wa s als o intereste d i n helpin g the m discove r area s tha t might allo w fo r contac t wit h th e patient . The intervie w wil l b e interrupte d periodicall y t o explai n th e inter viewer's choic e of comments .

Laying th e Groundwork : Establishin g Contac t Dr.: Well , i t wa s goo d o f yo u t o com e in . I don' t kno w wha t you r understanding i s of thi s meeting . P: Well , par t o f i t i s researc h o f th e staf f an d differen t clinic s o f th e hospital, an d par t o f i t i s practice fo r you . Par t o f i t i s practice fo r me, part o f i t is practice s o tha t yo u ca n giv e certain recommenda tions t o my doctor , Dr . Smith , abou t m y condition . Tha t migh t help. Therapeuti c advice , anyway , tha t migh t stimulat e somethin g where differen t drug s ar e used , o r differen t methods , o r differen t psychological abeyance . Dr.: A n abeyance ? P: I think I might have use d th e wrong term . Dr.: I don' t know . I t migh t b e th e righ t term . I' m jus t unfamilia r wit h what you'r e talkin g about there .

The Man with a Bug in His Brain 17 1

Interventions The First Intervention: Letting the Patient Know the Therapist Wants to Understand The interviewer note s the patient's od d use of th e word "abeyance " and draws attentio n t o it , wishin g t o clarif y ho w th e patien t i s usin g th e word. Mor e importantly , h e wishes t o infor m th e patient tha t the interviewer place s importanc e o n th e patient's choic e o f word s an d way s o f thinking abou t himself . The interviewe r als o wishes t o avoi d th e ris k o f ignoring wha t i s confusin g t o hi m abou t wha t th e individua l i s saying . Acting a s if he had understood th e patient's statement s when he has no t would mea n treating the patient's communication s a s unimportant and , therefore, no t wort h clarifying . Th e interviewer i s informing th e patien t about his rol e a s the provider o f data, a role that will eventuall y permi t the patient , wit h th e interviewer' s help , t o bette r understan d himself . Patients wh o hav e difficult y wit h self-objec t differentiatio n ma y assum e that other people kno w thei r thoughts withou t thei r having to explicat e them. Fo r thi s reason , i t i s importan t tha t th e interviewe r sa y tha t h e cannot rea d th e patient' s mind . Th e interviewe r communicate s thi s b y indicating that he does not automatically understan d what the patient i s saying. When he makes clear he has no special acces s to the patient's idiosyncratic use of the term "abeyance," the interviewer draws attention t o the fact that he is separate from the patient. Even though at this point we d o not hav e evidenc e tha t th e patient has problems wit h boundaries , i t is a possibility that would be important to consider early on. The interviewer chooses t o as k abou t th e use of tha t one wor d becaus e i t is the quickes t and probabl y leas t threatenin g wa y t o communicat e al l o f th e above . The interviewe r coul d hav e mad e a genera l observatio n abou t th e pa tient's elliptical , loos e speech , bu t th e patien t woul d probabl y hea r thi s as a criticism, which would halt the process at the beginning. A Second Intervention: Anchoring the Interview in the Patient-Interviewer Interaction Dr.: I don't know . I t might b e th e righ t term . I' m jus t unfamilia r wit h what you're talking about there.

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P: Jus t your advic e an d seekin g differen t advic e fro m anothe r docto r in layman' s term s i s beneficia l t o m e becaus e I'v e ha d a lo t o f doctors loo k a t me . An d I felt extremel y wel l whil e I was here . I had a problem wit h voices . They hav e completel y gon e away . I'v e had problem s wher e I , yo u know , wher e I was flying, an d I ha d cues i n me , bu t th e cue s go t al l messe d u p 'caus e peopl e wer e spinning m e on th e road s an d a lot o f peopl e wer e makin g love t o me, yo u know , the y wer e reall y fuckin g m e u p good ! I cam e i n here because I was all messed up and I wanted to straighten mysel f out with placements so I get myself o n the right trail again. Dr.: I' m particularly intereste d i n one thin g that you said—tha t a lot of doctors have looked a t you. The patien t ha s jus t presente d th e clinicia n wit h a n overwhelmin g amount o f data . As will b e seen in what follows , th e clinician intervene s by anchoring th e discussion i n the patient-interviewer relationshi p i n an effort t o slo w th e patient dow n an d thus reduce his potential fo r confu sion. Anchorin g th e intervie w i n thei r interactio n allow s fo r greate r clarity becaus e patien t an d interviewe r ar e then reflectin g togethe r o n a shared event, their relationship. It is likely that the patient's anxiety is largely a function o f his anxiet y about the interaction. To the extent that this is true, supportive attentio n to th e interaction woul d b e helpful i n reducing the patient's anxiet y an d might promote greater clarity in the interview. The clinician' s commen t als o introduces th e genera l subjec t o f ho w the patien t relate s t o doctor s and , i n particular, thi s docto r wh o i s no w sitting wit h him . Th e clinician' s commen t anticipate s a sequenc e i n which h e will confron t th e patient's tendenc y t o categoriz e hi m a s identical t o al l othe r doctors , wh o ar e intereste d i n hi m onl y a s a clinica l specimen. Suc h confrontatio n (o f ho w th e patien t lump s al l doctor s together) i s part of th e exploration o f th e patient's ability to differentiat e among individuals. P: A lot o f the m have , you know , a lot o f the m just said, "Okay , th e medicine's th e answer. " N o therapeuti c counsellin g o r anythin g like that. They just felt that if they gav e me medicine it' d take care of th e voices and that I'd be 10 0 percent better. The patient' s respons e t o th e clinician' s interventio n confirm s h e i s angry a t physician s wh o "loo k a t him " withou t tryin g t o understan d

The Man with a Bug in His Brain 17 3 him. At this point, th e patient seem s to b e categorizing this interviewe r with all the other doctors. The Third Intervention: Working on Differentiation and Discussing the Interaction P: [continuin g his statement] That's not the whole answer.The whole answer i s that I'v e go t man y problem s o n m y mind, an d som e of them—you wouldn' t believ e what some of the m are. Heavy problems and, and, and, what happens is they build up to an overloa d where I get these voices. I can hardly talk . I' m read y t o blur t ou t stuff, cues, and everything else. Everything's comin' out of me. You know? I t seem s lik e somebod y toye d wit h m y min d whe n I was young and they really screwed me up. The patient' s commen t "Yo u wouldn' t believ e [som e o f m y prob lems]" confirms th e hypothesis that he mistrusts his doctor. This speech also offers u s a look at his subjective experience: He feels himself hardl y able t o tal k an d i s threatene d b y th e possibilit y tha t everythin g insid e him is going to come out. Subjective Experienc e Central Issues Up to this point, the patient has been describing the actions of others on him; now , he tells u s abou t hi s inner experiences . He suggests tha t hi s way o f copin g i s fault y i n tha t h e feel s h e ma y no t b e abl e t o contai n himself. H e indicate s h e i s experiencin g difficult y wit h hi s sens e o f control over himself: "Everything is coming out of me." When he refers t o the voices as "they build up to an overload," he is hinting that ther e i s a mechanism withi n hi m that produce s them , suggesting tha t h e ha s though t abou t th e origi n o f th e voices . The inter viewer note s thi s statemen t becaus e i t suggest s tha t th e patien t ha s constructed a theory about his experience in order to understand what' s happening t o hi m and , b y implication, tha t h e is interested i n thinkin g about mental processes. The patient may be willing to elaborate his view of himself if the clinician supports him in this task. The clinician' s principa l ai m i n muc h o f th e intervie w wil l b e t o

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explore th e patient' s "self-construction, " hi s theor y abou t himself . B y suggesting amendment s t o or modifications o f that self-construction, th e clinician hope s t o b e abl e t o determin e th e degre e o f flexibilit y th e patient ha s wit h regar d t o considerin g alternativ e view s abou t himself . The extent to which the patient is able to consider other ways of lookin g at himself i s an important indicator of hi s availability fo r treatment .

Self-Other Differentiation At thi s poin t i n th e interview , self-othe r differentiatio n i s a ke y issu e under investigation . Th e interviewe r confront s th e patient' s attemp t t o categorize th e clinicia n (a s someon e wh o "woul d no t believe " him ) t o see i f th e patien t ca n differentiat e th e actua l clinicia n fro m th e patient' s a prior i expectation s o f him . Thi s interventio n evaluate s whethe r th e patient ca n recogniz e "yo u ar e no t wh o I though t yo u were. " Th e patient's failure to distinguish the other person from the patient's projections onto him would make meaningful interaction s problematic. At th e sam e time , th e clinicia n mus t b e awar e tha t th e patient' s attempt t o categorize th e interviewe r accordin g t o hi s a priori assump tions may be his attempt to deal with the anxiety engendered by being in contact wit h a stranger . I f th e patien t i s expecte d t o abando n thes e categories i n favo r o f activ e exploratio n o f wh o th e individua l inter viewer actually is, the interviewer will hav e to help the patient find other ways to cope with his anxiety. Dr.: On e thin g tha t I' m wonderin g abou t no w a s we'r e talkin g i s thi s idea tha t I wouldn't reall y believ e you . Wh y i s that ? Wh y d o yo u think I wouldn't believ e you? The interviewer here repeats his focus on the interaction as the central event. H e use s whateve r materia l th e patien t offer s t o underscor e th e point. Ha d th e patien t said , " I think yo u woul d believ e me, " th e inter viewer coul d hav e focuse d o n thi s issu e b y saying , "Give n wha t yo u have tol d m e ha s happene d t o yo u i n th e past , wh y woul d yo u believ e me a t this point?" Focusing o n th e interaction provide s a way t o clarif y the preconception s th e patien t bring s t o th e interactio n a s wel l a s t o determine whethe r th e patien t alter s hi s vie w o f th e interviewe r a s th e interaction unfolds .

The Man with a Bug in His Brain 17 5 P: I don' t know . I don' t kno w wha t you r affiliatio n is . I' m a Joh n Bircher, and you know our position is that you take all the pressure you can take and you don't budge an inch. If they put pressure on, you're not supposed t o buckle.

Vulnerability in the Interaction By indicatin g hi s interes t i n th e interviewer' s "affiliation, " th e patien t shows curiosit y abou t th e interviewer , a sig n tha t th e patien t ma y b e motivated t o loo k a t th e interaction . I n referrin g t o th e Joh n Birc h Society, th e patien t reveal s hi s predilectio n t o se e himsel f an d other s i n extreme terms . Consisten t wit h hi s ideal , h e wishes t o b e impervious t o pressure and implies that anything other than this stoic position is a sign of weakness . I n wondering wher e th e interviewe r stands , he is trying t o determine th e interviewer' s attitud e toward s vulnerability . Doe s th e cli nician se e i t as a sign o f weaknes s o r as something tolerable an d under standable? Thi s i s a n importan t questio n t o th e patien t becaus e h e ha s said h e feel s he' s abou t t o blur t everythin g out , t o los e control . Sinc e doing s o woul d mean h e ha s faile d t o achiev e hi s ideal , h e migh t b e concerned abou t ho w th e interviewe r judge s him . The patien t doe s no t appear t o b e awar e o f conflict s withi n himsel f concernin g ho w wel l h e can tolerat e hi s ow n vulnerability , bu t h e i s concerne d abou t th e inter viewer's response to his vulnerability an d whether the interviewer, like a "John Bircher, " wil l pressur e hi m int o breakin g i n orde r t o humiliat e him. A t thi s point , th e clinicia n migh t b e formin g a hypothesis tha t th e patient i s unconsciously wonderin g i f th e interviewe r woul d accep t hi m even though he cannot accept himself . What the patient himself consciousl y desire s is not clear a t this stage. The patient ma y desire to b e humilated o r feel deservin g of humiliation , while at the same time, a part of him may wish for acceptance . Returning t o th e issu e o f self-othe r differentiatio n an d assumption s about the interviewer in the interaction, the doctor persists: Dr.: Di d yo u thin k yo u answere d m y questio n abou t wh y yo u though t I wouldn't believ e you? P: Well , when I first started talking to Dr. Green, he wouldn't believ e anything tha t I was sayin g to him . He though t I was hallucinatin g or dreaming it up. Actually, I went through it. Dr.: Wha t would that have to do with me?

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Note her e th e clinician' s repeate d focu s o n th e centra l importanc e o f the interaction , a s wel l a s hi s communicatin g hi s expectatio n tha t th e patient ca n respon d t o a n inquir y abou t thei r relationship . Additionally , the interviewe r i s insisting tha t h e will no t trea t th e patient a s if h e wer e incapable o f thinking . P: I gues s I jus t too k th e negativ e attitud e jus t fo r a second , yo u know, without reall y testing you out , o r anythin g lik e that . The patien t acknowledge s hi s expectatio n tha t h e wil l b e misunder stood. Th e interviewe r consider s thi s migh t b e a way th e patient trie s t o maintain a self-objec t boundary . Tha t is , he i s separate insofa r a s he, a s the misunderstoo d person , i s distinc t fro m th e perso n wh o misunder stands him . A corollar y woul d b e tha t bein g understoo d migh t b e dan gerous becaus e i t coul d b e equate d i n th e patient' s min d wit h merger , understanding bein g seen a s equivalent t o sameness . Dr.: Bu t I wonder. . .. That' s a goo d poin t you'r e making . I wonder i f you ten d t o generaliz e P: [interrupts ] I might. Dr.: . . . and don' t reall y trea t m e as if I' m separat e fro m othe r people ? P: Tha t migh t have been the case, but I' m bein g very honest with you . I don' t kno w wha t yo u wan t t o kno w fro m me . I can g o bac k t o when th e illness started an d everythin g . . . Assessing the Patients Ability to Participate in Manifestations of Defensiveness

the Exploration:

The patien t her e indicate s tha t th e interviewer' s directio n i n th e inter view is making him nervous . Perhaps he is confused abou t th e interview er's psychologica l inferences . Whateve r th e cause , th e patien t attempt s to reduc e hi s anxiet y b y returnin g t o somethin g familiar—tha t is , a recitation o f hi s histor y an d symptoms . Thi s woul d sugges t tha t hi s return t o th e familia r ma y b e a reactio n t o th e interviewer' s attempt s t o expand thei r inquir y int o unfamilia r areas . The interviewer' s attempt s t o increas e the patient's awarenes s o f him self migh t mak e th e patien t curiou s a s wel l a s anxious . T o th e exten t that awarenes s seem s threatenin g (sinc e h e feel s bot h limite d i n hi s

The Man with a Bug in His Brain 17 7 capacity t o understan d himsel f an d threatene d b y self-exposure) , hi s becoming curiou s woul d itsel f pos e a threat . Hi s recitatio n o f all-too familiar symptom s coul d b e th e patient' s effor t t o resis t an y inquir y directed a t ne w area s o f information . A t thi s point , th e interviewe r would b e intereste d t o kno w i f th e patient ca n tolerate furthe r explora tion into self-awareness despit e his attendant anxiety . In th e interviewer' s nex t intervention , give n below , h e note s th e pa tient's conflicting self-images a s a knowing versus a not-knowing person. The interviewe r assume s tha t th e patien t ca n understan d wha t i s bein g asked of him, but is in conflict abou t acknowledging th e sentient part of himself. The interviewer' s interventio n i s frame d s o a s t o confron t th e patient with his responsibility fo r maintainin g awarenes s o f tha t knowl edgeable part of himsel f an d to resis t th e patient's temptatio n t o retrea t from it or act as if it doesn't exist. The interviewer selected this particular intervention becaus e th e patient' s prio r behavio r i n th e intervie w sug gested his own dissatisfactio n wit h types of inquir y that were not appreciative o f hi s abilit y t o understan d himself . I n addition , th e patient' s reference t o a John Birc h sor t o f stoicis m suggeste d tha t a confronta tional stanc e woul d b e efficaciou s (sinc e i t woul d giv e th e patien t a chance t o b e "tough" ) a s a first effort a t eliciting th e patient' s recogni tion that there is a "knowing" part of him. Dr.: Bu t why d o yo u no w ac t a s if yo u don' t understan d what' s goin g on? I' m tryin g t o find ou t somethin g abou t you r attitud e towar d me and I've bee n very clear, I thought, s o far . I asked very specifi c questions P: [interrupts ] I like you. In interruptin g th e interviewer , th e patien t suggest s h e i s anxiou s about what the interviewer is saying. The gratuitous offering o f affectio n might b e a n effor t t o concea l hi s ange r a t bot h th e interviewer' s intru sivenss an d deman d tha t th e patient d o somethin g (loo k a t why h e act s as i f h e can' t understand) , whic h h e experience s a s threatening . O n th e other hand, he is able to allow some expression of vulnerability—that is, of hi s feelings o f interes t an d affection fo r the interviewer. Perhap s he is in conflic t abou t hi s feeling s abou t th e interviewer , expresse d throug h his blurting out, " I like you," despite his also being angry with him.

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The interviewer continues to confront th e conflict withi n the patient: Dr.: . . . and you say, " I don't know what you want to know," when i n fact there' s n o reaso n fo r yo u no t t o know , sinc e I'v e aske d ver y direct questions. Haven't I? P: Yeah . When th e patien t agree s withou t argument , th e interviewe r repeat s his focu s o n th e interaction , bu t expand s thi s t o includ e hi s experienc e of othe r doctors. Dr.: Okay . Now , let' s go bac k t o somethin g I asked you a few minute s ago: wha t i t mean t t o yo u tha t a lo t o f doctor s hav e "looke d a t you"? T o m y ear, tha t sounde d lik e a n odd phrase . I t didn't see m like anything was going on between you and the doctor. P: Well , whe n I first got sick , I saw a docto r b y th e nam e o f Smith . He di d a lot o f counseling . I t was al l therapeutic . I was o n Thora zine. I didn't fee l goo d 'caus e I had th e voices , bu t h e sai d i t wa s more o r les s jo b counselin g an d othe r things . H e didn' t ten d t o attack the voices, but the problem was the voices and the cues. The drugs I' m o n now , I don't know , the y balanc e m y min d wher e I can sleep . I' m no t on e wher e I slee p a lot , bu t that' s becaus e o f boredom not depression. Dr.: Ar e yo u dealin g wit h m y question ? D o yo u remembe r wha t th e question was ? The patient , i n thes e comments , direct s ange r towar d others , specifi cally doctor s wh o hav e worke d wit h hi m i n th e past . Notably , th e interviewer is spared any criticism. The fact that the patient is repeatedly expressing ange r a t doctor s wh o hav e no t helpe d hi m make s th e inter viewer wonde r whethe r th e patien t i s angr y abou t th e immediate inter action but afraid to express his anger directly. The patient's anxietie s abou t expressin g aggressio n directl y ma y lea d him t o displac e i t ont o others , drif t awa y fro m focusin g o n th e interac tion, and, instead, talk abou t extraneous o r historical events . In order to assess th e patient's capacit y t o modulat e an d express affec t directly , th e interviewer trie s t o direc t th e patien t bac k t o th e interaction . Bu t th e patient ma y hav e difficult y wit h thi s tas k becaus e h e ma y b e frightene d that a focus o n th e interaction wil l lea d to a n eruption o f intens e affect , either in himself o r in the interviewer.

The Man with a Bug in His Brain 17 9 Dr.: D o you remember what the question was? P: No , I don't. Dr.: Th e questio n was : Wha t doe s i t mea n tha t a lot o f doctor s hav e looked at you? P: Okay , wha t tha t mean s i s tha t a lo t o f doctor s hav e trie d t o psychoanalyze m e and they'v e com e up with conclusion s that I' m in a spac e world , o r tha t I' m no t tellin g th e truth , o r tha t I' m making up a lot of stories. That uh, uh, those things didn't happen and, and, an d my problem with th e voices . .. the y couldn't solv e my problem with the voices. When th e patien t state s tha t h e doesn' t remembe r th e interviewer' s question, th e interviewe r wonder s whethe r thi s is true an d wha t migh t be responsibl e fo r th e patient' s memor y loss . I s h e to o distracte d t o remember or has he forgotten th e question because it is threatening? But the interviewer chooses to take the patient's statement of not remembering at face value, for several reasons. It is early in the interview, and the patient has not demonstrated a clear pattern of memory loss. Moreover, should th e interviewe r attemp t a n exploratio n o f wha t constitute s th e patient's difficulty wit h his memory, such an exploration might touch on themes of aggression (suc h as his wish to forget threatening questions or his anger at the interviewer fo r askn g disturbing questions), and, at this early poin t i n th e interview , th e allianc e ma y no t b e strong enoug h t o tolerate a n examinatio n o f aggressio n directe d towar d th e interviewer . On th e othe r hand , th e ris k o f th e interviewer' s acceptin g th e patient' s statement a t face value is that the patient might conclude from thi s that the interviewe r i s afrai d t o confron t (an d therefor e unabl e t o contain ) the patient's aggression. The patient' s respons e indicate s tha t h e feel s despai r abou t himsel f and hopelessnes s abou t bein g understood . H e say s tha t othe r doctor s have seen him as being in a "space world" an d unreachable or felt tha t he was a "liar" and beyond the reach of effective help. It appears that the patient is anxious partly because of the vulnerability implied in his answers as well as because the interviewer has persisted in drawin g th e patien t ou t wit h regar d t o hi s feelings , especiall y hi s feelings about treatment. The patient implies that doctors incorrectly see him as unreachable o r a liar because of their unwillingness to acknowl edge their own failure: "They couldn't solve my problem with the voices."

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The Patients Theory This las t statemen t i s importan t becaus e i t reveal s a theor y th e patien t has abou t wh y peopl e d o certai n thing s t o him . Whe n listenin g t o patients discus s thei r delusiona l perceptions , clinician s ofte n neglec t t o find ou t wha t patient s thin k ha s brough t o n th e event . Explorin g thi s issue i s crucia l sinc e i t tell s u s abou t th e patients ' attitud e regardin g people wh o interac t wit h them—i n thi s instance , th e peopl e wh o ar e trying t o help him. The ide a that the doctors though t o f hi m a s a liar or as unreachabl e becaus e the y wer e frustrate d i n thei r attempt s t o mak e his voices go away is the first theory that he has presented. Understanding th e patient' s theor y o f hi s experienc e i s crucia l t o planning treatment interventions . Fo r example, the patient may feel tha t previous doctor s ha d disregarde d hi m becaus e the y wishe d t o withhol d the appropriat e treatmen t fo r maliciou s and/o r enviou s reasons . Suc h understanding would need to be incorporated in any proposed treatmen t interventions: Th e staff , awar e o f th e likelihoo d tha t th e patien t woul d see their efforts a s malevolent, coul d anticipat e th e patient's rejectio n o f their ministrations an d would have a context in which to understand his behavior. Instea d o f seein g hi m a s negativistic , the y coul d appreciat e that, fro m his perspective, he was trying to protect himself. Further , they might articulate their understanding b y saying something like, "We wish to giv e yo u medicin e becaus e w e fee l i t wil l hel p yo u b e les s anxious . However, we are aware you may believe that our intent is simply to drug you." In thi s sequence , th e patien t als o demonstrate s hi s willingnes s t o reveal hi s ange r at doctors. In describing the errors of othe r doctors, th e patient may be attempting to build an alliance with the interviewer as an idealized object . A n allianc e base d o n a n idealizin g transferenc e woul d be acceptabl e a s a startin g poin t becaus e i t ma y b e th e safes t an d mos t workable transference th e patient can tolerate at the outset. The interviewer continue s t o examine th e possible implications o f th e patient's statement that "a lot of people have looked a t me." Dr.: Le t me be more specific. I f I say that a lot of people have looked a t me, I mea n tha t peopl e hav e bee n doin g thing s t o me , bu t tha t nothing much is going on betwee n myself an d anyone else.

The Man with a Bug in His Brain 18 1 The interviewer is suggesting that the patient has difficulty i n stating that he feel s tha t people, specificall y doctors , loo k a t him in a dehumanizin g and critical way. This is a hypothetical constructio n that the patient may endorse, elaborat e on , o r disagre e with . I n addition , b y presentin g thi s statement i n term s tha t sugges t wha t th e interviewe r woul d fee l i f h e were in the patient's place, he is implicitly evaluating the patient's capacity to empathize with the interviewer. That is, even if the patient did not (or coul d not ) agre e wit h th e interviewer , doe s h e hav e th e capacit y t o appreciate how the clinician might come to feel that way? The interviewer' s interventio n suggest s tha t th e patient' s statemen t (that peopl e hav e "looke d a t him" ) mean s tha t h e feel s abuse d an d disregarded an d tha t h e i s (appropriately ) angr y abou t tha t fact . The clinician's ide a tha t aggressio n o r resentment ma y underlie th e patient' s statement endorses the patient's right to express aggression . The conten t o f th e interviewer' s interventio n underscore s hi s expec tation tha t th e patient b e an activ e participant i n the intervie w process : What the interviewer implies is "That's how I see it. How d o you see it?" This i s especiall y importan t give n th e interviewer' s interventio n ("I f I i mea n tha t ") . The interviewer' s talkin g abou t ho w say y he see s thing s run s th e dange r tha t th e patien t ma y agre e i n orde r t o conceal his true feelings, but the risk is justified as long as the interviewer carefully continue s t o rely on the patient's responses fo r confirmation o r negation of hi s hypotheses. P: Oh , I se e th e analyzation . I'v e ha d a lo t o f doctor s wher e the y worked two-way feedbac k an d everything else, but every time I got to th e real problem o f th e voices, the y sai d they didn' t understan d the voices . The y didn' t kno w wha t cause d them ! They sai d i t wa s a chemical misbalanc e in my mind. The patient indicates his belief that, to cover up their ignorance of th e true etiology o f hi s voices, the doctors told him they were brought on by a chemica l "misbalance. " H e migh t hav e simpl y indicate d tha t h e an d the doctor s ha d a differenc e o f opinion—tha t h e understoo d hi s voice s one wa y an d the y another . Hi s vie w tha t the y concea l thei r ignoranc e through chemica l mumbo-jumb o ma y indicat e hi s ange r a t an d suspi ciousness o f doctors . I t may als o b e a way o f keepin g ope n hi s involve ment with them. Since they have not understood him, he may yet be able

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to convinc e them , a n attitud e tha t ma y impl y a n ambivalen t wis h t o maintain a connection with them. Dr.: Le t m e sto p yo u ther e an d se e i f w e can' t mak e sens e ou t o f something. I f a lot of doctors, when you got to the voices, said they didn't understand, in a way that you felt meant they dismissed you, then I wonde r i f yo u cam e i n toda y thinkin g tha t I woul d no t believe you? Perhap s you fee l tha t when the doctors sa y they don' t understand you , wha t the y reall y mea n i s the y don' t believ e you , and neither would I?

Presenting the Patient's Themes: The Patient Can Be Understood The interviewe r her e offer s a suggestion a s to ho w th e patient migh t b e experiencing th e interview . H e i s awar e tha t th e patien t i s confuse d about his internal experience and may not experience a sense of connect edness betwee n hi s feeling s an d behavior s o r betwee n hi s pas t an d hi s present. The interviewer' s formulatio n implicitl y connect s th e patient' s past wit h hi s present—tha t is , hi s attitud e toward s th e curren t inter viewer ca n b e see n a s influence d b y hi s prio r experience s wit h doctors . The interviewe r indicate s tha t wha t th e patien t say s abou t himsel f i s valuable no t onl y fo r th e immediat e understandin g i t provide s bu t als o because i t may predict how h e might behave wit h othe r clinicians i n the future, an d it may indicate the psychological motivatio n underlyin g tha t behavior as well. P: The y believ e me . Ther e i s a lo t o f peopl e wit h problem s wit h voices, especially i n the psychiatric hospitals. There's a lot of problems wit h it . The y jus t don' t understan d th e natur e an d wha t causes the m an d I talked t o Dr . Smit h an d I went into grea t detai l about pressure, anxiety . . . The mos t interestin g thin g abou t th e patient' s respons e i s his unwill ingness to agree with the interviewer's statement that he (the patient) fel t the doctor s didn' t believ e him . The interviewe r ha s presented a point o f view entirel y consisten t wit h th e patient' s presentation , bu t h e avoid s endorsing wha t th e interviewe r ha s said . Acknowledgin g tha t th e inter viewer understands him may threaten the patient, for reasons that are as yet unclear. The patient in effect denie s himself th e opportunity o f bein g

The Man with a Bug in His Brain 18

3

understood, eve n thoug h tha t i s somethin g h e ha s previousl y sai d h e yearns for . B y indicating t o th e interviewer tha t his assumption i s incorrect (th e doctor s reall y d o believ e him) , h e ha s groupe d th e interviewe r with all the other doctors who have not understood him. This represent s a dismissa l o f th e interviewer , perhap s a s a respons e t o hi s anxiet y o r irritation with the interviewer's mor e intimate understanding of him. In the nex t exchange , th e interviewe r persist s i n focusin g th e patien t on the immediate concern, which is the patient's expectations of whether or no t th e interviewe r woul d believ e him . Thi s exchang e confirm s th e interviewer's hypothesi s tha t th e patien t believe d tha t th e interviewe r would trea t him as other clinicians had. Dr.: Bu t those are all suggestions a s to causes, guesses. P: They'r e guesse s becaus e I get the voices reall y ba d when I do hav e a lot of pressure and anxiety. Dr.: Bu t I'm still confused a s to why you thought P: [interrupts ] That's nerves. Dr.: . . . I wouldn't beliv e you . Yo u see , I can't get off tha t yet becaus e until I understand that, I don't know how we can talk together . P: Okay . I felt like it was just a thing where a lot of doctor s have tol d me that . I figured you' d b e jus t anothe r docto r that' s gonn a g o along with the pattern of twelve to fifteen doctors. Dr.: I' m no t happ y wit h th e ide a tha t yo u woul d judg e m e s o quickly . Can you understand that? P: Yeah . I can understand that. The interviewe r close s thi s portio n o f th e exchang e wit h th e sugges tion tha t a central propositio n o f th e wor k i s tha t eac h b e ope n t o th e unexpected i n th e other . A t th e sam e time , th e interviewe r mus t b e mindful tha t th e patient' s tendenc y t o generaliz e ma y represen t a (mal adaptive) attemp t t o dea l wit h th e threatenin g natur e o f involvemen t with anothe r person . Nevertheless , th e interviewer' s assertio n tha t h e and th e patient canno t tal k meaningfull y unti l th e issu e o f th e patient' s expectations i s understoo d reinforce s t o th e patient ho w importan t i t is to the interviewer that he understand the patient's subjective experience . Dr.: And , it' s no t a t al l clea r t o m e whether , a t thi s moment , yo u ar e giving m e a chance, i n terms of whethe r I will beliv e yo u o r not. I don't kno w wha t yo u thin k abou t that . D o yo u thin k it' s possibl e that I might believe you?

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P: Okay . I know you'r e comin g in with a n ope n mind . Dr.: Bu t that' s no t wha t yo u sai d te n minute s ago . Yo u said , " I kno w you're no t goin g t o believ e me. " So , have yo u change d you r min d about tha t sinc e we started t o talk ? P: Jus t talkin g has changed m y mind . When the interviewer says , "I don't know what you think about that, " he i s askin g th e patien t i f h e ca n ste p bac k fro m th e expectation s an d prejudices tha t h e ma y hav e hel d whe n h e bega n th e intervie w an d "think about " wha t ma y be , for hi m a new idea . That is , the interviewe r is askin g th e patien t t o utiliz e hi s neutral , observin g capacitie s t o thin k about th e interviewer , no t i n term s o f hi s previou s assumptions , bu t i n terms of th e context o f what ha s actually transpire d betwee n the m i n th e last fe w minutes . The interviewer' s questio n remind s th e patient tha t th e interviewer values the patient's contribution s t o their work a s a thinking , observing collaborator . I n addition , i t assert s tha t th e interviewe r i s no t omniscient, tha t h e doe s no t kno w wha t th e patien t i s thinking . Whe n the interviewer asks , "Have yo u change d you r min d abou t tha t sinc e w e started t o talk? " h e i s underscorin g hi s assumptio n tha t th e patien t ca n change his mind, that h e can tak e i n new information . Having mad e progres s towar d hi s earl y goal s (assessmen t o f self object differentiation , presentin g a mode l o f therapeuti c partnership) , the interviewe r nex t pursue s thos e area s o f subjectiv e experienc e th e patient ha s indicate d h e i s willin g t o tal k about . Fro m those , th e inter viewer will attemp t t o expan d th e inquir y int o other areas . Building th e Mode l Further Exploration of Subjective Experience Dr.: Okay , then , sinc e thes e voice s see m ver y importan t t o you , tel l m e something abou t them . P: They'r e vicious , they'r e accusatory . The y neve r tel l m e t o d o any thing though . Dr.: Ar e they your voices ? P: I'v e bee n tol d b y doctors tha t sai d the y ar e my voices. Dr.: No , no, I'm intereste d i n only what yo u think—wha t yo u believe . P: I would sa y they're m y voices. The interviewe r reinforce s th e ide a tha t th e patient i s the final author ity abou t hi s experience . Th e emphasi s o n th e wa y th e patien t under -

The Man with a Bug in His Brain 18 5 stands himself , rathe r tha n relyin g o n wha t othe r peopl e thin k abou t him, has, as a second goal, reinforcing self-objec t differentiation . Dr.: Yo u believe that? Then, why do you say you "get" voices. If they're your voices, they belong to you. You don't "get" them. P: Let' s mak e a differentiatio n righ t now . There' s a differenc e be tween a thought and a voice. The interviewe r insist s o n clarifyin g th e patient' s experienc e o f th e origin of the voices. In so doing, the interviewer may privately think that the patient's inconsisten t presentation (o f whether the voices com e fro m within o r without ) reflect s hi s conflic t abou t wha t th e voice s represent . The interviewe r note s thi s an d will loo k fo r furthe r confirmatio n i n th e patient's discourse . A t th e sam e time , i n thi s comment , th e interviewe r indicates hi s willingnes s t o hea r th e patien t describ e thes e voice s a s something occurrin g outsid e o f hi m rathe r than attemptin g t o convinc e the patien t tha t th e voice s represen t hi s ow n thoughts . Th e interviewe r thereby give s th e patien t permissio n t o describ e hi s experienc e a s h e understands it . I n response, interestingly , th e patient , fo r th e first time, introduces a though t o f hi s ow n rathe r tha n simpl y reactin g t o som e inquiry o f th e interviewer . H e says , "Let' s mak e a differentiatio n righ t now." Hi s spontaneou s clarificatio n represent s earl y evidence o f collab oration. Dr.: Ar e they your voices? P: They'r e my voices, but right now I' m only getting thoughts. Dr.: Bu t when you get the voices, are they your voices? P: The y are my voices. Dr.: The n why d o you sa y you "get " them? If they ar e yours, you mus t have them all the time. P: Probabl y subconsciously . Dr.: Ar e yo u sayin g tha t yo u believ e tha t yo u harbo r withi n yoursel f accusations toward you? P: Yeah . Dr.: That' s your idea? P: Yeah . Dr.: The n why do you call your own accusation s "voices?" P: That' s no t true. The voice tells you tha t you're Himmler' s so n an d

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you kno w you'r e no t Himmler' s so n 'caus e yo u alread y checke d i t out wit h th e West Germa n Embassy . Dr.: Bu t you jus t tol d m e a minut e ag o tha t thes e voices ar e reall y you r voices. P: They'r e m y voices. Dr.: The y belon g to you? The y com e fro m you ? P: The y weren' t create d b y me. Dr.: Uh , I didn't understan d that . Through thi s exchang e th e patien t discusse s hi s interna l worl d wit h seeming ease . Thi s ma y b e a consequenc e o f th e interviewer' s repeate d emphasis o n th e patient's abilit y t o mak e himself clear . Autonomy and Control At th e beginnin g o f thi s exchang e th e patien t partiall y endorse s th e statement tha t hi s voice s ar e relate d t o "subconsciou s accusations, " bu t he remain s undecide d abou t thei r definitiv e origin . H e late r state s tha t the voice s d o no t com e fro m hi m an d wer e no t create d b y him . Hi s uncertainty i s importan t wit h respec t t o hi s experienc e o f th e locu s o f control. I s h e o r i s h e no t th e maste r o f hi s ow n fate ? Th e patien t ca n partly accep t th e ide a tha t th e voice s ar e a n expressio n o f hi s inne r feelings o f self-blam e (h e i s his ow n persecutor) . O n th e othe r hand , h e sees th e voice s a s havin g bee n impose d o n hi m b y som e outsid e force . The patien t i s als o uncertai n abou t whethe r h e ha s th e capacit y t o control th e voices . Thi s indicate s t o th e interviewe r th e importanc e o f continuing to as k th e patient abou t wh o i s really running th e show . Dr.: I didn't understan d that . P: Th e voice s wer e create d b y people sayin g stuf f an d puttin g cue s i n me. Dr.: Ar e yo u sayin g tha t a t thi s poin t thes e voice s ar e yours , bu t the y didn't originat e wit h you ? P: The y didn' t originat e with me . Dr.: Ho w doe s that work? Explai n tha t t o me . P: Well , sometimes whe n I get the voices Dr.: [interrupts ] Now , you'r e sayin g you "get " the m again . P: Okay , when I have them . Dr.: Whe n yo u tal k t o yourself ?

The Man with a Bug in His Brain 18

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P: No , not when I talk to myself. It's like I was lifted t o a point wher e I boi l ove r o r pressur e o r somethin g lik e that . M y anxiet y an d nerves ge t ba d an d i t triggers a bell . The voices just star t coming . I can hear the m fro m outside . The patien t ha s begu n t o relat e hi s understandin g o f th e processe s a t work withi n him . His last statement i s significant fo r severa l reasons . H e begins b y usin g a simile t o describ e wha t ha s occurre d i n his mind : "It' s like I wa s lifted. " Thi s represent s hi s effor t t o clarif y hi s experienc e a s well a s t o begi n t o construc t a mode l o f tha t experience . Hi s statemen t "It's like " suggest s distanc e o r uncertaint y o n hi s part , presumabl y indicating hi s unwillingnes s t o full y endors e thi s positio n (o f bein g lifted) , although i t ma y als o reflec t hi s difficult y i n puttin g hi s experienc e int o words. As he describe s this experience , the patient use s terms tha t depic t hi m as passive . H e i s "lifted " an d the n h e "boil s over " an d th e voice s jus t start coming . Many patient s d o not immediately identif y way s in which treater s ca n be o f hel p t o them . Ou r patien t say s h e feel s "pressure , anxiety , an d nerves." Th e patien t wh o ca n spea k o f feelin g anxiou s abou t wha t i s happening t o him - o r hersel f (whethe r w e agre e wit h thi s vie w o f th e experience o r not ) i s describin g a reactio n al l o f u s hav e ha d i n relatio n to a sens e o f danger , whethe r i t b e rea l o r imagined . Th e sam e ca n b e said o f this patient's speakin g of "pressur e an d nerves." 3 Developing the Patients Model Dr.: Now , jus t a minute . I thin k thi s i s terribl y important , an d I wan t to understand thi s with you , an d yo u wen t too fas t fo r me . P: Okay . Dr.: Yo u hav e a n ide a tha t there' s pressur e insid e you. I can't ge t to th e next ste p from th e pressure insid e you t o voices outside. Make tha t bridge for me . What i s it that happens ? The interviewe r reinforce s hi s commitment t o seein g the patient a s a n educator, someon e wh o mus t teac h th e interviewe r abou t hi s wa y o f experiencing himsel f an d th e world . Th e interviewe r acknowledge s hi s own limitation s b y th e statemen t " I [alone ] can' t ge t t o th e nex t step. " By askin g th e patien t t o "mak e tha t bridg e fo r me, " h e insist s tha t th e

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patient provid e th e connection . Thi s encourage s th e patien t t o mak e sense o f himsel f t o th e interviewe r an d repeat s th e interviewer' s convic tion tha t the patient has the capacity t o mak e sense of himsel f a s well a s the capacity to communicate tha t sense to the interviewer. P: It' s sort o f lik e yo u sa y somethin g t o yourself . I like a certain girl , or something like that. I say that girl's name. Dr.: Lik e what girl's name? P: I could b e lying in bed without n o voices an d if I say a girl's name, 'cause th e gir l migh t b e famou s o r sh e migh t kno w somebod y who's famous , or something like that, it'll trigger off a voice. Dr.: No w what' s th e connection ? I don't understan d that . I can sa y a girl's nam e whil e I' m lyin g i n be d an d I don' t hea r an y externa l voice. What' s th e mechanis m insid e yo u tha t make s you r sayin g the nam e caus e th e girl' s nam e t o soun d lik e it' s comin g fro m outside of you? I don't get the connection there . P: I think it's just pressure. Dr.: I don't understand how tha t works. P: I don't understand how i t works either. It's just the way i t is. I had a car accident and I'm not so sure. It could be a bug in my brain. The patien t begin s thi s segmen t i n a conversationa l idiom , speakin g with eas e an d familiarity , actin g a s i f th e interviewe r i s capabl e o f understanding wha t h e i s tryin g t o communicate . The patient' s manne r of speakin g indicate s hi s interes t an d absorptio n i n communicatin g hi s experience. This represents a change i n the interview becaus e i t suggest s that th e patien t ha s a t least temporaril y accepte d th e paradigm tha t th e interviewer has bee n presenting: We ar e meeting to try to mak e sense o f your life. When th e interviewer shortl y thereafte r ask s the patient, "What' s th e mechanism?" he i s usin g a concrete ter m tha t draw s upo n th e patient' s own earlier mechanistic descriptio n o f his mental life. The more familia r the terminology i s to the patient, the less likely he is to becom e confuse d or t o fee l tha t a n alie n mode l i s being impose d o n him . I t is not crucia l at thi s poin t tha t th e patient' s elaboration s b e final or correct . Wha t i s important i s the capacity o f th e therapist t o communicat e hi s interest i n developing with the patient a model o f his inner experience. The interviewe r focuse s o n elucidatin g thos e area s o f th e patient' s mental lif e wher e th e patien t appear s abl e t o tolerat e th e interviewer' s

The Man with a Bug in His Brain 18 9 participation. Whe n th e patient the n states , " I don't understan d ho w i t works either, " h e i s identifyin g tha t h e to o feel s uncertai n an d lack s control i n a crucial are a of hi s life. H e implies tha t his understanding o f himself i s no t fixed and , therefore , tha t h e ma y b e abl e t o conside r alternate hypothese s fro m thos e h e has alread y offered . Further , identi fying a n are a i n whic h th e patien t doe s no t fee l i n contro l present s th e interviewer with another topic to collaborate on. The patient' s las t commen t i n thi s segmen t introduce s a hypothesi s about what has happened to his mental life. He may have been bugged. The patien t ha s identifie d som e issue s tha t concer n him . Wha t th e patient identifie s a s dysphori c ca n serv e a s th e startin g poin t i n th e formation o f th e treatmen t alliance . The temptatio n o n th e par t o f th e clinician i s ofte n t o begi n b y focusin g attention o n wha t th e clinicia n defines a s th e disorder . Whil e keepin g i n min d wha t w e understan d th e problem to be , we mus t begin the treatment alliance around those issue s where th e patien t i s i n conflic t wit h himsel f an d wher e he , therefore , may be interested in pursuing the issue further . Dr.: Wha t do you mean, a bug in your brain? P: I had a car accident in 197 7 . . . Dr.: Yeah . P: . . . yo u know , an d I was drivin g o n th e roa d an d somebod y cu t me off. I started to speed up behind them to find out who i t was. I had tw o beer s i n m e an d a s w e wer e goin g aroun d a tur n the y opened u p thei r doo r an d thre w somethin g ou t th e doo r fro m a bucket an d i t went al l ove r th e road . I tried t o ge t ou t o f th e wa y and I went right into a telephone pole. I put my head right through a windshield righ t up here where th e gas h is . And the n th e policeman in the car says, "Watch out Bill, how man y beers you had?" I said, "Two " an d sai d "I' m alright, " an d h e says , "Okay , yo u watch out. They might put a bug in your brain." And I went to the hospital an d thi s Dr . Stee l starte d talkin g abou t bug s an d he said , "You should have a bug in your brain." Dr.: Wha t does that mean, "You should have a bug in your brain"? P: He' s a powerful ma n an d all thi s other stuff. I don't know wha t it is. I t could b e just a regular tap , you know , wher e a bug picks u p brain sense s an d thought s an d th e brai n translate s i t an d micro phones it out to the outside.

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Dr.: Le t me see if I understand i t s o far . Thi s i s a theory tha t I' m abou t to present P: [interrupts ] Well , it' s my experienc e tha t th e gu y sai d he' s gonn a put a bug in m y brain . The patien t ha s begu n t o describ e a n accident , whic h h e identifie s a s the startin g poin t o f hi s persecution . I t al l bega n o n th e road . Th e interviewer doe s no t focu s o n th e obviou s irrationalit y o f hi s claim s no r challenge the patient's idiosyncrati c logic. Rather, the interviewer's ques tions ar e geare d t o furthe r th e patient' s explanatio n an d exploratio n o f himself. In suspendin g hi s ow n sens e o f realit y i n favo r o f takin g i n th e patient's accoun t o f thes e events , the interviewer ca n the n appreciat e th e logic o f th e patient' s subsequen t constructions . I f w e ca n imagin e wha t it woul d b e lik e t o believ e tha t a n electroni c devic e ha d bee n implante d in our brain , the n muc h o f wha t woul d follo w woul d approximat e wha t our patien t ha s to sa y abou t hi s experience . We ma y speculat e abou t th e degre e t o whic h th e patien t doubt s hi s own story , bu t th e patien t make s ver y clea r that , a t thi s poin t i n th e narration (or , perhap s i n th e relationship) , h e i s adaman t tha t hi s con struction i s no t simpl y a hypothesis , bu t rathe r hi s "experience. " H e corrects th e interviewe r whe n th e interviewe r attempt s t o describ e hi s statements a s a theor y b y saying , "It' s m y experienc e tha t th e gu y sai d he's going to put a bu g in my brain. " The Interviewer's Reactions Empathizing wit h th e patient' s experienc e o f himsel f (whic h i n n o wa y implies agreein g with it ) require s a considerable cognitiv e an d emotiona l effort o n th e par t o f th e interviewe r because , a s i s eviden t here , th e patient's experienc e ma y b e on e tha t ca n b e frightenin g an d perplexin g to us . Th e patient' s recitatio n i s hi s attemp t t o mak e sens e o f and/o r exert contro l ove r hi s experience . Th e inciden t jus t describe d i s marke d by nake d aggression , danger , injure d narcissism , an d fear , a s wel l a s curiosity an d benevolence , th e latte r represente d b y th e policema n wh o offers hi m friendl y advic e an d a warning . Ther e i s als o th e ambivalen t figure o f th e docto r a s powerful , potentiall y helpful , an d certainl y dan gerous.

The Man with a Bug in His Brain 19 1 In listening to him, the interviewer silently notes those themes (aggression, danger , fear , benevolence , an d s o forth ) a s area s tha t h e wil l attempt t o explor e furthe r later . The cleare r bot h patien t an d clinicia n become regarding the patient's central concerns (includin g the extremel y important issu e tha t the y agre e o n wha t i s central) , th e greate r th e likelihood tha t the y wil l arriv e a t a workin g agreement . Th e natur e o f what i s agree d upo n mus t b e acceptabl e t o bot h parties . Fo r example , the clinician cannot agree to work with the patient on his literally having been bugged, since he does not believe that. He could, however, agree to collaborate on helping the patient feel less intruded upon and exposed. When w e refe r t o encouragin g th e patient t o elaborat e hi s version o f what h e feel s i s true , w e mea n tha t suc h a versio n represent s hi s bes t reconstruction a t th e moment . Th e patient' s presentatio n o f hi s o r he r internal contradictions, ambivalences, and self-doubts alert s the clinician to th e patient' s interna l conflict s abou t hi s story . I t i s precisel y a t tha t point where the clinician can join the struggle. As th e intervie w progresses , whethe r w e ar e becomin g familia r wit h the patien t ca n b e teste d b y ou r constructin g imaginar y situation s fo r ourselves an d seein g i f w e ar e able to imagin e wha t hi s behavio r woul d be. Onc e w e hav e reache d tha t leve l o f understanding , w e ca n begi n t o retranslate th e concret e informatio n h e i s presentin g int o a mor e meta phorical statemen t that does justice to what he is saying and also make s sense t o us . Thi s proces s generall y implie s a lea p o f severa l level s o f abstraction from what the patient has said without violating the spirit of his statements. Thus, in the above segment of narrative , we would know tha t "somebody cu t m e off " mean s h e fel t prevente d fro m doin g somethin g h e wanted t o d o a t tha t time . Whe n h e trie d t o clarif y th e natur e o f th e obstruction an d "starte d t o spee d u p behin d the m t o find ou t wha t i t was" an d s o on , h e experience d eve n greate r difficulty , whic h suggest s that he lacks the means to get on with his life on his own. The figure o f th e policeman , wh o warn s hi m o f th e dange r bu t i s unable o r unwillin g t o provid e furthe r protection , ma y represen t a real or, mor e likely , wished-fo r protectiv e figure. Hi s subsequen t givin g u p on such assistance ever happening suggests he is pessimistic about receiving help . O n th e othe r hand , th e policeman ma y represen t a n intrapsy chic event—that is , his inability t o hee d his own (th e policeman's) inne r warning signals about impending doom .

192 Working with the Person with Schizophrenia Based on what we know thus far, his inner sruggle appears to center on issue s o f powe r (rea l o r imagined ) symbolize d b y th e immensel y powerful an d controlling doctor . Note , too , that the patient is capable of observin g tha t what he is reporting i s bizarre. He strive s to correc t that impression b y presenting himself a s if h e were in the mainstream. For example, he refers t o th e bug as possibly "jus t . .. a regular tap," trying to cloa k thes e exoti c event s i n normalcy. This early evidence of his wis h t o presen t himsel f a s norma l i s somethin g els e th e clincia n makes note of and may call upon later to enhance collaboration. P: It' s an experience. Dr.: Okay , but I want to offer a theory. P: Yo u want people to hear the bugging? Dr.: I want t o presen t you r theor y a s I understand it . I t would b e a theory, based on certain real experiences o f yours , but this is the theory, the explanation, that I understand you offering me. Okay? I want to be sure I understand it. P: Okay . Dr.: Lik e all of us, you live with a certain degree of tension. However, unlike most of us, the consequence of the tension within your head may cause you to respond differently tha n most people. A pressure builds u p i n you r head , an d th e pressur e tha t build s u p i n your head can occur for a variety of reasons. So far you're in agreement with me? This is what you've been saying? [Patient nods.] At some point, ther e i s a triggering mechanism, which, if th e pressure exceeds a certain amount, the bug that has been placed in your brain, activates. It' s lik e throwin g a switch , an d th e switc h i s throw n when the pressure exceeds a certain limit, which one could perhaps even measure. At the point at which the switch is thrown, the bug is activated, throwing voices outside. The second part of the theory has to do with the implantation of the bug. That is, at some earlier point, peopl e tampere d wit h you r brain . No w yo u ar e walkin g around wit h a bu g i n you r brai n an d th e onl y contro l tha t yo u have would b e to diminish the pressure, because the pressure has to exceed a certain amount in order to throw the switch to activate the bug. Do I understand you? In his extended comment , th e interviewer take s th e raw data of the patient's experienc e an d provides a more integrate d constructio n tha n

The Man with a Bug in His Brain 19 3 that which the patient articulated. The model of th e interaction is that of tw o scientist s wh o ar e examining a phenomenon o f natur e an d attempting to elucidate its features. The value of thi s effort lie s partly in helping th e patien t structur e hi s experienc e an d conside r th e conse quences o f wha t h e believes , a n effor t that , i n bein g organizing , ma y therefore be anxiety reducing. At the same time, by establishing a structure t o clarif y th e connection s amon g variou s part s o f th e patient' s subjective experience, the interviewer forces more scrutiny of the details of that experience. In particular, the interviewer's reconstruction allows them both to examine in greater detail critical aspects of the theory the patient has presented, generating more information abou t the forces at work within him, in particular, the "pressures" that influence him. The manner in which the interviewer constructs this theory highlights the interviewer' s appreciatio n tha t th e patient' s subjectiv e experienc e represents his effort to cope with difficult and disorganizing events.

Resistance to Accepting Help as an Issue in Alliance Formation An important aim of this interview is to develop information abou t the patient's resistance to being helped. The interviewer comes to this interchange with the knowledge that many, if not most, schizophrenic individuals feel threatened by psychological exploration as well as by exposure to psychiatric treatment. We have already been told that this patient has been described as "treatment resistant," which suggests to the interviewer tha t h e ma y se e menta l healt h professional s a s dangerou s an d fight their effort s t o hel p him . Th e patien t provide s suppor t fo r thi s hypothesis i n th e way i n which h e describes hi s interactions wit h previous doctors and through his statement that it was a doctor who put a bug i n hi s brain . Hi s theor y o f wha t ha s occure d doe s no t allo w fo r psychiatric treatment, since he has attributed his troubles to the presence of a bug in his brain, not to a psychiatric condition. The interviewer's presentatio n o f th e theory allow s fo r furthe r join t scrutiny o f th e patient' s understandin g o f himsel f an d prepare s fo r a process in which the patient has the responsibility to identify how he can be helped and, in particular, how the interviewer may be of help to him. By forcin g th e issu e wit h respec t t o th e patient' s unwillingnes s t o se e

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himself a s troubled or ill, the interviewer plans to determine how he may be able to engage the patient most effectively .

The Alliance Using the Patients Model to Think About an Alliance The treatment allianc e can best be founded o n a collaborative proces s in which patien t an d interviewe r experienc e sharin g an d empathy . Th e world ou r patien t describe s i s shor t o n thes e qualities . Th e interviewe r wants t o presen t t o th e patien t a vie w o f himsel f tha t underscore s hi s struggles, hi s pain , an d th e sadnes s underlyin g hi s conflic t over aggres sion. I n his statement above , thi s interviewer focuse s o n thos e detail s o f the patient' s experienc e tha t hav e th e bes t chanc e o f formin g a soli d groundwork fo r thei r treatmen t alliance . Beginnin g wit h "lik e al l o f u s . . . , " h e reinforce s th e commo n huma n aspect s o f th e patient's experi ence. A t th e sam e time , th e interviewe r allude s t o th e idiosyncrati c nature of the patient's experience when he says "unlike most of us . . . " Then the interviewer describes how h e thinks the patient understand s himself. The interviewe r believe s th e patient' s self-constructio n repre sents hi s effor t t o adap t t o an d make s sens e o f a variet y o f disturbin g experiences. The interviewe r i s als o layin g out , fo r late r examination , the cos t t o th e patien t o f thes e adaptiv e efforts . Th e cos t lie s i n th e degree t o whic h th e patien t doe s no t experienc e himsel f a s havin g con trol over wha t happen s t o hi m an d i n hi s vulnerabilit y an d aloneness . The interviewe r anticipate s tha t furthe r wor k coul d hel p th e patien t construct a ne w understandin g o f himsel f tha t woul d b e mor e adaptiv e and tha t woul d permi t a greate r sens e o f control , mor e toleranc e o f interactions with others, less isolation, an d more hope. At a few points , th e interviewe r take s car e t o gai n th e patient' s endorsement, whic h wil l b e usefu l late r whe n the y retur n t o th e signifi cance of thi s theory. H e does this by saying, "So far you're in agreemen t with me?" and later, "Do I understand you?" While very concrete an d mechanistic, the theory has the advantage o f suggesting point s o f potentia l control . Whe n th e interviewe r says , "whic h one coul d eve n measur e perhaps, " h e suggest s t o th e patien t tha t the y can engag e i n a mor e precis e an d critica l examinatio n o f th e patient' s mental life . I n th e process , th e interviewe r indirectl y state s tha t th e patient i s no t helples s i n th e fac e o f hi s experienc e an d tha t area s o f

The Man with a Bug in His Brain 19 5 control ca n b e identified . H e suggest s tha t ther e ar e practica l way s t o look a t the patient's experienc e with th e promise of finding better adaptations. This proces s (o f finding bette r adaptations ) i s prefigure d whe n th e interviewer says , "Th e only contro l tha t you hav e would b e to diminis h the pressure. " Th e interviewer' s clarificatio n o f th e patient' s theory , while endorsing the patient's experience of a n environment where force s beyond hi s contro l ac t upo n him , suggest s way s i n whic h th e patien t may b e abl e t o contro l hi s experienc e mor e effectively . Thi s i s wher e treatment ca n help . A t th e sam e time , i t hints a t a later stag e whe n th e patient ma y b e helped t o acknowledg e tha t there are , indeed, aspect s o f his condition, including his illness, he cannot control . The patient responds: P: Yeah . It' s sort o f lik e a release mechanism , wher e i n othe r word s you don' t di e mentally . Whe n th e pressure build s u p t o a point i t won't kil l yo u 'caus e th e bu g wil l activat e somethin g whe n it' s released. The patient' s respons e t o th e interviewer's presentation o f hi s theor y endorses it s reasonablenes s t o hi m a s wel l a s it s importance . Whe n th e patient say s tha t th e pressur e migh t buil d u p t o a point wher e i t coul d kill hi m i f i t were no t released , h e i s revealing ho w threatenin g hi s ow n mental processes ar e to him and the degree to which he lives in a state of terror—a significant admissio n of vulnerability . Below, th e interviewer follow s thi s acknowledgment wit h a comment that represent s a logical conclusio n derive d fro m th e patient' s presenta tion of himself; tha t is, why is the patient seeing a psychiatrist instead of a surgeon ? Afte r all , ther e mus t b e som e explanatio n fo r wh y h e eve n bothers t o tal k t o a psychiatrist. H e could , fo r instance , choos e t o sa y nothing. Thi s lin e o f inquir y ask s th e patien t t o clarif y th e reasonin g behind his behavior; specifically, i t encourages th e patient t o present his rationale fo r seekin g psychiatri c treatmen t despit e presentin g hi s di lemma i n neurosurgica l terms . Sinc e th e patien t ha s jus t declare d hi s terror an d confusion , th e interviewe r know s tha t th e patien t feel s frus trated, helpless, an d alone and , therefore, o n som e level, recognizes tha t psychiatric help may be of benefit . Bu t the interviewer wishes the patient to tell him in what terms their collaboration may take place. Rather than

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telling th e patien t wha t h e wil l hel p hi m with , th e interviewe r ask s th e patient t o tel l hi m ho w h e ca n hel p him . A t th e sam e time , th e inter viewer i s staying within th e bounds o f th e patient's logi c an d communi cating t o th e patien t tha t th e interviewe r appreciate s hi s logic , withou t necessarily agreein g with th e underlying premises . By staying within th e framework o f th e patient's own story , patient an d therapist may be able to identif y a paradigm fo r thei r interaction , avoiding , thereby , som e o f the resistance coincident with mos t treatment alliances. P: . . . th e bug will activat e something when it's released. Dr.: Yes . No w th e thin g I don' t understand , however , i s wh y you'r e seeing a psychiatrist? P: I should be seeing somebody i n the operating room. Dr.: Exactly ! P: T o ge t the god dam n bu g the hell ou t o f me ! I don't want th e bu g in m y brain . I know dam n well , th e surgeon , yo u know , h e wa s talking t o m y father , h e said , "Well , I don't wan t a bug i n him. " And then I got out of the hospital an d you know, after walking out of th e hospita l wit h m y fathe r wit h bloo d al l ove r me , m y fathe r says to me, 'Is that you I hear?" The patient begins the segment with a statement, th e tone of whic h i s angrier than tha t of anythin g he has sai d previously. Thi s suggests that , in response t o th e interviewer's acceptanc e o f him , the patient i s able t o be mor e ope n abou t wha t ha s happene d t o him . A t th e sam e time , th e patient assume s to o readil y that the interviewer i s endorsing hi s view o f himself a s true, a s if to say , "Finall y someon e believe s me! " His lac k o f suspicion abou t wha t th e interviewer believe s suggest s somethin g o f hi s fragility a s wel l a s hi s tremendou s nee d t o b e understood , a nee d s o intense an d so frustrate d tha t it fairly bubble s ou t of hi m in response t o the interviewer's effort a t understanding. The patient' s introductio n o f hi s fathe r i s significan t fo r wha t i t suggests abou t hi s interna l struggle s aroun d powe r an d understanding . The fathe r i s presente d a s a compassionat e bu t ineffectua l figure. H e stands b y helplessl y whil e hi s bloodie d so n i s abused . The image o f th e father i s o f a diminishe d an d demeane d person , perhap s reflectin g a feeling tha t people wh o ar e not powerfu l ar e valueless. H e devalue s th e image o f hi s fathe r an d demean s th e peopl e wh o empathiz e wit h him , perhaps because he equates empathy with being powerless and unimpor-

The Man with a Bug in His Brain 19 7 tant. Thi s als o suggest s tha t th e patien t ma y vie w effort s t o empathiz e with him as being of little value if they are not associated with the power to change his circumstances. An important corollar y t o this image i s that the father ma y represen t some aspec t o f th e patient' s ow n experience—tha t is , his ow n devalue d view o f hi s empathi c capacities . Th e theme s o f devalue d empath y an d admired powe r woul d b e importan t aspect s t o explor e i n th e intervie w and later on in ongoing treatment . Dr.: Yes . Yes. But I'm confused. Yo u came to this hospital voluntarily ? P: Yeah . Dr.: Okay . I f I were you , m y temptatio n woul d b e t o leav e n o ston e unturned unti l I found someone , a n expert o n brai n matters , wh o could remove this bug. P: Ther e might b e one i n my heart too, 'caus e I had a heart attac k i n Seattle, and I felt something like a timer or something like that was put in. I felt m y chest went out, my head went bac k like this [jerk s his head back] , an d I went unconscious . Just before I went uncon scious I felt some real tapping. There could be bugs all around. Dr.: I think you'r e avoidin g th e implicatio n o f wha t I' m saying , whic h is wh y ar e yo u seein g a psychiatris t rathe r tha n a neurosurgeon ? Perhaps you should also see a heart surgeon, but one step at a time. The interviewe r focuse s o n th e questio n agai n i n orde r t o tr y t o determine whic h experience s ar e dysphoric fo r th e patient. Thos e area s that th e patien t acknowledge s a s conflictua l ar e th e one s wher e th e clinician ha s a possible entry : "Sinc e you ar e in pain [confusion , uncer tainty, etc. ] abou t X , I can help you t o decid e what yo u wan t regardin g X. However , t o d o that , first w e wil l nee d t o understan d muc h mor e about X. " What the interviewer has not thus far suggested, but which is crucially important t o th e patient' s understandin g o f himself , i s tha t h e i s i n conflict abou t and/o r unsur e o f th e validit y o f som e o f hi s perceptions . This doubt or inner struggle is experienced affectivel y a s dysphoria. The interviewer' s pressin g home th e apparen t conflic t i n the patient's behavior—that despit e hi s belie f abou t bein g bugge d h e i s seein g a psychiatrist rathe r a surgeon—helps th e patient identify tha t the contradiction i s a consequenc e o f conflic t an d uncertaint y regardin g wha t h e thinks is true.

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The Interviewer's Response to the Patient's Challenge: Can You Take It? The patien t respond s t o th e interviewer' s returnin g t o wha t h e believe s to b e th e patient' s predicamen t b y suggestin g tha t hi s proble m i s mor e serious an d pervasiv e tha n ha s ye t bee n understood . No t onl y doe s h e have a bug in his brain, but there is a timer in his heart that may, a t any moment, caus e hi m t o hav e a hear t attack . Thi s communicate s t o th e interviewer ho w frightene d th e patien t i s abou t hi s momen t t o momen t existence. A t th e sam e time , hi s allusio n t o a heart bu g i s a response t o the interviewer' s reques t tha t th e patien t explai n wh y h e ha s no t trie d harder to improve his condition. The interviewe r ask s ho w th e patien t view s th e proces s o f gettin g help. The patient responds a s if to say, "It' s futile t o try. They' no t onl y have m y mind , the y ar e al l over , an d the y hav e contro l o f m y ver y existence, an d that' s wh y I haven't trie d t o d o anythin g abou t it. " This represents a warning to th e interviewer tha t the patient feels exploratio n may b e dangerou s t o hi m an d perhap s t o th e interviewe r a s well . Th e patient warns the interviewer that getting involved with him could be an ordeal. I n effect, th e patien t i s sayin g t o th e interviewer , "Ar e yo u sur e you're prepare d t o joi n m e i n suc h a frightenin g endeavor? " o r "Ca n you tak e it? " The interviewe r addresse s thi s b y sayin g tha t whe n on e faces a n overwhelming situation , on e deal s with i t "on e ste p at a time." The interviewe r respond s t o th e patient's implici t warning in a way tha t he hope s wil l communicat e tha t furthe r understandin g i s neithe r futil e nor dangerous. Further , he indicates that the way fo r him to understan d the patien t i s b y dealin g wit h hi s experience s i n a steady , systemati c fashion. Implicitly , h e tell s th e patien t tha t thi s process wil l tak e a long time. This form s a crucial prelud e t o th e furthe r discussio n o f th e patient' s experience: P: I don't know who, you see, I know m y uncle John had a bug in his brain. H e said , "I' m gonn a giv e yo u th e power. " Now , whethe r these animals, these people ar e really animals . . . Dr.: Ar e yo u abou t t o explai n wh y yo u haven' t contacte d a neurosur geon?

The Man with a Bug in His Brain 19 9 P: Ever y tim e I tried, they'v e denie d m e an d sai d i t wasn' t a bu g i n my head. Dr.: Wh o have you seen? P: Dr . Steel. I went to see Dr. Steel. Dr.: Wh o is Dr. Steel? P: He' s the doctor who put it in. Dr.: Yo u wen t t o se e th e docto r wh o bugge d yo u i n th e first place, t o help you? P: T o take it out. Dr.: That' s th e first thing you've sai d t o m e that makes n o sens e what ever. Let's go bac k a step. Now I' m wondering whethe r yo u don' t need t o se e a psychiatrist. There' s somethin g od d abou t wha t yo u just said . I f I fel t tha t someon e ha d implante d a bu g i n me , tha t person woul d b e the last soul o n eart h I' d as k to tak e it out! Ho w can you trust such a person? Do you see that makes no sense? P: Yeah , but the way th e thing is set up, you have to put enough hea t on the man to take it out. Dr.: Yo u mean , yo u believ e tha t onl y th e perso n tha t inserte d th e bu g can remove it? P: No . Dr.: Well , then why are you seeing him? P: I don't know who t o see. I told . . . The interviewer' s thrus t i n thi s exchang e i s t o clarif y th e patient' s reasons fo r talkin g t o a psychiatrist rathe r tha n t o a surgeo n an d then , as the patient reveal s that he has talked t o people abou t gettin g th e bu g out, to understan d why the patient would go about it in the way that he has. Severa l issue s ar e presente d an d develope d simultaneousl y i n thi s line o f questioning . Mos t concretely , th e interviewe r i s attemptin g t o elucidate the patient's understanding of his motives and behavior and, in the process , t o lear n ho w th e patien t experience s hi s effort s t o hel p himself. Doe s h e se e himsel f a s someon e wh o ha s th e powe r t o chang e his circumstances ? Ho w overwhelmingl y powerfu l ar e th e peopl e wh o are persecutin g him ? Doe s h e thin k the y ca n b e mad e t o chang e thei r course o f actio n b y "puttin g hea t o n them, " a s h e suggests ? Woul d h e endorse th e ide a tha t he migh t b e abl e t o effec t a change i n his circum stances i f h e coul d gai n enoug h powerfu l allie s t o forc e th e enem y t o alter their behavior? And does he see the fallacies in his sense of reality ?

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Potential Mies As jus t discussed , th e interviewe r collect s dat a abou t th e patient' s atti tude towar d potentia l allies , wh o includ e th e interviewe r an d othe r people involve d i n th e patient's treatment . Thi s informatio n i s useful fo r predicting th e transferenc e issue s tha t th e patien t migh t develo p towar d those helpin g him . Fo r instance , woul d th e patien t devalu e helper s wh o are no t overtl y powerful ? Woul d th e patien t dismis s effort s t o hel p hi m that ar e no t directl y aime d a t helping him hav e more power t o challeng e his persecutors ? I s h e unintereste d i n understandin g himsel f i f tha t un derstanding i s not associate d wit h th e attainmen t o f greate r strengt h o r forcefulness? At th e sam e time , th e interviewe r i s pursuing thi s lin e o f questionin g with a crucia l hypothesi s i n mind : namely , tha t th e patient' s struggl e t o have the bug taken ou t represent s his internal struggl e to understand an d control th e disturbin g event s tha t hav e occurred . Th e patien t ha s mad e it clea r tha t n o on e ha s joine d hi m i n fighting hi s persecutors . O n th e contrary, h e has not bee n believed , an d h e feels alon e in his battle . There ma y b e a par t o f th e patien t tha t wishe s t o find allie s an d stil l hopes fo r a resolutio n t o hi s problem s throug h forcin g th e persecutor s to stop . O n th e othe r hand , ther e i s also a par t o f th e patient tha t take s note o f th e disapprova l an d disbelie f o f thos e aroun d him . At this point , he appear s extremel y resistan t t o acknowledgin g tha t thes e event s (th e persecutors, th e bugging , etc. ) ar e manifestation s o f inne r conflict . Hi s resistance i s represente d b y hi s adaman t vie w o f himsel f a s persecute d and hi s convictio n tha t th e onl y resolutio n i s to mak e thos e responsibl e for th e implan t remov e th e bug . Associated wit h tha t vie w is a feelin g o f hopelessness an d helplessnes s because , u p t o thi s point , hi s effort s t o convince others t o help him hav e been unsuccessful . The Patient's Conflict Alliance Formation

in Relationship to

The interviewe r ha s evidence that th e patien t i s uncertain abou t whethe r he i s a victi m whos e salvatio n depend s o n hi s tormentors . Hi s doub t i s most apparen t i n th e fac t tha t th e patien t i s talkin g t o a psychiatris t (rather tha n hi s tormentors ) abou t hi s difficulties . Th e radica l positio n that his only resolution i s by changing the mind of the persecuting docto r

The Man with a Bug in His Brain 20 1 or his cohorts is inherently frustrating because it cannot be effected. The interviewer hopes to help the patient see that he already partially understands this. Thi s acceptanc e woul d requir e th e patient t o fac e th e fac t that h e i s th e sourc e o f hi s difficultie s an d tha t hi s belie f syste m i s a distortion. The focu s i s o n providin g th e patien t wit h a n alternativ e wa y o f looking a t thing s and , therefore , a reaso n t o conside r changin g hi s (defensive) adaptation . Hop e i s intimatel y relate d t o th e concep t o f alternatives: If the patient can see other solutions to his predicament, he is then able to exercise choice. The alternatives may be ones he is aware of bu t feels have been beyond his grasp. The task of th e interviewer or the treatment staf f woul d b e to hel p the patient see that these ar e not beyond his grasp and that, indeed, some alternatives are potentially more rewarding than the resolution he consciously endorses . For example, if the patien t ca n understan d tha t h e ca n acknowledg e hi s helplessnes s directly, he may no longer find it necessary to believe he is being persecuted (as a way of justifying his sense of futility). Dr.: I just want to find out why you would go back and see the person who inserte d th e bu g in your head? That would see m to m e like playing right into the enemy's hand. P: Yeah . I know wha t you're saying. I know wha t you're saying. It was a stupid move on my part. Dr.: Mayb e it' s stupid , hut , i n m y experience , peopl e ar e not stupid . They're always after something. It's as if you want this to go on. P: N o I don't. I want it out. Interpreting the Wishes Behind the Conflict as Understandable The interviewer has just made a crucial intervention—namely, interpreting the patient's behavior. The interviewer has advanced the hypothesis that the patient "want s this to go on" (because the patient believe s an alternative view would be too threatening to him). In making this interpretation, the therapist also indirectly tells the patient that he possesses the power t o influenc e hi s circumstances . Suggestin g tha t th e patient's attitude (of wanting this to go on) has something to do with the malevolent process continuing implies that if the patient changed his attitude, he might alter the process.

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Dr.: D o yo u understan d wh y I would thin k yo u woul d wan t i t t o g o on? B y seein g Dr . Steel , yo u ac t a s i f yo u wan t t o pla y righ t int o their hands . D o yo u understan d that ? Ca n yo u follo w tha t rea soning? P: See , the whole thing is, I'm a John Bircher .. . Dr.: Ca n yo u follo w tha t reasoning ? No w you'r e goin g of f o n a track . It's hard fo r yo u t o tal k wit h m e an d sta y o n th e track . Hav e yo u noticed that? P: I know. It' s stupid reasoning. Dr.: Yo u keep on saying, "It's stupid reasoning," and I'm saying, "There's method t o you r madness. " You're actin g lik e a guy wh o want s t o stay bugged , eve n thoug h yo u say , " I want t o ge t thi s thin g out. " . . . Why did you see Dr. Steel? P: I saw Dr. Steel becaus e I wanted to find out definitely, 'caus e I saw him put something in my head and I wanted to find o u t . . . Dr.: Wh y would you trust him, of al l people? P: I want to make trouble for him, actually. The interviewe r ha s confronte d th e patien t abou t hi s contradictor y behavior regardin g removin g the bug. The patient no w indicate s that he conducted his efforts withou t any real expectation of success. He did not expect th e docto r t o remov e th e bu g bu t rathe r wishe d t o "mak e trou ble" fo r th e doctor . H e i s describin g a n essentiall y futil e positio n i n which hi s expressio n o f ange r canno t chang e th e on e thin g tha t mat ters—his bein g bugged . I f th e patien t ca n acknowledg e th e futilit y an d sadness implici t i n hi s expresio n o f impoten t rage , h e migh t b e abl e t o look a t th e maladaptiv e natur e o f hi s activite s and , therefore , begi n t o consider other alternatives. Dr.: Let' s tr y t o ge t somethin g straigh t her e i n term s o f ou r priorities . What's the most important thing for you? P: T o get the bug out. Dr.: Al l right . Wha t kin d o f reasonabl e pla n ca n yo u mak e now , per haps wit h m y help , t o d o somethin g abou t that ? Wha t kin d o f thought do you have about that? The interviewe r i s sensitiv e t o th e threatenin g natur e o f directl y pro posing an y suggestion s fo r ho w th e patien t migh t understan d himsel f differently o r affect hi s circumstances. With that in mind, the interviewer

The Man with a Bug in His Brain 2 0 3 cautiously make s a potentially facilitatin g suggestion . H e first alludes t o a collaboratio n i n creatin g a "reasonabl e pla n . . . perhap s wit h m y help," a comment that reinforces the interviewer's willingness an d availability to join with the patient. P: Okay , tak e a n x-ra y o f m y mind . It' s insid e th e gauze . H e pu t something inside the gauze and . . . Dr.: I s it a metallic substance? I s it heavy metal ? Is it going t o show u p on an x-ray? P: I' m not sure. I'm not sure what it was. Dr.: Well , have you had any x-rays of your mind? P: I'v e had . .. I'v e had no, no x-rays of m y mind. Using the Patient's Logic to Confront Him with His Sadness Dr.: Ho w lon g has this been going on? P: Seve n years. Dr.: Seve n years? Do yo u understan d that the more we talk , the more I begin to doubt whether you ever want to have any definitive infor mation abou t this bug? Could it be that you want to keep this bug inside you? P: N o I don't. Dr.: Firs t you tell me that you P: [interrupts ] I' m not 10 0 percent sur e there is a bug in me. He sai d he was gonn a pu t a bug inside of m e and I heard voices a s soon a s I walked out of the hospital doo r . . . The interviewe r pursue s a proces s tha t wil l b e repeate d throughou t the remainder of the interview. He stays within the frame of the patient's own experience , usin g term s tha t stic k closel y t o thos e th e patien t use s to describe himself. Fo r example, in pursing the question of th e patient's motivation abou t removin g th e bug , th e interviewer' s question s deriv e from th e patient' s suggestio n o f takin g a n x-ray . Thus , th e interviewe r asks abou t th e radio-opaqu e qualitie s o f th e bug . B y consistently utiliz ing the patient's own fram e of reference, the interviewer hopes to extend the patient's thinking to the point that he will discover the contradictions and ambiguitie s i n hi s ow n beliefs . Whe n confronte d wit h those , th e patient ma y b e abl e t o acknowledg e hi s uncertaint y an d becom e mor e open t o othe r options tha t offer greate r security or more effective adap tion.

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At the close of thi s exchange, th e patient acknowledge s tha t he is no t certain tha t ther e i s a "bug " i n hi s brain . Moreover , th e patien t nex t describes events that may be closer to the actual experience he had at the time o f th e acciden t i n hi s descriptio n o f hearin g voice s a s h e lef t th e hospital. Dr.: Twent y minute s ag o I presented a theory t o you, which I said wa s your theory , a s I understoo d it . Yo u agree d wit h me . Le t m e diagram it here, just to be sure that we agree. Let's see [interviewe r goes t o blackboar d an d begin s t o dra w a graph] , we'l l cal l thi s "voice" dow n here , okay ? Thi s i s th e voic e an d we'l l cal l thi s 'stress" over here, okay? P: Okay . Dr.: Now , a s I understand you, what you're saying is that everything t o this sid e o f th e lin e mean s tha t ther e i s n o voice . A t thi s poin t o f stress [point s to graph], and at this point of stress, and at this point of stress , there are no voices. At a certain point, fro m thi s here on, as the stress occurs, the voices star t appearing. Right ? More stress, more voices . . . . B y th e way , d o yo u thin k that' s true ? Onc e yo u get a certai n leve l o f stress , th e voice s start . Doe s mor e stres s produce more voices, or is there no relationship ? P: It' s a heavier voice with more stress. Dr.: Sam e number of voices , but the voice is more insistent? P: The voices are heavier and louder. Dr.: Louder . Okay , s o we'l l als o sa y tha t thes e voice s ar e no t onl y present o r absent , bu t tha t the y ge t louder . Wit h mor e stress , th e voice gets louder? Is that it? [adds this information t o graph] P: Yeah . Dr.: Okay . An d thi s point her e [indicate s poin t o n graph] , th e point a t which, righ t here , th e poin t a t whic h th e stres s occur s an d i s sufficient t o brin g ou t th e voice , i s th e poin t a t whic h a switc h i s thrown whic h release s th e bu g [mark s i t o n graph] . That' s you r theory, is that right? P: Right . The interviewe r step s bac k fro m hi s successfu l confrontation , an d constructs a grap h tha t illustrate s th e patient' s experienc e (se e Figur e 4.1). Th e grap h help s th e patien t concretel y visualiz e th e connection s between th e variou s statement s h e ha s mad e i n a wa y tha t allow s fo r

The Man with a Bug in His Brain 20

5

Figure 4. 1

0* 1 (•) =

2 3 4 VOICE (INTENSITY)

poin t a t which switc h i s thrown, releasing bug.

0 * = doe s no t mea n th e absenc e o f voice , simpl y tha t th e intensit y i s no t sufficient t o be heard. (The asterisked information represent s the revision based on additional informatio n supplie d b y the patient.) greater elaboratio n an d clarification . Th e proces s i s collaborative . Th e interviewer involve s th e patient i n modifying an d clarifyin g th e diagram . This collaboratio n i s a paradig m fo r th e treatmen t alliance , an d i t in cludes th e recognitio n tha t understandin g i s no t absolut e bu t rathe r a n ongoing proces s tha t i s enriche d b y furthe r exploration . Ther e ar e ele ments o f playfulness an d creativit y in thei r designin g the graph together , important attribute s fo r man y differen t kind s of treatmen t paradigms . Dr.: No w you'r e tellin g m e i n th e las t minut e o r two , tha t thi s mode l may no t work. I t may no t b e true . P: I' m no t sur e exactly . H e sai d h e wa s gonn a pu t a bu g i n m y brai n and h e had somethin g i n his hand an d h e put somethin g insid e th e gauze. What h e pu t insid e th e gauze , I don' t know . I don't know , I'm no t a doctor. I t could hav e bee n styrofoa m o r somethin g weir d or... Dr.: D o you know anythin g abou t electronics ? P: No .

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Dr.: Nothin g abou t electronics ? D o yo u hav e a stereo? D o yo u hav e a TV? P: Yeah , I have a TV. Dr.: I s ther e an y componen t i n tha t equipmen t that' s mad e ou t o f styrofoam? Yo u need some kind of circuitry , don't you? P: I t coul d b e tha t h e jus t planne d t o us e a regula r bu g that' s i n a lampshade, or when they bug a room. Dr.: Wha t do they look like ? P: I don't know fo r sure. Maybe it's that when stress hits me, it builds up the tensio n i n m y min d wher e th e voice s ge t louder an d loude r because o f th e fighting insid e m y mind . I t get s t o a certai n leve l where the bug actually picks it up.

Moving Toward a Psychological Mode l The interviewe r pursue s a clarificatio n o f th e patient' s mode l and , i n doing so , help s th e patien t se e tha t h e ca n us e hi s ordinary , everyda y experiences an d knowledg e t o explor e th e validit y o f hi s ow n thinking . The interviewe r portray s th e patien t a s havin g th e capacit y t o under stand himself an d suggests that the patient may not have made adequat e use o f al l o f hi s skill s an d talent s t o understan d himself . Fo r example , the patient can employ hi s knowledge o f electronic s (base d on th e home equipment h e possesses ) i n tryin g t o thin k abou t wha t ma y hav e hap pened to him. This proces s bring s th e patien t t o th e acknowledgmen t tha t hi s voices get louder "because of the fighting inside my mind." His acknowl edgement o f th e relevanc e o f hi s menta l lif e t o th e productio n o f hi s symptoms i s crucial . H e wil l repea t i t later , whe n h e speak s o f subcon scious event s influencin g hi s thinking . Th e interviewer' s ai m i s t o en hance th e patient' s appreciatio n o f thos e psychologica l force s withi n him, as well a s his capacity to look a t and understand them. Dr.: That' s this model [point s to graph] . Now you'r e makin g one mod ification that' s a n interestin g one . You'r e suggesting , i f I under stand you, tha t these voices , i n fact , g o o n al l the time . It' s simpl y that yo u don' t hea r the m unti l th e stres s throw s th e switc h tha t activates the bug. Is that right? In fact, it may be that the voices are

The Man with a Bug in His Brain 20 7 going o n righ t now , bu t yo u can' t hea r them ? [revise s grap h ac cording to new information ] P: Right ! Dr.: No w that' s a very confusing mode l to me for the following reason : I would the n hav e t o understan d what' s responsibl e fo r th e voic e or voice s i n th e first place , sinc e no w you'r e suggesting tha t th e voices may be going on all the time. P: I s there a constant interaction in the human mind . . . ? Dr.: Between ? P: Yo u know, a human mind never shuts off—it's alway s thinking. Dr.: Yes , that would b e your thoughts though. P: That' s how I would thin k it is. No matte r if you're speaking abou t one thing , your min d could , your subconsciou s could , b e thinkin g something else. Dr.: Bu t that' s al l withi n yo u then ? Le t m e b e explici t abou t wha t th e confusion i s fo r me . Originally , whe n I first heard you r theory , I heard yo u sa y tha t you r min d wa s perfectl y alrigh t an d that , fol lowing thi s accident , somethin g wa s inserte d i n you r brai n whic h carries withi n i t th e voices , s o tha t i f on e too k th e bu g out , th e voices woul d b e gone . Now , a s w e tal k further , i t turn s ou t tha t the bu g ma y b e simpl y a kind o f microphone , a n amplifie r i f yo u will, and that the voices are going on all the time in you P: [interrupts ] But I would never hear them if I didn't have the bug. Dr.: M y questio n t o yo u no w i s wha t ar e thos e origina l voice s i n th e first place ? You wouldn't hear them without P: [interrupts ] I would say they're my subconscious. Dr.: So , in this new theory, then, all of us have these voices? P: Al l of us. Dr.: Right . An d tha t the onl y differenc e betwee n you an d the nex t gu y is that you happe n t o b e unfortunate enoug h t o hav e a bug whic h amplifies th e voice s tha t al l o f u s have . So , fo r example , i f I ha d this bug, I would be hearing my voices? P: Yo u would b e able to hear your voices. Dr.: Yes , I would b e able to. P: It' s sort of like , you see, the whole thing with the bug is it takes the pressure away . Dr.: Wha t do you mean ? P: Yo u know, you call somebody a n SOB and you can hear it outside.

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Dr.: Alright , but let's go back P: [interrupts ] Peopl e ca n hea r i t an d i t take s th e pressure—i t take s the pressur e t o a certai n poin t wher e yo u won' t di e mentally , i f there's such a thing as dying mentally. Dr.: I' m not following thi s last point. P: I'v e ha d a lo t o f peopl e follo w m e o n th e roa d an d they'v e bee n white, bu t they'r e rea l thi n an d thei r face s ar e al l chocolat e lik e they're all black, withdrawn, you know. Somebody either has done something to their mind that's killed their system—their, some part of thei r norma l bod y system , yo u kno w tha t normally— I thin k they're dead in the head—that their mind is dead, 'cause they have no life. Dr.: The n wh y d o yo u preten d no t t o kno w whethe r peopl e ca n di e from menta l things ? You'v e com e t o you r ow n conclusio n abou t that. You'r e quite convinced one can. P: I think one can. Dr.: I n fact, if I understand you, your terror is that this may be happening to you. P: I think I'm dead. Dr.: Alread y dead? P: Alread y dead. Dr.: Bu t if you ar e already dead , what's th e relevance o f al l this ? Wha t can anyon e d o t o yo u anymore ? Th e popula r notio n o f bein g dead—the popula r notion—an d thi s may be incorrect, the popular notion i s onc e you'r e dead , nothin g mor e ca n happe n t o you . I s that a view you subscribe to? P: That' s a view I subscribe to. Dr.: Bu t then, if you believ e that, once dead , nothin g mor e ca n happe n to you , an d yo u believ e tha t you'r e dead , the n wha t ar e yo u worried about ? P: I still don't like my thoughts 'caus e Dr.: [interrupts ] But nobody can harm you anymore . P: Nobod y ca n harm me. Dr.: What' s the danger? P: It' s hard to say. Dr.: I t seems to me there is something unclear about your logic. P: I' m not sure I'm dead. I could be sick, and not dead. Dr.: It' s possible that you're sick?

The Man with a Bug in His Brain 20 9 P: 'Caus e I don't know how to handle myself, how to take out cues and things like that. Dr.: Ther e are three possibilities that occur to me immediately. On e is that yo u believ e you'r e sick . Anothe r i s tha t yo u believ e you'r e dead; not sick, but dead, and that you're worrying about nothing, since whe n you'r e dead , you'r e suppose d t o b e safe . Ther e i s a third possibility—that even though you believe you're dead, being dead doesn't give you any protection. There is hell for people after they're dead too. That's a third possibility. P: Yeah . I don't understand. I know I'm probably dead , but I don't understand the second or third one. You know, there's time when things change in my mind, you know, or something will come up that somebody put a cue in me, and the cue will stay in me. Dr.: Le t me go back now to this earlier question that confused me. On the one hand, it seems to me, you are presenting yourself as if you are the victi m o f som e weird , bizarre , an d rather uniqu e experience. A bug has been placed in your brain, and the experience is so unusual that there are very few people who could understand you, and yo u woul d b e feelin g quit e alone . I n that sense , thi s bu g in your brai n isolate s yo u fro m th e world . Bu t then , yo u hav e a n additional theory , which is that all of us have these voices inside, but only a few of us have a bug that increases the volume. In that sense, you belong to the community o f mankin d in that all of us have these voices. So, on the one hand, you are in a very unique group, and on the other, you belong with everyone. Right? You are with me so far? P: Yeah . I'm with you. Dr.: Now , wha t I don' t understan d whe n yo u hav e troubl e gettin g doctors to believe you is why don't you begin your story with the similarity between yourself and other people, rather than the differences. The similarity being, "Dr. X, you have voices inside you—I have voices inside me and the difference i s that I have an amplifier that makes my voices loud so I can hear them, while you lack that amplifier." . ., D o you follow me? P: I t makes sense. Dr.: Wha t do you think about what I said? P: I t makes sense. . . . I wish yo u could hel p me. I' m asking you to help me.

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Dr.: Ho w coul d I hel p you ? Wha t ca n a psychiatris t d o fo r a perso n who ma y b e dea d an d wh o ha s a n implantatio n i n thei r mind ? What w c I d b e m y role ? . . . No w you'r e smiling . [Patien t ha s broken into a grin.] P: I' d as k yo u t o tak e th e bu g out . It' s righ t here , it' s no t deep . It' s right here. Dr.: Yo u would trus t a surgical procedure to a psychiatrist? P: Al l i t i s . . . anybod y coul d d o it . Anybod y coul d d o it . Anybod y could take it out. Dr.: Ho w d o you know tha t what he did requires very little talent? Are you an expert on surgical procedures? How d o you know he didn't train for years to do that procedure? P: Th e onl y thin g I kno w is , i t can' t b e muc h 'caus e it' s no t dee p 'cause the cut, the laceration, was not deep. Dr.: Bu t isn't it dangerous t o foo l aroun d inside the head? Are there n o risks? P: It' s just a bug. It's probably somethin g like that. Dr.: Le t me go bac k th e other way. There are two parts to your theory. One part is the bug amplifies th e sound, right? But the first part of the theor y i s tha t th e soun d that' s bein g amplifie d i s you r "ow n unconscious," in your own words. Okay ? Let' s say, for a moment, that your voices which , fo r the mos t part, you don' t hear until th e stress facto r get s bi g enoug h t o thro w th e switc h t o activat e th e bug [point s t o graph]—wer e friendl y voices . I f yo u coul d chang e the characte r o f th e thing s yo u tel l yourself , i f th e voice s wer e friendly, would you mind having the switch thrown ? P: Yeah . Dr.: Why ? P: 'Caus e I hate when I go i n crowds o f people , you know , the y rea d your mind and say things that are . . . Dr.: D o the y rea d you r mind , o r d o the y jus t hav e goo d hearin g an d can hear the voice? P: The y lift up their ears and they say the same thing and it aggravates the shit out of me. Dr.: Bu t is it because the bug has been activated and they can hear? P: Right . Dr.: S o tha t i f I now understan d you—thi s i s th e nex t modificatio n o f

The Man with a Bug in His Brain 21 1 the theory—i f I no w understan d you , wha t you'r e sayin g i s tha t even i f yo u ha d sweet , loving , carin g voice s withi n yourself , i t would b e awkward , embarrassing , an d infuriatin g fo r yo u tha t other people woul d kno w you r innermost thoughts , since they ar e projected outwardly. Right ? P: Yes . Dr.: No w tha t make s sense . Yo u wis h t o hav e som e kin d o f sens e o f privacy. P: I hav e n o privac y [state d emphatically , leanin g forwar d towar d interviewer]. Dr.: Give n what you've described, that's correct. Now you've explaine d why, n o matte r wha t th e conten t o f th e voices , yo u don' t lik e having the m audibl e t o th e outsid e world . Still , I am intereste d i n why yo u woul d hav e withi n yourself self-accusator y thought s whic h then becom e hear d b y yo u a s voice s whe n th e switc h i s thrown . Why d o yo u fee l tha t wa y abou t yourself ? Wh y d o yo u accus e you? Remember , that's the other part of th e theory, your theory — that th e voic e withi n yo u i s you r ow n subconscious . Wh y don' t you tak e th e positio n tha t a terribl e thin g ha s happene d t o you , and tha t th e las t perso n o n eart h wh o shoul d b e critica l o f yo u i s yourself? Why don't you tell yourself soothing, comforting, protective things ? It' s true tha t you woul d stil l b e embarrassed i n publi c because people would hear your inner thoughts. I understand that, but at least you could be good to yourself . P: I' m good to myself. Dr.: I don't hear that. P: Thes e are subconscious things. When I talk Dr.: [interrupts ] Isn' t tha t par t o f you ? Isn' t th e subconsciou s par t o f you? P: Ho w d o you change your subconscious ? Dr.: Ar e you interested in finding out? P: Yeah . Dr.: That' s somethin g tha t a psychiatris t migh t b e abl e t o hel p yo u with. That's within the province of psychiatry. With all the doctors you've seen, have you ever discussed that? P: Yeah . I asked them, "How do you change this?" and they said they didn't know.

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Dr.: Yo u hav e talke d t o bonafid e psychiatrist s abou t ho w yo u migh t change you r subconsciou s an d the y al l sai d the y didn' t know ? What's your reaction to that? P: I thought there was no way you could change your subconscious . Dr.: S o you accepted that view? P: S o I accepted that view. P m not a doctor. Dr.: Well , le t m e pu t i t t o yo u thi s way . Psychiatrist s ar e not surgeon s and can't take the bug out. That's my statement to you today . P: Okay . Dr.: Psychiatrists , however , dea l wit h th e subconciou s al l th e time . I f they can't take the bug out and they can't change the subconscious, what good ar e they to you? [Telephon e rings. ] P: That' s wh y I keep tellin g everybod y P m i n th e hospita l fo r peac e and relaxation. Dr.: I would think it would be terribly frustrating to be in a place where you ca n neither get the bug removed nor get help with the subconscious. Is this relaxing to you? A man as tormented a s you are , not getting the relief you need? What is relaxing? P: S o I smoke cigarettes. Dr.: Yo u mean it's not relaxing here? P: No , it' s not relaxing. Dr.: I' m right back a t the beginning again , wondering wha t a guy wit h a bu g i n hi s hea d i s doin g i n a psychiatri c hospital ? I don't ge t i t yet. Are you here of your own fre e will? P: Yeah . The only thing is I want to be able to defend myself more . Dr.: Ho w ca n you do that? P: Yo u know , i n lif e tha t everybody , there' s war s an d menta l war s and stuff lik e that and . . . Dr.: S o you want to get some way to defend yourself against . . .? P: I want to know how t o defend myself . Dr.: Against ? P: Agains t othe r people . They'r e tryin g t o pu t stuf f i n m y mind . Th e reason wh y I went bac k t o hi m i s 'caus e he' s th e onl y on e who' d believe me that there's a bug in me, 'cause he put it in me. I've been told b y doctor s wh o sai d there' s n o suc h thing—"Yo u don' t hav e a bug in your head." Dr.: Bu t do you understan d th e irony of th e situation? The only perso n who wil l believ e you—loo k a t th e situatio n tha t yo u sa y yo u ar e

The Man with a Bug in His Brain 21 3 in—the onl y person who wil l believ e you i s your arc h enemy. An d why will he believe you? Because he, apparently, is the only perso n who know s tha t i t wa s don e because , i n you r view , h e di d it . S o you're withou t allies . Eithe r n o on e wil l believ e you , o r th e on e person who doe s believe you has absolutely n o interest in taking it out. P: Th e trouble with m e is I made myself s o valuable. Ever y time I try to ge t th e bu g ou t it' s bein g blocke d b y a telephone cal l o r some thing lik e that . Lik e yo u jus t ha d wit h th e telephon e ringin g an d nobody picke d i t up an d it stoppe d ringing . To m e that was a cue for you to get off th e subject. Dr.: S o now you'r e abl e to admi t that you ar e of th e opinion tha t I too may be involved in your destruction ? P: I didn't say that. It's just a warning. Dr.: But , did I get off th e subject? P: No . Dr.: Tha t interest s me . . . . I didn' t ge t of f th e subject . Ho w di d yo u interpret that? P: I interpreted tha t you ha d some backbon e an d you were willing t o make decisions. Dr.: S o tha t i t i s possibl e fo r yo u t o find allies ? I find tha t a rathe r optimistic note for a guy as isolated and struggling as you are. But, how was I to have known that if you didn't tell me? P: It' s just that I'd seen it so many times before . Dr.: Mayb e you were afraid to let me know abou t that? P: I didn't want to lose an ally. Dr.: I can appreciat e that , an d I think it' s ver y importan t tha t yo u ar e able t o acknowledg e you r wis h t o hav e someon e hel p you . . . . Unfortunately, ou r tim e i s nearl y up . We'r e goin g t o hav e t o sto p in a minute. I was wondering i f there was anythin g you wante d t o ask me? P: Okay . Yo u wan t t o hel p me . You'r e goin g u p agains t a whol e bunch of tough people. Dr.: S o yo u wan t t o kno w i f I want t o hel p you ? I s that th e question ? And you'r e sayin g tha t fo r m e t o wan t t o hel p yo u mean s tha t I better kno w tha t th e odd s ar e bad . Le t m e pu t i t t o yo u anothe r way. You'r e asking me whether I want to help you. Let me ask you whether you're willing t o —

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P: [interrupts ] Hel p myself ? Dr.: . . . wor k wit h someone . Becaus e I don' t thin k a t thi s poin t yo u can d o it alone, but I can b e wrong abou t that . P: I can, I want t o work . . . Dr.: Alright . Now, th e person P: [interrupts ] Yo u mak e th e rules . Dr.: No . That' s wha t I' m abou t t o say . I woul d mak e on e rule . Tha t whoever yo u work with , and apparentl y th e therapist you're work ing wit h i s Dr . Warren , b e someon e wit h who m yo u b e a s ope n with a s yo u possibl y can , eve n i f tha t make s yo u fee l you'v e pu t yourself i n an endangere d position . Okay ? P: Okay . [Patien t leaves]. EXPLICATION O F INTERVIEW What follow s i s an effor t t o organiz e th e patient's apparentl y disjointed , fragmented, an d bizarr e stor y int o a coheren t whole , whil e remainin g faithful t o th e chao s h e describes . Ou r conclusion s ar e no t final bu t rather represen t th e evolvin g stat e o f ou r understandin g o f thi s man . Our understandin g woul d underg o continua l revisio n throughou t th e course o f working with him . The Patient' s Subjectiv e Experienc e Persecution The patient's fundamenta l experienc e is that of persecution. In his world , even deat h fail s t o provid e rest , psychiatrist s fai l t o believ e him , an d hi s surgeon i s hi s torturer . Worse , becaus e n o on e believe s him , onl y hi s enemy ca n sav e him , sinc e h e alon e know s tha t th e patien t i s telling th e truth. Th e patien t define s hi s majo r persecuto r a s someon e who m h e might b e abl e to influenc e i n the futur e t o und o th e harm h e has caused . If persecuto r ca n becom e savior , ca n th e patien t mak e othe r dramati c changes in the way h e views himself an d thos e aroun d him ? Power The them e o f powe r preoccupie s ou r patient . H e suggest s tha t hi s ow n power ha s brough t abou t th e problem: "Th e troubl e wit h m e is that I'v e

The Man with a Bug in His Brain 21 5 made mysel f s o valuable." Even an indirect associatio n t o power ca n be dangerous: Pressure is brought to bea r on his mind not only i f he says a girl's name wh o i s famous bu t even if "sh e might have know n someon e who is famous." The abus e of powe r i s omnipresent. The most flagrant example i s the horrible surger y t o which th e patient believe s he was subjected . I n more subtle form, the abuse of power is seen in the notion that the reason that doctors tell him that "I was dreaming" or that "I'm in a space world" is because the y nee d t o preserv e thei r ow n self-estee m a t hi s expense . H e suggests this when he links "Many doctors have told me I am not tellin g the truth" with "The y couldn't solve my problems with the voices."

Relationships The patien t see s relationship s a s fraugh t wit h danger , characterize d b y duplicity an d envy, wit h onl y th e remotest hope fo r change . A n implici t theme migh t b e tha t hi s ow n sexua l an d aggressiv e impulse s threate n him an d tha t therefor e h e mus t displac e the m ont o others . Sinc e hi s wishes t o b e powerful ar e frustrated, h e feels helples s an d envies others' power. H e describe s a fantasy o f unleashed , disinhibite d impulse s whe n he pictures "people spinning me on the road or making love to me." In his interaction with the interviewer, he manifests his suspiciousnes s by announcing , "Yo u wouldn' t believ e wha t som e o f m y problems are . . . . I figured you'd be just another doctor going along with the pattern." However, whe n confronted , h e is abl e to recogniz e tha t " I took a negative attitud e withou t testin g yo u out. " Whe n h e says , " I don' t kno w what yo u wan t fro m me . I can g o bac k t o whe n th e illnes s starte d an d everything," w e se e that , wit h clinicians , h e handle s hi s anxiet y an d confusion b y returning t o a familiar thoug h stereotypica l exercise , recit ing his "history." His use of a "canned" history might also represent his effort t o concea l th e pain associate d wit h th e interaction, thu s isolatin g himself fro m th e interviewer' s potentia l empathy . Yet , despit e thi s pos sibility, hi s wis h fo r a n all-protectiv e figure emerge s wit h th e entreat y "I'd ask you to take the bug out." Perhaps it is this need that encourages him to keep trying and sustains him in his efforts . He i s abl e t o acknowledg e th e interviewer' s importanc e t o hi m bot h as a hoped-fo r rescue r an d dreade d foe , muc h lik e th e surgeon . Hi s interpretation that the interviewer's response to the phone ringing shows

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"backbone" migh t suggest he wants th e interviewer t o b e strong becaus e of hi s wis h t o find a n adequat e protector . However , hi s suspiciousnes s about th e interviewer' s sincerit y (o r hi s fea r o f hi s nee d o f th e inter viewer) prompt s hi m t o tes t th e clinicia n further , a s whe n h e ask s th e doctor i f he fully understand s th e dange r o f th e situation . The patien t ha s som e capacit y t o se e other s (th e policema n an d hi s father) a s supportive , albei t ineffectual . Th e policema n warn s him , "You' d better watc h out . The y migh t pu t a bu g i n you r brain, " whil e hi s fathe r does not wan t hi m t o b e bugged. However , neithe r mal e authority figure is able to prevent th e assault. Indeed, the father i s the first person to hea r the patient's amplifie d voice . The Bug Metaphor The bu g ide a i s a centra l organizin g mechanism . I t is a comple x fantas y serving multipl e functions . Th e patien t describe s i t a s "pickin g u p brai n senses an d thought s . . . an d microphonin g the m outside, " a concret e expression o f hi s boundar y disruption . Th e bu g link s hi m t o Dr . Stee l since h e i s th e onl y on e wh o ca n remov e th e implant . Th e lin k i s o f a particular nature : "Th e thin g i s se t up—sor t o f lik e yo u hav e t o pu t enough hea t o n th e ma n t o tak e i t out." Thus , the bu g force s a sadoma sochistic ti e betwee n th e patien t an d hi s persecuto r an d als o hint s a t underlying homosexual concerns . The bu g als o provide s som e degre e o f safety , thoug h a t considerabl e expense: "I t [th e bug] reduce s pressure, so you don' t di e mentally. " Safety A recurrin g them e i s hi s searc h fo r safet y an d ho w tha t ques t compro mises his self-esteem. H e needs to find a way t o stop the (bug-activating ) switch fro m bein g throw n b y searchin g fo r method s t o decreas e th e pressure. H e see s th e hospita l a s a respit e fro m thi s struggle : "I' m her e for peac e an d relaxation. " Ultimately , however , th e struggl e mus t g o o n if h e i s t o fee l safe : " I wan t t o b e abl e t o defen d mysel f mor e agains t other people. " Though h e focuse s o n th e dange r bein g outsid e him , there i s evidenc e that, ove r time , h e coul d understan d hi s struggl e i n intrapsychi c terms . He hint s a t tha t whe n h e says , "I n life , everybody , there' s war s an d

The Man with a Bug in His Brain 21

7

mental wars, " and , mor e specifically , "I' m no t sur e there' s a bu g insid e me," and "Th e voices get louder because of the fighting inside my mind. " As a n alternativ e t o th e bu g theory , h e eve n suggest s tha t th e pressur e may b e relate d t o th e fac t that , " A huma n min d neve r shut s off . It' s always thinking. " Burie d i n thes e remark s i s a potentia l rol e fo r a therapist. " I coul d b e sick . I don't kno w ho w t o handl e myself. " Mor e explicitly, he inquires, "How d o you chang e your subconscious? " Loss His experienc e o f los s is devastating. H e think s h e may hav e los t his lif e and describe s a mode l fo r ho w thi s coul d hav e happened : "Somebod y has don e somethin g i n thei r min d that' s kille d thei r system—som e par t of thei r norma l bod y system . . . . I thin k they'r e dea d i n th e head. " Perhaps eve n mor e significan t i s hi s los s o f th e capacit y t o b e hi s ow n person, a n even t h e speak s o f a s havin g take n plac e man y year s before : "It seem s lik e somebod y toye d wit h m y min d whe n I wa s youn g an d they reall y screwe d m e up. " H e als o note s a los s o f spirit : "I' m no t on e where I sleep a lot but that's becaus e of boredom. " Autonomy and Control His experienc e o f autonom y an d contro l i s mos t poignantl y expresse d when h e explain s how , becaus e o f th e "overload" , h e "gets " the voices , which caus e him t o "blur t ou t stuff, cue s and everythin g else. Everything is comin g ou t o f me. " O n anothe r occasio n h e expresse s hi s sens e o f porousness whe n h e says , " I hav e n o privacy. " H e feel s h e i s a passiv e container fo r hostil e projections comin g fro m th e outside. Not onl y doe s he "get " th e voice s bu t h e ha s n o contro l ove r th e pressur e tha t build s up to activate the bug: "It's like I was lifted t o a point where I boil over. " He make s a valian t effor t t o counte r hi s helplessnes s throug h hi s identification wit h the John Birc h Society. "You tak e all the pressure yo u can tak e an d yo u don' t budg e a n inch . I f the y pu t pressur e on , you'r e not suppose d t o buckle. " Self-Object Dlfferentatlon Although th e patien t experience s a considerabl e assaul t o n hi s sens e o f wholeness, self-objec t differentiation , a t leas t superficially , appear s t o b e

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relatively intact . A t th e ver y beginnin g o f th e intervie w h e i s able t o sa y that th e intervie w i s "an experienc e wit h advantage s fo r eac h o f us—it' s part practic e for yo u an d it' s part fo r me, " as well as "I'm no t a doctor. " Perhaps th e clea r presenc e o f a n externa l foe , "th e animals " responsibl e for th e implantation , couple d wit h hi s militan t posture , maintai n hi s boundary wit h th e outsid e world . However , hi s boundar y i s tenuous a s the statement abou t lac k o f privacy suggests . Assessment o f Integratio n o f Subjectiv e Experienc e This assessmen t illustrate s tha t a n intervie w wit h a schizophreni c indi vidual ca n productivel y elucidat e crucia l aspect s o f hi s o r he r subjectiv e experience. Th e clinicia n the n move s o n t o conside r th e effec t o f th e patient's subjectiv e experienc e o n hi s o r he r psychologica l life , motiva tion, an d behavior . Priorities The patien t i s pushe d an d pulle d b y opposin g priorities . I n a n effor t t o avoid persecution , h e mus t decreas e hi s importance , while , a t th e sam e time, h e feel s th e nee d t o b e powerfu l i n orde r t o fac e hi s persecutors . He mus t liv e u p t o th e hypermasculin e ideal s o f th e John Birc h Societ y while strugglin g t o find a protector . T o preserv e hi s ifttactness , h e mus t try t o kee p everythin g insid e himself , but , i n doin g so , h e risk s menta l death. The bu g (whic h projects hi s thoughts t o the outside) prevents hi m from dying , bu t a t th e ris k o f bein g humiliated . Th e struggl e i s betwee n power an d dependency , retainin g contro l an d acknowledgin g hi s vulner ability an d nee d fo r help . Introspection The patien t show s a (limited ) capacit y fo r introspectio n an d self-obser vation. Fo r example , h e i s abl e t o observ e tha t h e treat s individual s i n terms o f categories . A cas e i n poin t i s hi s recognitio n tha t h e view s th e interviewer a s someon e wh o would , a priori , "b e exactl y lik e th e othe r doctors." His commen t tha t h e wants t o b e able to defen d himsel f bette r reflects hi s belie f tha t h e i s a n endangere d individua l needin g additiona l strength. Thoug h predominantl y viewin g himsel f a s th e victi m o f exter -

The Man with a Bug in His Brain 21 9 nal forces , h e voice s doubt s abou t whethe r ther e i s a bu g insid e him . Moreover, he acknowledges a role for inner processes in the production of voices : "Th e voice s ge t loude r becaus e o f th e fighting insid e m y mind." Relationships In a man who sees relationships as power struggles in which the oppressor hounds the oppressed, it is difficult to speak of intimacy. Compounding hi s difficult y i s his troubl e differentiatin g libidina l fro m aggressiv e impulses. They are equally dangerous. The most he can hope fo r inter personally i s t o becom e bette r abl e t o "defen d myself. " Bu t ho w t o accomplish tha t whe n th e mer e mentio n o f a girl' s nam e ca n caus e instant retaliation? There is the suggestion that he would like to surrender himself t o someon e els e in th e hope o f bein g protected, bu t suc h a venture would require him to relax his guard. The patien t woul d prefe r t o kee p th e worl d a t arm' s length , and , better yet , t o remov e himsel f fro m i t altogether . Wha t bedevil s hi m i s precisely the opposite: his inability to keep the world from knowing even his most intimate thoughts. Attitudes Toward Change Though extremel y pessimisti c abou t effectin g change , h e nonetheles s struggles t o accomplis h it . The first step is to become stronger, so as to tolerate mor e "withou t buckling. " H e als o consider s othe r strategies , such as finding a way to decrease the pressure so that he will not have to endure s o much , convincin g th e surgeo n t o remov e th e implant , o r finding an all y wit h sufficien t "backbone " t o joi n i n th e struggle . O n occasion, he alludes t o th e possibility o f intrapsychi c change , acknowledging that he "could be sick" and indicating an interest in changing his subconscious. Loss Our patien t constantl y struggle s agains t loss . His bodil y sel f ha s bee n damaged by the transplant, his psychic self by the projection o f his inner

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thoughts, and hi s self-esteem b y the discrepancy betwee n th e triumphan t figure h e would lik e to b e and th e defeated figure h e sees himself t o be . Assessing his subjective experienc e bring s us to a clearer awarenes s o f the pai n th e patien t woul d experienc e i f h e recognize d hi s vulnerability . This recognitio n woul d conflic t wit h hi s expectatio n tha t h e be a wholl y self-determined individual . Th e patient' s conflic t wit h regar d t o ac knowledging hi s nee d fo r hel p heighten s ou r sensitivit y t o ho w h e ma y experience th e ac t of bein g helped an d thu s influence s ho w w e approac h him i n a treatment setting . The assessmen t identifie s som e o f th e liabilitie s tha t h e experiences — for example , his limited capacit y fo r insigh t an d intimacy—an d portray s these a s at leas t a partial consequenc e o f th e psychological adaptatio n t o his illness. From thi s integration , w e mov e t o a consideratio n o f ho w w e woul d construct a treatment alliance .

BASIS O F TREATMENT ALLIANCE A treatmen t allianc e i s a pac t betwee n tw o peopl e tha t maintain s the y will wor k togethe r o n som e issue or issue s fo r som e state d purpose . Th e most importan t facto r i n selectin g whic h issu e o r issue s t o focu s o n i s that i t (they ) b e of centra l concer n t o th e patient. Next , th e issu e chose n must b e identifie d b y bot h partie s i n mor e o r les s th e sam e way , an d patient an d clinicia n mus t b e reasonabl y comfortabl e tha t wha t the y have chose n t o examin e merit s thei r effort. b Ther e ma y b e vas t area s o f disagreement o n a hos t o f othe r issues , but , unles s the y imping e o n th e agreed upo n task , the y hav e n o immediat e relevanc e an d ma y o r ma y not b e take n u p late r i n th e treatment . Th e clinicia n mus t als o fee l tha t the natur e o f th e tas k fall s withi n th e purvie w o f hi s o r he r expertise . For example, to the patient who insiste d tha t th e solution t o her proble m lay i n astrophysics , th e clinicia n woul d sa y h e kne w nothin g abou t tha t subject bu t woul d b e happ y t o discus s wit h he r th e dilemm a o f bein g treated b y a psychologist whos e are a o f expertis e was in matters psycho logical rathe r tha n astrophysical . Our patient has let us know tha t he does not fee l safe. Othe r problem atic issue s fo r hi m includ e hi s profoun d difficult y determinin g basi c questions abou t himself , such a s whether h e is alive or dead an d whethe r

The Man with a Bug in His Brain 22 1 the enem y i s insid e o r outsid e o f him . I n addition , h e lack s a wa y t o prevent others from knowing his innermost thoughts. A clinicia n seekin g t o for m a n allianc e wit h hi m woul d hav e t o demonstrate tha t h e o r sh e understand s an d give s credibilit y t o th e patient's sens e of bein g endangered. We are not saying that the clinicia n must clai m t o believ e tha t th e patien t has , i n fact , bee n bugge d ( a distinction w e hav e mad e i n previou s chapters) , bu t th e clinicia n mus t indicate an appreciation that the patient feels porous. The clinicia n woul d indicat e th e patien t i s raisin g concern s tha t ar e the prope r provinc e o f thei r work . Wit h th e patien t jus t described , th e clinician migh t say , "Th e issue s yo u hav e spoke n t o m e about—you r uncertainty abou t whethe r you'r e dea d o r alive , whethe r ther e i s a bu g inside you r head—ar e precisel y th e kin d o f worrie s tha t menta l healt h professionals ar e interested i n and able t o help you with." The clinicia n would next suggest how together they might go about the task and what the clinician' s responsibilitie s an d limitation s were , a s wel l a s wha t would b e require d o f th e patient . Assuming , a s i n thi s case , tha t th e patient i s i n th e hospital , h e woul d b e informe d tha t differen t clinica l services would b e utilized, each tackling different tasks . Let us for a moment consider how the various members of a treatment team migh t for m alliance s wit h th e patient: Th e psychotherapist woul d attempt a n alliance in much the same manner a s the interviewer did . H e or sh e woul d confron t th e patien t wit h hi s doubt s abou t th e externa l nature o f th e assault , couple d wit h th e suggestio n tha t interna l matter s (the "subconscious") ar e the domain of th e therapist. A rehabilitatio n therapis t migh t selec t a task jus t a t th e threshol d o f the patient' s functiona l abilities . Th e rehabilitatio n therapis t woul d b e wise no t t o giv e th e patien t task s tha t ar e to o eas y becaus e h e woul d likely devalue these tasks and see them as being insufficiently challengin g for a John Birche r an d thu s damagin g t o hi s self-esteem . B y th e sam e token, th e rehabilitatio n therapis t coul d introduc e th e tas k wit h th e statement "Since you are used to fighting long and hard, I didn't want to start yo u wit h anythin g easy. " I f th e patien t become s annoye d wit h himself fo r havin g difficulty wit h th e task , th e therapis t coul d point ou t to hi m ho w harshl y h e judge s himself , eve n o n th e basi s o f hig h stan dards. The nursing staff coul d becom e allie s with th e patient b y considerin g issues of privacy , acknowledgin g ho w understandabl e i t is to want one' s

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own privacy . Staf f member s coul d giv e example s fro m movies , books , and s o o n illustratin g ho w peopl e fel t whe n thei r privac y wa s invaded . While acknowledgin g thei r understandin g o f the patient's concer n abou t loss o f privacy , th e nursin g staf f woul d als o insis t tha t the y wer e unabl e to hear hi m unles s he chose to make himself audible . That is , they woul d be agreein g wit h hi s feelin g tha t los s o f privac y i s terrible , bu t insistin g that, fro m thei r perspective , he has no t los t hi s privacy. I n eac h o f thes e modalities, th e clinicia n woul d hav e t o acknowledg e tha t h e o r sh e i s unable t o chang e certai n thing s abou t th e patient' s experience , whil e recognizing that th e patient ma y wish fo r hi m o r he r t o d o so . To facilitat e a n emergin g alliance , th e clinicia n mus t respec t wha t supports th e patien t ha s alread y se t up . Ove r time , thes e ma y b e modi fied, but , a t the outset , the y for m a crucial elemen t o f th e initial alliance . In ou r patient , i t would b e essential t o respec t hi s need t o b e stron g an d "not buckle, " t o indicat e awarenes s an d appreciatio n o f ho w har d i t i s to liv e u p t o suc h a demandin g se t o f principle s a s thos e th e patient ha s set out fo r himself . To th e extent tha t th e clinician ca n appreciat e th e magnitude o f effor t the patient ha s mad e i n his own behalf , (eve n though th e specific for m i t has take n appear s maladaptiv e t o th e therapist), he or she will be able t o consider th e patien t a s possessin g a potentia l fo r contributin g t o hi s treatment. Th e clinicia n ca n thu s imagin e th e patient a s collaboratin g i n the struggl e t o see k answer s t o th e perplexin g problem s confrontin g th e patient, recognizin g tha t th e patien t ha s th e strengt h t o persever e i n th e absence o f quic k o r eas y answers . TECHNIQUES OF INTERVIEWING AND INTERVIEWING PRINCIPLE S Each patien t tell s the stor y o f hi s o r he r experienc e i n a n individua l an d characteristic voice . W e begi n b y identifyin g th e patient' s uniqu e idio m and adjustin g ourselve s to it . Thus, with ou r patient , his telling us abou t his torment an d humiliatio n throug h th e tal e of th e bu g show s us wher e we shoul d begin . Withi n tha t frame , w e see k t o sho w hi m tha t hi s fundamental messag e ha s bee n receive d wit h seriousnes s an d interest . The interviewe r doe s thi s b y makin g a grap h depictin g th e patient' s experience wit h voic e transmission . Th e grap h i s a collaborativ e effort ,

The Man with a Bug in His Brain 22 3 the interviewer modifying th e points on the graph on the basis of corrections made by the patient. The summar y tha t follow s i s offered a s a guide to clinician s engage d in interviewing and assessing chronic schizophrenics. 1. Recogniz e tha t patient s ar e th e centra l informant s abou t them selves, thei r experienc e o f thei r world, an d thei r treatment . Whe n clini cians believ e tha t understandin g thei r patient s depend s o n wha t th e patients tel l them , clinician s communicat e thei r belie f tha t wha t th e patients say can , over time, be understood a s something patients ar e not always certain about or wish to acknowledge . Clinicians see k a pictur e o f patients ' sens e o f themselves . Unlik e the traditiona l medica l mode l o f history-taking , clinician s mus t no t rel y too much on their own assumptions. They must be careful no t to dismiss patients' attitudes o r conclusions a priori; and they must discourage th e fantasy i n either the patients o r themselves tha t everything that needs t o be understood has already been understood. 2. Assis t patient s i n elaborating thei r view o f themselves . Communi cate t o patient s th e belie f tha t the y ca n tel l u s abou t themselve s an d reinforce thos e instance s wher e patient s demonstrat e thei r desir e t o kno w and b e known . ( A clinicia n migh t say , fo r example : "J us* no w yo u allowed yourself t o see that, despite the fact that you came in describin g a fixed universe in which everything is determined i n advance, includin g all aspect s o f you r life , you'r e als o thinkin g thi s migh t no t b e true. The thing tha t tippe d m e of f t o tha t wa s whe n yo u sai d a minut e ago , ' I wonder i f I can chang e an y o f this? ' ") Patients ar e often unclea r abou t what ha s happene d t o the m an d why , an d the y ar e demoralize d an d uncertain abou t wha t the y hav e becom e an d what , i f anything , ca n b e done about it. Clinicians ar e not attemptin g t o nail dow n th e absolute definition s o f who eac h patien t is , bu t onl y t o develo p som e understandin g o f th e patient's self-perceptio n a t th e moment . Thi s importan t tas k involve s getting patients interested in thinking about themselves, expecially abou t their self-construction a s an evolving event. As patients attempt to clarif y who the y ar e t o clinician s an d t o themselves , the y begi n t o demystif y their psychotic experiences. Turning patients ' attentio n t o th e tas k o f understandin g themselve s

224 Working with the Person with Schizophrenia implicitly fights against th e demoralizatio n an d helplessness tha t ofte n accompany chroni c schizophrenia. I n addition, b y supporting patients' own efforts an d helping them feel les s helpless, clinicians are less likely to be seen as omniscient, omnipotent, or the object of the projections of patients' superego s (i.e. , a s a n oppressor). Th e latte r vie w i s ofte n a n outgrowth o f patients ' struggles with feelin g guilt y and at fault fo r the illness. 3. Ancho r the discussio n i n the here-and-now o f th e interview. Focusing on th e patient's interactio n wit h th e interviewer ha s several advantages. A s compare d t o anythin g th e patien t ma y sa y regardin g hi s past, th e interactio n i n th e interview i s th e on e aren a where the interviewer can confront the patient with the interviewer's first-handknowledge of what is going on in order to try to clarify difference s i n perception. At th e beginnin g o f thi s interview , th e interviewe r says , "I' m interested i n one thin g that you said—tha t a lot o f doctor s hav e looke d at you." This comment invites the patient to explore several issues directly and indirectly related to the current interaction. The focus is not on the past (wha t th e previou s doctor s hav e said) , bu t how tha t past history relates t o th e current moment. On e says, in short, "S o what does that [past event] have to do with us?" The interviewer's commen t opens up an exploration of th e patient's overall attitude s about trust; about his perception of doctors and treatment, includin g bot h ho w h e has fel t abou t it in the past an d its relevance to him now; and what his expectations an d attitudes are toward the intervie w itself . I n anchoring th e discussio n i n the interaction , the interviewer als o encourage s relatednes s and , therefore, provide s a n invivo opportunit y t o experienc e directl y ho w th e patien t handle s a n interaction. By concentrating on the interaction, the clinician opens a door through which the patient's reaction to the interviewer and the interview can be explored. B y understanding th e patient's attitud e towar d th e interview process, the therapist can put the patient's remarks in context. If patients are mistrustful of interviewers, they will sound more hesitant and guarded, which may or may not be the way they would speak about themselves or others in anothe r setting . The patient's attitud e abou t the interview (and interviewer ) wil l influenc e hi s o r he r presentation o f man y other

The Man with a Bug in His Brain 22 5 topics. O f course , i t i s als o tru e tha t th e patient' s attitud e abou t th e interviewer may also reveal the patient's picture of him- or herself in the world. I n either event, clarificatio n o f th e patient's expectation s abou t and experience of the interview is a crucial step in assessing what he or she says. These firs t thre e principle s constitut e a genera l understandin g o f th e attitudes tha t th e clinicia n wishe s t o conve y durin g th e cours e o f th e interview, an d som e broa d outline s abou t th e goal s o f th e interview . What follows ar e some specific suggestion s referring either to the clinician's attitud e o r intervie w techniqu e an d direction s fo r wha t kin d of information w e need to glean fro m th e interview i n order to construct an understanding of the patient's subjective experience. 4. Communicat e to patients that understanding their points of view on al l matter s (includin g thei r idea s abou t etiology ) i s crucia l t o ou r understanding them . Thi s migh t b e described a s a n attitude o f benig n curiosity on the interviewer's part. In later work with patients, it will be important to present our model of what is happening to or in them, but, in a n assessmen t interview , w e wan t t o obtai n a s muc h detai l an d richness a s possible regardin g patients' understanding themselves . This process woul d b e hindere d b y a premature confrontatio n o f patients ' distorted, idiosyncratic, or delusional interpretation s of their symptoms or problems. I n practice, this means avoiding an y direct confrontatio n with patient s regardin g th e etiolog y o f thei r symptom s unti l patient s have communicated their understanding of them. An important corollar y i s that obtainin g a clearer view o f patients ' positions regarding themselves and their symptoms helps detect the degree to which patients are aware that their self-constructions ar e inadequate with regard to their power to explain and predict experience. As the interviewer does in our example, clinician s must probe the internal consistency o f patients ' positions (a s when the interviewer asks, "Why didn't you go to see a neurosurgeon?"). In doing so we will learn more about patients ' view s o f themselves . I f w e ha d said , "That' s craz y t o think someon e put a bug in your brain," we would have inhibited the patient's efforts to describe his experience. Most patient s wh o hav e delusiona l construction s o f themselve s wil l directly or indirectly reveal the ways in which their views of themselves

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fail to explain their experiences. It is this inefficacy o f their self-view that provides us with a place to begin work with them. When we assist them to see that their self-view severel y limits their ability to accurately anticipate thei r inne r an d oute r experiences , the y ca n the n b e helpe d t o consider alternative points of view. 5. Pa y clos e attentio n t o th e issu e o f objec t differentiatio n i n th e interview. I f patient s ar e confuse d abou t wher e the y en d an d other s begin, they may attempt to create physical distance or otherwise control the situation. In addition, if patients do not feel separate from clinicians, they ma y no t b e motivate d t o hel p clinician s understan d them . I f a patient doe s no t distinguis h a boundar y betwee n th e clinician' s min d and his o r hers, the patient ha s no nee d to pu t his or her thoughts or feelings int o words. Such patients ma y experience requests for them to articulate feeling s an d thought s a s tauntin g o r humiliating , sinc e the y believe interviewer s alread y kno w wha t the y ar e thinking, and , therefore, thei r question s ar e insincere. Interviewer s cop e with thi s issu e by confronting patients about their assumptions regarding the interviewers, forcing patients to attend to the here-and-now experience and to contribute thei r observation s t o it . Thi s techniqu e emphasize s th e difference s between patients' perceptions an d those o f interviewer s and , therefore, their separateness. A clinician might say, "So, though from my perspective I' m askin g yo u t o tel l m e more becaus e I don't understan d wha t you've said so far, you hear my request as an effort to put you down." Interviewers shoul d als o b e ope n abou t wha t the y don' t understand , primarily fo r th e sak e o f authenticity , but , i n th e context o f problem s with differentiation, to reinforce a boundary. 6. Conve y t o th e patient s a n interes t an d abilit y t o contai n thei r affect, particularl y thei r rag e an d grief . Man y schizophreni c patient s have horrific fantasies abou t the power of (thei r or others') anger . This may be associated with psychotic experiences in which emotional states have been translated into physical actions with terrifying consequences, or i t ma y reflec t a degre e o f cognitiv e disinhibitio n i n whic h intens e affects are associated with cognitive disorganization. Nevertheless, when one simply looks at the factual circumstances of their lives, it is apparent that schizophrenic individuals have much to be angry about. In addition, the fac t tha t the y ofte n exis t i n a n atmospher e o f suspiciousnes s an d

The Man with a Bug in His Brain 22 7 mistrustfulness add s to their resentment and anger or helplessness. It is important to let patients know that interviewers can listen to that anger and help them express it verbally and safely. Grief is most often the affect patients would experience if they faced the reality o f thei r curren t situation . Indeed , rage defends agains t that grief. "Support " from family, friends , or clinicians may be their efforts to deny schizophrenic individuals' grief. Frequently, the patients are left to bear it alone. "I'm sure you'll get better" may, on the conscious level, be meant as a friendly, helpfu l comment , bu t it can make patients less able to express their anger. Assurances from others about the future may be heard by them as an unwillingness to listen to their anger and despair. The primary way interviewers communicate their willingness to work with affects i s by their attitude. Clinicians raise such questions as "You must be furious" or "It must seem so terrible," and, most importantly, they continue their inquiries after patients have refused to answer (often as a way of testing interviewers). 7. Resis t patients' pressure to come to premature closure about who they ar e an d what ha s befalle n them . Allo w ambiguity , contradiction , and, most importantly, ambivalence to emerge. In the preceeding interview, the patient attempted to present himself as a victim who could do nothing on his own behalf. The interviewer persisted in exploring alternatives—such as the possibility that the patient did indeed play a role in shaping th e event s o f hi s lif e an d tha t hi s behavio r wa s no t entirel y consistent with his view of himself as a victim (i.e., having been bugged). Many schizophreni c person s dea l wit h thei r difficult y i n organizin g their experience s b y insistin g o n a rigid , devitalize d categorizatio n o f those experiences. These individuals talk about themselves and others in ways that rely on stereotypes rather than on the qualities of nuance and ambiguity tha t ar e s o muc h a par t o f life . On e consequenc e i s tha t patients trea t thei r understanding o f themselve s an d of other s i n ways that lea d t o prematur e rejectio n o f ne w area s o f inquir y an d t o th e unrealistic expectation of being able to arrive at solutions rapidly, without the tension and uncertainty that is a part of any learning process. It is importan t fo r clinician s t o avoi d reachin g definit e conclusion s an d treating the m a s immutable. Clinician s mus t help these individual s accept their potential for change. And patients must accept that growth is gradual an d slow. Th e unrealistic expectation s tha t bese t mos t schizo-

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phrenic individual s hav e a grea t dea l t o d o wit h thei r lac k o f self acceptance, thei r impatience , and , often , thei r self-destructivenss . Help ing patient s t o se e tha t thes e attitude s ar e hurtfu l ca n ope n u p th e assessment interview fo r a more collaborative an d free exchange an d set the stage for a more productive treatment alliance . 8. Asses s th e patients ' flexibility wit h regar d t o thei r vie w o f them selves an d others. As suggested b y the preceding principle, many schizo phrenic individual s ar e no t flexible, fee l the y ca n tolerat e onl y minima l uncertainty o r ambiguity, an d are wary o f lookin g a t the conflictual an d contrasting nature of human experience, including their own. While it is difficult t o asses s ho w flexible patient s ar e wit h respec t t o toleratin g uncertainty and ambiguity and to considering alternative positions abou t themselves or others, it is nonetheless a n important diagnostic task. This assessment i s mos t readil y carrie d ou t b y askin g patients : (a ) whethe r they ca n imagin e themselve s differentl y and/o r (b ) whethe r the y ca n empathize with th e interviewer's position , when tha t position represent s a chang e withi n th e interviewe r and/o r i s a t variance wit h th e patients ' position. In the intervie w treate d i n thi s chapter , th e patien t wa s abl e t o con sider th e possibilit y tha t th e interviewe r migh t b e differen t fro m hi s expectations (and , b y implication , th e possibilit y tha t hi s perceptio n o f previous psychiatrists ma y have been distorted). In addition, he expressd some doub t abou t whethe r h e ha d bee n bugged , a crucia l admissio n given tha t th e ide a o f a n electroni c transplan t wa s a centra l organizin g mechanism fo r him . Hi s willingnes s t o conside r a n alternativ e t o thi s idea indicate s significan t flexibility an d is, therefore, a positive prognos tic indicator. 9. Identif y thos e things about which patients are curious. This assessment includes the degree to which th e patients ar e interested in knowin g about wha t ha s happene d t o them , wh y it' s har d fo r the m t o ge t alon g with othe r people , wha t make s othe r peopl e respon d t o the m th e wa y they do , an d s o forth . Thes e issue s ar e th e one s t o whic h patient s ar e affectively connecte d and , therefore , investe d i n exploring . Curiosit y implies that the issues involved are not so dangerous that patients cannot afford t o ris k wonderin g abou t them . Identifyin g thes e issue s ofte n indicates th e first topic s fo r engagement . I n th e intervie w above , th e

The Man with a Bug in His Brain 22 9 clinician use d th e patient' s curiosit y abou t ho w th e bu g operated t o explore whether his model adequately explained what was happening to him. The patient was able to begin to think creatively about himself and to reflect on how the views he held did not satisfactorily account for his experience. One conclusion derived from this interview would be that a treatment pla n shoul d tak e int o accoun t th e patient's curiosit y abou t how his mind works. 10. Us e the patients' ow n idioms, particularl y whe n explorin g patients' understanding of their psychology, thinking, or symptoms. Using patients' particular word choices, symbols, and way of thinking helps to foster th e discours e an d to communicat e tha t w e respec t th e way in which they think about themselves. Patients are more likely to consider any suggestion we make about a new way of viewing themselves if that suggestion i s expresse d i n phrase s tha t ar e alread y familia r t o them . However, befor e employin g patients ' idioms , i t is necessary t o understand the idiosyncratic meanings they give to particular words or phrases. We must be careful not to assume that we and patients are talking about the same thing, even though we use words that may seem to mean the same thing. In the earlier example, the interviewer chose to describe the patient's mental operation s in mechanistic terms—"pressures," "forces," "tolerance points," "excess loads," and so on—thinking the patient would be more receptive to that phrasing since it mirrored the way he spoke about himself. The clinician used the patient's metaphorical sense of his world as the vehicle to communicate an alternative point of view. 11. Encourag e patients to remember their own prior experiences in order to better understand themselves in the here and now. In doing so, we demonstrat e t o them tha t the y ca n understand thei r curren t selves better b y linking the m t o previou s aspect s o f themselve s (whic h the y may devalu e o r vie w a s irrelevan t o r dangerous) . Mos t importantly , helping patients appreciate how their past lives can illuminate the present underscores the value of acknowledging a historical sense of self. Many schizophreni c individual s vie w tim e a s having stoppe d a t the point when their illness began. They experience a sense of discontinuity between the self prior to the illness and the subsequent self. This discontinuity promote s a tendenc y t o avoi d an y important relationshi p be-

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tween aspect s o f th e pas t an d th e presen t self . Alternatively , ther e ar e patients who hav e the fantasy tha t things can be put exactly right again, that the y wil l retur n t o th e precis e plac e wher e the y wer e befor e the y began to have difficulties, tha t no time has been lost. I t is as if the illness occurs i n a time war p the y wil l on e da y ste p ou t o f an d retur n t o thei r previous selves . No t uncommonly , suc h patient s ar e unwilling t o recal l their past. This attitud e (o f murderin g th e past ) leave s patient s feelin g ther e i s nothing withi n the m tha t the y ca n cal l upon . Sinc e they den y thei r pas t experiences, the y mus t greet each situatio n a s if the y were encounterin g it for th e first time . It' s as if patients have made deals with themselves in which the y agre e t o ac t a s i f the y hav e n o pas t s o tha t the y won't hav e to compare what they were with what they are. In eliminating their past, they hav e ha d t o forge t al l tha t was effective , adaptive , an d pleasurabl e then. The final three items refer to tasks that are appropriate to the later stages of th e assessment interview , althoug h clinician s will certainl y hav e these in min d i n th e earl y stages . The y represen t furthe r mean s fo r gatherin g relevant dat a a s wel l a s intervention s t o facilitat e th e beginnin g o f a treatment alliance. 12. Clarif y wit h patient s eac h instanc e i n whic h eithe r thei r patho logic views lac k explanatory o r predictive power or in which the y are in internal conflic t abou t thes e views . I n th e intervie w above , a strikin g example occurre d whe n th e interviewe r confronte d th e patient wit h th e illogic of seein g a psychiatrist if indeed he had a problem that could only be dealt with b y a surgeon, unless the patient was acknowledgin g b y his request tha t h e viewe d hi s problem s a s fundamentall y psychologica l i n origin. The identificatio n o f a n are a o f interna l conflic t withi n patient s indi cates t o clinician s th e issue s aroun d whic h the y ca n begi n t o for m a n alliance betwee n themselve s an d th e health-seekin g aspec t o f th e pa tients. I n the case o f th e patient just described, th e clinician migh t begi n the treatmen t b y saying , "A s w e bot h sa w i n th e evaluation , ther e i s a part o f yo u tha t recognize s th e nee d fo r psychologica l help . Tha t part , which I actively endors e an d will support , will hav e to struggl e wit h th e rest o f yo u tha t i s dedicate d t o seein g yoursel f a s victimize d b y a n

The Man with a Bug in His Brain 23 1 electronic inplant, incapable of helping yourself or profiting from psychiatric intervention." 13. Establis h a n empathi c environment . Thi s wil l b e accomplishe d through many of the techniques already suggested. In addition, recognizing the commonality between patients' experiences and their own allows clinicians t o identif y wit h patients. I n the interview jus t presented, the clinician might have said, "I would have been quite frightened had I felt that [th e bugging] were happening to me. " Or, following th e patient's acknowledgement tha t ha d h e bee n entirel y comfortabl e wit h th e implant idea , h e woul d hav e searche d fo r a neurosurgeon rathe r tha n a psychiatrist, the clinician might have said, "It was hard for you to admit that whatever is the matter with you isn't just the result of an evil doctor. I can appreciate how things could feel so overwhelming that you might wish that you could pin your entire bag of trouble s on someone else." Therapists should articulate such sentiments only after they have recognized analogou s situation s withi n themselves . Clinician s wh o spea k without having made that internal association firstrun the risk of sounding (an d being ) patronizing . Recallin g thei r own simila r reaction s permits clinicians to better assist patients in accepting their experience. This process, however , mus t b e distinguishe d fro m clinicians ' actin g o n a n awareness o f commonalit y b y making self-disclosin g statements . Mos t often these actions stem from the therapists' own needs, such as seeking expiation from or closeness to patients. When addressed to patients' needs, such comments help them experience the interviewer as understanding what they are going through. At other times, interviewers are empathizing with some buried or withheld aspect of patients ' inner lives. I n those instances, the interviewers' empathy anticipates and paves the way for the patients' own acknowledgements. This i s especially tru e for those schizophreni c person s who fee l quite distant from their own affective life, who may not value it, or who may be suffering states of emotional numbing. 14. Provid e suggestions for how patients can develop alternative adaptations to their problems. Once we have some idea about the patients' views of themselves , understand something abou t the forces tha t cause them to behave in certain ways, and have identified ho w those adaptations may not work effectively fo r the patients, we can begin to facilitate

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their engagemen t i n treatmen t b y makin g suggestion s abou t alternativ e solutions. Thi s woul d b e th e tas k o f a treatment plan , bu t i t would no t be inappropriate in an assessment interview, which, after all, is the initial step in a treatment process. In the case under discussion, the interviewe r suggested that , ha d th e patien t wishe d t o mak e contac t wit h people , h e might have approached the m b y emphasizing his similarities rathe r than his differences. 0 In th e proces s o f a n assessmen t intervie w i t i s importan t t o observ e how th e patient s accep t th e interviewers ' suggestions . Suggestin g alter natives ca n b e usefu l i n assessin g patients ' flexibility. Durin g th e inter view, our patient demonstrated his ability to collaborate b y participating in the construction o f th e graph. This joint effort provide d the staff wh o were viewin g th e intervie w wit h th e encouragin g evidenc e tha t th e pa tient did have the capacity to collaborate . With som e patients , assessmen t interview s ma y yiel d usefu l startin g points fo r treatmen t plans . Eve n withou t this , however , th e proces s o f collaboration base d o n carefu l understandin g o f patients ' experience s begins i n the assessment intervie w an d creates bot h reasonabl e expecta tions and a framework fo r all of the treatment that follows .

5 The Case of Sharon: A Hospital Stay Involving Noncompliance, Violence, and Staff Conflic t

In thi s chapter , w e discus s th e difficultie s i n treatin g schizophreni c individuals wh o requir e inpatien t car e becaus e o f noncomplianc e an d potential fo r violence . W e hav e take n th e cas e o f a woma n name d Sharon a s an example. Thi s case was noteworthy fo r many difficultie s and failures, bu t we chose i t to illustrat e ou r approach t o th e troublesome management and therapy issues raised by violence and noncompliance. Hospitalization is a frequent solution, but hospital treatment raises issues of its own because of the complexity of the institutional and social systems it entails. How th e hospitalization become s part of th e overall treatment is a challenge for both outpatient and inpatient therapists. Sharon's noncompliance was so severe that her refusal to participate in a medicatio n regim e onc e i n th e hospita l eventuall y resulte d i n a request for a court order, and at times she was an involuntary patient. As we have discussed in previous chapters, our approach to understanding this person's subjectiv e experienc e center s on the themes of auton omy and control because we believe that noncompliance implies extreme concern with these themes. Similarly, violence expresses a need for control whil e presentin g a n extrem e statemen t o f autonom y fro m socia l norms. Issues of autonom y an d control ar e therefore played out in the experiences of patient and therapist as well as the hospital staff who had to work with this woman on a daily basis. We also take this opportunity t o explor e th e nature of th e working relationship between a hospital psychotherapist an d the other members of the hospital staff o r team. This relationship is always important, but especially so when the patient requires more than a brief inpatient stay and when , a s i n thi s case , th e interpersona l demand s mad e b y th e ill person ar e extravagan t bu t compelling . I n ou r example , Sharo n wa s 235

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generally experience d b y others , a t leas t initially , a s quit e appealing . I t was only with tim e and experienc e that people realized that her demand s for proo f o f concer n require d complete , irrationa l loyalt y t o he r para noid delusiona l system . Whe n thi s loyalt y wa s absent , sh e fel t betrayed , abandoned, an d despairing , and th e likelihood o f violence toward other s or hersel f increased . Thi s sor t o f impossibl e deman d ofte n confront s th e clinician working wit h individual s sufferin g fro m schizophrenia , an d ou r discussion use s merely a n extrem e exampl e t o illustrat e ou r approac h t o this problem .

BACKGROUND: SHARON'S HISTORY AND INDICATION S FOR HOSPITALIZATIO N Sharon wa s a 24-year-ol d woma n admitte d t o th e inpatien t servic e fo r suicide threat s an d decreasin g abilit y t o car e fo r herself . Sh e ha d man y paranoid idea s abou t famil y an d friend s an d delusion s o f persecutio n b y government intelligenc e agencies . She had a history o f abortiv e attempt s at outpatien t psychotherap y directe d a t he r recurren t suicida l ideatio n and sever e difficultie s i n gettin g alon g wit h others . Althoug h sh e wa s intelligent an d ha d complete d college , sh e wa s unabl e t o kee p jobs . Former therapist s ha d though t sh e suffered fro m depresio n an d sever e personality problems , a commo n histor y fo r som e well-educated, intelli gent, and very paranoid individual s who actually suffer fro m schizophre nia. Lik e Sharon , thes e individual s ar e s o investe d i n issue s o f contro l and autonom y tha t th e acknowledgemen t o f seriou s symptom s i s ex tremely difficul t fo r them . The y ar e severel y conflicte d abou t lettin g another perso n b e helpful an d importan t t o them becaus e the y drea d th e associated feeling s o f vulnerability . Thi s lead s the m t o den y thei r illness , blame family , employers , o r pas t therapists , an d hid e thei r symptoms . For years , Sharo n ha d feare d tha t i f peopl e kne w ho w fearfu l an d paranoid sh e was , the y woul d us e thi s knowledg e t o hur t her . Sh e ha d read som e psychiatri c texts , and sh e used thi s knowledg e t o decid e wha t to tel l th e professional s sh e consulte d i n a n effor t t o contro l wha t diagnostic labe l woul d b e assigned , althoug h sh e woul d neve r admi t t o this and perhaps di d i t unconsciously . While he r guardednes s prevente d he r fro m receivin g th e mos t appro priate treatmen t a t times , thi s wa s th e bes t compromis e fro m he r per -

The Case of Sharon 23 7 spective. He r psychological respons e t o he r illness wa s t o den y al l sign s of difficult y i n herself . An y admissio n o f patholog y wa s experience d a s an extreme blow to her view of herself a s intelligent and talented, a view that ha d bee n developed , wit h outsid e validation , i n her childhoo d an d adolescence. Blamin g other s whil e admittin g sh e wa s "unde r stress " of some kin d allowe d Sharo n som e minima l contac t wit h helpin g profes sionals, which wa s al l that she could tolerat e an d still maintai n a necessary feelin g o f safety . Mor e interactio n woul d hav e le d t o humiliatio n and increased depression . Sharon wa s pron e t o episode s o f violenc e t o protec t he r self-image . She attempte d suicid e whe n sh e fel t to o demoralize d b y he r failure s t o live u p t o he r unrealisti c goals . An d sh e assaulte d a therapis t wh o ha d wanted t o pu t he r i n a psychiatri c hospita l afte r a suicid e gesture . Terrified a t this perceived threa t to her autonomy, Sharo n instantl y los t any insight int o th e possibilit y tha t th e gestur e wa s a cr y fo r help . Sh e threatened t o kil l th e therapist , and , whe n th e therapis t picke d u p th e phone t o cal l a n ambulance , Sharo n thre w a paperweight a t th e thera pist, and fled. When sh e wa s finally hospitalized , Sharo n externalize d al l responsi bility fo r her predicament t o malevolent oute r forces: her family an d the FBI. Following a disappointment i n a formerly idealized outpatient therapist, Sharo n ha d lef t hom e an d begu n t o trave l aroun d th e country , impulsively visitin g friend s an d relatives , bu t more ofte n roamin g with out an y plan, frequently withou t an y money , picking up men i n bars or sleeping in parks. She was molested a number of times . When she would call an d ask fo r money , he r parents attempte d t o convinc e he r to retur n home an d t o treatment ; the y fel t powerles s t o contro l her . Throughou t this time , Sharo n bega n t o believ e tha t sh e wa s actuall y a n undercove r agent recruite d b y th e FB I agains t he r wil l an d initiall y withou t he r knowledge an d that she had been brainwashed an d was now th e subject of min d contro l procedures . Sh e believe d that , sinc e leavin g home , sh e had had devices implanted in her that directed her speech, behavior, an d thoughts, an d sh e though t tha t thes e device s woul d tortur e he r i f sh e attempted to resist. She also felt that psychiatrists had been a part of th e FBI's plan an d tha t the y ha d use d hypnosi s t o contro l her . Thes e delu sions seeme d i n par t a reaction t o th e increasin g evidenc e o f he r failur e to succee d a s a writer, whic h ha d bee n the rationalization fo r he r odyssey. Thi s explanatio n ha d worke d u p t o a point, allowin g he r t o creat e

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distance fro m famil y an d therapist s an d t o fee l independent , althoug h she had t o go to considerable extreme s t o establish thi s condition (whic h suggests th e dept h o f he r difficultie s wit h autonom y an d dependency) . This wa s Sharon' s sustainin g experience , bu t i t wa s a ver y maladaptiv e one sinc e i t entaile d a grea t dea l o f sufferin g an d kep t he r lonel y an d without help . Sharon wa s hospitalize d whe n sh e returne d hom e briefl y an d he r parents sa w her agitated , delusional , semi-starve d conditio n an d insiste d she se e he r forme r doctor , who m Sharo n allowe d t o admi t he r t o a hospital. Indications fo r Hospitalizatio n Sharon's situatio n exemplifie s certai n issue s regardin g hospitalization . Though sh e wa s psychotic , i t wa s no t he r psychosi s tha t le d t o th e hospital stay ; rather , i t wa s he r inabilit y t o us e outpatien t treatmen t t o manage he r illnes s an d henc e t o manag e he r lif e safely . Whil e sh e wa s not i n immediat e dange r o f morta l hur t t o hersel f o r others , her histor y indicated a n inabilit y t o car e fo r hersel f tha t migh t wel l becom e life threatening i f change s di d no t occur , change s tha t onl y treatmen t coul d offer. Wha t brough t Sharo n t o th e hospita l wa s he r inabilit y t o for m a treatment partnershi p i n a n outpatien t settin g becaus e o f idiosyncrati c relatedness. Thus, i n ou r opinion , nee d fo r hospitalizatio n i s no t directl y depen dent o n th e degre e o f psychosi s present . Condition s suggestin g tha t hospitalization shoul d b e considered include : 1. Inabilit y t o relat e t o clinician s i n a collaborativ e wa y despit e clea r need fo r treatmen t (1)—tha t is , serious problem s i n formin g a treatmen t partnership. Thi s include s intens e transferenc e reaction s tha t d o no t appear t o b e resolvabl e i n outpatien t treatmen t sinc e the y see m t o re quire greate r distanc e fro m th e clinicia n an d th e availabilit y o f othe r objects (i n th e hospital ) s o tha t th e patien t ca n gai n perspectiv e an d control ove r th e reaction . In general , i f ther e i s a soli d treatmen t partnership , th e clinicia n i s usually willin g t o tolerat e greate r latitud e an d uncertaint y abou t a pa tient's "disturbed " behaviors , i f th e individua l i s comin g t o appoint ments, taking medication , talkin g abou t hi s or he r life , an d s o fort h i n a committed way .

The Case of Sharon 23

9

2. Acute risk o f violence . 3. Ris k o f sel f destructiv e behavior . 4. Ris k tha t th e patient' s lif e situatio n wil l b e destroye d i f hi s o r he r behavior ha s th e potentia l t o irretrievabl y alienat e family , residentia l treatment staff , o r othe r person s critica l t o the patient's well-bein g with out whom th e patient face s los s of job or home . 5. Nee d fo r contro l o f th e patient' s externa l life , whic h canno t b e provided b y family, da y hospital, and/o r halfwa y house , as in the case of a ver y withdraw n patien t wh o need s constan t suppor t an d encourage ment t o maintain minima l self-car e an d relatedness . Thus, a perso n wh o woul d b e considere d ver y psychoti c becaus e o f fixed delusion s an d somati c hallucination s abou t a radi o i n hi s brain , who nonetheles s maintain s a jo b an d a treatmen t relationshi p an d take s his medicatio n faithfull y becaus e i t allow s hi m t o "tur n dow n th e vol ume" o n th e radio , woul d no t requir e hospitalizatio n unles s othe r fac tors entere d th e clinical picture . Clinician's Attitude s Towar d Hospitalizatio n The clinician's attitud e toward hospitalizatio n an d how i t is presented t o patient an d famil y shoul d b e informe d b y hi s o r he r hypothese s abou t the patient's understandin g an d experienc e of his or her current situatio n and probabl e reaction s t o th e hospitalization . Fo r example , fo r a n indi vidual wh o wil l fee l humiliate d becaus e i t i s critica l fo r hi m t o b e i n control, th e approac h need s t o include his involvement i n th e mechanic s of th e proces s t o remin d hi m tha t h e i s a n adul t makin g a decisio n an d carrying i t out . Anothe r individua l wil l nee d t o fight th e hospitalizatio n and th e clinicia n an d famil y nee d t o find a face-savin g wa y th e patien t can acced e to the request fo r hospitalization , afte r whic h th e patient wil l be secretly relieve d an d grateful . Individual s wit h sever e stimulus barrie r problems may be happy to temporarily relinquis h th e struggle to manag e ordinary existenc e b y movin g int o a settin g wit h les s stress , an d th e hospital ca n b e presented a s a refug e o r respit e fro m challenge s suc h a s the stres s o f dail y life , a specifi c trauma , o r th e emotiona l demand s o f family an d others . Others fea r bein g surrounded b y troubled people , an d the therapist shoul d emphasiz e th e possibilities fo r empath y fro m other s in the same predicament an d help the individual t o see the ways in whic h she ca n maintai n he r autonom y eve n i n thes e surroundings . Fo r many ,

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the hospital represent s a place of regressio n that can be either frightenin g or attractive . From th e patient' s poin t o f view , hospitalizatio n ca n giv e a messag e to importan t others , includin g th e outpatien t therapist , tha t somethin g in th e person' s lif e wa s becomin g unbearable . In thi s case , i t i s helpfu l for th e clinicia n t o le t th e patien t kno w tha t h e o r sh e ha s hear d th e message, whethe r i t pertains t o family , friends , work , o r som e aspec t o f the treatmen t relationship . Fo r example , on e schizophreni c ma n wh o had bee n maintainin g a stabl e existenc e fo r eigh t month s followin g discharge fro m a mediu m lengt h hospita l sta y suddenl y brough t bee r t o his dormitory , breakin g a rul e wit h whic h h e wa s ver y familiar . Thi s occurred a s he an d hi s therapist discusse d th e latter' s first vacatio n sinc e the patient's discharge . Despit e considerabl e discussio n an d support , th e patient's behavio r deteriorate d unti l hospitalizatio n wa s inevitable . A n important componen t o f th e therapist' s presentatio n o f th e necessit y o f hospitalization an d o f th e hospita l staff' s wor k wit h th e patien t wa s t o acknowledge tha t th e patient fel t (rightl y o r wrongly) completel y unabl e to functio n i n the therapist's absence . What th e Hospitalizatio n Mean s t o th e Outpatien t Clinicia n A ke y facto r i n th e outpatien t therapist' s attitud e towar d th e hospitali zation i s wha t i t mean s personall y t o hi m o r her , becaus e thi s affect s how th e patient' s experienc e i s perceived b y th e clinician . Fo r th e thera pist, hospitalizatio n ma y represen t th e onl y respons e t o a crisis , bu t i t may also serve other functions : t o adjus t medication , to provide a respit e from th e patient' s demand s o n th e clinician , t o enabl e th e clinicia n t o regain perspectiv e o n th e treatment , t o obtai n consultation . Thus , de pending o n th e settin g an d th e clinician' s wishe s an d needs , hi s o r he r relationship wit h th e hospita l staf f wil l vary . Th e clinicia n ma y mak e regular visit s t o carr y o n psychotherap y o r t o consul t wit h staff , o r th e clinician ma y us e this time to reconside r th e nature o f hi s or he r involve ment wit h th e patien t fro m a distance , free d fro m certai n worries . Th e patient ma y als o nee d t o reconside r hi s o r he r investmen t i n continuin g with th e therapist , an d i t ca n b e easie r t o chang e therapist s fro m th e safety o f a hospita l room . I t ca n b e ver y therapeuti c an d supportiv e o f self-object differentiatio n fo r th e schizophreni c individua l t o se e tha t a therapist ca n recommend , withou t losin g face, tha t h e or sh e might nee d

The Case of Sharon 24 1 to b e replaced i n th e patient' s life . Thi s als o lessen s th e schizophreni c person's fear of bein g controlled b y the therapist, so that just seriously considering the possibility may have a beneficial impact on the treatment partnership. The therapist's willingness to consider these options during a hospita l sta y ar e par t o f hi s o r he r sensitivit y towar d th e patient' s experience. Even i f hospitalizatio n occur s fo r crisi s management , th e hospita l milieu provides an excellent opportunity to understand the meaning of a regressed patient's central concerns through his or her various manifest communications, or specific behaviors. The number of people interacting with the schizophrenic individual and their ability to share their experiences an d tr y t o understan d wha t i s occurrin g ma y clarif y issue s tha t were clouded in outpatient treatment. Hence, the hospital staff can serve as consultant s t o th e outpatien t therapist . Conside r th e followin g ex ample: A 23-year-old man was hospitalized for an acute psychotic epidode in which he was found disrobing on a busy street instead of beginning a new job he had worked hard to obtain. He had been ill for many years but had an apparently good relationship with his outpatient therapist and had been doing better over time, using his therapist's encouragement to socialize mor e and look fo r a better job. Once in the hospital, he appeared quite regressed to the staff, sitting silentl y fo r hours , apparentl y withdraw n an d unabl e t o relate t o others , wit h man y characteristi c negativ e symptoms . However, discussio n amon g staf f o f brie f interaction s wit h hi m revealed a subtl e bu t definit e patter n o f provocative , passive-ag gressive behaviors that were too precise and directed to be merely the sid e effect s o f socia l withdrawa l an d a n amotivationa l syn drome. Alerted to these by staff and his own feelings of annoyance, which had seemed excessive, the patient's hospital therapist began to talk to the patient about the possibility that he was furious, not just withdrawn. The young man then revealed a wealth of sadistic fantasies that occupied him much of th e time and were related to specific disappointment s wit h important people in his life, including the disappointment of grandiose hopes in his outpatient therapist. He imagined he had been pressured by the therapist to finda better job and he was angry that he had to, as he felt, "perform. "

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His regression reduced the stress he felt. Onc e this issue was out in the open , h e wa s abl e t o find other way s t o expres s thi s anger , s o that he became less provocative and more able to participate meaningfully i n hi s treatment , instea d o f needin g t o destro y hi s ow n chances o f succes s t o communicat e (i n a ver y idiosyncrati c way ) his anger at the expectations an d hopes of others. This exampl e als o demonstrate s th e advantage s o f a goo d allianc e between th e inpatien t staf f an d inpatien t therapis t an d betwee n th e inpatient therapis t an d outpatien t clinician , wh o ar e thereby enable d t o share information . I n to o man y situations , competitiveness , envy , o r feelings o f failur e interfere with thi s type of collaboration .

Sharon's Nee d for Hospitalizatio n In Sharon' s case , hospitalizatio n wa s indicate d becaus e sh e wa s unabl e to tak e goo d car e o f herself , an d he r ver y lif e wa s threatene d b y he r disorganization an d neglect . Sh e ha d begu n t o fee l tha t killin g hersel f might b e bette r tha n a lif e o f contro l b y th e FB I couple d wit h nearl y complete inhibitio n o f he r creative writin g skills . Her sustainin g experience was n o longer sustaining. I n addition, she had been unable to for m a treatmen t partnershi p ove r th e years , despit e severa l attempt s wit h various clinicians an d her serious need for treatment. Her suspiciousnes s and nee d t o contro l he r relationship s le d he r t o b e totall y unabl e t o develop a trustin g therapeuti c relationship . Moreover , sinc e sh e denie d she was ill, she was irresponsible abou t medication, limiting the possibility fo r gatherin g goo d informatio n abou t he r respons e t o medications . When sh e fel t he r self-imag e an d autonom y wer e threatened , sh e wa s also pron e t o intens e an d hostil e an d sometime s simultaneousl y eroti c and hostil e transferenc e reactions , whic h coul d erup t int o violenc e o r other action s tha t completely disrupte d therapy . Becaus e her experienc e of psychologica l continuit y an d clarit y wa s ver y poor , sh e quickl y los t sight of episodic good experiences wit h professionals . With thi s extrem e nee d t o contro l th e environmen t an d henc e he r treatment ( a need that may be hypothesized t o ste m from th e severity o f the illnes s sh e sough t t o control) , i t was ver y har d fo r Sharo n t o accep t hospitalization. Sh e was willing to tr y it in her current situation becaus e of th e degre e o f physica l discomfor t sh e wa s beginnin g t o experience ,

The Case of Sharon 24 3 including malnutrition , fatigue , an d th e bruise s sh e ha d suffere d i n a recent traumati c episod e durin g he r wanderings . Although Sharo n wa s very well aware that sh e was entering a mental hospital, not a conventional medica l setting , sh e di d no t mak e a n issu e o f this ; instead , sh e merely agree d tha t sh e wa s sufferin g an d an d tha t i t woul d b e wort h getting a rest. After hi s initial recommendation , he r docto r wa s carefu l not to talk about the hospital in a way that would "rub it in" for Sharon that she would become a psychiatric patient, although he did not misrepresent the setting. HOSPITAL COURSE On admission, Sharon appeared waif-like, emaciated, and very burdened by notebooks containin g he r "case. " She was oriented, an d he r speec h was clear and goal-directed bu t extremely delusional in content. On the ward, Sharo n wa s aloo f an d inten t o n concealin g an y psychic distress; however, sh e struck ou t a t the nurses who trie d t o look a t her bruises , claiming tha t the y wer e goin g t o attac k her . I n individua l therap y sh e took pain s t o b e pleasant , charming , an d agreeabl e an d t o presen t a n appearance o f interes t i n an d motivatio n fo r psychotherapy . Unfortu nately, this apparent motivation was primarily part of a complex defen sive process to protect Sharon's self-image rathe r than a firm basis for a therapeutic relationship. Individual Therapy This nee d t o convinc e he r hospita l therapist , Dr . B. , of he r goodness , health, intelligence, and desirability characterized the initial stages of her hospital therapy . Dr . B . hope d t o for m a treatmen t allianc e aroun d Sharon's acknowledge d sadnes s abou t th e wa y he r lif e ha d gone , al though he recognized that he would probably need to confront he r helprejecting behavio r carefully . Developmen t o f som e basi s fo r collabora tion would precede Sharon's willingness to admit she had an illness and symptoms needing attention. Sharon ha d a differen t consciou s agenda . T o impres s Dr . B. , sh e showed him articles she had written, pictures of herself from colleg e and high school, awards, and artwork. She begged him to keep an open mind

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about her diagnosis, though sh e had heard man y times that she suffere d from schizophrenia . Sh e sought t o convinc e hi m that this was incorrect , claiming tha t al l he r sufferin g wa s du e t o persecutio n b y the FB I or he r mistreatment b y famil y member s wh o di d no t understan d he r sensitiv e feelings. Whe n sh e briefl y discusse d som e sadnes s an d regre t abou t th e years sh e waste d wanderin g aroun d th e countr y an d abou t a lif e tha t was nonfunctional despit e her intelligence and talents, Dr. B. felt encouraged. Bu t Sharo n coul d neve r sustai n exploratio n o f he r depressive an d suicidal feeling s i n thi s contex t an d woul d rever t t o externalizatio n instead. At such times, she quickly wanted Dr. B. to just "do something" about he r depression , becaus e sh e ha d "explained " i t an d ther e wa s nothing els e sh e coul d do—certainl y nothin g mor e t o tal k about . Al though a t such times i t seemed a s if hi s failur e t o produc e a miraculou s improvement in her situation migh t lead Sharon to feel angr y at him, she maintained a steadfastl y idealize d vie w o f hi m (a s wel l a s o f herself ) during the first part of the treatment . In th e contex t o f he r resistanc e t o ful l discussio n o f he r difficulties , Sharon wa s als o developin g a n eroti c transference . He r attempt s t o impress Dr . B . wer e als o directe d towar d convincin g hi m o f he r loveli ness an d desirability . Sh e trie d t o mak e hi m se e he r a s a n innocen t victim, a charming girl, not the controlling, devaluing , aloo f woma n sh e appeared a t othe r times . A s wil l b e detaile d below , Sharo n wa s conde scending an d obnoxiou s i n he r interaction s wit h nursin g an d activitie s staffs, an d he r onl y contact s amon g th e patient s wer e wit h th e mos t paranoid individuals , who m sh e trie d t o organiz e agains t th e staff . I t was notable tha t none of he r complaints abou t her hospitalization expe rience were directe d a t Dr. B. It was late r learned that she did wish tha t he ha d th e powe r t o chang e hospita l rule s an d expectations , sinc e sh e held fas t t o th e convictio n tha t h e share d he r view o f hersel f a s merel y mistreated, no t ill , an d as not contributin g i n any way t o her difficultie s (as when she was verbally abusive or contentious o r refused to cooperat e in ward activities). In th e therapy , Sharo n a t time s talke d i n a blan d wa y o f wishe s t o mutilate herself , th e detail s o f pas t suicid e attempts , an d th e viciou s revenge she felt entitle d to wreak o n he r FBI tormenters. But Dr. B. was not suppose d t o commen t o r questio n he r o n thes e issue s becaus e hi s doing s o threatene d he r need t o presen t hersel f a s blameless an d not ill . At th e sam e time , suc h image s an d hints tende d t o destro y th e "good "

The Case of Sharon 24 5 image she tried to build in his mind, a form of destructio n fo r which sh e refused t o tak e responsibility . A s tim e wen t on , Sharo n di d begi n t o become exasperate d wit h Dr . B.'s refusal t o join in her idealized view o f the tw o o f them . Sh e sough t t o cas t Dr . B . in th e rol e o f rescue r t o he r damsel i n distres s bu t wa s disappointe d i n hi s unwillingnes s t o sustai n this drama. On the one hand, Sharon believed she was good and innocent, totall y worthy an d deservin g o f lov e fro m Dr . B . Sh e ofte n requeste d proo f o f his devotion b y asking him t o strok e her face (althoug h h e never agree d to d o this) . O n th e othe r hand , sh e gleefull y detaile d ho w sh e woul d torment the FBI agents who sh e felt had wronged her , including th e FBI psychiatrists. However, she never accepted the implication of this behavior: tha t sh e wa s als o capabl e o f angry , vengefu l feeling s an d wa s no t simply a harmless innocent. For example, on one occasion she alternated among statement s tha t he r fac e wa s mutilated , tha t thi s wa s goo d be cause i t justifie d he r revenge , an d tha t sh e wante d Dr . B . t o cares s he r face. Dr.: Yo u would really like it if I would touc h your face. S: Yes . Dr.: Ho w woul d that help? What are your thoughts about that? S: I t would b e so nice, we have such a special relationship . Dr.: Bu t I can' t hel p rememberin g ho w a fe w minute s ag o yo u wer e talking abou t you r fac e a s mutilated , an d yo u seeme d t o wan t t o hold o n to tha t idea, a s proof o f th e wrong you sa y has been don e to you an d the revenge you want. S o I don't understand the shift — it's lik e yo u wan t m e t o forge t somethin g importan t tha t yo u jus t told me about your angry feelings. S: Yo u don' t understan d anything ! Yo u onl y thin k abou t th e ba d things abou t me , yo u focu s o n m y faults ! Those thing s ar e such a small part of me ! You never praise me for how wel l I can manage, for al l I'v e accomplished , yo u ar e alway s remindin g m e o f thing s that don't matter! Dr.: Bu t i t doe s matter , i f it' s a par t o f you , becaus e I' m intereste d i n everything about you, and I don't want you to feel a s though ther e are parts of you that should be cut off an d we shouldn't talk abou t them. S: Yo u don't understand at all.

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The therapis t trie d to engag e Sharo n i n the process o f integratin g th e disparate parts of herself , th e angry an d ugly parts as well a s the charming, affectionate , childlik e parts , believing tha t this was a necessary ste p before sh e could admi t the rage and wishes fo r reveng e implicit i n som e of he r rejection s o f treatment . Bu t hi s ple a wa s agai n rejected , an d instead, Sharo n bega n t o spen d par t o f he r session s debatin g whethe r therapy could be any use to her or not.

Counlertransference Therapists o f patient s lik e Sharo n mus t struggl e wit h countertransfer ence tendencies to join them in their avoidance of painful confrontation s with thei r angry , sad , despairin g selve s (2-3) . Whe n Dr . B . reminde d Sharon o f som e o f he r pas t strength s an d trie d t o buil d o n these , h e wondered if he was helping her with her problems in continuity or trying to sanitiz e th e unpleasan t her e an d now . Bu t th e effec t o f therapists ' avoiding painfu l realitie s i s t o leav e patient s alon e i n th e miserabl e present with their despair. In fact, research has suggested that therapists' ability t o remai n comfortabl e wit h schizophreni c patients ' stron g affec t positively influence s therapeuti c outcom e (4) . Ye t th e extensiv e denia l and projectio n use d b y peopl e lik e Sharo n severel y ta x clinicians . Th e attempt t o tactfull y hel p Sharo n t o recogniz e he r illness , he r difficul t personality traits, and the ways she made it nearly impossible for anyon e to help her became a wearing struggle. In her guise o f th e innocent victim, Sharon was extremely controllin g of interaction s wit h her , constantl y settin g limit s o n wha t sh e woul d discuss. There was als o the threat that she would lose control an d throw things i f sh e becam e enrage d a t wha t sh e experience d a s a criticis m o r threat t o he r autonomy . I n this context , Dr . B . a t time s fel t s o angere d and frustrated tha t he wondered i f in fact her critical accusation s of hi m were correct : Wa s h e confrontin g he r to o harshl y i n som e o f hi s com ments? Was he really being sadistic in some of his interpretations ? This i s th e kin d o f confusion , guilt , an d implici t los s o f boundarie s that therapist s o f ver y paranoid person s undergo , sinc e eventuall y thes e therapists wonde r i f th e patients ar e more tha n partially correc t in their accusations. That is, therapists doubt their own ability to judge interpersonal reality , an d this doubt constantly plague s such patients, who reac t by developin g a rigi d syste m o f mistrus t tha t provide s a rul e fo r inter -

The Case of Sharon 24

7

preting ever y questionabl e situation : The y wan t t o hur t me . Therapist s begins t o suffe r confusio n an d doub t abou t contro l issues , a confusio n that parallel s patients ' distortion s i n thi s area : A m I bein g sadisticall y controlling ou t o f m y anxiety , o r a m I merely assertin g m y ow n identit y in the face o f contro l b y others ? Another aspec t o f Sharon' s boundar y confusio n resulte d i n a pull fo r others t o shar e he r world-vie w i n it s entirety , sinc e sh e sa w an y dissen t or questionin g a s life-threatening . He r preferre d mod e o f idiosyncrati c relatedness was to fuse i n some way with a n omnipotent, idealize d objec t (5), and sh e tried t o make her therapist int o this, creating a pressure tha t added t o countertransferenc e problems . These patients ' combinatio n o f boundar y confusion , pul l towar d a n omnipotent, idealized object, an d contro l issues results in a countertrans ference paradig m i n whic h therapist s mus t constantl y b e awar e o f wha t it mean s t o b e one' s "ow n person. " A t time s therapist s ma y nee d t o strongly asser t thei r identit y i n wha t see m t o b e trivial ways . They ma y feel a n overwhelmin g nee d t o hol d session s i n th e offic e rathe r tha n o n the ward , eve n whe n patient s ar e no t allowe d t o leav e th e ward ; the y may strenuousl y insis t o n endin g appointment s o n time ; o r the y ma y refuse t o answe r reasonabl e questions , feelin g the y ar e persona l intru sions. Transference In he r consciou s experience , Sharon' s mos t importan t goa l wa s t o enlis t Dr. B' s suppor t i n he r battle , s o tha t h e woul d testif y i n he r favo r an d intervene i n he r lif e b y contactin g th e FB I o n he r behalf . In a simila r way, sh e insiste d tha t staf f an d othe r patient s agre e tha t sh e wa s bein g persecuted, a stance tha t placed everyon e a t a disadvantage . Thus, while Sharon appeare d t o have a positive, erotic transference t o Dr. B. , she a t th e sam e tim e behave d i n a hostil e an d masochisti c way . She constantl y pu t hi m i n th e uncomfortabl e positio n o f havin g t o tel l her tha t h e couldn' t d o a s sh e insiste d becaus e he r demand s wer e s o unrealistic. I n effect , sh e wa s constantl y askin g hi m t o tel l he r sh e wa s psychotic. Then sh e would becom e enrage d o r saddene d an d blam e hi m for he r depression , agai n failin g t o acknowledge , eve n whe n h e pointe d it out t o her, ho w sh e contributed t o th e situaiton tha t was s o painful t o her. That is , she demanded tha t her therapist liv e in her delusiona l worl d

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with her , a s if an y compromis e represente d th e death o f he r ideal s or th e destruction o f he r self-image . Faced wit h suc h a controllin g individual , a therapis t ca n subcon sciously star t t o fee l tha t th e interactio n i n a treatmen t i s base d o n th e question "Wha t wil l sh e mak e o f me? " rathe r tha n o n "Wha t i s sh e telling m e abou t herself? " Tha t is , eve n mor e tha n usual , th e therapis t ends u p havin g t o us e some o f hi s or he r ow n subjectiv e feeling s a s clue s to th e patient's feeling s an d needs , since the patient i s so unable t o us e a psychotherapeutic relationshi p i n th e usua l way . Th e exampl e abov e demonstrates thi s process, in which Dr . B . felt tempte d t o join Sharo n i n avoiding th e painfu l presen t b y remindin g he r o f he r pas t successes . Hi s awareness o f thi s wis h i n himsel f alerte d hi m t o th e possibilit y tha t Sharon wa s activel y trying to avoi d lookin g a t her present conditio n an d situation. In th e wor k wit h a perso n wh o feel s s o threatene d tha t sh e mus t b e this rigid , i t i s helpfu l t o ste p bac k fro m th e therap y experienc e an d t o ask, "Wha t i s th e overal l pattern ? Wha t i s thi s individua l tryin g t o achieve wit h me , an d why ? Wha t doe s thi s tel l m e abou t he r experienc e of hersel f an d th e worl d an d abou t wha t sh e ca n tolerat e i n th e wa y o f treatment righ t now? " Treatment Allianc e Evaluatio n (se e Tabl e 2.1 ) Sharon's state d understandin g o f he r conditio n wa s almos t totall y delu sional: Sh e wa s th e unwillin g (thoug h perhap s important ) subjec t o f others' malevolen t acts . These other s include d psychiatrists . Sh e had n o realistic ide a o f treatmen t othe r tha n tha t i t was , perhaps , a res t fro m her lif e o n th e streets ; he r goa l wa s t o us e thi s hospita l sta y t o gathe r evidence fo r he r cas e against th e FBI. Sharon's firs t priority , maintaine d a t risk t o he r life, was t o preserve a strictly define d sens e o f persona l contro l an d autonom y i n whic h al l blame an d responsibilit y fo r anythin g negativ e wa s place d elsewher e than o n her . I t wa s har d t o se e an y conflic t abou t thi s priorit y o r an y other prioritie s i n oppositio n t o this ; however , th e fac t tha t sh e ha d entered th e hospita l voluntaril y (i n th e lega l sense—obviously , sh e wa s under pressure ) an d attende d psychotherap y session s migh t b e indica tions tha t o n som e leve l sh e wa s willin g t o as k fo r hel p an d t o admi t t o some difficultie s i n herself. But th e paucity o f evidenc e fo r an y abilit y t o

The Case of Sharon 24 9 consider alternative viewpoints that would allow others to help seriously limited Sharon's flexibility in accepting treatment of an y sort. Her illnes s ha d ru n a chronic , deterioratin g cours e s o far , despit e what appeare d t o b e above-averag e constitutiona l an d environmenta l endowments. Th e long history o f relativel y fixed delusions als o bespok e a severe core disturbance. Whether these delusions derived directly fro m the core disturbance or from her adaptation to her difficulties i n concentrating, problem-solving, an d processing stimul i (obligator y versu s func tional priorities), thei r severity an d pervasiveness wer e remarkable. Furthermore, sh e ha d bee n actin g accordin g t o he r delusiona l belief s fo r some time , s o tha t thei r integratio n int o he r lif e wa s complex : T o giv e them u p abruptly would hav e bee n like amputatin g a limb. I n addition, Sharon's illnes s ha d neve r responde d ver y wel l t o medication . Al l o f these factor s limite d Sharon' s availabilit y t o change . The y als o pointe d to th e importanc e o f autonom y an d contro l issue s i n he r life , becaus e change seemed not only difficult bu t terrifying t o her. Still, the fact that Sharon was in treatment at all had to mean that she had som e hop e tha t human contac t woul d b e gratifying. Th e complica tion wa s tha t he r manifes t communication s an d attitude s towar d relat edness define d suc h narro w rule s fo r sustainin g huma n contact : Eithe r she was fre e o f conventiona l constraints , roamin g th e countryside bein g abused, o r sh e wa s i n a hospita l angril y limitin g wha t sh e woul d tal k about an d insistin g tha t everyon e joi n i n he r fight agains t th e FBI . Al l interactions wit h th e potential fo r mor e richnes s o f huma n contac t an d feeling seeme d repeatedly to collapse into battle s for control: Would sh e attend a meeting, tak e her medication, sta y in the hospital, ge t up in the morning? The explicit deman d that Sharon placed on her environment was tha t everyone follo w he r rules completely. Sinc e this was impossible , it made sense to consider whether this concealed a n implicit demand from Sharon, perhaps t o hav e a n environmen t t o fight against , perhap s i n orde r t o reinforce a set of very tenuous self-other boundaries . Perhaps the rigidity of Sharon' s condition s fo r contac t indicate d th e degre e o f threa t t o he r sense of self an d self-worth, huma n contact entailed. While thes e demand s di d no t leav e a grea t dea l o f roo m fo r th e clinician to for m a n alliance with Sharon, they did suggest that interventions aime d a t supportin g he r sens e o f autonom y an d contro l an d a t clearly outlinin g th e boundarie s betwee n hersel f an d other s woul d b e

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important steps . For example, a comment directe d a t Sharon's boundar y problems migh t hav e been : "It' s clea r tha t I canno t convinc e yo u o f anything yo u d o no t wan t t o accept . I wish I could. Sinc e I can't , I a m unable t o figure ou t a wa y t o begi n wit h you . Th e advantag e t o thi s i s that i t make s m e thin k I ca n understan d bette r wha t it' s lik e t o no t b e able t o ge t anywhere—whic h seem s t o b e a predicament yo u hav e expe rienced." Whil e thi s remar k woul d emphasiz e th e boundarie s betwee n the patien t an d therapist , i t could als o tactfull y offe r a mean s t o contac t and th e beginnings o f collaboration . Thus, ou r recommendatio n tha t clinician s spel l ou t thei r ow n limita tions an d th e limitation s o f th e therapie s the y offe r woul d b e part o f th e basic wor k o n th e allianc e wit h Sharon , sinc e thi s shoul d reassur e he r than th e clinicia n wa s no t abou t t o tr y t o tak e ove r o r chang e her entir e life, no r di d h e hav e th e powe r t o d o so . Findin g area s wher e i t woul d not b e to o detrimenta l t o th e earl y phas e o f he r hospita l treatmen t i f Sharon refuse d participatio n woul d b e anothe r wa y t o encourag e a n alliance. Tha t is , becaus e i t woul d b e necessar y fo r Sharo n t o sa y " n o " often, staf f woul d quickl y becom e discourage d an d frustrate d i f the y began enthusiasticall y wit h man y plan s fo r he r treatmen t i n whic h the y felt ver y invested . A discourage d an d frustrate d staf f woul d no t b e abl e to respon d a s wel l whe n (an d if ) Sharo n becam e les s frightene d an d rigid. Medication Although i t wa s no t th e onl y goa l o f hospitalizatio n fo r Sharon , on e hope was tha t a better medicatio n regim e could b e developed s o that sh e could manag e bette r outsid e th e hospital . Sharo n ha d bee n give n neuro leptic medication prio r t o hospitalization b y her doctor, bu t thi s had ha d minimal effec t o n he r delusion s an d agitation . I n the hospital, continue d trials of various neuroleptic s wer e made, again with limite d success . At one point, a case conference wa s held i n which Sharo n stresse d he r depressive symptom s t o th e visiting consultant. Sinc e she had though t o f suicide fo r years , th e possibilit y tha t sh e suffered fro m a n affectiv e disorder rathe r tha n schizophreni a too k hol d i n th e mind s o f th e staff , with th e hope that a trial of antidepressan t medicatio n woul d help . (Thi s is a commo n developmen t i n familie s an d clinician s i n thes e day s wher e new drug s fo r affectiv e illnes s see m mor e plentifu l tha n ne w treatment s

The Case of Sharon 25 1 for schizophrenia. ) Sharo n als o eagerly accepted thi s idea an d reporte d marked improvement in her mood and a decrease of suicidal wishes after a tricycli c antidepressant wa s begun. Unfortunately, sh e responded withi n three days of the institution of the medication, rather than the period of several weeks required t o reach adequat e bloo d level s of thi s drug, and her changes appeared mor e consistent with a "flight int o health" as she tried to convince hospital personnel that she was no longer suicidal and could leav e th e hospita l soon . He r moo d remaine d slightl y improve d when she was told that staff sa w her as being in need of a long period of hospitalization. Eventually , th e antidepressan t tria l ende d becaus e i t seemed t o hav e littl e impac t an d becaus e ther e wa s considerabl e fea r among the staf f abou t eventuall y dischargin g Sharo n fro m th e hospita l while sh e wa s takin g a medicatio n whic h sh e coul d easil y us e t o kil l herself. Sharon continued on a regimen of thiothixene, which seemed to have been most helpful t o her in the past, but she frequently complaine d tha t the medication interfered with her thinking and that the nurses who gave her th e pill s were unsympatheti c an d critica l o f her . Sh e met regularl y with her psychotherapist bu t tended to use this time to complain abou t the rest of the hospital staff whil e idealizing the therapist, althoug h thi s idealization intermittently collapse d into rage or pouting when the therapist took n o steps to rid th e institution o f th e people Sharon fel t wer e incompetent. In the midst of one such disappointment, Sharon ran away from th e hospital to live on the streets, but eventually showed up at her father's offic e an d allowed herself to be taken back to the ward. That Patient's Subjectiv e Experience o f Medication For most individuals with schizophrenia, medication symbolizes the fact of illness, reinforcing idea s about being a passive victim of a chronically out of control condition. For those who deny or minimize the idea tha t they have an illness, medication is a terrible narcissistic blow that seems to define the m as mental patients, unless they can keep awareness of its implications separat e fro m th e action o f takin g it, a policy followe d b y Maryann in chapter 6. Side effects reinforc e the feeling of being unfairly treated b y fat e an d discourag e compliance . I n addition , person s wit h particular concern s react badly to specific side effects; fo r example , it is well know n clinicall y tha t ver y paranoi d invididual s find eve n mil d

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sedation excruciatingl y distressin g becaus e i t is so importan t t o the m t o maintain their alertness. Other reaction s includ e mournin g th e loss o f familia r symptom s tha t served a purpose in the patient's psychic life. Especially if a hallucination disappears abruptly , th e drasti c chang e ma y b e overwhelmin g t o some one wh o ha s live d wit h thi s fo r a lon g time . Then , wit h les s florid psychotic symptoms , th e individua l i s aske d t o dea l wit h th e demand s and frustration s o f everyda y life , bu t wit h th e histor y o f hi s o r he r psychosis a s a contex t an d usuall y wit h personalit y problem s o r ego function deficit s tha t medicatio n ha s no t cured . Thi s lead s t o greate r frustration. I n order to form a partnership with the patient in the area of medication treatment, the clinician must be sensitive to issues of loss and mourning as the patient's subjective experience changes in the context of medication response . However , ther e is some possibility tha t the forma tion of a psychotherapeutic relationshi p ca n enhance the effectiveness o f medication (6) . All o f thes e negativ e reaction s t o medicatio n ca n lea d t o noncompli ance. Fo r som e patients , i t ma y actuall y see m preferabl e t o si t quietl y with familia r hallucination s tha n to hav e to fac e the world an d compet e with "normal" individuals as anxious, confused, partially skilled persons with ordinary problems. At least the problems of being overtly psychoti c have a dramati c an d specia l fee l t o them . A s w e hav e stressed , schizo phrenic individuals need to maintain self-esteem a s much as anyone else, and th e choic e betwee n medicatio n an d havin g t o fac e a difficul t lif e with residual impairments or remaining ill enough to avoid some of life' s responsibilities ca n be more difficult tha n we might think. Our approach is to present medication a s a partial treatment in which the patient's effort s ar e still ver y important . W e tr y to hav e th e individ ual collaborate a s fully a s possible in decisions about drug treatments, at the very leas t b y providing a s much informatiio n a s possible an d givin g the patien t responsibilit y fo r report s o n symptom s an d side effects . I n some cases , i t i s appropriat e fo r a schizophreni c individua l t o contro l dosage o r timing of administratio n withi n limit s given b y the physician. For example: One highly intelligen t an d talented semi-professiona l tenni s player had compete d nationall y whil e finishing colleg e despit e sever e

The Case of Sharon 25 3 paranoid delusion s tha t wer e accompanie d b y hallucinations . H e had alway s refuse d treatment , especiall y antipsychoti c drugs , unti l his behavior grew s o bizarr e that he would b e involuntarily hospi talized. H e quickl y gre w mor e cal m an d rationa l whil e takin g medication, bu t it was clear that he would never continue taking it once he left the hospital. On e consultant, however, spen t a considerable lengt h o f tim e tryin g t o understan d wha t h e dislike d abou t the subjectiv e experienc e o f takin g medication . The youn g ma n gave vagu e remark s abou t bein g sedated , the n finally mentione d some physica l sensations . Th e consultan t continue d t o questio n him in detail: C: S o it slows down your reaction time, you think? P: Yes , it interferes. C: S o does it interfere when you play tennis? P: Yes . C: Tel l me more about that. How exactl y does it interfere? P: Well , it interferes. C: Doe s it interfere al l the time, or only with some strokes? P: Som e of the time. C: I s it when you serve, for example, or whenever you hit the ball? P: I notice it when I serve. C: S o it's when you serve. Can you tell me how i t interferes? P: Well , it's most of the time when I serve. C: Wha t does it do, for example, when you serve? P: I t ruins it. C: A t what point i n your serve? What doe s it do, exactly? Doe s i t slow dow n the serve, or the toss, or what? P: Well , I ca n stil l tos s th e bal l an d brin g m y racke t back , bu t when I bring m y racke t forwar d t o mee t th e ball , it' s jus t no t as fast—just a few milliseconds off , bu t it ruins my serve. C: S o that's really bad. P: Yes . C: An d what dosage does that? P: Thirt y milligrams. C: Woul d twenty-five hav e the same effect, d o you think, or twentyseven, or twenty?

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Eventually th e patient decide d tha t h e might b e able to bea r takin g 23 milligram s an d agree d t o tr y thi s an d t o tr y playin g tenni s o n this dosage while in the hospital s o that h e could se e the effects . One o f th e point s w e wis h t o mak e throug h thi s exampl e i s the nee d for clinician s t o b e seriou s an d patien t i n thei r inquirie s an d t o avoi d assuming tha t the y kno w bes t o r kno w wha t patient s wil l say . Patient s are accustome d t o bein g aske d briefl y abou t sid e effects , bu t the y them selves hav e a detaile d imag e o f th e deleteriou s effect s o f th e medicatio n on specifi c element s o f th e activitie s tha t for m th e basi s o f thei r self esteem an d identities . The y d o no t assum e tha t clinician s ar e intereste d in thi s unti l clinician s hav e prove d th e contrar y b y length y an d precis e inquiry. I n al l likelihood , patient s agre e t o tr y a medicatio n i n par t because they fee l understood , rathe r tha n coerced . Thus, th e mos t importan t aspec t o f th e clinician' s wor k i n th e treat ment partnershi p aroun d dru g therap y i s his o r he r attitud e towar d th e medication an d towar d th e patient' s attitude . A s always , i t i s necessar y for clinician s t o empathiz e wit h th e specific s o f patients ' reluctanc e t o engage i n suc h treatmen t an d t o avoi d preaching . Clinician s shoul d b e clear an d explici t abou t wh y the y ar e askin g fo r dru g compliance : lif e goals expresse d b y patients , makin g therap y feasible , keepin g patient s out o f troubl e o r ou t o f a hospital , reducin g clinicians ' anxiet y abou t suicide i n depresse d bu t impulsiv e an d disorganize d patients . This latte r rationale fo r a request fo r medicatio n complianc e ca n b e very powerful : It let s patient s kno w tha t clinician s ar e no t i n contro l o f patients ' live s because clinician s hav e t o ask fo r complianc e t o manag e thei r ow n feelings o f worry . I t is much bette r fo r clinician s t o openl y acknowledg e their wis h t o contro l patient s t o preven t thei r deat h o r destructivenes s than t o verbally present the need fo r medicatio n a s something simply fo r patients' ow n good , whil e i n a contradictor y wa y clinicians ' action s express th e nee d t o contro l patients . Th e clinicians ' attitud e shoul d b e that th e individua l wit h schizophreni a i s nontheles s a n individua l wit h the righ t t o mak e unhealth y choice s withi n limit s se t b y societ y an d th e physician's concer n t o save life . Sharon's Medicatio n Experienc e Sharon illustrate s a particular typ e o f medicatio n noncompliance , whic h is relate d t o he r genera l noncomplianc e an d inabilit y t o for m stabl e

The Case of Sharon 25 5 treatment partnerships. When she returned to the hospital sh e was globally bitter , hostile , an d withdrawn . Sh e bega n t o refus e medicatio n an d eventually refuse d t o ea t o r t o tak e car e o f he r personal hygiene . Whil e her lif e wa s no t immediatel y a t risk , hospita l personne l bega n t o thin k of requestin g a cour t orde r fo r involuntaril y medicatin g Sharon . How ever, i n th e contex t o f he r life-lon g aversio n t o participatin g i n treat ment, takin g thi s ste p fel t t o he r therapis t lik e gettin g int o on e mor e power struggle in which Sharon would temporarily submit to control b y others mor e powerful tha n she, with he r basic reluctance t o for m a true treatment partnershi p unchange d throughout . I n fact, sh e migh t b e les s likely t o wor k wit h staf f i n the future , sinc e ther e was n o evidenc e tha t she was significantl y mor e trusting or cooperative with medicatio n tha n without. Sh e ha d bee n aske d o r force d t o tak e medicatio n o n others ' terms man y time s before , withou t an y lastin g chang e i n he r attitud e toward compliance . Knowing he r long histor y o f noncomplianc e an d he r concern s abou t control, whic h stemme d fro m extremel y porou s self-othe r boundaries , the therapist sough t t o find some paradig m fo r negotiatio n abou t medi cation i n th e hop e tha t the y coul d avoi d havin g thi s becom e anothe r major battle. He waited to apply for a court order, simply having Sharon weighed dail y an d her input an d output note d fo r a time when sh e wa s not i n physical danger , whil e tryin g t o discus s wit h he r ways sh e coul d participate i n the developmen t o f a drug treatment plan. H e sa w thi s a s merely a continuatio n o f he r treatment , whic h ha d focusse d o n he r noncompliance base d o n he r rejection o f th e idea tha t she wa s il l since , she insisted, sh e was the victim o f min d control experiment s b y the FBI. Sharon was relativel y unabl e t o for m a treatment partnership, a t least a stable one , becaus e o f he r nee d t o sa y sh e wa s no t il l an d t o avoi d rea l contact wit h other s wh o coul d help . He r therapis t sa w he r refusa l t o take medicatio n a s a desperat e attemp t t o asser t a self-othe r boundar y and wa s concerne d that , i f thi s powe r wa s forcibl y remove d fro m her , she might reason that suicide or violence directe d at others was the onl y way t o asser t self-control an d to differentiat e hersel f fro m th e powerful , controlling others in her life. Sharon and her therapist spoke about whether there was any way her "brain coul d b e repaired, " utilizing he r idea tha t th e FB I had tampere d with he r b y implantin g device s i n her . Bu t Sharo n use d th e ide a o f revenge agains t th e FBI as a n organizin g principle , s o tha t th e ide a tha t

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she, o r sh e an d he r therapist , o r sh e an d th e medication , coul d d o anything t o repai r th e damag e don e t o he r wa s unacceptable . Sh e wa s set o n a tria l t o prov e th e FB I had harme d her , an d he r goa l i n lif e wa s therefore t o gathe r evidenc e t o suppor t thi s contention . Th e ide a o f medication wa s to o frightenin g an d mad e he r fee l to o powerles s fo r he r to respon d t o th e therapist' s offer . I n th e end , lega l proceeding s wer e necessary t o convinc e he r t o tak e medication . Th e therapis t tol d Sharo n of hi s feeling s o f powerlessnes s an d hi s willingnes s t o ris k he r ange r b y going against her wishes a s part o f th e discussion o f thi s development . Sharon's noncomplianc e reste d on her failur e t o integrate informatio n about he r illnes s int o he r pictur e o f herself . This , i n turn , reste d o n he r considerable proble m maintainin g a sens e o f he r identity—henc e he r rigid rule s fo r hersel f an d other s an d fo r interactions , tha t is , her para noid an d avoidan t stance . To integrat e awarenes s tha t sh e had a n illnes s into he r self-imag e woul d apparentl y hav e represente d to o muc h o f a loss, too muc h damag e t o he r self-estee m an d he r hopes . She was unabl e to find i n herself th e flexibility t o allo w fo r a different self-image .

THE HOSPITAL THERAPIST'S RELATION S WITH HOSPITAL STAFF When th e patient' s docto r i s engage d i n psychotherap y i n th e hospita l setting an d whe n thi s tas k i s differentiate d fro m thos e performe d b y other disciplines , certain issue s tend t o arise simply because of the natur e of th e syste m (7-9) . Mos t often , ther e ar e narcissisti c conflict s i n staff , centered o n env y an d it s denia l throug h devaluation . Tha t is , becaus e the therapis t i s usuall y a membe r o f a professio n wit h highe r statu s i n the hospita l setting , othe r staf f focu s thei r env y o f statu s attribute s o n the psychotherap y activity , whic h i s a clear-cu t exampl e o f somethin g that i s suppose d t o requir e a grea t dea l o f trainin g an d skil l bu t tha t superficially appear s eas y to do—after all , it's just talk. Or, alternatively , they ma y devalu e psychotherapy , relegatin g i t t o th e real m o f ivor y towers an d fantas y lands , while considerin g th e work the y d o i n dealin g with th e patient' s concret e problem s o f gettin g u p i n th e mornin g o r going into tow n a s more important . Eithe r way , the system i s usually se t up s o tha t narcissisti c issues , envy, competition , idealization , an d deval -

The Case of Sharon 25 7 uation are close at hand if a patient arrives whose pathology ca n exploi t the situation.

Sharon's Idealization of the Therapist The situatio n tha t develope d wit h Sharo n wa s no t uncommon . Sh e wa s generally devaluin g an d uncooperativ e wit h nursin g an d activitie s staf f and frequentl y refuse d t o b e civi l t o them . Althoug h sh e wa s no t reall y very cooperative in psychotherapy, the rest of the staff shared the fantasy (which represente d on e side o f Sharon' s idealize d fantasy ) tha t sh e wa s talking t o he r therapis t an d ha d som e kin d o f goo d relationshi p wit h him. Sharon supported this fantasy wit h glowing reports of he r wonderful session s wit h Dr . B.—report s tha t lea d t o th e staff' s env y o f tha t (imaginary) goo d relationship . Furthermore , staf f sa w th e docto r a s a powerful figure who ought to be able to control this (impossible) woma n since he fel t i t worthwhile t o spen d s o muc h tim e talkin g with her . The staff assume d that if he didn't stop her devaluation o f th e staff, h e mus t be doing somethin g wrong . I t is worth addin g that the kind of idealize d relationship betwee n Sharo n and Dr. B. the staff imagine d has its reflection i n realit y i n the kin d of specia l relationship s schizophreni c individ uals ofte n tr y t o se t u p wit h person s wh o the y fee l wil l tak e car e o f al l their problems . Sharo n wa s i n fac t attemptin g t o establis h thi s typ e o f relationship wit h Dr . B. , who a t times restraine d himsel f wit h difficult y from feelin g a specia l closenes s wit h he r tha t wa s onl y partiall y sup ported by the reality of their interactions. Another aspect of th e staff's idealize d fantasy abou t this pair reflecte d the feelin g tha t Sharo n wa s reall y a ver y powerful , controllin g person . This fantasy wa s that, if Sharon talked to her therapist at all, he must be so influenced b y her powers that he would alway s believe her distortions and neve r believ e tha t th e staff' s vie w o f he r problem s wit h the m ha d any validity . Sh e wa s see n a s someon e wh o coul d spoi l wha t the y ac tually knew to be the therapist's good ability to understand and empathize with staf f reactions to a patient and with the difficulties presente d by someone like Sharon. Envy of th e therapist's real or supposed abilit y to contain an d not ac t on th e rag e generate d b y a patient lik e Sharo n i s als o frequentl y a part of staf f reactions . Sharo n mad e everyon e fee l frustrated , helpless , an d furious. Thos e wh o fel t leas t awar e o f o r leas t comfortabl e wit h thei r

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anger wer e mos t likel y t o als o fee l intens e guilt , whic h wa s agai n deal t with b y projection . I n thi s kin d o f situation , th e therapis t sometime s overtly o r covertl y accuse s othe r staf f o f bein g sadistic , an d sometime s the nursin g staf f accuse s the therapist o f th e crime of "overinvolvement " or countertransferenc e tha t interfere s wit h th e prope r therapeuti c ma neuvers. Usually , th e fantas y abou t prope r therapeuti c maneuver s in volves somethin g punitiv e an d controllin g to "get " th e patient t o behav e differently. With Sharon , staff wer e angry an d guilt y a s well as afraid tha t Sharo n would repor t thei r ange r t o he r docto r i n a way tha t fit in with Sharon' s view o f hersel f a s th e righteou s accuse r o f th e evil-doer s o f th e world . On th e othe r hand , the y als o wishe d tha t sh e would spen d he r session s on thei r anger , sinc e the y neede d t o hav e i t expresse d somewher e an d their guil t assuaged . Discussion s revealed tha t man y staf f entertaine d th e notion tha t th e therapis t wa s neve r angr y a t Sharon : i t wa s onl y th e "bad" staf f wh o had t o try to get her out o f be d in the morning and wh o felt suc h rag e when sh e would strik e out a t them. This notion intensifie d their feeling s o f guil t fo r thi s anger . The resul t o f al l thes e factor s wa s a powerfu l nee d i n th e staf f t o defend agains t feeling s o f guil t arouse d b y understandabl e rag e a t a troublesome patient . Th e defens e consiste d o f contemp t fo r th e thera pist's work, idealizatio n o f th e staff's wor k ("It' s harder"), and denia l of guilt abou t th e anger . Staf f member s typicall y fel t tha t i t wa s th e thera pist's faul t tha t Sharo n considere d th e aide s "ba d objects, " sinc e th e therapist shoul d hav e bee n insistin g t o Sharo n tha t sh e ge t u p i n th e morning. I f h e didn' t ge t he r t o d o this , i t mean t tha t h e faile d t o understand th e nursing point o f view and wa s underminin g treatment . Management o f th e Dilemm a This typ e o f proble m exemplifie s th e nee d fo r regular , ope n discussion s among therapis t an d staf f members . Otherwise , hospitalization an d hos pital rule s ca n b e use d t o kee p th e patient' s difficultie s wit h certai n affects ou t o f everyone' s consciou s awarenes s (10) . Th e crucia l elemen t in thes e discussion s abou t Sharo n wa s Dr . B.' s sharin g hi s feeling s o f frustration an d ange r an d th e fac t tha t Sharo n wa s no t utilizin g psycho therapy ver y well . This countere d th e fantas y tha t onl y th e nursin g an d activities staf f ha d suc h feeling s (11) , but furthe r stimulate d guil t a s Dr .

The Case of Sharon 25 9 B. spoke of how he tried t o manage thes e feelings i n the service of the therapy and to minimize the likelihood that he would act on his frequen t wish to be rid of Sharon. In this way, Dr. B. modeled how he used his feelings wit h Sharo n to understand not only her subjective experience but that of the staff. This knowledge als o helpe d hi m clarify wha t Sharo n wa s trying t o accom plish. Just as it is necessary for therapists to manage their countertrans ference, containin g patients ' unwante d affect s i s helpfu l i n managin g difficult patients ' hospitalization. Dr. B.' s opennes s create d a proble m fo r th e staff. I t disrupte d th e defenses alread y i n place , whereb y therap y wa s devalued bu t secretl y idealized and envied. That is, there was the hope (which, paradoxically, forms th e basis for the disappointment an d the rage) that Dr. B. would make everythin g better . Instead , th e staf f ha d t o confron t thei r ow n realistic failure s i n treatin g Sharon : The y wer e generall y approachin g her in a way that reflected their hatred of and hopelessness about her, by acting as if their only task with her was to "get her to do" something. The Nursing Role This vie w o f th e rol e o f staf f reflect s a basi c erro r i n understandin g schizophrenia. From this perspective, patients are assumed to be able to just "will" themselves to do something, including acting well or getting better, an d if the y don't , thi s is seen a s "acting out. " It also reflect s a despairing feelin g tha t i f patient s ar e ill with somethin g a s hopelessl y severe as schizophrenia, al l that a concerned, traine d staf f membe r can do i s tak e car e o f the m i n a materna l way , withou t expectin g an y contribution from the patient or any role for the psychiatric nurse's skills in understandin g an d conceptualizin g th e physical an d emotiona l de mands o f life . Suc h a n attitud e contrast s wit h ou r belie f tha t som e behaviors resul t fro m psychologica l reaction s t o the core disturbance s and hence are amenable to change. The role of nursing staff i n the treatment of this kind of patient is far different, i n our opinion, unless an informed decisio n for custodial care is made . Gettin g patient s t o "d o something " i s no t th e majo r role ; rather, staff serv e as auxiliary egos, models of how to deal with life and its demands and frustrations, peopl e who know how to contain feeling s and ac t appropriately . The y realiz e tha t patient s requir e example s of

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how t o dea l wit h variou s situations . The y understan d tha t patient s ar e sick, bu t nonetheles s the y tel l th e patient s th e effec t o f thei r behavior s on others, including themselves, to provide data for patients. They articulate th e detail s o f patient-staf f interaction s s o tha t patient s ar e force d to loo k a t what the y ar e doing, wha t th e impac t o f a behavio r is , goo d or bad. Staff maintai n their own view but realize that delusional patient s do no t se e thing s i n th e sam e way , an d tha t a delusiona l world-vie w dictates certain actions. For example , a nurs e migh t hav e sai d t o Sharon , " I understan d yo u don't trust me and you fee l yo u must treat me like a jailer because that' s what you thin k I' m here for, bu t I have a different view . I don't believe I am your jailer, and it hurts my feelings an d makes me feel unappreciate d when yo u don' t trus t m e afte r al l thes e months . I know yo u hav e you r view, bu t I hav e min e too. " Thi s interventio n coul d als o hav e helpe d Sharon with self-other differentiation . Another elemen t i n Sharon' s presentatio n t o nursin g staf f wa s he r need t o ac t a s a n advocat e fo r al l th e paranoid , hostil e patient s o n th e ward. Sh e di d thi s i n suc h a contentiou s wa y tha t i t wa s ver y har d fo r staff t o fin d th e kerne l o f trut h i n complaint s an d respon d seriousl y rather tha n defensivel y o r b y dismissin g Sharo n completely . Thi s i s where th e therapist o r clinical administrato r o f th e ward ca n b e helpful . It is necessary t o empathiz e with the staff's plight , when the y ar e feelin g devalued, frustrated , an d criticized . A t the sam e time , i t is important t o continue t o relat e to the patient i n a therapeutic way, identifyin g a n ego strength i n th e patien t tha t i s bein g utilize d i n a maladaptiv e wa y an d then offering othe r avenues for its expression, given an understanding o f what it means to the patient. For Sharon , organizin g th e patien t grou p (o r it s mos t paranoi d subgroup) fel t lik e proof tha t she would eventuall y b e abl e to plea d her case against the FBI successfully, convincin g the world that she had been wronged. Bein g a n advocat e fo r th e downtrodde n wa s als o par t o f he r liberal—creative write r identity . Allowin g Sharo n t o b e a n advocat e bu t limiting he r activitie s t o communit y meeting s wher e sh e ha d previousl y arranged t o b e on th e agend a an d where sh e agree d to follo w th e usua l procedural rule s offere d som e relie f t o bot h Sharo n an d th e staff . Thi s compromise allowe d he r t o advocate , bu t i n a muc h mor e bearabl e fashion. Staf f coul d eve n complimen t he r on th e strengt h o f he r convictions whil e disagreein g wit h he r presentation o f th e fact s an d he r inter-

The Case of Sharon 26 1 pretations of them. This empathy from staf f wa s made possible by their feeling tha t th e war d administratio n di d no t pla n t o allo w Sharo n t o attack the m constantl y an d tha t empath y fo r thei r situatio n wa s avail able. In turn, this freed people to see her strengths, such as they were, so that the y coul d b e more creativ e i n offering he r alternativ e channel s t o express them. THERAPEUTIC ACTIVITIES Therapeutic activitie s ar e a n importan t par t o f th e rehabilitatio n pro gram now offered b y psychiatric hospitals. Patients are usually evaluated in term s o f task , social , an d occupationa l skill s an d the n place d i n appropriate groups, their activities progressing to more challenging ones as th e individual' s conditio n an d lengt h o f hospita l sta y allow . Thes e activities include discussion groups (current events, information o n local community activities , assertivenes s training ) aime d a t withdraw n pa tients or those who need help with social skills; sport and hobby groups to help develop leisure interests; and supervised work programs, such as putting togethe r a hospital literar y magazin e o r runnin g a gif t sho p o r snack bar . Thes e activitie s includ e grou p meeting s i n whic h issue s o f stress management an d authorit y relation s ca n b e discussed wit h voca tional counselors who have observed the patient's job performance. The Noncompliant Patien t i n Therapeutic Activitie s Evaluation an d placemen t o f Sharo n i n therapeuti c activitie s program s was ver y difficul t fo r th e sam e reason s tha t mad e i t har d fo r nursin g staff t o wor k constructivel y wit h her . He r attitud e wa s critica l an d antagonistic, an d sh e ofte n refuse d t o wor k a t anything . Whil e he r disorganization an d intens e concer n wit h he r delusion s prevente d he r from effectiv e cognitiv e work , sh e refuse d t o openl y acknowledg e he r own limitation s i n anythin g resemblin g a task . A t th e sam e time , sh e scorned les s challenging work an d viewed i t a s a deliberate attemp t b y staff t o humiliate an d frustrat e he r (which , at times, it was, though no t on a conscious level). At such times, she would fee l that sh e was losing her identit y a s a colleg e educate d perso n an d tha t th e staf f ha d als o forgotten, in a very real way, who she was.

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Part o f Sharon' s delusio n wa s that , i n a plo t t o preven t he r fro m exposing a gigantic, evil FBI project, sh e was bein g held agains t he r will . Since sh e planne d t o leav e someda y an d b e vindicate d b y th e Suprem e Court, sh e was concerne d t o mak e he r cas e while in the hospital. Unfor tunately, sh e fel t tha t thi s mean t tha t sh e must refus e treatmen t i n orde r to maintai n he r position . T o ac t lik e a patien t i n an y wa y would , sh e feared, weake n he r cas e an d argu e agains t he r basi c contentio n tha t sh e was incarcerate d i n error—whic h di d no t leav e muc h o f a rol e fo r staf f to wor k wit h Sharon . Suc h limitin g o f staff s usefulness , a s muc h a s th e derogation o f staff , i s a typica l proble m wit h ver y paranoi d patients , whose nee d t o kee p thei r distanc e fro m staf f an d t o contro l th e possibil ity o f an y mutua l relationship s and , especially , th e developmen t o f an y dependency need s o n th e patient' s part , i s particularl y severe . Bu t th e staff trie d t o work withi n th e bound s tha t Sharo n first set . They initiall y attempte d t o respec t Sharon' s trainin g i n literatur e an d creative writin g b y assignin g he r t o a grou p tha t publishe d a patien t newspaper, eve n thoug h mos t patient s i n thi s grou p ha d prove d th e status o f thei r tas k skill s throug h earlie r participatio n i n les s comple x group tasks . However , th e fac t tha t staf f allowe d he r t o "ski p steps " i n the hierarch y o f activitie s programs , combine d wit h misconception s abou t the natur e o f th e illness , le d t o a poo r outcome . Activitie s staf f woul d give Sharo n assignment s wit h th e feelin g tha t sh e ha d t o prov e hersel f and then criticize d her severel y for he r failings, sinc e she wasn't perform ing a t th e proper level . The ide a wa s tha t i t was beneficia l fo r Sharo n t o be confronte d wit h he r disabilities , a s i f i t were th e tas k o f th e activitie s therapists t o disabus e he r o f he r delusio n that , whil e in th e hospital, sh e was a n investigativ e reporte r collectin g materia l o n th e plans o f th e FBI . Since thi s delusio n wa s a centra l par t o f he r identit y an d ha d bee n unresponsive t o man y type s o f treatmen t efforts , includin g medication , this plan fo r Sharon' s self-confrontatio n wa s doomed . Drawbacks i n Confrontin g a Patient' s Deficit s This experienc e illustrate s on e o f th e problem s wit h certai n type s o f psychosocial rehabilitatio n programs . Give n Sharon' s nee d fo r denia l i n order fo r he r t o maintai n he r autonomy , confrontin g he r wit h he r defi cits in functioning destroye d th e chances of formin g a treatment alliance . Attempts t o forc e confrontation s derive d fro m th e assumption s tha t sh e

The Case of Sharon 2 6 3 would never change or get better and that she should just learn to accept her difficultie s an d giv e u p al l thought s o f bein g a writer . Whil e suc h change i n vocationa l plan s migh t eventuall y hav e becom e par t o f Shar on's life, to impose it on her at a time when she barely accepted any need for treatmen t a t al l coul d onl y b e demoralizin g an d enragin g t o her . I t made he r fee l no t s o muc h tha t peopl e wer e wron g i n thei r judgment , but tha t the y ha d n o concer n fo r he r feeling s an d coul d no t b e trusted . Thus, the y coul d no t b e truste d t o collaborat e helpfull y wit h he r if sh e did admi t sh e ha d problems , sinc e the y ha d show n themselve s t o b e s o tactless. Th e ne t resul t wa s Sharon' s greate r feeling s o f despai r an d a n upsurge of suicida l ideation . One alternative approach might have been to allow Sharon to publish articles in which sh e had a specific interest—fo r example , article s detail ing he r view s abou t th e FBI . Suc h a n approac h woul d sideste p th e control issu e somewhat, especiall y if staff coul d refrain fro m destructiv e criticism. However, there are risks in approaching too directly a patient's skills when th e individual i s as sick a s Sharon was an d when ther e is s o much denial . Sharo n migh t hav e verball y responde d wel l t o suc h a suggestion, but probably would have discovered reasons for its not being a goo d idea : I t migh t revea l wha t sh e kne w t o th e enemy , i t migh t weaken he r defens e i n court , an d s o on . T o hav e th e opportunit y t o show wha t sh e coul d d o woul d hav e touche d to o centrall y o n he r delusional syste m an d he r denial , s o tha t eventuall y sh e woul d hav e experienced thi s activit y a s a humiliating ploy t o ge t her to revea l wha t she secretly knew—that she was too disorganized to write coherently . Partial succes s was achieve d b y allowing her to meet regularly with a poetry an d writing consultan t wh o volunteere d tim e on the unit. Osten sibly, the two me t to discuss Sharon's writing projects, but the definitio n of thei r activit y wa s broa d enoug h s o tha t n o pressur e wa s place d o n Sharon t o produc e material . Instead , Sharo n an d Ann , th e volunteer , went over articles she or Ann had read recently, or they discussed stories and poetr y fro m book s the y rea d together . Eve n thoug h th e materia l Sharon selecte d fo r criticis m wa s obviousl y relate d t o issue s o f majo r dynamic significanc e fo r her—control , invasion , autonomy , bound aries—Ann kne w t o avoi d an y potentiall y interpretiv e wor k abou t thi s content. Give n tha t Sharo n wa s i n a ver y beginnin g stag e o f tryin g t o form a treatment partnership, th e goal o f thei r meetings was fo r Sharo n to hav e positiv e experience s o f sharin g wit h othe r peopl e tha t di d no t

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turn int o situation s o f dange r fo r her . I t wa s understoo d tha t Sharo n needed no t example s o f vocational successes , but example s of sharin g a n activity wit h anothe r huma n bein g i n a wa y tha t di d no t threate n he r self-other differentiatio n problem s an d need s for safet y an d control . Sharon fel t sh e wa s engagin g i n thes e literar y activitie s voluntarily , not a s a menta l patien t performin g a n assigne d task . Th e approac h t o her activitie s wa s nonconfrontationa l an d noninterpretive : Thes e activi ties di d no t involv e a typ e o f psychotherapy , eve n thoug h th e ide a tha t rewarding huma n contac t coul d b e possibl e despit e he r sever e psycho logical problem s cam e fro m a n understandin g o f Sharon' s psychologica l life. Using th e Patient' s Subjectiv e Experienc e t o Desig n a Rehabilitatio n Progra m The approac h t o rehabilitativ e activitie s therapie s wit h schizophreni c patients ca n be , as in Sharon' s case , noninterpretive an d nonpsychologi cal, utilizing the principle o f approachin g a patient's talent s tangentially , as i t were, rather tha n makin g a direc t deman d fo r performance . T o as k a patien t t o us e a skil l tha t wa s formerl y par t o f hi s o r he r lif e ca n b e supportive, bu t unles s ther e i s evidence tha t th e skil l i s relatively intact , it can b e yet another invitatio n t o defeat an d humiliation. O n som e level, schizophrenic individuals ar e aware o f their limitations—tha t is , they ar e aware o f th e area s t o avoi d s o tha t the y wil l no t fee l humiliate d b y a public failur e t o function . I t is crucial fo r clinician s to respec t th e signal s the patient s giv e abou t thes e limitations , eve n thoug h th e message s ma y be indirect . Fo r example , i f a patien t misse s therapeuti c activitie s ap pointments, behave s obnoxiousl y so tha t h e o r sh e i s asked t o leave , o r develops paranoi d idea s abou t th e tas k leader , i t ma y mea n tha t th e patient ha s judged th e task t o b e too difficul t t o risk a t thi s time . Approaching task s a s tasks , rathe r tha n a s materia l t o b e interprete d in the activities setting, also respects th e person's difficultie s wit h bound aries. Sharon ha d mad e n o agreemen t t o discus s meaningfu l psychologi cal materia l wit h Ann . Eve n thoug h suc h materia l appeare d i n thei r meetings, i t woul d hav e bee n intrusiv e fo r An n t o interpre t it , fo r he r doing s o woul d hav e assume d mor e o f a treatmen t partnershi p tha n existed. I f the patient agree s to participate i n creative art s therapie s wit h the goa l o f increase d self-understandin g an d th e expectatio n tha t mate -

The Case of Sharon 26 5 rial t o b e discusse d furthe r i n psychotherap y wil l arise , th e situatio n i s different, bu t i t i s wis e no t t o assum e tha t th e patien t agree s t o thes e conditions o f participation unles s they are explicitly discussed .

VIOLENCE Sharon's propensity fo r violence toward herself an d others magnified th e difficulties i n forming a treatment partnership an d underscored he r concern for control an d autonomy: Sh e often "neede d t o b e controlled." In addition, everyon e wh o trie d t o wor k wit h he r felt , i n som e way , vio lently controlle d b y her , i n th e sens e o f bein g pu t i n a positio n wher e nothing seeme d t o hel p an d everythin g seeme d t o mak e he r mor e en raged an d unavailable . Staf f an d therapis t alik e fel t coerce d int o bein g something othe r tha n the y were , a s Sharo n mad e i t clea r sh e viewe d nurses a s crue l jailers , an d then , becaus e o f he r behavior , the y foun d themselves having to restrict her. Sharon's actua l violence , no t jus t the violence o f he r feelings , wa s a n ongoing issu e fo r al l th e staf f bu t mos t o f al l fo r th e aide s an d nurse s who ha d to try to engage her in daily activitie s a s simple a s making sure she go t u p an d washe d i n th e morning . He r tendenc y t o strik e ou t a t them was frightenin g an d enraging, since she took virtuall y no responsi bility fo r thi s behavior . Knowin g he r history o f violenc e wit h therapist s and he r presen t behavior , Dr . B . felt , uneasily , tha t sh e coul d suddenl y strike out at him in response to some perceived failure on his part, but it was hard for him to engage her in discussion o f thi s behavior because of her need t o idealiz e hi m while sh e devalued everyon e else . He r inabilit y to admi t t o bot h positiv e an d negativ e feeling s towar d hi m reflecte d Sharon's problem s wit h cognitiv e integratio n an d he r fear s o f anothe r kind o f boundar y loss , whereb y sh e fel t tha t sh e coul d no t preven t an y potential rage at him from completely spoiling her good feelings for him. Naturally, Sharon' s selectiv e assaultivenes s exacerbate d staf f ange r and envy. It was necessary for the therapist to tell Sharon that he viewed her violence a s directed at him as well a s at the specific nurse s she hated because they were his colleagues and because her behavior indicated that her treatmen t partnershi p wit h him , a s par t o f th e hospita l package , must b e ver y poor . H e als o ha d t o remin d he r tha t i f sh e continue d t o attack people , sh e would no t b e allowe d t o sta y i n the hospital , s o tha t

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her contention s tha t h e wa s s o wonderfu l an d tha t sh e wante d t o kee p working wit h hi m wer e contradicte d b y th e behavio r tha t woul d resul t in a n en d t o thei r work . Th e therapis t wa s abl e t o se e ho w Sharon' s violence wa s directe d a t hi m b y recognizin g ho w violentl y coerce d an d controlled h e fel t wit h he r an d sometime s b y noticin g ho w violen t wa s his wis h fo r he r to jus t leav e hi m alone . H e wa s thu s abl e to empathiz e with the staff's reactio n an d to see how Sharo n was using the rest of her day i n th e hospita l t o expres s a part o f hersel f sh e ha d troubl e talkin g about i n therapy . This , i n turn , le d hi m t o tr y t o addres s thes e issues . Without his alliance with the rest of the staff, Dr. B. would have thought he ha d a n allianc e wit h Sharo n wher e i n fac t ther e wa s none , o r no t much o f one . Thi s cas e thu s demonstrate s th e therapist' s nee d t o main tain a treatment partnership with all staff member s as well as to consider all th e patient' s behavior s an d peoples ' reaction s t o thes e a s usefu l information.

SUMMARY We hav e no t covere d al l aspect s o f hospita l treatmen t o f schizophreni a in thi s chapter . W e have , however, attempte d t o demonstrat e ho w con sideration o f th e patient' s subjectiv e experienc e ca n b e use d t o infor m potentially difficul t area s o f thi s work : whe n a patien t i s violen t an d noncompliant an d stir s u p rag e an d guil t i n al l wh o wor k wit h hi m o r her. Having a psychological mode l o f Sharon' s experience o f hersel f an d her illness in mind made it possible to understand what capacity sh e had for formin g treatmen t partnership s wit h staff . Thi s facilitate d th e devel opment o f practica l intervention s an d dictate d psychotherapeuti c ma neuvers. W e hav e als o stresse d th e importanc e o f th e partnership s be tween outpatien t therapis t an d inpatien t staf f an d betwee n inpatien t therapist and inpatient staff . Given he r need to deny her illness, Sharon's marginal abilit y t o allo w another to help her limited what could be accomplished with her, despite the sustaine d effort s o f many . Sh e eventuall y returne d t o a somewha t nomadic existence, yet the hospital wher e this treatment had taken place became the geographic center of he r movements.

The Case of Sharon 26 7 But we can never predict what thoughtful car e means to the severely resistant patien t wh o apparentl y refuse s ou r help . Sharo n ultimatel y returned t o th e hospita l a t he r ow n request , withou t pressur e fro m others, and began to try to create for herself a life that would include the fact of her illness.

6 The Case of Maryann: Psychotherapy and Community Management, Rehabilitation, and Rehospitalization

1 h e individual wit h schizophrenia wh o is able to live in the communit y needs th e hel p o f family , friends , therapist , an d communit y agencies . The collaboratio n wit h a clien t i n suc h circumstance s mus t tak e int o account th e involvement o f other s in the person's life and , in particular, work wit h rehabilitatio n an d othe r agencies , da y hospitals , an d resi dences. Th e patient' s wishe s fo r th e therapis t t o tak e a particula r rol e vis-a-vis thes e other s complicat e thi s process . Th e patient' s nee d fo r other professionals i n addition t o th e therapis t affect s th e patient's feel ings an d hope s wit h regar d t o th e therapist . Whil e othe r program s ar e not designe d t o addres s the patient's subjectiv e experience s o f hi s or her daily life , th e psychotherapis t ca n d o so . Ye t th e patien t ofte n need s support t o manag e th e demand s o f rehabilitatio n program s i f h e o r sh e is t o maintai n a rewardin g existenc e an d a s a result, ofte n require s th e therapist's help to collaborate effectively wit h outside agencies. For severel y il l patient s wit h previou s hospita l stays , concer n abou t rehospitalization i s alway s a part of outpatien t treatment . Suc h individ uals fea r th e disruptio n t o thei r lives , th e interruption t o thei r freedom , the los s o f therapists , an d th e visible sig n o f illnes s tha t th e hospita l comes to represent . Rehospitalizatio n ma y also feel lik e an indication o f failure. O n th e othe r hand , th e hospita l ma y wel l represen t safet y an d asylum—in th e bes t sense—fro m th e demand s o f a world tha t i s poorl y designed fro m th e standpoin t o f schizophreni c individuals ' vulnerabili ties. The hospita l ma y als o b e th e onl y wa y i n whic h patient s ca n imagine creatin g emotiona l distanc e fro m thei r outpatien t therapists , who ar e usually very important figures in patients' lives. Hospitalizatio n can interrupt this dependency. With the added pressure of a n emergency situation the question of rehospitalization raise s all these issues. 271

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In thi s chapter , w e tak e u p th e issu e o f rehospitalizatio n i n a recur rently suicida l patien t livin g i n th e communit y an d discus s th e effect s o f the therapist-communit y relationshi p fo r thi s particula r individual . Th e case w e conside r als o exemplifie s th e difficult y o f th e allianc e wit h th e apparently help-rejectin g client : tha t is , ho w th e therapis t foster s an d tolerates a "hidden " allianc e wit h a patien t wh o need s a grea t dea l o f support bu t fear s wha t i t may cos t in term s o f th e patient's self-imag e o f independence. In addition , w e addres s th e developmen t o f a disruptiv e transference an d it s management i n term s o f th e principle that , sinc e th e patient ha s no t becom e a ne w individua l whe n disruptiv e transferenc e occurs, consistent attentio n t o th e patient's experienc e remain s th e goal . Finally, thi s cas e als o show s ho w i t ofte n fall s t o th e therapis t t o b e th e repository o f th e patient' s histor y an d o f th e histor y o f th e patient therapist relationship .

OUTPATIENT PSYCHOTHERAPY AND REHOSPITALIZATION ISSUE S FOR THE CHRONICALLY SUICIDAL PATIENT One day, after havin g been out of the hospital fo r abou t a year, Maryan n left a messag e cancellin g a psychotherap y sessio n fo r th e secon d tim e that week , addin g tha t th e therapis t coul d cal l her . Whe n h e di d so , Maryann sai d tha t sh e ha d lef t he r da y hospita l progra m earl y becaus e she fel t ill , a s sh e ha d al l weekend , whic h sh e spen t i n bed . Whe n th e therapist aske d abou t he r depressio n an d th e suicida l thought s tha t sh e had bee n havin g lately , Maryan n sai d tha t sh e was stil l havin g impulse s and thought s abou t killin g herself, but tha t sh e had n o plan t o do so an d was als o tellin g hersel f tha t sh e really didn' t wan t t o die , blocking thes e thoughts ou t o f her mind . Maryann adde d tha t ove r th e weeken d sh e ha d bee n disturbe d b y a movie i n whic h a docto r fel l i n lov e wit h hi s femal e patient . Sinc e Maryann's therapis t wa s male , the referenc e t o th e movi e seemed highl y significant. Sh e sai d sh e fel t alienated , disoriented , an d a s i f sh e go t n o support fro m anyone . Sh e wa s generall y annoye d a t th e therapis t bu t agreed t o hi s suggestio n tha t sh e com e i n earlie r tha n he r regula r ap pointment th e next day . On Thursday , Maryan n attende d he r da y hospita l progra m an d he r therapy sessio n an d sai d sh e fel t better . Th e therapis t insiste d tha t sh e

The Case of Maryann 2 7

3

talk abou t th e session s she' d missed latel y an d abou t whether she' d fel t suicidal. H e als o inquired abou t whether he eould trust her to b e honest about thes e issues , give n tha t sh e ha d bee n tellin g hi m tha t ther e wer e many areas of her life, especially her religion, she felt she could not share with him . I n a n apparentl y sincer e an d relate d way , Maryan n repeate d that she think s o f suicid e bu t knows tha t Go d doe s no t want he r to kil l herself. Sh e didn' t wan t t o die , bu t i t was ver y har d fo r he r t o thin k o f facing the rest of he r life if things did not get easier. T: Ca n you understan d my concern about whether or not I can believ e you th e time s whe n yo u promis e you'l l g o t o th e emergenc y roo m rather than act on a suicidal thought ? M: Yes , I know you're worried when I don't tell you things—but I don't want t o change , you know , I just can't change . Yo u know , yo u ar e still a threat to me sometimes. I know yo u don' t share my faith. It' s bad for my mind for me to try to talk to you about these things. T: S o there are still a lot of area s where you reall y can't trust me, as if I'd try to get you to change your identity or your religious beliefs ? M: Well , yes there are. I don't want to tal k abou t it. I've been thinkin g a lo t abou t judgmen t da y lately . Yo u kno w tha t th e Bibl e i s ver y meaningful t o me—I'v e bee n readin g i t a lo t lately . I thin k tha t judgment day is coming sooner than most people think. T: Lik e how soon ? M: I kno w mos t peopl e wouldn' t believ e this , an d sometime s I don' t either, but sometimes I think i t might b e in two weeks . I know tha t you probably think that's crazy. T: Wha t I was wondering abou t was how you se e all this in relation t o you an d your life specifically , becaus e judgment da y usually implie s people bein g dead , an d I wondered i f yo u wer e feelin g tha t you'r e supposed t o tak e a n activ e rol e i n this—lik e makin g sur e you'r e dead in two weeks. M: O h no, nothing like that. That's not the way it works. T: Bu t whe n yo u tal k abou t i t lik e this , an d whe n I kno w tha t yo u don't trust me very much, I worry that you might not feel you could tell m e i f yo u wer e goin g t o kil l yourself . D o yo u thin k yo u migh t feel mor e saf e i n th e hospita l fo r a while ? I' m stil l worrie d abou t whether you' d reall y trus t me enough t o tel l m e just how ba d you r suicidal impulses were getting.

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M: I know wha t you'r e saying , I know wha t yo u mean . I really don' t think I need to go into the hospital now—I' m really not suicidal lik e that. I would definitel y g o t o th e emergenc y roo m i f I needed to . I wouldn't try to hurt myself. I' m not planning anything . Patients wh o hav e suffere d th e turmoi l an d humiliation s o f schizo phrenia fo r year s ar e ofte n depressed , discouraged , an d a t ris k fo r sui cide. Ho w t o manag e thi s ris k i n th e contex t o f th e patient' s an d clini cian's join t effort s fo r th e patien t t o buil d a stabl e lif e i s a recurrin g theme in outpatient treatment. While the clinician does not wish to leave a seriously suicidal patient without sufficient supervision , hospitalizatio n is disruptive t o th e lif e th e patient ha s tried to build , an d man y patient s resist rehospitalization s becaus e the y hav e unpleasan t memorie s o f pas t stays an d vie w hospitalizatio n a s a sig n o f failure . Family , communit y residence staff , an d staf f o f da y program s an d rehabilitatio n facilitie s may shar e thi s bias , a s might a therapist, especiall y i f h e or sh e equate s hospitalization wit h a failur e a s a healer . Thi s bia s complicate s assess ment o f th e patient' s abilit y t o continu e i n outpatien t settings , particu larly when there is a possibility tha t the patient is concealing distress out of reluctance to return to the hospital. The nature of the patient's current alliance wit h th e therapist, th e state o f th e transference, an d the curren t stresses in the patient's lif e al l affec t thi s assessmen t process. Inpu t fro m other agencies working with the individual ma y prove useful . For example , conside r th e perso n who , i n th e mids t o f a psychoti c transference, believe s th e therapis t t o b e exceedingl y powerfu l an d ho mosexually intereste d i n th e patient . Suc h a patien t migh t wel l see k suicide t o protec t himself , feelin g ther e i s no saf e have n fro m thi s pow erful figure. Th e sam e patient , havin g a sexua l delusiona l belie f abou t his boss an d a relatively nonconflicted positiv e transference t o the therapist, migh t no t requir e hospitalization, becaus e h e could discuss i n therapy his ideas about his boss. Using the system of hypothesi s building and attending to the patient's subjective experienc e an d th e wa y i t inform s th e treatmen t partnership , as outlined i n the first section of thi s book, we will try to show ho w thi s orientation cause d th e therapis t t o decid e t o se e Maryan n fo r a n extr a session, a t which tim e h e hospitalized her . Though o n th e fac e o f it , hi s rationale fo r this decision might not appear obvious, we will try to sho w

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how, i n following th e schema outlined i n the earlier chapters, the therapist arrived at this particular set of interventions .

History First, Maryann's history a s known to the clinician at this time. Maryann was a 32-year-old woma n wit h a B.A. wh o ha d initially develope d clea r symptoms of schizophrenia in the course of her first post-college employment. A t that time, she developed religious preoccupations an d believe d she wa s possesse d b y th e devil . Soo n Maryan n wa s hospitalize d b y he r anxious parents . Afte r a shor t sta y an d treatmen t wit h phenothiazines , she lef t th e hospital—prematurel y becaus e sh e fel t overmedicated—an d gradually bega n to work agai n part time. Her medication was graduall y tapered b y he r outpatien t psychiatrist , wh o sa w he r monthl y t o chec k on her symptoms. Maryann was off medicatio n within a year of this first hospitalization an d supposedly symptom-free ; i t later seemed likely that she continued covertly to have religious and paranoid delusions. A fe w month s afte r stoppin g al l medications , Maryan n onc e agai n became terrifie d an d distraugh t an d locke d hersel f i n he r roo m ou t o f fear. Sh e wa s hospitalize d fo r wha t turne d ou t t o b e a six-mont h stay , because eve n a s he r pacing , agitation , an d report s o f delusion s an d hallucinations abated , sh e continue d t o engag e i n risk y behavior s whil e out on passes, such a s picking up men in disreputable bars . The focus i n this hospitalization was to help Maryann to "seal over" (1) her psychosis by puttin g i t behin d he r rathe r tha n b y tryin g t o understan d it , sinc e Maryann's interes t i n recognizin g he r illnes s an d learnin g abou t situa tions tha t cause d he r t o develo p symptom s appeare d t o b e limited . Nonetheless, Maryan n wa s no t fel t t o b e stabl e enoug h t o leav e th e hospital unti l a n extended period o f inpatien t treatmen t with increasin g passes int o th e communit y ha d take n place . Sinc e Maryan n alway s seemed to get into some kind of trouble as discharge plans to home were made, a decision was take n to refer her to a residential treatmen t cente r from whic h sh e coul d loo k fo r wor k outsid e a protecte d setting . I n contrast t o th e cas e describe d i n chapte r 7 (i n whic h th e hospita l staf f insisted on a discharge plan which separate d patient an d family), Mary ann an d he r famil y ha d decide d thi s wa s th e bes t pla n durin g a perio d

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of famil y work , an d althoug h the y misse d eac h other , th e separatio n seemed manageable . Maryann di d well , eventuall y holdin g a jo b an d returnin g t o he r hobbies o f sewin g an d hiking . Sh e wa s maintaine d o n chlorpromazine . But tw o year s afte r he r hospita l discharge , sh e agai n ha d difficult y concentrating an d bega n t o mis s work , an d sh e fel t sh e mus t retur n home. Whe n sh e di d so, sh e fel t bette r fo r awhil e an d worked par t time while angerin g her parents with her attitude of entitlement an d apparen t laziness. Sh e returne d t o drinkin g an d contracte d pneumonia , durin g which he r physician temporaril y discontinue d he r psychotropic medica tion. Hom e alon e an d physicall y ill , Maryann' s delusiona l idea s flourished. Sh e staye d u p al l nigh t playin g lou d music , until , enraged , bu t with n o wa y t o kno w ho w delusiona l Maryan n was , he r parent s at tempted to get her to mov e ou t of th e house. When she became belliger ent, they took he r to the hospital. This wa s t o b e a short-term stay ; Maryan n quickl y bega n t o behav e more appropriately. He r parents expressed their inability to have her live at home , an d Maryan n seeme d t o accep t this . Whil e sh e continue d t o refer to the suicidal ideatio n she had experienced prior to admission, sh e reassured staf f tha t sh e wa s i n contro l whe n the y aske d he r abou t suicidal impulses . Bu t followin g a n upsettin g grou p therap y session , Maryann badl y cu t her wrists with a broken piec e o f plastic , necessitat ing an emergency roo m visit. This was the beginning of another long-term hospitalization, this time with a n adde d psychotherap y focu s i n whic h Maryan n wa s encourage d to explor e he r feeling s abou t he r illnes s an d th e possibl e relationship s between her delusions an d other symptoms an d her emotional reactions . This recommendatio n fo r exploratory psychotherap y wa s mad e becaus e Maryann ha d begu n t o expres s curiosit y abou t wha t wa s happenin g t o her an d a motivatio n t o improv e he r relationships . Also , lon g trial s o f supportive treatmen t aime d a t sealin g over ha d faile d t o mak e majo r changes i n he r illnes s an d th e managemen t o f he r symptoms . Whil e psychotherapy wa s ver y difficul t fo r her , give n he r grandios e wis h t o claim sh e alread y understoo d everythin g abou t herself , Maryan n di d develop a psychotherap y relationshi p an d gaine d som e insight s int o some o f he r feeling s abou t he r family , especiall y thos e tha t repeatedl y led he r t o wan t t o b e a t hom e an d the n behav e i n a wa y tha t mad e remaining ther e impossible . Sh e wa s discharge d t o a da y hospita l an d

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halfway hous e an d t o psychotherap y thre e time s a week . He r medica tions controlle d som e o f he r anxiet y an d delusions , althoug h sh e re mained somewha t delusiona l throughou t man y adequat e trial s o f var ious medications . At thi s time , Maryan n spok e o f hig h expectation s fo r hersel f bu t complained abou t th e demand s o f th e halfwa y house , th e da y program , and psychotherap y an d di d no t see m t o se e tha t he r difficultie s ther e implied a nee d t o lowe r he r sights . She continue d t o b e paranoid, gran diose, and irritabl e whe n unde r an y stress . Her religiou s belief s coul d b e seen alternatel y a s delusiona l symptom s o f he r illnes s o r a s a n adaptiv e response t o th e man y disappointment s an d humiliation s o f he r illness . She spoke o f he r convictio n tha t Go d ha d som e reaso n fo r askin g her t o suffer fro m schizophreni a an d tha t i t wa s he r rol e t o underg o thi s suffering unti l som e unreveale d tim e in the future . In he r halfwa y house , Maryan n followe d th e rule s bu t hate d th e group meeting s an d th e nee d t o tak e turn s wit h cleanin g chores . Sh e presented th e sam e picture a t th e da y program, indicatin g i n a variety o f ways tha t sh e considered hersel f abov e the other client s and, a t the sam e time, tha t th e responsibilitie s an d group s wer e a terrible burde n becaus e of he r constan t distress . In bot h settings , Maryan n wa s initiall y success ful i n making staf f believ e she was much les s fragile tha n sh e in fact was . To Hospitalize o r No t t o Hospitaliz e The Therapist's Model At th e tim e o f th e phon e cal l an d sessio n describe d above , the therapis t already ha d a se t o f hypothese s abou t Maryann' s experienc e o f herself , the therapy, th e therapist, th e day hospital an d halfway house , and othe r significant element s of her life. In the first part of this book, we presente d a mode l fo r conceptualizin g schizophreni a an d a serie s o f foc i fo r gath ering data t o us e in the assessmen t o f a patient's subjectiv e experienc e i n order t o maximiz e th e developmen t o f a therapeuti c collaboration . Thi s model wa s used with Maryann . Physiological Substrate ("Primary" Disturbances) The therapis t kne w tha t th e biologica l substrat e o f Maryann' s illnes s was quit e severe , sinc e sh e ha d severa l schizophreni c relative s an d ha d

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been il l wit h man y sever e symptom s fo r severa l years . Thi s mean t tha t all o f Maryann' s accomplishment s ha d t o b e viewe d agains t th e back ground o f th e sever e disturbanc e wit h whic h sh e struggled daily . Mary ann experience d constan t mistrus t an d anticipator y anxiet y o f gettin g into troubl e becaus e othe r people migh t suddenl y mistrea t an d provok e her or attack her physically without reason. Her baseline level of anxiet y was s o hig h tha t sh e almos t neve r rea d o r wen t t o movie s becaus e sh e would b e distracte d b y he r fears , no t t o mentio n b y th e vivi d fantasie s the material migh t evoke, and thus was unable to concentrate. "Secondary" Disturbances with Probable Physiological Basis At time s o f change , loss , o r highe r expectation s fro m others , Maryan n regularly develope d dermatitis , althoug h sh e believe d thi s t o b e du e i n part t o he r hig h consumptio n o f sugar . Sh e als o becam e physicall y anxious an d restles s prio r t o recognizin g tha t sh e migh t b e havin g a n emotional reaction . He r sleep varied with her psychological life , an d she was subjec t t o nightmares , whic h suggeste d tha t he r physical sel f wa s poorly protecte d fro m th e vicissitudes o f he r emotional reactions . While she rarely hallucinated, sh e had man y grandios e an d paranoid delusion s and overvalue d ideas , an d managin g t o ac t appropriatel y i n spit e o f these used a great deal of time and energy. Maryann's availabl e range of affect wa s relativel y normal , bu t sh e wa s frequentl y enraged , worried , and discouraged , an d he r fear s an d suspiciousnes s limite d he r sens e o f humor. She was very vulnerable t o intense depression an d despair at her setbacks, and, although sh e denied that losses or rejections ha d much o f an impac t o n her , he r increase d anxiet y an d sleeplessnes s a t suc h time s suggested otherwise . Psychologically Mediated Responses to the Core Physiological Deficits. Subjective Experience Interaction with the Environment. Managemen t o f he r environmen t (see Tabl e 2.1 ) include d a variet y o f manifes t communication s an d a form o f idiosyncrati c relatednes s characterize d b y control . Maryann' s behaviors include d arrogance , a sens e o f entitlement , an d widesprea d complaining abou t he r struggle s an d he r mistreatmen t b y others . Ob viously, sh e could b e suspiciou s an d paranoid. Becaus e i t was s o impor -

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tant fo r he r t o se e hersel f a s good, i t wa s ver y difficul t fo r he r to allo w herself t o becom e awar e o f bein g angr y unles s sh e felt completel y justi fied by others' real or imagined mistreatment. As a result, those she dealt with dail y tende d t o experienc e he r a s passively aggressiv e o r rud e an d self-centered, lackin g i n awarenes s o f he r impact o n others—on e o f he r forms o f idiosyncrati c relatedness . Maryan n viewe d other s i n extreme , need-gratifying terms , according to whether they made her feel comfort able o r uncomfortable . Sh e wa s quit e contemptuous , althoug h a t time s she tried to hide this attitude with clinging behavior, which also irritated others. The manifest communicatio n o f these behaviors was "Le t me see myself a s good; I can't bea r to thin k I might b e responsible fo r som e o f the bad things that happen to me."

Quality of Patient's Experience. Thes e manifes t communication s an d idiosyncratic, rigid ways of dealin g with others implied, to her therapist, a particular set of subjectiv e experiences and view of herself. He hypothesized Maryann' s vie w o f hersel f t o b e tha t o f a specia l perso n bein g misunderstood an d burdene d b y a n insensitiv e world , whic h wa s un aware of o r unwilling t o acknowledg e he r special gift s an d the fac t tha t she was chpsen to suffer . This vie w o f hersel f an d he r tas k i n lif e represente d a sustainin g experience fo r her . Sh e saw hersel f proudl y a s struggling o n despit e he r misfortunes. Sh e felt irrevocably differen t fro m other s in her specialnes s and sufferin g (whic h supporte d wea k self-objec t differentiation ) and , because o f this , commandin g thei r hel p an d respec t (allowin g fo r th e possibility o f relatedness) . I t wa s importan t fo r he r t o se e hersel f a s totally goo d an d righ t i n he r actions , an d sh e als o believe d tha t sh e had a detailed an d complete psychological understandin g o f hersel f an d others. As noted , Maryann' s belie f tha t sh e wa s specia l an d deservin g o f comfort an d support mad e i t possible fo r he r to liv e wit h th e disabilit y of he r illness: This was a sustaining experienc e fo r her . Her narcissistic , entitled stance warded off th e terrible humiliation that would have come with a les s denyin g approach . Afte r all , hadn' t Go d selecte d he r t o endure incredibl e suffering ? Mos t importantly , althoug h sh e mistruste d others, with the above-outlined view of herself an d others to sustain her, Maryann continued to seek human contact as part of her conviction tha t

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she was deserving of specia l attention , a conscious goal dispit e her belief that she was so different fro m other people. However, Maryann' s fantas y lif e an d sustaining experience s include d more work-oriented elements. If she won the lottery, she said, she would want t o bu y th e kin d o f expensiv e compute r equipmen t tha t woul d enable he r t o hav e he r own business . (O f course , th e ide a o f th e lotter y posed ticklis h problem s fo r Maryann . If , indeed , sh e wa s chose n abov e others fo r specia l attentio n fro m God , wh y resor t t o a lotter y a t all ? Wouldn't ther e b e divin e intervention ? Maryan n struggle d wit h thi s problem, an d eac h tim e sh e lost , announce d tha t i t wa s on e mor e tes t for her. On another level, Maryann was testing the therapist's sensitivit y and timing , waitin g fo r hi m t o challeng e he r with "I f you'r e s o special , how com e yo u lost?" ) Other , overtl y hostil e fantasie s o f wishin g t o kil l her grandfather, whic h ha d been present as obsessional thought s thoug h never acted upo n when sh e was in the hospital, suggeste d tha t Maryan n continued t o hav e sadistic fantasie s alon g with th e ones sh e was willin g to share. Under the heading of psychological continuity , clarity, and what have been traditionally calle d ego strengths, Maryann had been able to get an education and to work intermittently, and she maintained faith in herself despite setbacks, even if a t times this confidence showe d itself a s grandiose delusions. This kind of optimis m an d grandiosity serve d as an adaptive respons e t o Maryann' s sens e o f bein g invaded , controlled , humili ated, and exploited by others. In terms o f othe r eg o functions , Maryann' s capacit y t o maintai n he r stimulus barrie r an d self-object differentiatio n wa s fragile . Sh e was ver y sensitive t o othe r people, watchin g the m carefull y an d tryin g to analyz e what the y wer e thinkin g o f her . But she alway s foun d the m disappoint ing and her interactions frustrating , whil e other s felt she was excessivel y demanding. Sh e had t o us e contemp t fo r other s an d a n inflate d vie w o f herself t o suppor t self-objec t differentiation—tha t is , sh e coul d se e he r identity as separate from others by seeing herself a s special. Concerns. A major implication o f th e manifest communications , form s of idiosyncratic relatedness, and quality of subjective experience outlined for Maryan n wa s tha t contro l wa s a major them e o r preoccupation fo r her. Sh e carefull y hi d he r fea r tha t other s wer e goin g t o manipulat e he r and sustaine d he r fragil e autonom y throug h arroganc e an d contempt .

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She wa s bette r abl e t o tolerat e contac t wit h other s tha n man y person s with such severe illnesses and actually sought some contact, although, of course, sh e readil y becam e suspiciou s an d fel t tha t other s expecte d to o much o f he r o r wante d he r t o grove l i n retur n fo r thei r attention . He r conception o f he r own an d others' limitations wa s minimal , an d i n thi s context, sh e experience d littl e consciou s conflic t abou t he r manne r o f adapting t o he r illness , sinc e i t was essentia l fo r he r to believ e tha t sh e was capabl e an d i n contro l an d tha t sh e ha d mad e th e bes t choice s possible. (I n fact, th e choice s ha d bee n mad e fo r her. ) Actually , fo r he r even t o conside r thi s questio n o f limitation s wa s impossible , since sh e experienced hersel f a s fighting fo r he r life , usin g he r belief s i n th e onl y way sh e knew . An y alternativ e viewpoin t threatene d t o destro y he r entire syste m o f adaptation . Thus , he r majo r priority , tha t whic h too k up th e bul k o f he r attentio n an d energy , wa s he r denia l o f he r illness . The only evidenc e o f an y benign conflic t abou t this priority was the fac t that, rathe r tha n completel y refusin g treatmen t a s migh t b e consisten t with he r state d views , Maryan n di d allo w hersel f t o se e a therapist an d to atten d a day progra m an d live a t a halfway house , an d sh e was ver y responsible abou t taking her medication. The Therapeutic Alliance All of thes e hypotheses abou t Maryann's experienc e informed th e therapist in considering how Maryan n would feel abou t being in therapy an d how bes t to for m a n allianc e wit h her . The therapist sa w Maryan n a s a frightened perso n longin g fo r contac t bu t fearin g it , whil e fighting t o contain intens e drive s an d fantasie s tha t threatene d t o overwhel m her . But for Maryann herself, a traditional vie w of psychotherapy wa s nearl y impossible. T o b e understood b y a therapist was tantamoun t t o invitin g invasion an d manipulative control . I t meant admitting she really neede d another huma n being , wh o woul d onl y disappoint , frustrate , an d hur t her. It meant acknowledging that she was not fully in control of her own life and that she was ill. To her, this implied that she was weak, tha t she was not special i n the ways sh e believed, that she needed help in managing he r lif e an d understandin g herself . I t meant allowin g th e possibilit y that sh e was no t alway s correc t i n her perceptions an d choices . Despit e her wishe s fo r friends , Maryan n ofte n fel t tha t i t wa s preferabl e t o b e omnipotent an d lonely than to be painfully involve d with people.

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As note d above , Maryann' s preferre d mod e o f relatin g wa s t o see k contact whil e maintainin g contro l b y arming herself agains t rebuf f wit h contempt an d devaluation . Peopl e wh o treate d he r a s specia l an d wh o could tolerat e he r passive-aggressiv e behavior s wer e th e mos t likel y t o remain i n touc h wit h her , an d sometime s he r clingin g behavio r evoke d impulses in others to take care of her in this way. Still, she was bound t o feel alienate d and paranoid in therapy. How t o offe r psychotherap y t o suc h a n individual ? The therapist' s goal wa s to help Maryann become mor e flexible in her understanding o f herself an d other s throug h a stronger sens e o f he r identity an d her self other boundaries . H e hope d tha t greate r understandin g o f th e interna l pressures tha t drov e he r woul d enabl e Maryan n t o fee l greate r confi dence i n he r abilit y t o contro l hersel f s o tha t sh e coul d mak e mor e adaptive, less self-destructive choices . In order to offer therap y to Maryann in a way that she could tolerate, the therapist considered Maryann' s priorities an d sustaining experience s as describe d above , wit h thei r associate d demand s o n hi m an d th e res t of th e environment. H e realize d that Maryann was able to manage to be in therapy b y viewing i t a s somethin g impose d fro m th e outside: I t had been recommende d b y th e hospita l staff , an d some kin d o f therap y wa s required by her halfway house . The therapist had to be willing to accep t temporarily a rol e tha t allowe d Maryan n t o maintai n he r denia l o f illness whil e sh e attende d therap y appointments . Sh e ofte n tol d th e therapist tha t a s soo n a s sh e wa s o n he r own , sh e woul d "drop " him. She allowe d hi m i n he r lif e a s a friendl y audienc e t o he r discussion s o f her daily experiences an d her complaints, her hopes an d dreams and her understanding of hersel f an d others. He could also be used, in her mind, to bear witness to her specialness an d suffering . From thi s perspective , i t wa s no t necessar y t o challeng e Maryann' s rationale for being in therapy as long as she continued to attend sessions. The therapis t coul d accep t tha t fo r som e time , hi s rol e wa s t o b e a somewhat devalue d audienc e who wa s t o step in to do the "dirty work " when necessary. Maryann was willing to have a therapist if it meant that there was someone else to take her part or try to explain her troublesome behaviors when she episodically alienate d th e staff a t the day hospital o r halfway house . I n "allowing " hi m t o "front " fo r her , sh e ha d foun d a way to accept help without losing face. The therapist also seemed willing to liste n t o ho w angr y sh e wa s an d eve n encourage d he r t o tal k abou t

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her sadistic fantasie s a s lon g a s sh e mad e i t clea r sh e wouldn' t ac t o n them, an d sometime s doin g thi s le d Maryan n t o hav e fewe r o f he r painful idea s o f reference . Althoug h sh e didn' t acknowledg e this , some times she felt the therapy gave her some relief. In the first part of thi s book, w e articulate d the principle of establish ing what the patient can and cannot d o at this time. Usin g that principle and incorporatin g tha t informatio n int o a treatment , th e therapist' s initial techniqu e wa s t o support th e ide a tha t Maryann' s inne r lif e wa s special an d privat e an d tha t sh e coul d refus e t o shar e thi s wit h th e therapist unles s i t bor e o n th e issu e o f suicide . H e supporte d th e ide a that it was norma l fo r Maryann's thought s an d dreams t o be sources of pleasure fo r he r (a s on e o f he r fe w sustainin g experience s an d thu s important for the therapist to pay attention to) an d that it was immater ial i f th e pleasurable thought s wer e delusional , unles s th e thoughts cause d her to act in ways that caused trouble in her life. Even then, the therapist was sensitiv e t o preservin g he r narcissism , referrin g t o suc h episode s a s ones i n which "ther e woul d b e a serious differenc e o f opinio n betwee n you an d others , who , becaus e o f thei r wa y o f understandin g things , could en d u p causin g yo u grief. " H e thu s sough t t o regularl y reinforc e the distinctio n betwee n inne r an d oute r reality , betwee n though t an d action. The therapis t kne w tha t Maryann' s pictur e o f hersel f a s especiall y good an d talented an d able to understand herself an d others was crucia l to maintainin g a n otherwise ver y fragile sens e of self-estee m an d safety . At th e sam e time , sh e fel t ver y sensitiv e an d experience d wha t other s would se e a s ordinar y demand s o f lif e a s hugel y burdensom e expecta tions. Whil e i t wa s importan t t o he r t o believ e i n he r capacit y t o hav e close, war m relationships , sh e fel t painfull y dependen t o n authorit y figures and regularly imagined that they intended to humiliate or exploit her. Thus , th e therapis t tolerate d he r devaluatio n o f hi m an d o f th e therapy, a s lon g a s certai n othe r condition s wer e met , since thi s deval uation defende d he r against her terrible fear of needin g him. He insiste d that sh e kee p hi m full y informe d abou t he r suicida l thought s an d feel ings, an d sh e ha d alway s agree d t o thi s an d understoo d tha t otherwis e he couldn't be her therapist. The therapis t als o monitore d hi s countertransferenc e constantly . Sometimes, he felt the need to retaliate against Maryann's contempt an d dismissal o f him—retaliatio n tha t usuall y too k th e for m o f a wis h t o

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ruthlessly expos e th e dept h o f Maryann' s (denied ) nee d fo r him . The n he woul d realiz e tha t implicit i n Maryann' s expresse d devaluatio n wer e other feeling s tha t wer e har d fo r th e therapis t t o tolerat e a t th e time , such as her sense of despai r and longing for him. Thus, th e therapis t accepte d Maryann' s verba l denia l an d minimiza tion o f he r illnes s a s lon g a s sh e indicate d otherwis e b y he r behavior , attending da y hospita l program s an d psychotherapy session s an d agree ing t o liv e i n a supervise d residence . T o som e extent , h e accepte d he r paranoid transference, challengin g it only when it intruded into the basic arrangements o f th e therapy—tha t is , th e agreemen t tha t Maryann woul d be hones t abou t suicida l feeling s an d othe r potentiall y dangerou s im pulses. H e wa s awar e tha t Maryan n experience d chang e a s a tota l revolution i n he r sens e o f identity , whic h woul d leav e he r feelin g mor e empty, lonely , an d insecure . Maryann' s delusion s wer e preciou s t o he r because the y mean t tha t sh e wa s special . T o admi t tha t the y wer e onl y the symptoms o f a n illness would mea n viewing herself a s a person wh o had not accomplished muc h in conventional terms , although her accomplishment i n livin g wit h a n illnes s a s sever e a s her s wa s considerable . Any revisio n i n the perspective brough t t o these beliefs ha d to be undertaken slowl y an d respectfull y becaus e o f thi s implication . Furthermore , Maryann's delusion s wer e old , familia r part s o f he r personality b y no w (2). Sh e neede d t o hav e attractive , alternativ e view s o f herself , an d transformed view s o f he r symptoms t o allo w he r to kee p her self-estee m in plac e befor e sh e coul d surrende r an y o f he r delusion s an d grandios e thoughts. Fo r example , sh e neede d t o transfor m he r delusion s o f gran deur int o pleasan t daydream s tha t wer e understandabl e an d justifiabl e given her difficult life . Maryann's habi t o f occasionall y missin g appointment s wa s under stood by the therapist in terms of her difficulty i n accepting therapy. Her missing appointment s wa s on e o f he r mechanism s fo r maintainin g a sense of herself a s spearate from the therapist, reminding herself that she was i n contro l an d tha t sh e di d no t nee d hi m s o much . Th e misse d sessions wer e discusse d i n thes e terms , th e therapis t empathizin g wit h Maryann's experienc e o f th e session s a s quit e tirin g a t time s whil e reiterating hi s nee d t o kno w tha t sh e wa s no t missin g a n appointmen t because o f suicida l plan s o r feelings . Maryan n usuall y note d whe n sh e called to cance l tha t she was "doin g ok" but just didn't fee l lik e comin g to the appointment .

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Maryann was terrified to say how little she trusted and how muc h she feared th e therapist , ofte n preferrin g t o sta y away . Thi s was par t of he r devaluing and paranoid attitude toward the therapist. It was very important fo r he r tha t th e therapis t hav e n o reaso n t o thin k tha t h e wa s important to her . She saw him because she "had" to, and on a nice day, it was pleasan t t o wal k t o hi s offic e an d tel l hi m abou t he r dream s an d thoughts an d the events of th e day and how terribl e her life was, alway s with the assurance that she could stop telling him something at any time. Within tha t contex t o f idiosyncrati c relatedness , Maryan n wa s actuall y doing a grea t dea l o f therapeuti c wor k toward s shorin g u p he r self boundaries an d understandin g mor e abou t he r paranoi d delusion s an d how the y aros e i n everyda y life , despit e he r clai m tha t sh e alread y understood everything about herself. Delusional Systems The problem of understandin g the meaning of religio n to Maryann is an example o f th e way i n which th e therapist was alway s tryin g to balanc e the nee d t o b e awar e o f th e exten t o f Maryann' s patholog y an d it s impact on her functioning with the adaptive value of many of Maryann' s behaviors an d beliefs , eve n thoug h thes e migh t see m pathologica l t o a n observer. Thi s perspectiv e o n th e patient' s behavior s wa s crucia l t o understanding he r attempt s t o functio n whil e maintainin g som e leve l o f self-esteem an d freedo m fro m pain . A s w e note d i n chapte r 1 , under standing the adaptive attempts in symptoms, or apparent symptoms, can lead to ways to deepen the therapeutic alliance. Maryann's delusion s abou t th e devi l seeme d t o hav e fade d wit h th e remission o f he r acute phase o f illness . Sh e gradually develope d a set of beliefs focuse d o n he r religiou s positio n a s a "bor n again " Christian . Most o f he r belief s an d practices wer e thos e o f other s i n such sects . She watched Christia n T V programs , listene d t o th e speaker s giv e advic e about ho w t o understan d suffering , an d fel t tha t Go d ha d forgive n he r for her sins. At times , however , Maryan n woul d mak e comment s tha t implie d a certain leve l o f magica l i f no t delusiona l thinkin g i n th e contex t o f he r religious beliefs . Further inquiry confirmed th e impression that Maryann continued t o have , o r perhap s ha d redeveloped , religiou s delusions , although sh e limite d discussio n o f thes e t o th e therapy . The therapist' s

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first reactio n wa s uneasines s an d anxiet y abou t th e fac t tha t Maryan n was s o clearl y stil l psychotic , an d he foun d himsel f toyin g with th e ide a of tryin g to find a reason tha t would see m plausible to Maryann t o raise her medication ; certainl y th e ide a o f increasin g medicatio n t o suppres s what t o he r were importan t religiou s belief s woul d no t appea r t o he r a helpful step . He then began to try to assess whether Maryann's function ing wa s deterioratin g i n an y wa y tha t woul d sugges t tha t th e religiou s delusions were but one sign of increasing illness. Eventually, he began to see tha t i n tellin g hi m mor e abou t he r religiou s ideas , Maryan n wa s indicating greate r trus t i n an d closenes s t o him . Whe n h e expresse d interest i n he r thoughts , wit h less anxiet y abou t th e morbidit y implie d by the symptoms sh e was revealing, Maryann also began to mention her own concern that she keep her religious feelings an d beliefs in balance in her life—becaus e sh e recalle d th e terrifyin g religiou s delusion s an d hal lucinations tha t ha d tormente d he r i n acut e phase s o f he r illness . Sh e distinguished thes e fro m he r belief s i n he r specialnes s an d i n God' s forgiveness an d specia l plan s fo r her . Thus , b y no t insisting o n hi s priorities i n thi s area , b y appreciatin g th e sustainin g functio n o f thes e ideas t o Maryann , th e therapis t helpe d he r t o arriv e a t greate r clarit y about her inner versus outer experiences. In th e bes t circumstances , Maryan n wa s abl e t o discus s openl y he r difficulty talkin g abou t he r religious feeling s wit h th e therapist, an d thi s became a wa y t o discus s mor e genera l psychologica l an d transferenc e issues: M: Yo u know , basicall y I' m worrie d tha t al l thi s psychologica l stuf f i s really i n conflic t wit h m y belie f i n God , s o I don't lik e t o tel l yo u about it. T: D o you wonder what I'm thinking, or how I'l l react maybe? M: Well , I assume you think I'm just crazy, or just wrong. T: I t sounds like you're thinking I would criticiz e you fo r belief s whic h are ver y importan t fo r you , a s i f I couldn't accep t yo u a s a perso n any more. M: Mayb e that' s becaus e I don't reall y accep t yo u a s a perso n o r se e you a s human a t all—it's very hard for me , I usually jus t see you a s a professional, a s if you're not a member of the human race. At th e poin t Maryan n an d he r therapis t ha d reache d whe n th e issu e of rehospitalizatio n aros e again , Maryann' s relationshi p wit h he r thera-

The Case of Maryann 28 7 pist coul d b e describe d a s on e o f denie d dependenc e an d consciou s suspiciousness, which she generally chose to conceal from the therapist. The therapist repeatedly tried to enable Maryann to discuss her paranoid reactions to him and the circumstances under which they arose or were exacerbated, and she had gained some insight into the fact that her anger at bein g il l fo r s o lon g an d th e ide a tha t sh e neede d th e therapis t contributed to her paranoid thoughts. Another major theme of the work was th e slo w transformatio n o f wha t ha d bee n terrifyin g bu t magical delusions int o pleasurabl e thought s an d fantasie s Maryan n fel t t o b e under her control. She began to see that her inner life could add to the richness of her experience of life and that confronting this life would not necessarily mak e he r nee d hospitalization . Nonetheless , ther e wa s a sense of loss as she came to see certain grandiose beliefs as delusions that had interfere d wit h he r life i n th e past. I t should b e stressed tha t this process occurre d i n a gradual an d subtl e wa y a s th e therapis t simpl y encouraged Maryann to talk about what it had felt like, for example, to believe she was possessed by and then in a battle with the devil. Note th e progression: In the most primitive and regressed form, the devil had inhabited Maryann, directing her. Her ego-boundary porosity was metaphoricall y expresse d through thi s image o f bein g taken over. At a later point, Maryann, with clearer self-object differentiation, was in a struggle with an outside force—the devil outside. Both were delusions, yet the latte r spoke to a higher level o f eg o integration an d self-objec t differentiation. The therapist did not suggest that Maryann's beliefs were delusional or confront her with reality or try to educate her about reality as long as her beliefs were not interfering with her responsibilities. When her narcissism got her into trouble, because others found her "lazy," he empathized wit h ho w har d it wa s t o fee l s o unabl e t o wor k an d yet have to meet the demands of th e rehabilitation program. Maryann would then decide on her own to make a greater effort. "Confronting " Maryann's narcissism as immature or unrealistic would have been dealing Maryann another narcissisti c blo w a t a tim e i n he r lif e whe n sh e di d no t fee l capable of tolerating any further blows at all.

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Crisis and Rehospitaiizatio n The therapist viewed the incident outlined a t the beginning of thi s chapter a s a crisi s becaus e th e issu e o f rehospitaiizatio n wa s s o sensitiv e fo r Maryann at a narcissistic level. The most conservative move , to immedi ately rehospitaliz e Maryan n when sh e began to talk a t all abou t suicide , was obviou s an d saf e fro m man y perspectives . However , frequen t hos pital stays , eve n i f saf e i n th e shor t run , threatene d t o ad d t o he r depression an d demoralizatio n i n th e lon g run . I f sh e coul d manag e a severe depressiv e episod e withou t goin g int o a hospital , thi s woul d enhance he r confidenc e i n hersel f (an d i n he r therapis t an d othe r staf f with who m sh e worked) . O f course , th e ris k o f repercussion s i n askin g too muc h o f Maryan n a t this point was considerable , an d asking Mary ann directl y abou t he r tolerance leve l i n an y are a of functionin g threat ened her fragile self-esteem . How, then , to understand what the patient was feeling an d telling the therapist i n th e materia l presente d a t the beginnin g o f th e chapter ? He r message tha t th e therapis t "could " cal l he r wa s a s direc t a reques t fo r contact as she could muster, suggesting either than she was not desperate but would lik e to tal k o r that she was i n distress bu t was feelin g unwill ing, perhaps du e to paranoid fear s or embarrassment abou t her need, t o request hel p mor e clearly . He r depressio n an d absence s du e t o som e minor physica l illnes s wer e recurrin g event s a t thi s time ; th e absence s became more frequent . The mos t disturbin g piece o f dat a wa s Maryann' s statemen t tha t sh e had bee n upse t b y th e movi e abou t a romanti c involvemen t betwee n a patient an d therapist. The therapist kne w tha t Maryann was sufficientl y aware o f hi s interes t i n he r dream s an d fantasie s t o kno w tha t thi s comment abou t he r distres s wa s a n importan t messag e t o him . Mary ann's ide a abou t he r distress—tha t i t wa s becaus e i n thi s movi e th e doctor stop s bein g a doctor becaus e o f hi s infatuatio n wit h a patient — suggested tha t sh e wa s feelin g tha t h e coul d b e unreliable—an d need y like her . Mor e ominously , i t suggeste d tha t sh e though t h e coul d b e psychotic. Sinc e th e majo r plo t o f th e movie , thoug h no t mentione d b y Maryann, deal t with a therapist who fel l i n love with a patient an d then devoted his life to her in a very overinvolved way, the idea that Maryann was developin g a delusiona l eroti c transferenc e cam e readil y t o mind . That is, Maryann might have been imagining things about the therapeu-

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tic relationship tha t were making it very hard for her to b e honest, since she migh t b e imaginin g tha t th e therapis t wa s no t onl y untrustworth y but also in love with her. This would imply that he was having problems maintaining boundarie s an d was psychoti c an d i n need o f hel p himself , which perhap s h e wa s goin g t o deman d fro m her . Couple d wit h Mary ann's consciou s complain t tha t sh e fel t alienated , thes e issue s suggeste d that sh e wa s i n mor e troubl e tha n sh e wa s lettin g o n bu t als o tha t sh e felt that to ask for help was dangerous . Hence th e therapist' s offe r o f a n earlie r sessio n th e followin g day , which constitute d a respons e t o th e cover t urgenc y i n Maryann' s mes sage, while avoiding her usual complaint that she didn't feel lik e comin g to therap y afte r a lon g da y a t th e da y program . The therapis t offered , rather tha n waitin g fo r Maryan n t o ask , becaus e h e kne w tha t sh e needed t o se e hersel f a s strong—no t a s th e sort o f perso n wh o woul d ever as k fo r a n extr a sessio n fro m he r devalue d therapist , whos e rol e was to beg to take care of her. Since she generally expected him to mak e the overture s i n he r treatment , i t di d no t see m tha t thi s actio n woul d appear excessively seductiv e or make the situation worse. Fro m a differ ent perspective , i t migh t hav e bee n that , throug h th e movi e reference , Maryann was indicating that she was coming to see something about the therapist's vulnerability an d humanness. I n this context, Maryann' s for mer adaptation failed , leavin g he r momentarily a t greater risk , muc h a s a hermit cra b is more vulnerable durin g the transition fro m on e shel l t o another. In this light, Maryann's crisis was less a relapse-under-pressur e than a crisis of development— a kin d of growing pain. The psychotherap y sessio n th e followin g da y summarize d th e thera pist's dilemma . I t wa s importan t fo r Maryan n t o minimiz e he r depen dency needs in order to continue t o feel good abou t herself an d to avoi d feeling humiliated, discouraged, and suicidal. It was important for her to know tha t sh e di d no t hav e t o tel l he r therapis t ever y detai l o f he r precious inne r lif e an d risk th e feelin g tha t he was intrudin g an d takin g over her identity. Th e therapist knew tha t she could keep the severity of her suicida l impulse s secre t fro m him . However , i f h e too k th e mos t conservative positio n an d insiste d o n hospitalizin g he r agains t he r protestations, an d i f h e di d s o i n erro r abou t th e seriousnes s o f he r self destructive tendencies , damag e woul d hav e bee n don e t o Maryann' s fragile sense of autonomy . Sh e may have felt that the therapist was more concerned with controlling her than with fosterin g her ability to manag e

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her own life, despite his previous efforts t o maximize her autonomy. He r view o f hi m as a unique person with whom sh e had a useful relationshi p could hav e collapsed . Sh e coul d hav e discounte d hi m a s a n all y i n he r struggles, becomin g eve n mor e paranoi d an d les s likel y t o b e hones t i n the future abou t her suicidal thoughts . In the material that led to the question about whether or not Maryann should g o int o a hospital , Maryan n ha d introduce d a ne w religiou s theme, that of judgment day—although i f this represented a change fro m her usua l religiou s concern s i t wa s a subtl e one . Despit e he r denia l o f any suicide plan or death wish in connection with this, knowing that she often used her religious beliefs to guide her daily life and reassure herself, the therapis t agai n fel t worried . Thi s i s a n exampl e o f ho w therapist s become th e repository fo r the histories tha t they and their patients shar e and o f ho w therapist s mus t us e thi s histor y whe n thei r patients ' abilit y to do so is in question. To recapitulate , a t this point the therapist had the following evidenc e regarding the degree of Maryann's suicide risk: 1. Sh e was i n somewhat mor e distres s than usual, a s indicated b y her missing more sessions and asking (indirectly ) tha t he call her. 2. He r usual complaint s o f feelin g alienate d an d unsupported an d her annoyance a t the therapist were more in evidence. 3. He r religiou s concern s wer e takin g a directio n tha t suggeste d in creased concern with death : the day of judgment . 4. Whe n aske d i n a detailed way abou t th e level o f he r suicide intent , Maryann denie d a pla n an d stated tha t sh e fel t i n contro l o f thes e thoughts, which were similar to those she had experienced intermittentl y for years . Sh e appeare d t o b e abl e t o participat e seriousl y i n th e thera pist's inquiry into her suicidal risk . 5. He r histor y als o include d a serious suicid e attemp t whil e i n th e hospital a t a tim e whe n sh e wa s denyin g tha t sh e ha d a pla n t o hur t herself. 6. There was reaso n t o think tha t Maryann's experienc e o f th e therapist wa s mor e severel y distorte d tha n usua l an d that , i n particular , sh e may hav e bee n havin g sever e paranoi d delusion s abou t him . Sh e thu s may hav e fel t mor e mistrustfu l tha n usua l o r even tha t sh e had t o ac t a certain way to prevent him from becoming psychotic. This hypothesis, if true, mean t tha t al l o f Maryann' s statement s t o th e therapis t ha d t o b e seen t o b e affected b y her current belief s abou t the therapist, which ma y

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have include d th e belie f tha t she could not trus t him an d had to protec t him, perhap s b y hidin g he r self-destructiv e tendencie s fro m hi m ou t o f fear of his possible reaction. At thi s point , whil e ther e wa s evidenc e fo r concer n an d continue d monitoring, th e indication s fo r hospitalizatio n wer e no t definite , espe cially give n th e risk s fo r th e patient' s long-ter m prognosi s tha t coul d result from an unnecessary hospitalization . With some patients, it would b e enough at this point fo r therapists t o request a commitmen t tha t thei r patient s as k fo r hel p fro m availabl e community staf f o r th e loca l emergenc y roo m i f thei r suicida l impulse s mounted an d for the therapists t o warn da y hospital an d halfway hous e staff an d enlist thei r hel p i n continuin g t o monito r patients ' condition s between therap y appointments . Man y suc h programs hav e read y acces s to inpatien t service s an d coul d hav e hospitalize d Maryan n i f th e nee d arose. In a similar situation, it is sometimes possible to involve a willing and available family i n providing the supervision an d constant company tha t the hospital provides, while the patient continues psychotherapy an d the therapist also meets with patient and family to discuss daily managemen t questions. I f a famil y ha s sufficien t resource s t o provid e supervision , daily contact s wit h th e therapist , an d som e lo w stres s activities , suc h a plan is often ver y valuable to bot h patient and family. The family learn s about th e patient' s illnes s an d strength s an d weaknesse s an d abou t hi s or her subjective experience s i n a very intens e way , which , i n turn, ca n help the m manag e futur e crise s an d mak e long-ter m plan s fo r th e pa tient. Th e patien t an d famil y ar e spare d th e disruptio n an d probabl e stigma o f a psychiatri c hospita l stay , an d th e patien t alway s benefit s from th e concret e sign s o f lov e an d suppor t tha t th e family' s effor t represents, althoug h thi s ma y als o induc e guil t i n a depresse d patient . However, suc h a n effor t i s no t alway s withi n th e family' s resource s o f time an d mone y an d emotiona l stamina , an d i t i s no t feasibl e wit h a patient wh o ma y becom e violentl y assaultiv e o r suicida l o r attemp t t o run awa y whe n acutel y psychoti c o r wit h on e wh o ha s physica l condi tions or a medication regime that requires constant medical monitoring . It i s ver y importan t tha t th e clinicia n b e abl e t o accuratel y asses s a family's capacit y t o participate i n such a plan o f famil y supervisio n an d support an d it s possibl e ramifications . Fo r example , i t i s no t usefu l t o suggest such an option where the family is already drained from years of

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trying t o manag e a disruptive membe r a t home o r where overwhelmin g family guil t an d depressio n wil l b e evoke d b y th e clos e obeservatio n o f the famil y member' s acut e symptoms . I t i s especiall y dangerou s i f th e family's motivatio n i s primarl y expiation—tha t is , i f the y fee l i n som e fundamental wa y responsibl e fo r th e illnes s an d therefor e mus t mak e amends. Suc h circumstance s reinforc e th e patient' s sadism , leadin g hi m or her to further regression . To retur n t o Maryann' s situatio n an d th e decisio n t o hospitaliz e he r at thi s point . The optio n o f famil y supervisio n wa s no t feasibl e sinc e Maryann live d a t som e distanc e fro m he r parents. Sh e might hav e bee n able to make some use of day hospital an d halfway hous e staff, althoug h she tende d t o remai n aloo f fro m th e possibilit y o f indicatin g an y nee d for their support. The therapist' s decisio n wa s t o se e Maryan n fo r anothe r sessio n th e next day and to urge hospitalization a t that point. He felt that it was to o risky t o assum e tha t Maryan n wa s abl e t o b e entirel y hones t wit h him , given hi s suspicio n tha t sh e wa s mor e paranoi d abou t hi m tha n usual . He als o wa s no t convince d tha t Maryan n woul d b e abl e t o fac e wha t she viewe d a s th e humiliatio n o f askin g halfwa y hous e staf f fo r emer gency help if she became overwhelmed wit h suicidal feelings ; he thought it more likel y sh e would first engage i n some kin d of self-destructiv e ac t and then inform staff, a t which point little discussion (an d therefore littl e humiliation) woul d b e required. He also knew that staff usuall y fel t tha t Maryann neede d hospitalizatio n a t time s whe n he r functionin g ha d overtly deteriorate d mor e an d tha t a t present , sinc e ther e wa s littl e change, they might have felt that he was overreacting . Somewhat t o hi s surprise , Maryan n rathe r quickl y agree d t o g o int o the hospita l an d use d hi s telephon e t o mak e he r arrangements . Durin g the res t o f tha t session , sh e openl y expressed , wit h a sense o f relief , he r fears abou t th e therapis t changin g an d th e fac t tha t sh e ha d begu n thinking about local building s from which she might jump. She was abl e to reveal these critical development s t o her therapist only after she knew that sh e wa s goin g int o th e hospital , onl y whe n sh e fel t saf e wit h hi s understanding o f ho w h e wa s seein g he r a t thi s time , onl y whe n sh e knew tha t h e wa s stil l capabl e o f protectin g bot h o f the m fro m th e potentially disruptiv e consequences o f he r paranoia.

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Impact of the Hospita l o n Outpatient Treatmen t It i s no t onl y th e patien t wh o ma y vie w rehospitalizatio n a s indicatin g failure. Th e therapist mus t conten d wit h th e conventional vie w tha t sh e or he has "failed " to keep th e patient ou t of th e hospital an d often als o struggles wit h countertransferenc e feeling s aroun d thi s issue . The thera pist ca n anticipat e a n interruptio n i n th e therapeuti c allianc e an d th e continuity o f th e wor k eve n i f contac t wit h th e hospitalize d patien t i s carefully maintained . Furthermore, i n man y hospita l settings , th e assumptio n o f hospita l staff i s the conventional one : that the outpatient therapis t has failed an d is someho w incompeten t an d tha t wha t i s neede d i s ne w medication , a new typ e o f therapy , a ne w therapist . Th e patient' s wis h t o avoi d al l consideration o f hi s or her contribution t o the rehospitalizatio n an d the mixed feelings abou t the therapist who coul d not effect magica l cur e but who had the sense to put the patient in a safe place are reinforced by any tendency th e hospita l staf f ha s t o se e th e hospita l a s goo d an d th e outpatient therapis t a s bad . Thi s suppor t fo r th e patient' s tendenc y t o categorize peopl e a s eithe r al l goo d o r al l ba d i s particularl y likel y t o occur in teaching hospitals, where the trainee staff ar e relatively inexpe rienced i n dealin g wit h th e myria d emotiona l complexitie s o f suc h a situation an d ma y nee d t o defen d agains t feeling s o f intimidatio n b y criticizing th e outsider . I n the worst scenario , the outpatient therapis t i s dismissed fro m th e mind s o f inpatien t staf f a s i f n o longe r o f an y significance i n a for m o f devaluatio n an d denia l tha t parallel s th e pa tient's fantas y o f forgettin g abou t al l ambivalen t feeling s an d startin g fresh i n a newer an d more perfect world—t o b e "born again, " in Maryann's terms. The therapist's rationale for hospitalizing Maryann was that she needed to b e abl e t o tal k mor e abou t emergin g paranoi d fear s o f him , les t th e treatment founde r an d les t sh e enac t som e relate d fantas y tha t migh t involve tryin g t o kil l herself . Since , despit e thei r join t efforts , sh e wa s not abl e t o sustai n suc h discussion s i n thei r outpatien t session s (excep t to tell him indirectly, b y reference t o the movie, that she thought he was crazy), h e decide d t o guarante e safet y an d reduc e stres s wit h th e possi bility of talking to other people about her feelings fo r him. In his contact s wit h Maryan n an d hospita l staf f afte r admission , th e therapist suggeste d t o Maryan n tha t i t wa s natura l tha t sh e fee l mor e

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comfortable wit h he r hospita l therapist , wh o wa s no t associate d i n he r mind wit h th e difficultie s o f he r dail y lif e i n th e communit y a s h e was . He recommende d tha t Maryann' s hospita l docto r encourag e he r t o tal k about he r feeling s abou t hi s decisio n t o hospitaliz e her , he r disappoint ments an d dissatisfactio n an d mistrus t o f him , an d ho w sh e fel t abou t the prospec t o f returnin g t o treatmen t wit h him . In thi s case , the traine e assigned t o Maryan n wa s no t threatene d o r rendere d defensiv e b y th e need to perform thi s role with a patient hospitalized b y a senior clinician , and th e hospitalizatio n wen t well once this focu s wa s established. Mary ann reflecte d o n som e concret e alternative s developin g i n he r da y hos pital an d halfwa y hous e treatmen t an d me t with he r outpatien t therapis t several time s befor e discharge , durin g whic h meeting s th e therapis t wa s able t o satisf y himsel f tha t sh e ha d a les s distorte d vie w of hi m an d would b e abl e t o sustai n he r involvemen t i n therapy . Considerin g ho w essential th e appearanc e o f autonom y wa s fo r thi s patient , i t i s saf e t o assume tha t th e therapist' s willingnes s an d eve n suppor t fo r Maryann' s seeing someone els e were reassuring to that part of her that fel t in dange r of bein g invaded .

THE PSYCHOTHERAPIST, REHABILITATION , AND COMMUNITY AGENCIES Individuals wh o suffe r fro m schizophreni a an d wh o ar e fortunat e enoug h to b e abl e t o liv e i n th e communit y ver y ofte n nee d extensiv e an d enduring communit y services . Livin g i n a halfwa y hous e o r othe r com munity residenc e an d attendin g a da y hospita l ma y b e part o f a plan fo r rehabilitation endorse d b y clinicians . Ho w individua l therapist s dea l with thi s communit y syste m an d th e staf f member s wh o see much mor e of th e patient , albei t i n a ver y differen t settin g tha n a therap y session , has a major impac t o n ho w patient s wil l far e i n community living . Some therapists hav e traditionally avoide d contac t wit h outsid e agencies , fear ing this would "contaminate " th e treatment . Rehabilitation facilitie s ar e no t designe d primaril y t o addres s th e subjective experienc e o f individual s wit h schizophrenia . Wher e appro priate, a plan fo r outpatien t car e will allo w patient s t o hav e psychother apists wit h who m the y ca n discus s thei r subjectiv e feelings , thei r inne r reality, whil e th e othe r part s o f thei r treatmen t wil l focu s o n ho w the y

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manage externa l reality . The residenc e o r da y progra m represent s th e demands o f conventiona l reality , althoug h somewha t modulated . Thes e programs provid e a bridg e t o th e demand s o f a n ordinar y jo b o r livin g situation. Th e psychotherapy goa l i s t o enabl e patient s t o develo p thei r own abilities to cope with unusual internal states that stem from psychological conflict s an d deficits. Th e combine d focu s o n externa l an d internal realities , i n ou r view , result s i n mor e stabl e improvement s i n func tioning in community life than either approach taken separately. While th e individua l ma y a t time s prefe r th e atmospher e o f therap y because o f th e careful , intens e attentio n tha t ca n b e pai d t o hi s o r he r every nuanc e o f feeling , i t i s importan t tha t th e therapis t implicitl y o r explicitly support th e importanc e o f learnin g t o manag e everyda y lif e with its myriad disappointments, as in the following example : One woman , a colleg e graduat e bu t il l an d marginall y func tional fo r man y years, claimed that the program staf f spok e t o her and generally treated her as if she were a "brain-damaged moron. " Her therapist , wh o ha d bee n present wit h he r a t staf f conference s where thi s wa s evident , agree d wit h he r perception bu t suggeste d that ther e wer e reason s h e coul d thin k o f fo r staf f doin g this . H e empathized with her rage and hurt, but further implied that even if it wasn' t fai r fo r staf f t o behav e i n thi s way , sh e neede d t o find a way t o dea l wit h the m sinc e the y wer e a n importan t par t o f he r life. Sh e could , fo r example , demonstrat e he r competence . A s pa tient an d therapis t discusse d way s t o d o this , th e patien t becam e frightened. Eventuall y sh e wa s abl e t o se e he r ow n rol e i n he r interactions wit h staff—he r fea r o f appearin g effectiv e and , there fore, i n he r mind , o f bein g abandoned . Onc e again , th e principl e that guide d th e therapist' s stanc e wa s t o appreciat e th e patient' s experience an d to recogniz e th e limits sh e placed o n herself , whil e trusting that eventually th e patient would transcen d he r defensive ness. Thus , th e initia l formulation , "The y ar e a t fault, " graduall y shifted t o " I have a part in this." Often i t will see m t o th e patien t an d sometime s t o th e therapis t tha t rehabilitation staf f ar e insufficientl y "understanding " o f th e patient' s limitations. However , th e patien t mus t lear n t o dea l wit h peopl e wh o are not "understanding"—wh o ar e simply concerne d wit h gettin g a job done o r maintainin g publi c order . Th e schizophreni c individua l ma y

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need th e psychotherapist' s hel p t o understan d th e impac t h e o r sh e ha s on others and to take responsibility fo r this. For instance: One ma n cam e t o therap y bitterl y complainin g abou t havin g been kept back fro m a scheduled jo b intervie w b y the interventio n of da y program staff. Furthe r exploration o f th e situation reveale d that h e ha d appeare d a t th e da y progra m befor e th e intervie w i n disheveled clothe s an d unshaven. The staf f ha d served a protective function b y makin g hi m cance l hi s appointment . I n th e therapy , discussion focuse d o n wh y h e ha d neede d t o se t u p thi s situatio n and en d u p angry a t staff, rathe r than feelin g abl e to directl y stat e his fear that he was no t ready to go to work part time. In this case, the therapist' s attentio n t o th e experienc e o f th e patient i n feelin g angry an d i n creatin g th e situatio n tha t le d t o hi s ange r le d t o a n important piec e o f informatio n abou t functioning , whic h th e pa tient was urged to share with his program. At othe r times , th e schizophreni c individua l i s unabl e t o mak e hi s position clea r t o th e staff . The therapis t ma y the n nee d t o serv e a s ombudsman, clarifyin g t o th e communit y servic e organizatio n how , fro m the patient' s perspective , hi s o r he r action s wer e necessar y an d eve n adaptive. The therapist in such situations i s in a tricky position, becaus e he o r sh e i s vulnerabl e t o countertransferenc e need s t o lectur e th e staf f of the treating facility. A t the same time, the staff ma y view the therapist and his o r her information wit h suspicion , concerne d les t the patient b e "excused" from living in the "real world." Maryann presented a particular type of problem for the staff member s at he r halfwa y hous e an d da y hospita l program . O n th e on e hand , he r long histor y o f illnes s mad e i t clea r tha t sh e mus t b e sufferin g fro m a severe form of schizophrenia. O n the other hand, because of the methods she use d t o dea l wit h he r illness , Maryann' s presentatio n o f hersel f tended to make people forge t this. In he r rehabilitatio n program , Maryann' s presentation wa s tha t sh e was ver y capabl e an d tha t sh e ha d littl e nee d fo r th e aspect s o f th e program tha t stresse d interpersona l relationships: ho w t o dea l wit h criticism a t work ; ho w t o b e assertive ; ho w t o ge t alon g wit h othe r clients better . A s note d above , t o maintai n he r self-estee m i t was neces sary fo r Maryan n t o believ e tha t sh e di d no t hav e problem s i n thes e areas. Instead , sh e believe d tha t sh e ha d problem s resultin g fro m th e

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stresses othe r peopl e create d b y expectin g he r t o atten d th e progra m regularly an d t o participat e i n th e group s tha t discusse d relationships . Thus, he r over t behavio r wa s tha t o f a complaine r wh o coul d no t b e bothered t o participat e o n th e level requeste d b y the program staff . Sh e seemed t o prefe r t o us e th e da y progra m a s a plac e t o dro p i n an d socialize rathe r tha n a s a major ste p in her transition fro m a n inpatien t setting to ful l independence , which was th e kind of goa l th e staff ha d in mind. Because Maryan n wa s uncomfortabl e acknowledgin g t o hersel f tha t she became enraged by others' demands, she also behaved provocativel y as one wa y t o expres s he r annoyance . Sh e ofte n brok e mino r rule s an d would interrupt staff conference s i f she felt she needed something. At the same time , sh e was onl y marginall y adequat e i n her performance i n the work sectio n o f th e program , althoug h sh e wa s ver y boastfu l o f ho w hard sh e worke d an d ho w competen t sh e was . Thes e behavior s tende d to cause staff t o think of Maryann as narcissistic and lazy, while, in fact, she wa s usin g thes e behavior s t o den y he r needines s an d he r fear s o f being invaded psychologically. Maryan n was actually fairly successful a t hiding th e degre e o f he r grandiosity , paranoia , idea s o f reference , an d the like , bu t th e cos t wa s greatl y reduce d efficienc y i n carryin g ou t assignments an d th e task s o f dail y life . B y no t revealin g he r internall y experienced symptom s an d limiting her behavioral one s to lessened productivity an d interpersona l failures , sh e supporte d he r self-estee m bu t failed to keep staff informe d of how many psychiatric symptoms she still had. While i t wa s ofte n possibl e fo r th e staf f t o se e Maryann' s over t obnoxiousness a s par t o f he r illness , a t time s he r entitle d attitud e an d arrogant behavio r le d professional s t o perceiv e he r i n term s o f a com mon misconceptio n abou t person s wit h schizophrenia . Tha t is , the y forgot ho w fragil e Maryan n wa s an d how he r behaviors stemme d fro m needs t o protec t hersel f fro m th e ravages o f he r illness ; they sa w he r a s not ver y sic k bu t laz y instead . Thi s le d t o periodi c difficultie s an d re quests for consultation fro m the therapist. Knowing how bes t to respond to such requests depends on a complex understanding o f th e situation. I n Maryann's case , it was no t enoug h t o simply remin d th e staf f o f he r fragility ; i t wa s als o importan t fo r the m to fee l tha t th e therapis t appreciate d th e predictabl e frustratio n the y experienced i n workin g wit h Maryann . I n addition , patient s ma y ar -

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range t o hav e rehabilitatio n staf f contac t thei r therapist s i n orde r t o communicate somethin g t o the m tha t patient s canno t expres s directly . For example, a patient ma y act out sexuall y i n a day program a t a time when sh e want s t o tal k abou t sexua l impulse s wit h th e therapis t bu t cannot begi n t o d o so . Likewise , whil e a patient is verbally reportin g n o problem carrying out work assignments , he may want to let the therapist know tha t h e i s havin g difficulty , althoug h h e canno t brin g thi s u p directly i n sessions . I n Maryann' s case , sometime s sh e neede d t o b e reminded o f th e therapist' s concer n fo r he r an d willingnes s t o "tak e care" o f he r i n som e way , a s i n hi s "goin g ou t o f hi s way " t o tal k t o halfway hous e staff . A s shoul d b e clea r fro m ou r discussion , w e vie w this kin d o f contac t i n thi s kin d o f cas e a s a necessar y par t o f th e psychotherapy. Agency staf f als o ma y no t hav e a clea r ide a o f wha t th e therapist' s goal i s wit h a schizophreni c client , o r ma y hav e fantasie s abou t wha t goes o n i n therapy tha t will mak e them mor e or less able to collaborat e with th e individual therapis t in the treatment. Th e idea tha t therapy i s a luxury wher e th e patien t i s encourage d t o wallo w i n fantas y material , while th e rehabilitatio n staf f hav e t o manag e th e client' s dail y proble m behaviors an d reluctanc e t o work , interfere s wit h optima l collaboratio n among professionals workin g with th e schizophrenic individual . Indeed , at worst , th e staf f ma y ten d t o vie w th e therapis t a s encouragin g th e patient's regression a t their expense. "H e gets the glory while we have to clean u p th e mess " i s a commo n attitud e o f progra m staf f regardin g psychotherapists. In th e cas e unde r discussio n i n thi s chapter , th e therapis t ha d goal s interrelated wit h thos e o f th e da y progra m an d residence . On e goa l o f psychotherapy wa s tha t Maryan n woul d becom e mor e abl e t o rel y o n her capacit y t o separat e inne r fro m oute r realit y an d would thereb y b e able to us e available help more constructively an d less defensively a s she felt les s threatene d an d intrude d upo n b y others . Anothe r goa l wa s t o foster Maryann' s autonom y a s muc h a s possible, s o tha t eventuall y sh e could manag e he r lif e wit h fewe r outsid e interventions . Therefore , th e therapist trie d t o le t Maryan n manag e he r externa l lif e a s muc h a s i t seemed saf e t o rel y o n he r judgmen t o r whe n i t wa s clea r tha t sh e wa s able t o ge t goo d advic e fro m others , suc h a s progra m staff . Therap y sessions often focuse d o n how Maryan n could understand and deal with the paranoi d projectio n o f he r ange r o r th e fea r o f psychologica l inva -

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sion tha t prevente d he r fro m makin g goo d us e o f th e hel p offere d b y program staff. Th e existenc e o f thes e programs, in fact, wa s what mad e outpatient psychotherap y possibl e fo r a n individua l lik e Maryann . I f Maryann was i n a network o f programs that could help her manage her external life , th e psychotherap y coul d b e use d t o hel p he r wit h he r internal, emotiona l life , s o tha t over tim e sh e would hav e mor e psychological resource s an d coul d tak e ove r mor e o f th e da y t o da y manage ment o f he r ow n life . Maryan n als o neede d opportunitie s t o b e wit h other peopl e an d t o lear n mor e abou t gettin g alon g wit h them , despit e her assertions t o th e contrary , an d she needed th e vocational rehabilita tion aspect of the work s o she could be productive again. The therapis t trie d t o le t Maryan n manag e he r interaction s wit h th e program staf f withou t hi s interventio n a s muc h a s possible . I n fact , consistent wit h he r us e o f th e therapy , Maryan n ofte n idealize d th e program staf f an d devalue d th e therapis t sinc e h e rarel y gav e advic e o r assisted wit h concret e problem s i n he r life , a s othe r staf f did . Whe n problems aros e a t th e residenc e o r da y program , however , Maryan n sometimes neede d th e therapist' s intervention , althoug h sh e feare d feel ing dependent on him. She was afraid , fo r example, that he would exac t humiliating expressions of gratitud e from her as payment. In suc h cases , th e therapis t woul d mee t wit h th e progra m staf f o r consult b y telephone . H e woul d als o tr y t o minimiz e th e wa y i n whic h this kin d o f interventio n cas t hi m a s a n authorit y figur e b y discussin g with Maryan n ahea d o f tim e what sh e would lik e hi m t o d o o r say. A t this stag e o f th e treatment , Maryan n wa s usuall y reluctan t t o involv e herself ver y fa r i n suc h discussion s an d preferre d t o hav e th e therapis t take responsibility. Therefore , the y would work ou t some specific thing s for him to say and then agree that he would use his best judgment abou t further matters that might arise. Maryann was not able to tolerate bein g present a t al l suc h join t discussions , since th e necessar y mentio n o f th e severity o f he r symptoms humiliate d her . The ne t effec t o f hi s interven tion i n thes e situation s wa s t o gratif y som e o f Maryann' s dependenc y needs withou t makin g a point o f doin g s o and , usually , t o smoot h th e way for better relations between Maryann and the treatment staff. While reminding staf f o f ho w il l Maryan n was , th e therapis t als o reminde d staff o f hi s awarenes s o f ho w frustratin g an d irritatin g Maryan n coul d be and, further, noted for them the psychological function s this behavior served for Maryann. In reporting to Maryann a summary of the contact,

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he would als o remind her of the need to learn to follow rule s in life, even if the y seeme d unfai r o r silly , simpl y a s a matte r o f self-protection , o f avoiding trouble. In hospitalizin g Maryann , th e therapis t encourage d he r t o mak e he r own arrangement s a s far a s possible, bu t he also informed th e residenc e and da y hospita l staf f o f hi s decisio n an d reasoning . H e urge d he r t o maintain contac t wit h the m durin g her hospital sta y and to b e responsible abou t arrangin g he r retur n t o thes e program s an d mad e sur e th e inpatient hospital staf f kne w whom t o contact at the agencies.

SUMMARY We hav e see n i n thi s chapte r ho w th e principle s w e hav e outline d ca n inform outpatien t treatment involving community agencie s and the issue of rehospitalization s fo r a chronicall y suicida l patient . Maryan n pre sented arrogan t behavior s an d entitle d attitude s tha t serve d t o obscur e her dependenc y needs . A grandios e vie w o f hersel f a s havin g a specia l relationship with Go d represented th e sustaining experience upon whic h her self-esteem rested . Similarly , he r paranoid an d contemptuous stanc e toward importan t people i n her life, a form o f idiosyncrati c relatedness, revealed tha t contro l an d autonom y wer e majo r preoccupations . Thes e led her to the central priority of minimizin g her illness. In order to form a treatment partnership with Maryann, her therapist had to utilize this information abou t her to decid e in what role he coul d offer himsel f t o her in terms of his hypotheses abou t what she could an d could no t d o a t thi s time . The solutio n wa s t o allo w he r t o devalu e th e therapy an d be secretive an d paranoid a s long as she maintained a basic contract t o b e hones t abou t suicida l impulse s an d responsibl e abou t sessions, th e da y program , an d medication . The therapist' s interaction s with th e communit y agencie s wer e dictate d b y hi s understandin g o f Maryann's subjectiv e experience , an d rehospitalizatio n wa s indicate d when th e therapis t cam e t o believ e tha t Maryan n wa s temporaril y un able to carry out the contract upon which the partnership was based and was therefore a t risk for suicide despite her denials.

7 The Case of Roger: Outpatient Psychotherapy—From Apathy to Communit y Involvement

I n wor k wit h inaccessibl e patients , there ar e times when i t is necessar y to relinquis h on e or more elements of th e usual psychiatric stance in the service o f establishin g a n ambienc e o f trus t an d curiosit y an d thereb y gaining entr y int o th e patient' s inne r world . I n thi s cas e history , i t quickly becam e clea r t o th e therapis t tha t th e patient , havin g accumu lated ove r twent y year s o f experienc e wit h menta l healt h professionals , was impatien t wit h an d intolerant o f th e customar y method s o f clinica l inquiry. H e presente d wit h a diagnosi s o f schizoaffectiv e disorde r wit h prominent negativ e symptoms , includin g profoun d apath y an d indiffer ence t o an y o f hi s forme r interest s an d a thoroughgoin g aversio n t o clinical intervention s oriente d towar d improvement . The therapis t pu t aside her commitment to significant elements of the usual clinical posture in the hopes o f finding a residue of alivenes s i n this man, who appeare d to have abandoned his belief i n the possibility o f meaningfu l recovery . For patient s wh o hav e no t improve d wit h standar d treatment , thi s story illustrate s th e importanc e o f identifyin g a path tha t thes e patient s are willing t o follow , eve n when , fo r a s lon g a s tw o year s i n thi s case , there i s littl e reason—othe r tha n a tenaciou s belie f i n th e unconfirme d possibility o f a n eventual benevolen t outcome—t o continu e th e work o f psychotherapy. Th e story also indicates the importance o f respecting the patient's priorities—i n thi s case , th e patient' s nee d t o preserv e som e semblance o f dignit y b y supportin g a persona l syste m o f belief s that , although delusiona l b y all ordinar y standards , had the effect o f keepin g alive a raison d'etre whe n al l th e usua l source s o f meanin g ha d lon g since dried up. It ma y als o b e usefu l t o not e tha t th e writin g o f thi s stor y ha s bee n taken up somewhat i n the manner of a n experiment. The majority of the

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account, u p to "Learnin g to Use the New Paradigm, " was written durin g the thirtiet h mont h o f th e work . Th e remainde r o f th e stor y wa s writte n nine month s late r an d therefor e constitute s a follow-up. Thus , the valid ity of theme s first identifie d i n the thir d yea r o f th e work, whic h hav e t o do wit h a reformulatio n o f th e phasi c natur e o f th e illness , ca n b e checked agains t subsequen t events . BEGINNINGS O F THE WORK The Firs t Encounte r The circumstance s o f th e therapist' s first encounte r wit h Roge r ma y b e significant i n th e evolutio n o f subsequen t events . Durin g th e summe r o f 1984, a t th e suggestio n o f friend s wh o had foun d som e value in consult ing wit h th e therapis t abou t thei r mentall y il l daughter , Roger' s parent s consulted regardin g hi s statu s then . H e ha d bee n readmitte d fo r a sev enth psychiatri c hospita l sta y som e tw o month s earlier . A t first respon sive t o car e i n a short-ter m unit , h e wa s subsequentl y transferre d t o a n intermediate-stay unit , wher e th e staf f soo n cam e t o th e conclusio n tha t his interest s woul d b e bes t serve d i f h e lef t th e confine s o f th e parenta l home, takin g u p residenc e i n a psychiatri c halfwa y house . Th e parent s were tol d o f thi s conclusio n and , wit h som e difficulty , persuade d t o support th e recommendation . In a subsequen t meetin g le d b y th e uni t social worker involvin g Roger an d his parents, Roger exploded i n a fury , directed mostl y towar d hi s mother , whe n bot h parent s appeare d t o sid e with th e staf f o n th e halfwa y hous e issue . Immediatel y followin g th e meeting, h e becam e suicidall y depresse d an d inaccessible . Shortly , h e proclaimed h e wa s intereste d onl y i n th e pla n t o g o t o a ver y long-ter m hospital i n which h e would liv e out th e res t o f hi s short life . H e avoide d all activities . H e woul d no t permi t visit s fro m th e family . H e complie d with medication , whic h ha d bee n increase d followin g th e bitte r confron tation, an d had , a s a result , develope d a persisten t an d ver y uncomfort able tremor o f th e Parkinsonia n type . At thi s poin t th e parent s requeste d a consultatio n wit h th e therapis t in a n effor t t o reasses s th e curren t treatmen t plan . Whil e no t a uniqu e occurrence, thei r son' s bitte r rejectio n o f the m differe d i n it s persistenc e and intensit y an d i n hi s simultaneou s rejectio n o f bot h parents . The y were alarme d a t th e developmen t o f sever e suicidal thinkin g an d Roger' s

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total lac k o f interes t i n an y plan , eve n th e plan o f returnin g hom e wit h them. At first Roger rejected out of hand the parents' request that he permit a visi t fro m thei r consultant , an d i t appeare d likel y tha t th e therapist' s only role would b e as a consultant to the family. The possibility of direc t therapeutic work with Roger came only later. At this point, the therapist reasoned tha t Roge r mos t certainl y viewe d he r a s a n extensio n o f hi s parents and that Roger was alread y suffering fro m a diminished sense of personal contro l ove r his circumstances. Sh e thus recommended tha t the parents acced e t o Roger' s refusa l t o se e th e therapis t an d infor m hi m that th e therapis t ha d specificall y mad e tha t recommendation . I f th e patient wa s goin g t o thin k o f th e therapis t i n an y way , th e therapis t wanted t o b e viewed a s someone wh o too k seriousl y his desires , including his desire not to be intruded on by his parents' agents. Following a month-lon g vacation , th e therapis t learne d fro m th e parents tha t Roger had reconsidered an d was no w willin g t o permit th e therapist to visit him. The first visit was characterized by two prominen t manifestations o f hi s condition . First , h e presente d wit h a continuou s tremor, s o sever e that he managed t o smoke a cigarette onl y b y bracin g the han d holdin g th e cigarett e a t th e wris t wit h hi s othe r hand . Roge r offered th e observatio n tha t th e tremo r wa s induce d b y haloperidol , which b y the n h e wa s takin g i n larg e doses , an d th e therapis t agreed , indicating tha t th e tremo r woul d i n al l likelihoo d diminis h whe n th e dose wa s reduced . Second , h e appeare d t o have n o interes t i n anything . It woul d b e mor e accurat e t o sa y tha t Roge r wen t t o som e length s t o make sur e tha t th e therapis t kne w tha t h e wa s i n n o wa y intereste d i n activity, i n involvement , i n retur n t o lif e i n th e communit y an d tha t indeed th e onl y pla n fo r a future tha t had an y salienc e fo r hi m wa s fo r him to live out his life a t a long-term hospital doin g as little as possible. 3 He aske d whether th e therapist thought a hospital woul d tak e him on if he wanted to do so little. The therapist indicated she was pretty sure that most places would wan t som e sor t of commitmen t o n hi s part to a goal of recovery and eventual discharge , suggesting all the same that he could still investigat e an d perhap s sel l th e hospita l o n th e ide a tha t h e ha d a unique, specia l nee d t o b e lef t alon e an d tha t th e usua l expectatio n o f involvement would actuall y b e counterproductive i n his case. The therapist als o piece d togethe r enoug h historica l informatio n t o for m th e impression, whic h sh e share d wit h him , tha t hi s conditio n appeare d t o

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have a fluctuating course and that, although a t present he thought of th e future onl y i n term s o f a lon g sta y i n a long-ter m hospital , th e tim e might com e whe n h e woul d find himsel f thinkin g o f doin g somethin g with hi s life . A t th e en d o f th e consultatio n interview , t o th e therapist' s surprise (sh e was stil l gratefu l tha t the patient had permitted he r to visi t on thi s on e occasion) , Roge r aske d i f sh e would b e comin g bac k t o se e him again . He did not seem to be asking the therapist to return, nor was there a hint tha t h e desire d t o mee t wit h he r again . Rather , hi s manne r was mor e on e o f seekin g disinterestedl y t o discove r whethe r he r rol e a s consultant calle d fo r subsequen t visits . Th e therapis t indicate d that , although sh e ha d n o pla n t o d o so , i t was possibl e tha t sh e migh t hav e reason to visit after meeting again with his parents. In the next consultation wit h the parents, the therapist recommende d that the y withdra w thei r endorsemen t o f th e half-wa y hous e plan . Th e recommendation ha d bee n introduced b y the hospita l staf f i n a manne r that completel y ignore d th e patient's preference s i n th e matter o f wher e he was to live and what he was likely to want to do with and for himself . Moreover, hi s family' s endorsemen t ha d lef t hi m feelin g abandone d b y them. Thi s neglec t o f th e patient' s prioritie s is , o f course , a n al l to o common aspec t o f contemporar y hospita l treatment . I t is likely that , o n the basi s o f thei r observation s o f Roger' s interactio n wit h othe r peopl e in th e unit , togethe r wit h thei r correc t assessmen t o f th e exten t o f hi s inability t o car e fo r himsel f i n a n independen t apartmen t arrangement , the staf f recognize d tha t h e require d a supervised livin g arrangemen t a s a step i n regaining a niche amon g hi s peers. However, i n the current era of brie f hospita l treatment , th e staff o f inpatien t units ar e nearly alway s confronted wit h the institutional priority of identifying a disposition that will lea d t o a n earl y discharg e whil e a t th e sam e tim e meetin g accepte d standards fo r decen t aftercar e planning . I n thes e circumstances—an d especially when , a s i n thi s case , th e patien t ha s littl e o r n o interes t i n developing a plan tha t ca n b e immediately pu t int o effect—th e patient' s priorities rarel y remai n primary . Th e famil y i s commonl y recruite d b y the staf f i n a n effor t t o gai n th e wides t possibl e suppor t fo r th e plan , with th e resul t tha t th e patient' s experienc e i s on e o f bein g treate d lik e cargo by the staff an d being betrayed b y the family . In thi s meeting , th e parent s informe d th e therapis t tha t Roge r ha d shared wit h the m a desir e t o hav e he r undertak e hi s ongoin g care . Apparently, h e ha d discovered , followin g th e therapist' s meetin g wit h

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him, that the Austen Rigg s Center , his preferred long-ter m hospital , di d require a higher leve l o f participatio n tha n h e wa s prepare d t o commi t to. Following th e decisio n no t t o pursu e th e Rigg s option , Roge r ap peared t o becom e less desperat e bu t no t les s apathetic . Fo r thei r part , the parent s wer e quit e eage r t o foste r a connectio n betwee n Roge r an d the therapist , havin g decide d o n th e basi s o f thei r contac t wit h th e therapist an d the alleviation o f Roger' s desperatio n followin g th e therapist's visit that she was goin g to b e a good influenc e o n thei r son. So, in response t o thi s reques t fo r a visit, mediate d t o a n unknow n exten t b y the parents ' ow n attitude s towar d th e therapist , sh e agree d t o visi t Roger again on the hospital unit, with a view toward determining whether they might work together following hi s discharge.

The Patient Engage s His New Therapist If th e firs t visi t wa s characterize d b y sufferin g an d apathy , th e secon d was give n mor e t o understandin g an d optimism . Upo n th e therapist' s arrival o n th e unit , Roge r aske d i f the y coul d wal k outside , explainin g without promptin g tha t he had noticed i n the past fe w day s that he fel t better if h e arrange d t o ge t off th e unit each day. As before, h e was stil l refusing all off-unit activitie s and his only way of getting off th e unit was to g o fo r a walk . H e ha d bee n abl e t o d o thi s onl y whe n staf f wa s available to accompany him, and he appeared to be taking this opportunity t o ge t a wal k i n o n th e da y o f th e therapist' s visi t b y askin g i f th e therapist would be that staff person. The therapist agreed, noting silently that the plan to walk i n order to feel bette r stood in some contrast to the global negatio n o f interest s i n th e first visit. Roge r then too k th e thera pist o n a bris k wal k o f a larg e portio n o f th e hospita l grounds , durin g which, fro m the very beginning of thei r time together, he poured out his psychiatric history . H e di d no t wai t fo r th e therapis t t o intervie w him , take a history , o r otherwis e star t u p a conversation . H e appeare d t o anticipate tha t this was wher e th e inquiry was mean t to g o o n tha t day , since the y wer e considerin g th e possibilit y o f th e therapist' s takin g o n his care . H e coul d easil y b e considere d a "veteran " of psychiatri c treat ment, an d hi s expectatio n tha t th e therapis t woul d tak e a histor y pre sumably gre w fro m th e conduc t o f othe r psychiatrist s i n hi s ow n pas t experience.

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The Patien t Set s Fort h Hi s Paradig m What wa s mos t strikin g abou t thi s historica l sojour n wa s th e wa y i n which Roge r charte d th e cours e o f hi s condition . H e note d a fairl y predictable patter n o f phases , whic h h e ha d alread y com e t o cal l b y name: • Phas e 1 , th e phas e h e wa s currentl y in , wa s characterize d b y a com plete absens e o f vitality , imagination , desir e t o d o anything , o r an y anticipations o f an y sor t o f favorabl e futur e thought , action , o r event . • Phas e 2 wa s characterize d b y the presence o f a desire to d o thing s an d to ge t bac k int o life , bu t wit h som e limitation s i n term s o f bein g abl e to d o thos e things . • Phas e 3 wa s characterize d b y th e bes t o f functioning , representin g what h e could d o when everythin g wa s working just right . The patien t allowe d tha t h e ha d bee n i n phas e 3 o n ver y fe w occasion s in recen t times . H e indicate d tha t th e transition s betwee n phas e 1 an d phase 2 tha t h e ha d observe d ove r th e year s wer e alway s relate d t o on e or anothe r externa l event—somethin g tha t i n hi s view jus t happene d t o him, alway s fro m th e outside , withou t an y explicit , intentional , proac tive contributio n o n hi s part. Furthermore , phas e 1 was i n al l respect s a state o f min d tha t wa s highl y undesirable , havin g nothin g goo d abou t i t and representing pure illness, a state in which h e waited fo r tha t extrinsi c something t o happe n tha t woul d transpor t hi m int o phas e 2 . H e indi cated tha t al l the bones o f hi s face, i f not hi s whole body , wer e shattere d in phas e 1 ; h e ha d n o spine , an d al l hi s feature s wer e sunken . Phas e 2 was no t muc h better , bein g characterize d onl y b y hi s desir e t o liv e without th e capacit y t o live . By his reckoning, throug h th e year s h e ha d spent a maximu m o f si x month s continuousl y i n phas e 2 befor e fallin g again int o phas e 1 , an d thi s wa s no t a sufficientl y lon g tim e t o for m th e basis o f a lif e tha t wa s satisfyin g enoug h t o sustai n hi m throug h th e much longe r phase 1 periods. Phase 3 was the only stat e in which h e ha d any activ e interest , and , accordin g t o hi s calculations , h e had spen t onl y a fe w hour s i n phas e 3 i n al l hi s life . B y implication, then , h e ha d spen t very little time living at the level at which, i n his view, most people spen t most o f thei r lives , an d whic h wa s th e onl y stat e tha t justifie d bein g alive. He asserte d that , upo n entr y t o th e hospital , h e ha d bee n i n phas e

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2 an d tha t th e confrontatio n ove r th e halfwa y hous e pla n an d th e subsequent increase in haloperidol ha d triggered a switch to phase 1 . Since th e therapis t kne w b y thi s tim e tha t som e clinician s believe d that Roge r ha d a bipola r affectiv e disorder , sh e wondere d alou d wit h him whether thi s set of phase s might in some way b e a manifestation o f that condition . Wit h polit e annoyance , th e patien t dismisse d thi s ide a out o f hand , assertin g tha t this stat e had nothin g t o d o wit h mani a an d emphasizing tha t i t wa s no t depressio n h e fel t bu t a complet e an d irreversible disintegration o f hi s bones . Th e bone s o f hi s skul l wer e actually shattered . Wha t di d tha t hav e t o d o wit h depression ? Further more, h e rejecte d ou t o f han d th e therapist' s nex t suggestio n tha t the y might inquir e a s t o wha t h e ha d contributed—perhap s withou t bein g aware o f havin g don e so—o r coul d contribut e towar d triggerin g tha t sought-after transitio n t o phas e 2 . Insistin g tha t th e therapis t di d no t understand hi s condition (an d this insistence ha d the flavor of hi s wanting th e therapis t t o ge t i t right ) h e reiterate d th e specifi c events—th e breakup o f a love relationship , bein g fire d fro m a job—that had , i n hi s view, incontestably triggere d transitions from phase 1 to phase 2. It seemed clear that in order to create a bridge to her new patient, the therapist woul d hav e t o relinquis h certai n procedure s commonl y em ployed in her work with patients, including psychiatric diagnostic inquiries, discussion s abou t th e stress-diathesi s mode l regardin g th e timin g o f changes in mental state , and questions an d interpretation i n the conduc t of th e interview . Sh e sat o n a benc h i n th e hospital' s forma l gardens , shivering i n th e earl y autum n twilight , whil e Roge r pace d bac k an d forth, smokin g on e cigarett e afte r another , recountin g th e event s o f hi s ten-year experienc e wit h illnes s an d institutions , detailin g especiall y th e external event s that were known to produce a transition to phase 2. The therapist acknowledge d tha t hi s wa s a very complicate d conditio n an d that she could only assur e her new patient of he r commitment t o understanding th e patient's experienc e o f th e conditio n a s bes t sh e coul d an d that no guarantee s beyon d tha t assurance coul d b e made. O n thi s basis, after anothe r tw o week s o f hospita l care , th e twice-weekl y offic e wor k began.

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THE INTERIM PERIO D The bul k o f th e nex t twenty-seve n month s consiste d o f preliminaries , a period tha t ha s bee n calle d "th e lon g gray middle " (1 ) of psychotherap y with patient s wh o hav e schizophrenia . W e wil l chronicl e thi s perio d t o give som e flavor o f th e interva l an d t o buil d a basi s fo r reference s tha t will b e mad e durin g th e perio d o f reformulatio n t o b e describe d i n th e following section .

Failure an d Apathy The therapist' s las t encounte r wit h Roge r befor e discharg e serve d t o underscore th e significanc e o f persona l failur e i n Roger' s inne r life . Th e therapist cam e t o se e hi m fo r th e thir d time , fres h fro m havin g rea d Zelin e t al.' s pape r o n sustainin g fantasie s (2) . Unlik e hi s behavio r th e second contact , Roge r was very flat, lacking in spontaneity, although no t avoidant i n hi s presentation . Intrigue d b y th e importanc e o f th e ide a o f sustaining fantasie s i n patient s wit h schizophrenia , th e therapis t aske d him how he managed t o cope with the difficulties o f being ill. The patien t looked a t he r blankl y fo r a momen t an d the n smile d hi s first smile , a t which th e therapis t immediatel y declare d he r curiosit y a s t o th e inne r workings behin d suc h a n unexpecte d tur n o f affect . Th e patien t ex plained freel y tha t h e ha d jus t ha d a thought , i n respons e t o th e thera pist's question , o f th e downfal l o f hi s bes t friend , a ma n wit h who m h e had spen t man y years , th e tw o o f the m ofte n bein g dow n an d ou t together. Recentl y thi s man's lif e had take n a turn fo r th e better: H e wa s working. Roge r wa s quic k t o poin t ou t tha t th e jo b wa s i n a famil y business an d tha t hi s frien d wa s pullin g dow n a paychec k whil e doin g nothing, s o thi s jo b didn' t reall y count . Bu t hi s frien d ha d als o recentl y gotten engaged . Roge r coul d stil l remembe r time s whe n th e frien d ha d lost i t al l afte r a perio d o f goo d luck , an d i t wa s thi s remembrance , together wit h th e anticipatio n o f ye t anothe r failure , tha t ha d brough t him a momen t o f satisfaction . Whil e thi s interchang e aros e fro m th e therapist's interes t i n th e patient' s sustainin g fantasies , hi s smil e sus tained he r durin g th e prolonge d emotiona l deadnes s tha t dominate d th e first three months of offic e work . I t is just such smal l "leaks of aliveness " that th e therapis t mus t identif y i n work wit h ver y unresponsiv e patients .

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The evidenc e o f vitalit y serve s t o ancho r th e therapis t agains t th e ever present dange r o f slidin g int o deadness with th e patient. I t also points t o the kind s o f priorities , th e aspect s o f lif e tha t ar e o f interes t t o th e patient, aroun d whic h th e allianc e will ultimately b e forged . Session afte r session , h e entere d th e office , alway s o n time , an d jus t sat, often motionles s fo r severa l minutes, alway s starin g a t th e therapist , with n o indicatio n o f fea r an d mor e wit h a countenanc e tha t suggeste d he wa s drinkin g i n th e therapis t o r perhap s waitin g fo r he r t o ad d something, to sa y somethin g t o get things going. Yet, when th e therapis t would mutte r somethin g or ask after hi s thoughts, he would, afte r a lon g delay b respon d monosyllabically , onl y t o continu e starin g emptily . Th e therapist ha d th e distinc t sens e that sh e was alon e in her discomfor t an d that Roge r wa s bot h comfortabl e i n hi s remotenes s an d unobservan t o f her unres t wit h it . A t n o tim e di d th e therapis t find hersel f concluding , after du e consideration , tha t th e patien t wa s attemptin g t o provok e he r distress o r takin g an y pleasur e i n it . H e wa s quit e simpl y blank : Ther e was nobod y home . Reasonin g tha t h e migh t b e overmedicated , th e therapist lowere d an d ultimatel y discontinue d thiothixene , which h e ha d been give n a t discharg e fro m hospital , supplantin g thi s medicatio n wit h chlorpromazine, a t th e patient' s request , fo r us e a t bedtime . Eve n throug h his torpor , Roge r wa s quit e insisten t a t thi s tim e (an d o n man y subse quent occasions ) tha t h e di d no t requir e antipsychoti c medication s be cause he was not a schizophrenic. He claimed to benefit fro m chlorprom azine solel y fo r it s soporifi c effects . Whe n thi s chang e o f medication s proved ineffectiv e i n alleviatin g hi s blankness , th e therapis t muse d wit h him tha t h e migh t b e activel y numbin g out , i n th e manne r describe d b y McGlashan i n hi s discussio n o f aphanisis—tha t is , he migh t b e seekin g to avoid his pain wit h numbness . (3 ) The patient brushe d thi s suggestio n aside without an y apparen t feeling . First Evidenc e o f Aliveness: Working fo r th e CI A In th e thir d mont h o f offic e work , Roge r opene d th e nex t par t o f th e interim period with a most unexpected disclosure , which w e will recoun t as muc h a s possibl e a s a story , rathe r tha n a s histor y o f illnes s i n th e usual clinica l sense . This wa y o f reportin g th e dat a reflect s th e ambienc e in the room: Durin g the entire interim period, the therapist worke d har d to retain a state of listenin g in which sh e could accep t the veracity o f he r

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patient's report s an d declin e th e temptatio n t o adop t a diagnosti c pos ture.0 Roger disclose d tha t he had once bee n recruite d b y the CI A and tha t he migh t stil l b e unde r thei r surveillanc e no w o r a t an y tim e i n th e future. H e wa s carefu l t o prefac e thi s disclosur e wit h th e informatio n that he had not share d thi s secret with othe r therapist s fo r fea r of bein g discredited. I n that moment , th e preface wa s o f greate r interest than the disclosure. I t affirme d that , althoug h h e wa s stil l presentin g himsel f a s having n o interes t i n anythin g an d althoug h h e looke d psychologicall y inert, th e patien t di d wan t somethin g fro m th e therapist . H e wante d affirmation, o r at least the absence of disaffirmation. H e wanted to bring the therapis t i n o n hi s secre t occupatio n withou t a t th e sam e tim e triggering a typical clinica l response . The therapist was to b e his psychiatric lawyer and a partner in the vindication o f his pride and dignity. H e would revea l th e detail s o f hi s experience s wit h th e CIA , an d h e woul d seek affirmatio n that , fa r fro m bein g schizophrenic , h e wa s indee d a n important person , a n agen t i n tha t mos t clandestin e o f securit y organi zations. The stor y o f th e CIA' s entry int o Roger' s lif e bega n eightee n month s prior to hi s first encounter wit h th e therapist. Followin g discharg e fro m another psychiatri c hospital , h e returned t o hi s apartment i n New Yor k City, livin g alon e an d eagerl y anticipatin g a perio d durin g whic h h e would rebuil d hi s life . H e ha d jus t bee n triggere d ou t o f phas e 1 int o phase 2 b y the breakup of a love relationshi p tha t began in the hospital . After a period o f mor e tha n eigh t month s i n hospital , durin g whic h h e had full y expecte d t o liv e i n hospital s fo r th e res t o f hi s life , h e ha d begun t o fee l somethin g fo r thi s woman , wh o wa s als o a patient a t th e hospital. H e wa s stil l i n phas e 1 , despit e hi s increasin g longin g fo r her , until sh e lef t th e hospita l an d then immediatel y brok e of f contac t wit h him. A t the precise momen t o f tha t break, h e fel t lighte r an d was thrus t into phas e 2. Soo n h e was abl e an d even eager to leav e the hospital an d to rebuil d his life. This apparen t paradox—a los s evoking a n increase in vitality—suggested t o the therapist that anticipatio n o f failur e serve d o n some occasions a s the trigger for a retreat to complete psychic numbing , a them e tha t woul d surfac e muc h late r whe n th e therapis t woul d pre scribe temporar y numbin g a s a metho d o f copin g wit h anticipator y anxiety an d ultimatel y a s a mean s o f preventin g drasti c an d prolonge d periods of complete inaccessibility .

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Now, bac k i n th e cit y an d livin g alone , i n th e absenc e o f al l forme r psychiatric symptoms , h e note d wha t sounde d t o hi m lik e a beepin g noise i n o r aroun d th e apartment . Thoug h h e though t nothin g o f i t a t first, soo n h e wa s draw n t o locat e th e sourc e an d foun d t o hi s disma y that th e soun d wa s emanatin g fro m th e floor o f hi s bathroo m an d appeared ove r th e cours e o f a few day s t o mov e fro m th e floor u p int o the walls. I t quickl y becam e apparen t t o hi m tha t thi s wa s th e work o f the CIA, their way of makin g contact with him and of inducing him into a role as an informer. H e had spent time a year earlier with some "heav y political types " and was no w convince d tha t the CIA had identified hi m as someon e wh o kne w somethin g o f importanc e t o th e futur e o f th e presidency. H e knew , withou t havin g t o thin k to o muc h abou t it , tha t Reagan's presidenc y wa s o n th e lin e an d tha t h e hel d informatio n that , when revealed , woul d brin g Reaga n down . Believin g tha t CI A agent s were listening in, he played with them, telling them everything that came to his mind from those former heavy political times . ,He teased them and ridiculed the m fo r no t knowin g wha t h e knew . An d the n h e note d tha t when the y wer e especiall y please d wit h som e disclosure , the y woul d crank u p th e volume o f th e beepe r o r turn on a prolonged b-e-e-e-e-e- p response. The beepe r would alway s respond to a revelation. Soon Roge r was transformed , lik e a rat pressing a lever t o ge t a pleasure jolt, int o a person wh o woul d tel l thing s h e kne w jus t t o ge t a respons e fro m th e agents. At som e poin t i n thi s strin g o f conversations , th e CI A bega n t o pla y with Roger , acknowledgin g hi m wit h a bee p o n som e occasion s an d withholding acknowledgmen t o n others . Afte r th e regularit y o f th e ear lier conversations , th e shif t t o a mor e sporadi c repl y sequenc e wa s disconcerting. Roge r eventuall y decide d t o forc e th e issu e b y removin g the beepe r fro m th e wall . H e obtaine d a hamme r an d proceede d t o rip ou t a larg e portio n o f th e bathroo m wall . T o hi s surprise , h e wa s unable t o locat e th e beeper . Thi s developmen t wa s s o frustratin g tha t it triggere d a burs t o f activit y an d aggressiv e behavio r that , i n short , brought hi m t o th e attentio n o f other s i n th e buildin g an d le d t o a series o f shor t hospita l stays . Eve n whil e h e wa s i n th e hospital , h e received tw o communication s referrin g t o th e CIA . O n on e occa sion, anothe r patien t rushe d u p t o hi m i n a n agitate d stat e an d fel l to th e floor blurtin g out , "He' s protecte d b y th e CIA! " O n anothe r occasion, a secon d patien t cam e u p t o hi m i n th e manne r o f a mes -

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senger an d sai d i n a lo w voice , "Fro m no w on , yo u won' t hea r sounds." If th e first o f thes e communication s serve d t o affir m hi s statu s vis-a vis th e CIA , th e secon d prepare d hi m fo r wha t wa s t o come . Followin g his discharg e an d u p t o th e presen t time , the y ha d no t communicate d with hi m agai n throug h th e us e o f a beepe r o r othe r audibl e device . Instead, h e would onl y hea r click s in th e walls, sounds tha t t o an y othe r observer woul d see m like the natural noise s one hears in an old building , but tha t t o Roger , prepare d a s he had bee n b y th e tim e i n his apartmen t and b y th e messenger , wer e certainl y evidenc e o f th e ongoing interes t o f the CI A in hi m an d hi s information .

Validation of the Patient's Experience During th e perio d o f thes e conversation s wit h th e CIA , Roge r hear d from friend s o n tw o separat e occasions . On e friend , a woma n h e ha d known fo r som e years, heard th e sound o f th e beeper, remarking, "Wha t was that? " The othe r friend , o n hearin g i t durin g a phone conversation , asked, "Ar e yo u wired? " In bot h cases , h e responde d s o a s t o concea l what wa s happening . These tw o report s wer e critica l i n th e therapist' s earl y relationshi p with Roger , inasmuc h a s the y suggeste d a uniqu e i f disorientin g (fo r a psychotherapist) perspective . Tw o friend s ha d give n externa l validatio n to a n experienc e tha t otherwis e woul d lea d a reasonabl e listene r t o conclude tha t h e ha d bee n hallucinating . I n tellin g o f thei r validations , he appeare d t o b e tryin g t o establis h tha t h e wa s no t hallucinatin g an d seemed inten t o n gainin g a n affirmatio n fo r thi s conclusio n fro m th e therapist. Appealin g t o th e part o f hi m tha t wa s abl e t o muste r evidenc e and specificall y t o tak e a n evidentiar y orientatio n t o a n unusua l experi ence, the therapis t too k th e positio n that , whil e this was a most implau sible occurrence , sh e wa s no t prepare d t o dismis s i t a s hallucinator y since h e wa s reportin g tha t tw o othe r individual s ha d verifie d th e pres ence of a n actua l sound . Decline an d Reentr y t o th e Hospita l Eight month s afte r treatmen t began , th e session s ha d becom e virtuall y dominated b y Roger' s description s o f hi s mos t recen t interaction s wit h

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the CIA. They were now tamperin g with the lighting in his bedroom, o n one occasio n makin g a bedsid e ligh t g o o n fo r n o apparen t reason . H e became increasingly distraugh t an d irritable during this time, often lou d and verbally threatening toward the therapist in sessions, and describin g a ris e i n hostil e interaction s wit h hi s parents . Th e therapis t bega n t o sense tha t h e migh t b e losin g contro l an d wondere d whethe r al l th e discussion abou t th e CI A migh t i n som e wa y b e contributin g t o hi s anger. The situatio n di d get out of control . I n the ninth mont h o f th e work , for the first time ever, Roge r punched his mother and then assaulte d his father, settin g i n motio n a n involuntar y commitmen t t o th e hospita l coordinated b y th e therapist . Durin g th e first par t o f hi s sta y i n th e hospital, h e wa s lou d an d abusiv e towar d th e staff , refuse d t o se e hi s parents, an d fired th e therapist , agai n viewin g he r a s th e agen t o f hi s parents. After fou r weeks on a strict room care plan, while being treated with chlorpromazine an d then with chlorpromazine an d lithium carbonate^ h e calme d down , reopene d contac t wit h th e parents , an d the n asked to se e the therapist, a week befor e hi s scheduled discharge , with a view toward deciding whether he would rehire her or find another. As wit h th e encounte r te n month s earlier , Roge r aske d tha t thi s meeting b e conducte d o n th e ground s o f th e hospital . Whil e retracin g some o f th e same ground covered in their first walk, h e shared his sense of betraya l upo n learnin g tha t th e therapis t ha d participate d i n hi s commitment t o the hospital. The therapist affirmed Roger' s reservation s about her , spellin g ou t th e exten t o f he r involvemen t i n hi s retur n t o hospital an d directl y confirmin g tha t sh e ha d strongl y recommende d commitment i n severa l conversation s wit h hi s fathe r immediatel y afte r the assault o n hi s mother an d again, two day s later, afte r th e assaul t o n his father . Sh e furthe r indicate d that , althoug h th e patien t wa s fre e t o tell her about his gripes toward his parents, he should not have expected the therapis t t o loo k o n a s a witness t o hi s effort s t o punis h the m wit h physical abuse . Th e therapis t suggeste d tha t he carefully conside r whethe r he wante d t o wor k wit h he r agai n an d tha t h e conside r alternativ e therapists. Sh e emphasized that , should he elect to rehir e her, she woul d be pleased to resume the work, provided they had an understanding that no physical abuse would be tolerated. Indeed, control of his anger would be a n importan t goa l o f an y futur e work . Towar d th e en d o f thi s meeting, th e patien t indicate d tha t h e woul d thin k abou t wha t th e

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therapist ha d sai d an d le t he r kno w hi s decisio n i n a da y o r two . H e called th e nex t da y t o as k fo r a n appointment , a t whic h poin t th e therapist reiterate d th e requiremen t o f abstainin g fro m violence , whic h he acknowledge d an d accepted . Fro m tha t poin t on , ther e wer e n o further episode s of los s of control . Getting Throug h Har d Times : The Wonderfu l CI A Throughout th e followin g si x months , a s th e therapis t listene d t o Roge r relate hi s discontent s abou t th e banalit y o f hi s life , sh e note d tha t hi s interest i n the CI A fluctuated. Ther e were long stretches o f week s durin g which h e would hardl y mentio n th e CIA and whe n th e therapist cam e t o believe that h e had pu t asid e his interest i n them. Then h e would tel l th e therapist tha t th e CI A wa s bac k again . Becaus e o f th e turmoi l o f th e summer an d it s apparen t connectio n wit h th e risin g preoccupation wit h the CIA , eac h ris e i n hi s interes t i n th e CI A wa s no w associated , fo r th e therapist, with a certain amoun t o f anticipator y anxiety . Would h e agai n lose control ? Coul d th e relationshi p surviv e anothe r force d hospita l stay? Instead , eac h increas e i n interes t i n th e CI A wa s followed , withi n two t o three weeks, by a waning o f tha t interest . The fluctuation i n Roger' s involvemen t wit h th e CI A bega n t o loo k like a n endogenou s cycl e until , o n on e occasion , i t cam e clos e o n th e heels o f a potentiall y stressfu l event . On e day , twelv e month s int o th e work, h e tol d th e therapis t tha t h e had receive d a call fro m a woman h e had date d som e year s earlier . Sh e woul d soo n b e drivin g throug h hi s area an d wante d t o dro p i n just fo r ol d times ' sake. He had consente d t o the visit , but , i n a sessio n betwee n th e cal l an d th e visi t h e voice d fear s about tw o consequence s of attemptin g to act like a normal perso n a t thi s time. First, he feared tha t h e might no t remembe r ho w t o act in ordinar y social situation s an d tha t h e migh t revea l to o muc h o f hi s psychiatri c troubles, causin g thi s woma n t o b e repulse d b y hi m an d b y hi s de meanor. A t th e sam e time , h e feare d tha t h e migh t b e abl e t o pas s fo r normal, in which cas e she might want t o see him again . He did not thin k he wa s u p t o resumin g ordinar y socia l contacts , especiall y thos e tha t might mov e in a n amorou s direction . At the next session, it appeared tha t hi s second fea r ha d com e to pass. The woma n visited , an d the y ha d a goo d tim e talkin g abou t thei r live s in th e year s sinc e thei r forme r relationship . A t th e en d o f th e afternoon ,

The Case of Roger 31 7 she asked him to call her, which meant to him that she was interested in reactivating the relationship. In the very next session, his interest in the CIA returned with marked vigor. He told the therapist that he had gone home, entere d th e bathroom , an d literall y commande d thei r attention , shouting out, "Where is the CIA?" whereupon they replied with a series of click s in the bathroom wall . He then carrie d o n a long conversatio n with them through the night. There was no mention, either by Roger or the therapist , o f th e possibilit y o f a connectio n betwee n th e woman' s visit and the return of the CIA. It was clearly premature to advance that idea. He would perceiv e it a s a direct assaul t o n his status a s a valued government informer . A t thi s tim e o f declinin g self-esteem , suc h a n interpretation would be like pouring acid into his wounds. A NEW DEVELOPMENT Looking Forward to the CIA' s Return Therapist an d patien t wer e no w abl e t o agre e that , a t leas t o n som e occasions, Roge r wa s willing to activel y see k ou t th e CI A and tha t o n these occasions, he was interested i n their companionship , perhaps as a buffer agains t the fear of social rejection an d loss of self-respect. To this date, although the correlation betwee n a real or anticipated social rejection an d th e retur n o f th e CI A ha d ofte n seeme d compellin g t o th e therapist, Roger had never been willing or able to confirm such a connection directly. He had consistently appeare d to experience the therapist's musings abou t suc h a connectio n a s a n assaul t o n th e veracit y o f th e CIA's interest in him. These were separate events, having nothing whatever to do with each other. He was, nevertheless, willing to confirm th e therapist's observatio n tha t h e ofte n sough t ou t th e CI A activel y an d that he looked forwar d t o his conversations with th e agents behind th e walls, signifyin g a s they di d a futur e tim e i n which th e natur e o f thei r interest in him would be revealed. This type of observation stand s in contrast t o the more conventiona l interpretative interventio n commonl y mad e i n th e contex t o f delusio n formation. Typically , th e therapis t strive s t o mak e hi s o r he r patien t aware of th e defensive functio n o f a delusion. However, when the state of th e allianc e doe s no t ye t permit th e patient t o replac e th e defensiv e benefits o f a delusion wit h a n involvemen t wit h th e therapis t o r whe n

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the patien t ha s no t ye t forme d gratifyin g rea l relationships , interpreta tions tha t furthe r thi s ai m carr y th e ris k o f prematurel y disablin g th e patient's capacit y t o cop e wit h isolation . I n thi s setting , th e preferre d intervention is one that leaves delusion formation intact while permitting other wor k t o b e accomplished . A t thi s poin t i n th e wor k wit h Roger , the therapist' s priorit y wa s t o obtai n hi s endorsement fo r two represen tations that would com e into use repeatedly a s the treatment progressed: first, sh e wante d th e patient' s endorsemen t fo r describin g hi m a s a n active agent—on e wh o recruit s an d dismisse s delusiona l companion s a t will; second , sh e sough t hi s consen t t o describ e hi m a s exercisin g thi s capacity i n the service of bufferin g himsel f agains t excesses o f lonelines s and insignificance . Thus , th e therapis t electe d t o leav e th e delusio n in tact, i n exchang e fo r Roger' s agreemen t tha t h e value d an d activel y sought human involvement an d personal significance .

The Reappearance o f Real-Object Hunge r Not unti l th e fourteent h mont h o f treatmen t di d Roge r begi n t o sho w evidence o f a n interes t i n bein g wit h people . Hi s lonelines s fo r peopl e came as an abrupt departure from th e musings about his role in the CIA that had so completely dominated the work in the previous nine months. He wa s alon e a t home. Hi s parent s ha d departe d t o spen d th e holiday s in Florida. A t 4:30 A.M . o n Christma s Eve , he placed a n emergency cal l and begge d th e therapis t t o ge t hi m ou t o f th e house . H e aske d th e therapist t o arrang e a sta y a t a hospital . Thi s developmen t wa s mor e disorienting tha n al l th e month s o f dialogu e abou t th e CIA , since thi s was the first time in her tenure that Roger sought entry to a hospital an d the first evidenc e tha t h e wante d somethin g othe r tha n isolatio n an d reverie. The therapis t reasone d tha t i t was essentia l t o respon d materiall y t o the patient's desire , rather than attemptin g t o retai n him in the commu nity with a crisis intervention. Th e critical element s in her decision wer e the observations that, despite his opposition to institutional controls , the patient wa s givin g evidenc e o f lonelines s an d ha d issue d a clear reques t for a specifi c service . Treatin g th e patien t i n th e communit y a t thi s juncture—the therapist' s preferre d respons e i n such circumstances—woul d have require d he r t o ignor e thes e developments . Overcomin g he r sur prise an d movin g i n oppositio n t o he r standar d response , th e therapis t

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asked the patient which hospital he preferred, arranged for his admission on a n emergenc y basis , an d wen t t o th e patient' s hom e jus t a s th e su n was rising to escort him to the hospital. The patien t an d a n affectionat e mongre l b y th e nam e o f Paddy , greeted the therapist at the door. Roger then revealed that in his parents' absence h e had bee n playin g with th e wish tha t the y would die , onl y t o find himsel f swep t int o th e convictio n tha t th e whol e family—bot h parents an d bot h sisters—ha d actuall y die d i n a plan e crash . H e pre sented thi s ide a gravel y a s a fac t an d appeare d quit e frightene d fo r hi s future. Th e prospect o f bein g surrounde d b y people , eve n i n a n institu tion, ha d become very attractiv e in the aftermath o f thi s family tragedy , and he eagerly prepared fo r th e trip to th e hospital. O n the way out , h e turned bac k an d remarked , " I can't g o o n lik e this , livin g i n the wood s with a dog. " Then , thinkin g perhap s ho w lonel y h e ha d become , h e insisted o n bringin g Padd y wit h him , assertin g tha t sh e woul d di e o f loneliness if left behind .

Taking Control of Coming and Going So bega n Roger' s first elective hospita l sta y i n th e thre e year s sinc e th e appearance o f th e CIA . H e staye d fo r a month an d aske d th e therapis t to visi t hi m twic e a wee k o n th e unit . Ther e wa s n o tal k o f th e CIA . Uncharacteristically, h e joine d i n th e activitie s o f th e unit. H e talke d t o the staff . H e befriende d tw o mal e fello w patients . Whe n th e tim e cam e for discharg e planning , h e tol d th e therapis t i n a worrie d voic e tha t h e was afrai d tha t th e staf f woul d agai n decid e tha t h e shoul d g o t o a halfway house . H e wante d t o avoi d thi s developmen t b y leaving , eve n though h e was not , i n the staff' s vie w an d b y his own estimate , entirel y ready for discharge. This wa s a moment o f opportunity . Throughou t th e entir e period o f his psychosis, Roger's arrivals to and departures from hospitals had been occasions o f humiliation . H e wa s brough t i n agains t hi s will . H e lef t when th e staf f decide d h e wa s ready . H e ha d littl e t o sa y abou t hi s comings an d goings . No w again , th e staf f wa s indee d movin g i n th e direction o f recommendation s tha t Roge r coul d no t endorse , includin g referral t o da y treatmen t an d placement i n a supervise d residence . Thi s time, h e ha d reveale d a capacit y t o initiat e hospita l treatmen t appro priately. I t wa s essentia l t o acknowledg e hi s evolvin g clinica l judge -

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ment. The therapis t elected t o endors e a departure on hi s own schedul e and t o hi s preferred destination , aimin g i n this actio n t o enabl e he r patient t o recaptur e a portio n o f hi s los t dignity . Additionally , thi s wa s a tim e t o prepar e fo r possibl e futur e electiv e hospita l stays , affirmin g his us e o f th e hospita l a s a temporar y asylum . Ther e woul d b e a n un usual twist , o f course . Hospital s commonl y functio n a s a refug e fro m the stresse s o f life . I n hi s case , th e hospita l coul d becom e a refug e from the unique stresses of self-enforced isolatio n and its attendant loneliness.

The Search fo r a Social Nich e At th e firs t offic e sessio n followin g hi s retur n home , Roge r note d th e appearance o f depression . To hi s surprise, he was missin g the friends h e had made an d the total immersio n i n the life of th e unit. H e was lonely . One coul d almos t sa y tha t h e wa s lonel y again , excep t tha t i n n o prio r session, durin g th e earlie r part s o f th e interi m period , di d h e spea k o f being lonely . Rather , h e ha d bee n eithe r disparagin g o f contac t wit h other peopl e o r fearfu l o f th e demands t o relat e that emerge d o r woul d emerge if he had elected to spend time with others. Now h e was noticin g the absenc e o f th e companionshi p o f th e unit . H e reminisce d abou t a time, before the onset of his psychotic experiences, when he had yearned for involvemen t an d ha d ofte n bee n i n th e compan y o f others . Th e therapist wa s abl e t o remin d hi m o f hi s statemen t abou t "livin g i n th e woods with a dog" and to suggest, without his dismissing the suggestion, that hi s lonelines s heralde d a shif t i n hi s priorities . Th e lif e o f self enforced reclusivenes s wa s no t al l o f hi s life . H e coul d begi n thinkin g about reinvolving himself with people. In th e contex t o f thi s development , Roge r bega n t o connec t wit h others again . H e establishe d contac t wit h on e o f th e people h e had me t in the unit, a former cleric. Over the course of a week or two, they spoke several time s b y phone , bu t h e demurre d o n meetin g face-to-face . Fo r some weeks , th e therapis t though t sh e ha d see n th e en d o f thi s littl e burst o f alivenes s an d full y expecte d tha t Roge r woul d soo n retur n t o his relationshi p t o th e CIA . However , a s winte r turne d t o spring , th e yearning to be with others resurfaced, this time in the form of an interest in working again : If he was t o hav e a woman, he must have a n occupation, so he would work . H e spok e in several session s in the spring of hi s

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former occupatio n o f som e month s a s a rea l estat e broker . Seekin g t o affirm th e value of thinking of himself a s a person who works when well enough to do so, the therapist encouraged him to consider taking up real estate agai n an d t o begi n b y readin g th e rea l estat e listing s fo r hal f a n hour eac h day . Soo n h e wa s readin g listings , makin g calls , goin g t o se e properties, al l fro m th e positio n o f becomin g a privat e investor . H e found a friend o f th e famil y wit h who m h e coul d wor k a s a n investin g partner an d starte d readin g abou t rea l estat e appraisal . H e wa s o n hi s way. Then, i n th e eighteent h mont h o f treatment , th e cras h came . I n a session in May, he recounted with considerable discouragement his utter confusion ove r a n apparentl y simpl e appraisa l formula . Unabl e t o com prehend th e mathematic s involved , h e sai d t o himself , "You'r e no t a credible man , Roger! " an d swep t th e whol e rea l estat e busines s aside . He wa s heade d fo r a retreat . H e referre d t o himsel f a s havin g bee n a t phase 2 fo r a perio d o f a wee k o r two , exhilarate d tha t h e wa s agai n interested i n havin g a life , believin g tha t h e als o ha d a future . No w h e wanted only to plunge into phase 1 again and to forge t tha t he had ever wanted anything . At first th e therapis t foun d hersel f investe d i n holdin g o n t o th e momentum gaine d i n th e tim e sinc e Christmas . H e ha d com e s o far . Must al l o f thi s b e los t jus t becaus e o n th e first try h e couldn' t maste r the formula ? Th e therapis t kne w bette r tha n t o encourag e hi m t o g o back t o th e beginning , bu t th e therapis t di d s o anyway , suggesting tha t he return in his involvement t o the original half-hou r o f readin g listings. But Roge r woul d hav e non e o f it : I t was stupi d o f hi m t o thin k tha t h e could d o rea l estate , tha t h e coul d hav e a life , tha t h e coul d hav e a woman. Observin g the full forc e of his commitment to receding to phase 1, th e therapis t quickl y switched , b y th e nex t session , t o a complet e endorsement o f retreat . Hi s priorit y wa s th e avoidanc e o f th e humilia tion o f bein g a witness t o hi s ow n inabilit y t o d o simpl e thing s tha t h e had once , i n hi s recollection , don e effortlessly . Th e effor t t o becom e involved was producing only an assault on his pride, with no appreciabl e compensations. I t wa s prematur e (a t th e least ) t o support a partia l retreat. To this point in the interim period, the therapist had had little contact with the family. Now i t became apparent that they were distressed abou t the retreat that was under way. Roge r informed her , in the next session ,

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that hi s fathe r wa s encouragin g hi m t o sta y involve d i n rea l estate , an d this pressure was complicating life fo r him. The therapist considered this an indicatio n fo r a direct intervention , th e ai m o f whic h wa s t o protec t Roger's right to resign, to preserve for him the dignity of resting up afte r an exhaustin g effor t t o ge t hi s lif e movin g again . Roge r accepte d th e therapist's offe r fo r a join t meetin g wit h hi m an d hi s fathe r t o discus s the nee d fo r retreat . I n tha t meeting , i t quickl y becam e clea r tha t th e parents had seen real improvement in Roger's morale and in his behavior and hygien e durin g th e rea l estat e perio d an d coul d no t se e th e los s o f this interest as anything but a backward move. For her part, the therapist was concerne d that , withou t suppor t fo r temporar y time-out , Roge r would hav e t o produce mor e compellin g evidenc e o f infirmit y i n behav ior that would quas h their sense of optimis m but would at the same time trigger a full-blown "crackup " with a very prolonged period of indiffer ence, suc h a s th e on e tha t ha d dominate d th e first fourtee n month s o f treatment. Aimin g fo r a shorte r an d les s self-destroyin g retreat , th e therapist recommende d t o th e fathe r tha t th e famil y se e thi s a s a n obligatory period of recuperation, perhaps to be followed b y yet another period o f activit y an d reinvolvement . Turnin g t o Roger , th e therapis t recommended tha t h e tak e t o be d an d surrende r th e busines s o f rea l estate completely. Anticipatin g that Roger might feel demoralize d b y the therapist's support fo r th e retreat , th e therapis t wondere d openl y wit h him, i n hi s father' s presence , whethe r h e fel t discouraged . H e reporte d instead som e relief . I n the followin g session , h e share d hi s gratitud e fo r the therapist's role as a protector. There followe d a perio d o f fou r week s durin g whic h Roge r wa s apathetic an d disinterested, bu t there was n o full-scal e retur n of hi s CIA musings. Then , jus t a s abruptl y a s i t ha d disappeared , hi s lonelines s returned i n the fifth week o f hi s retreat. This time , informe d perhap s b y the failure t o move toward employment , hi s yearning took th e form of a reconsideration o f th e ide a o f goin g t o a long-term hospita l t o live . Bu t in contrast to his talk abou t this idea in the very first interview, when he represented a long-term hospita l sta y a s a way t o avoi d involvement , h e now though t o f i t as a place to b e with peopl e without th e performanc e demands o f th e worl d o f work . H e spok e fondl y o f a n earlie r hospita l stay i n whic h th e companionshi p o f othe r patient s wa s th e salutar y ingredient. H e aske d th e therapis t t o chec k ou t specifi c institution s tha t he ha d hear d o f a s decen t long-ter m places . H e wante d t o kno w wha t

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the average length of sta y was in these places, remarking that he wanted to know "whethe r I can stay as long as I need to." The search was on for a place in which he could be with people whil e continuing t o b e inactive. Thi s ma y no t soun d lik e much o f a n advanc e over hi s origina l interes t i n long-ter m inpatien t care , bu t th e nove l ingredient wa s hi s interes t i n involvement wit h others . Hi s lonelines s o f the winte r ha d survive d th e onslaugh t o f hi s failur e a t work . H e stil l wanted somethin g instea d o f nothing . Th e therapis t endorse d th e pla n and made calls to several hospitals, asking directors of admissions specifically abou t th e lengt h o f sta y an d th e qualit y o f th e othe r patients — how muc h the y woul d b e intereste d i n companionshi p an d s o forth . After each call, she related her findings to Roger, functioning a t this time as a consultant to a client, returning from her fact-finding missio n of th e week an d constantl y read y t o g o nex t i n th e directio n o f he r client' s interest, alway s representing him to the offices o f admission s a s a fello w interested i n a restorativ e lon g stay . Durin g thi s period , sh e fel t mor e like a headhunter or a matchmaker than like a therapist. Distinctly absen t fro m ope n discours e a t thi s tim e wa s th e possibl e impact o n Roge r o f hi s leavin g th e immediate are a an d thu s ceasin g regular, twice-weekly meeting s with the therapist. It was certainly on her mind at each session that she would miss him. But there was no evidence coming directl y o r indirectl y fro m Roge r tha t th e relationshi p wit h th e therapist wa s centra l o r indispensable . Indeed , the y wer e agree d tha t i t was tim e fo r hi m t o mak e a chang e fro m hi s lif e "i n th e woods " an d that, give n th e persistenc e o f hi s yearning s t o b e wit h peopl e an d hi s still-thorough disinclinatio n t o mov e to a halfway house , he had to seek out a hospital environment. They both knew that, as much as they talked of th e possibilit y o f occasiona l trip s bac k int o th e area , an y mov e t o a hospital woul d substantiall y interrupt their work together . All the same, the priorit y wa s finding a socia l nich e tha t offere d rea l companionshi p with real people. Their relationship would b e subordinated to that goal. In th e nineteent h mont h o f treatment , Roge r identifie d th e Auste n Riggs Cente r a s th e plac e t o go . The perio d betwee n applicatio n an d interview was devoted to a review of the developments leading up to the application and the goals for his stay there. There was some talk betwee n therapist and patient about finding a way to continue their meetings, but the therapist indicated t o Roge r that this would b e something to discus s at a tim e whe n h e becam e clea r tha t h e wante d t o sta y a t Riggs . H e

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asked i f th e therapis t would continu e t o wor k wit h him upo n hi s return some years hence, and the therapist assured him that she would continu e to b e availabl e t o hi m a t an y poin t i n th e indefinit e future . H e openl y acknowledged th e therapist's role as his principal frien d during the prior eighteen months . Nevertheless , h e stressed , hi s lif e i n th e suburb s wa s devoid o f contac t wit h rea l friends , a stat e o f affair s tha t ha d finally become intolerable . H e spok e of thi s concern in the admission intervie w at Riggs and was admitted there five days later. Throughout th e perio d o f th e patient' s searc h fo r a mor e socia l set ting, th e therapis t communicate d implicitl y he r understandin g tha t th e treatment relationship, althoug h important , wa s not sufficient t o sustai n the patien t an d di d not , b y itself , offe r a n adequat e contex t fo r th e patient's socia l recovery . Sh e activel y supporte d th e patient' s effort s t o assess eac h setting , functionin g mor e lik e a cas e manage r linkin g th e patient t o resource s than lik e a therapist encouraging a focus o n chang e of self . Like s so man y othe r aspect s o f th e treatment o f thi s patient, thi s orientation wa s a direct outgrowt h o f th e therapist's recognitio n o f an d respect fo r th e patient's priorities . H e wa s no t intereste d i n psychother apy. Indeed, he scolded the therapist on each occasion when she assumed an interpretiv e stance . Rather , h e struggle d t o find a way t o reente r th e world o f rea l peopl e fro m a position o f sever e negativis m regardin g hi s prospects fo r a successful comeback . Supportin g his search, even thoug h it woul d brin g thei r work t o a halt , wa s he r wa y o f promotin g th e patient's movemen t towar d hi s avowe d goal . T o discourag e th e search , by emphasizin g interna l change , woul d hav e bee n t o disaffir m t o th e patient the importance an d believability o f that goal. The sta y a t Riggs lasted al l of tw o weeks . Immediatel y o n arrivin g at home, h e calle d th e therapis t fo r a n appointmen t an d arrive d a t he r office th e next da y lookin g amuse d an d saying, "Well , I'm all better and I'm goin g t o ge t married! " An d althoug h thi s wa s obviousl y sai d i n humor, i t wa s als o hi s first reference t o marriage . Upo n arrivin g a t th e Center, h e ha d discovere d tha t ther e wer e to o man y isolate d people , leading hi m t o conclude , almos t immediately , tha t th e plac e woul d no t afford hi m th e kin d o f companionshi p h e required . I n tha t first retur n session, h e aske d th e therapis t t o refe r hi m instea d t o a da y program , suggesting tha t hi s searc h fo r a mor e companionabl e nich e wa s stil l a n active goal . H e ende d th e nex t session , thre e day s later , pointin g t o th e air conditioner an d remarking tha t it was goin g o n an d of f i n a manner

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reminiscent o f hi s forme r CI A times an d indicating furthe r tha t over the intervening weekend he had been "thinking about talking to the CIA out of loneliness. " If th e sta y a t Rigg s wa s abbreviated , Roger' s involvemen t i n a loca l day progra m wa s shorte r still . H e wa s accepte d an d bega n an d lef t th e program al l withi n eigh t days . I n a conferenc e wit h th e da y progra m staff, th e therapis t learne d tha t durin g hi s fou r day s i n th e progra m h e had bee n ver y restless , ha d troubl e concentrating , an d starte d hi s first men's group meeting by asking whether it was possible to get AIDS from oral sex . Whe n th e recommendatio n ha d bee n mad e tha t h e tak e addi tional medication, 6 h e ha d refuse d an d subsequentl y intrude d angril y into a staf f meetin g t o sa y tha t h e wa s goin g t o tal k t o th e therapis t about the medication issue, but that if she agreed with the recommendation, he would fire her once again. In spite of its brevity, the day program stay turned out to be a catalyst for a cours e o f event s tha t serve d a s a n importan t preceden t fo r late r developments. The session began with Roger's very vocal criticism of the day program. He was contentious towar d th e therapist as she attempte d to discus s th e issu e o f hi s disruptiveness . Suspectin g tha t he had experienced th e recommendatio n fo r a n increas e i n medicatio n a s a n assaul t on his integrity, bu t also knowing that, unless he agreed to this measure, he would certainly be asked to leave the program, the therapist suggested two possibl e remedie s t o hi s emergin g unsteadiness . The first would b e an increas e i n medication . Sh e opene d a discussio n abou t medication , hoping tha t he would conside r thi s proposal . H e appeare d t o b e unrav eling in the face of increased interaction with people in the program, and an increas e i n neurolepti c medicatio n wa s a rationa l response , i f hi s disruptiveness wa s see n a s a manifestatio n o f physiologica l stimulu s overflow. However , the therapist talked around this idea, representing it merely as a possibility. She stopped short of advancing it as a recommendation since , eve n whil e sh e wa s sayin g th e words , th e patien t wa s drawing breat h t o rejec t i t ou t o f han d an d perhap s t o fulfil l hi s threa t to fire her. The secon d remed y woul d b e a voluntar y retur n t o phas e 1 . Th e therapist allude d t o th e time , thre e month s earlier , whe n h e ha d force fully withdraw n fro m hi s rea l estat e activities , plungin g fro m phas e 2 into phase 1 , and suggested he consider using the same strategy now. A t that time, th e cras h had seeme d desperat e an d impulsive, no t a t all part

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of a plan. The therapist' s onl y rol e had bee n a s a witness t o th e inevita ble. Now, jus t slightly befor e th e patient bega n anothe r plunge (bu t at a point whe n anothe r plung e appeare d inevitable) , sh e recommende d a n elective return to phase 1 , transforming what would otherwise have been a desperate man's solitary ac t into the decision o f a team acting strategically t o preserv e hi s dignity . Sh e represente d i t a s a strategy fo r dealin g with th e challeng e o f gettin g too muc h contac t with people to o quickly . If it worked—if h e did it in time—he would no t lose much time, thereby enabling them to continue the search for companionship . To th e therapist' s relief , Roge r accepte d th e latte r recommendation , appearing able to see this as a positive step . At the same time he allude d to th e difficult y o f acknowledgin g anothe r defeat , saying , "Th e pai n i s awesome an d nearl y overtake s me. " There followed , i n this session an d the next , a discussio n abou t th e importanc e o f dignity , i n whic h i t became clea r that, a s disappointing a s it was t o los e th e companionshi p promised b y participatio n i n th e da y progra m an d a s loathsom e a s a return t o phas e 1 migh t be , i t wa s bette r t o g o tha t rout e tha n t o participate i n bein g induce d int o patienthoo d b y acceptin g mor e medi cation. H e gav e hi s notic e t o th e da y progra m an d commence d hi s first prescribed retreat . I n thes e sessions , Roge r als o reporte d tha t h e wa s actively inviting the CIA back into his life. Taking a chance, the therapist remarked that objectivity mus t be subordinated to dignity an d that right now th e CI A serve d th e purpos e o f promotin g hi s dignity . H e di d no t confirm th e embedded interpretation; nor did he object to the inference. After cancelin g th e nex t tw o sessions , sayin g b y phon e tha t h e wa s too il l t o com e in , Roge r appeare d muc h improve d an d claime d t o b e feeling bette r a t th e nex t tw o sessions . B y the fourteent h da y followin g the discussio n abou t medication , h e wa s abl e t o pus h throug h th e ba d feelings, tak e a shower, an d ge t dressed . H e wa s stil l i n phase 1 , bu t a t least hi s irritabl e over-arousa l ha d com e t o a n end , an d b y th e en d o f another tw o weeks , h e wa s agai n complainin g o f depression , boredom , and loneliness . H e ruminate d openl y abou t hi s bitternes s a t bein g ex cluded fro m th e famil y business . Fo r a brie f interva l o f a fe w days , h e was open , fo r th e first time , t o a suggestio n fro m th e therapis t tha t h e consider a training program. He phoned th e day program, askin g whether he coul d arrang e a voluntee r jo b i f h e wer e t o return . An d b y th e thirtieth day , hi s interes t i n finding a refug e fro m lonelines s wa s activ e again.

The Case of Roger 32 7 From the twenty-third to the twenty-sixth months, Roger was actively engaged in a search, coaching the therapist in her role as his placement counselor on how to approach the hospitals in which he took an interest. In seria l fashion , h e assesse d Fou r Wind s Hospital , th e Institut e fo r Living, an d th e Menninger Foundation . I n each case , it appeare d that the pressure to improve was likely to be unacceptably high, outweighing the potential benefits of the companionship of other patients. Late in the twenty-fourth month, the therapist explained that a significant limitation of thes e an d al l othe r institution s wa s tha t mos t hospital s wer e no w under increasin g pressur e t o demonstrat e active , goal-oriente d treat ment. This may have had a certain consciousness-raising effect on Roger, because, within a week, h e asked abou t non-medical residentia l placements, includin g Goul d Far m an d Sprin g Lak e Ranch . Thes e setting s stood in contrast to hospitals in that they usually were not characterized by th e pressure s o f activ e treatmen t an d typicall y ha d a mor e low keyed orientation towar d progress. At the patient's direction , the therapist contacte d th e admission s offic e a t Gould Farm , ascertaining that the Farm had a long enough lengt h o f stay . However , ther e was a requirement fo r regula r participatio n i n th e wor k o f th e Far m fo r up wards of si x hours a day. The discussion of his preparedness to sustain this leve l o f activit y continue d o n an d of f fo r th e nex t thre e months. During thi s interval , h e applie d t o th e Far m an d aske d th e therapis t to sen d a strongl y supportiv e lette r o f recommendation . Shortl y afte r this decisio n wa s reached , th e patien t calle d th e therapis t On e day , from th e family's winte r home in Florida, sayin g he would b e back in three weeks. He had decided to take a vacation, to try his hand at cruising the socia l club s an d discos o f Miam i fo r a while i n search of ne w friends. By th e beginnin g o f th e activ e psychotherapeuti c phas e t o b e de scribed i n th e nex t section , th e patien t ha d considere d an d rejecte d nearly al l o f th e programs—al l o f th e hospitals , da y programs , an d rehabilitation centers—that he and the therapist had together been able to propose as potential resource s in his avowed search for companionship. Within a week o f enterin g the active psychotherapeutic phase , he also rejected and was rejected by Gould Farm, the last of the alternatives investigated, and then entered new ground. In reviewing th e prolonged pretherapeuti c interval , th e outstandin g features of the work were:

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1. Th e patient' s movemen t fro m a stat e o f continuous , extrem e apath y and anhedoni a t o a state of yearning fo r rea l human companionship ; 2. Th e therapist' s willingnes s t o subordinat e th e continuit y o f th e ther apeutic relationship t o th e patient's nee d fo r rea l relationships ; 3. Th e therapist' s movemen t towar d increasin g acceptanc e o f an d com fort wit h th e primitiv e defense s o f delusio n formatio n an d apatheti c disengagement; 4. Subordinatio n o f th e realit y principle to the patient's avowe d priorit y of retainin g hi s dignit y an d avoidin g experience s tha t le d t o furthe r humiliation; 5. Th e patient's acceptanc e o f th e therapist's injunctio n agains t physica l abuse; 6. Th e therapist' s acceptanc e o f th e patient's expresse d unwillingnes s t o subject himsel f t o conventional interpretiv e psychotherapy ; 7. Th e emergenc e o f a spirit of collaboratio n an d teamwork ; 8. Identificatio n o f th e mutuall y agreed-upo n goa l o f addin g t o th e patient's qualit y o f lif e i n ways that mattere d t o th e patient; an d 9. Subordinatio n o f th e goa l o f improve d socia l functionin g t o th e goa l of preservin g th e patient's self-respect . Patient an d therapis t wer e brough t togethe r i n thei r frustratio n a t failing t o find a settin g that afforde d th e patient a n opportunit y t o buil d real relationship s an d attai n th e companionshi p tha t h e ha d com e t o desire. Tha t share d frustratio n se t th e stag e fo r th e wor k o f th e nex t treatment period . B y default , h e ha d nex t t o wor k o n hi s capacit y t o engage flexibly i n an d then disengag e from whateve r socia l involvement s were availabl e t o him , forgin g a socia l styl e tha t simultaneousl y too k into accoun t hi s objec t hunger , hi s ver y considerabl e narcissisti c vulner abilities, and hi s tendency towar d stimulu s overflo w an d affectiv e flooding in the context o f social involvement .

A NEW PARADIGM: PHASIC INSTABILITY REDEFINE D Twenty-seven month s fro m th e outset o f the work, Roge r began to sho w what turne d ou t t o b e a persisten t interes t i n mappin g th e transition s between th e phase s o f hi s conditio n tha t h e ha d identifie d i n th e secon d interview. Fo r si x weeks , thi s interes t becam e centra l i n th e treatment ,

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serving a s th e basi s fo r activ e psychotherapeuti c intervention s aime d a t offering a ne w an d mor e enablin g paradig m throug h whic h t o under stand the dramatic fluctuations tha t patient an d therapist had witnesse d throughout th e treatmen t t o date . Durin g th e lon g interi m period , th e patient had regained the courage an d the capacity to want involvement s with othe r people . Bu t rathe r tha n leadin g t o a n increase d abilit y t o b e with others, his new-found abilit y to yearn had given birth to a renewed dread of participation : H e coul d plunge into life, takin g u p a pursuit o r searching for other people t o be with, but he had not yet learned how t o cope with the virtual flood o f affect s tha t accompanied th e involvement s he wa s abl e t o begin . H e alternate d betwee n involvemen t an d with drawal, betwee n alivenes s an d deadness . H e sa w n o wa y t o b e aliv e without bein g overwhelmed , an d th e specte r o f anothe r cracku p trig gered by too much involvement was, in his view, never more than a step away and could easily lead to another years-long loss of vitality . Now, als o fo r th e first time, h e reveale d a belie f tha t h e migh t lear n how t o prevent breakdowns—thos e state s of min d that followe d a transition fro m phas e 2 t o phas e 1 or fro m phas e 3 t o phas e 1 . I n the first conversation o n thi s topic , buildin g o n th e concept s o f humiliatio n an d demoralization a s develope d i n th e interi m period , th e therapis t de scribed him as going into a power dive when he met up with the smallest frustration i n a tas k tha t wa s to o muc h fo r him . Sh e suggeste d tha t h e had n o forgivenes s fo r himsel f eve n whe n h e wa s experiencin g a mil d break. Atypically , Roge r confirmed thi s formulation, acknowledgin g hi s inability t o forgiv e himsel f fo r no t bein g "kin g o f th e hill. " At th e nex t session Roger , agai n uncharacteristically, reporte d a dream, in which h e was fallin g throug h a trap door a t the famil y business , onl y t o hav e th e salesmen there leave him hanging, danglin g at the edge of th e trap door. He the n turne d t o a review o f event s i n a previous treatmen t program , revealing tha t h e simpl y coul d no t absor b a s trut h th e representation, offered b y a forme r therapist , tha t h e di d no t wan t t o ge t better . Th e therapist shared with the patient her own sense , born of thei r two an d a half years together (an d of th e real estate caper of th e previous sprin g in particular), tha t th e forme r therapis t ma y hav e misse d a n invisibl e bu t very rea l limitation , namel y hi s tendenc y t o pani c whe n h e wa s feelin g things strongly. This limitation was behind his reluctance to move ahead. But i n th e absenc e o f recognitio n o f thi s pani c b y th e therapist , h e ha d created a mor e obviou s malad y (an d her e th e therapis t wa s repeatin g

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and incorporatin g a vie w discusse d a yea r earlier)—namel y a psy chosis—as a way of compellin g the staff o f th e program to the view tha t he wa s genuinel y incapabl e o f movin g ahead . I n thi s conversation , th e therapist asserte d fo r th e firs t tim e tha t th e patien t ha d a ver y rea l impairment—which the y agree d t o refe r t o a s a "panic disorder"—tha t had been manifes t i n relationships an d possibly i n work setting s as well. Even thoug h i t containe d a n assumptio n o f deficit , Roge r appeare d t o accept th e formulation , i n sharp contrast t o al l previous time s when th e therapist had advanced such ideas. At the next session , Roge r began immediately b y asking the therapis t to tell him more about panic disorder. Together, they elaborated a model in which a n event triggers a state of terror—to which, the therapist again asserted, wit h n o objectio n fro m Roger , th e patien t i s exceptionall y vulnerable. Indeed , no w feelin g mor e confiden t tha t the y wer e o n ne w ground an d tha t she coul d g o further , since Roge r was no t rejectin g th e stress-diathesis model , th e therapis t claime d tha t thi s wa s hi s primar y vulnerability, t o whic h h e responde d b y entering, defensivel y an d adaptively, int o somethin g mor e recognizabl e t o us—namely , a cracku p o r psychotic break . Ther e wa s stil l n o objectio n fro m th e patient . Goin g on, th e therapis t suggeste d tha t hi s occasiona l us e o f variou s sub stances—benzodiazepines, heroin , alcohol—wa s a n attemp t t o ri d him self o f th e terror, but that, sinc e these were ofte n proscribe d o r unavail able t o him , h e ha d evolve d a capacit y fo r psychi c numbin g an d th e erection of a n enforced invalidis m a s his preferred respons e to the experience o f terror . Th e therapis t the n suggeste d th e us e o f th e ne w anti anxiety agen t buspirone a s a possible buffe r agains t this terror. Since he was als o nearin g the time to visit Gould Farm , the therapist forewarne d the patien t o f th e possibilit y tha t goin g t o th e Far m coul d evok e thi s terror. The nex t sessio n wa s cancelle d du e t o a major snowstorm . H e cam e into th e followin g sessio n lookin g wrecked , wit h a furtive, vigilan t glance , reminiscent o f th e glance o f thos e hallucinating , an d readily confirmin g that h e ha d use d cocain e th e nigh t befor e fo r th e first time i n a month . Spontaneously, h e attribute d thi s laps e t o missin g the dail y compan y o f his parents , who ha d b y thi s tim e bee n awa y i n Florida fo r a week. H e said nothin g abou t th e visi t t o Goul d Far m th e nex t day . A t th e nex t session, h e indicate d h e ha d no t like d th e Far m an d then quickl y refo cused o n th e breakdow n process . A t hi s suggestion , th e therapis t too k

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careful note s o n th e element s o f th e proces s tha t wer e know n t o them , as i t ha d occurre d i n th e tim e since it s onse t i n 1975 . Followin g thi s session, the therapist was off o n a winter vacation for a week. At the next session, Roge r immediately starte d in again on th e break down process . He looke d an d smelled good , was clea n shaven , and was dressed casuall y bu t well , muc h lik e a n uppe r middle-class , thirty-yea r old banke r on the weekend. I n this conversation, buildin g on his apparent acceptanc e o f th e concep t o f deficit , th e therapis t advance d th e notion tha t pani c increase d hi s nee d fo r rest , whic h wa s greate r tha n that of othe r people, an d suggested that he think about allowing himself to ente r a state of mind , which the y coul d cal l phase 2.1, or even phase 2.01, i n whic h h e woul d b e mor e ope n tha n a t phas e 1 an d ye t woul d not expec t himsel f t o b e i n an y wa y active . Thi s wa s clearl y a nove l thought t o Roger , an d hi s first reaction wa s no t on e o f curiosity . Nor , however, di d h e conclude , a s he had s o man y time s before , tha t fo r th e therapist t o inven t somethin g lik e this , somethin g abou t hi s conditio n that di d no t com e fro m him , mean t tha t sh e di d not understan d hi m a t all. The therapis t talke d fas t abou t th e advantage s o f hi s permittin g himself t o res t an d catc h hi s breat h fro m th e depletion cause d b y socia l involvement, withou t a t the sam e tim e sufferin g th e los s o f dignit y tha t he ha d alway s foun d waitin g fo r hi m wheneve r h e resorte d t o a transition into phase 1 as a way to get the needed rest. With a lot of tal k fro m the therapist , h e appeare d abl e t o accep t tha t sh e ha d describe d some thing unknow n t o hi m abou t hi s condition . H e di d not incorporat e th e idea in this session, but he left without completely rejecting the idea. In th e nex t session , Roge r announce d that , durin g th e las t session , during al l o f thei r talk abou t finding a way t o sta y a t phase 2.1 o r 2.0 1 and whil e h e ha d bee n insisting tha t unde r n o circumstance s wa s h e a t anything highe r tha n 1.9 , h e wa s actually—h e ha d late r realized—a t phase 3. The next day , afte r a night of n o chlorpromazin e an d no sleep, he ha d becom e frightened , ha d take n som e chlorpromazine , an d ha d become awar e o f a stron g impuls e "t o reente r th e menta l patien t role " [the patient's ow n words] . H e the n revealed that when he really wante d to dive into phase 1 , he would wear old, very ill fitting, and mismatche d clothes, dressin g t o loo k lik e a menta l patient . H e wen t o n t o describ e how, late r i n tha t sam e day , h e ha d nearl y gon e i n th e direction o f th e mental patient , nearl y givin g i n t o a small bu t notabl e impuls e t o wea r an ol d "menta l patien t sweater. " Th e therapis t aske d whethe r h e wa s

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saying tha t h e ha d actuall y fough t wit h suc h a n impulse ? Yes . An d h e had resiste d th e impulse ? Yes . The therapis t indicate d t o hi m ver y mat ter-of-factly, righ t there and then, that this was new ground, that he had never reporte d fighting of f tha t sor t o f impulse . Ho w differen t thi s wa s from las t spring , when, a s he headed int o phase 1 because o f th e failur e to do a real estate formula, there was no stopping him and no indicatio n that an y interna l struggl e coul d b e goin g o n aroun d th e impuls e t o fal l into phase 1 . The patient the n recounted tha t on th e followin g mornin g he had awakened quit e uncertain whether he would find himself movin g toward phas e 1 or phase 3 an d had see n himself goin g towar d phas e 1 , only to find that on the very next day he arrived by some unknown pat h in phas e 2.6 ! Roge r himsel f remarke d tha t thi s wa s a mos t unusua l event, sinc e o n virtuall y al l othe r occasion s whe n h e ha d gon e fro m phase 3 t o phase 1 , he had ended u p spending months t o years in phas e 1 befor e movin g ou t t o phas e 2 again . The therapis t aske d hi m t o consider a t leas t th e possibilit y tha t thi s kin d o f short-ter m variabilit y had importan t positiv e implication s an d dre w thre e graph s depictin g increasing degree s o f variability—an d mobility—an d a t th e sam e tim e increasing access to phase 3. The therapis t wa s workin g her e to challeng e th e patient's fundamen tal, rigid assumption tha t phase 3 should be a permanent status and that a perso n existin g i n a ful l stat e o f alivenes s doe s no t requir e res t (i.e. , phase 1 ) of an y kind. Roger started the next session by focusing o n the breakdown process , indicating furthe r tha t h e wa s gla d tha t the y wer e finally attendin g t o this. H e wen t o n t o describ e tw o model s o f processe s tha t coul d b e making contribution s t o th e breakdown . First , ther e wa s a self-induce d numbing process , throug h whic h h e shut dow n hi s min d an d entere d more o r les s deliberatel y an d intentionall y int o th e menta l patien t role . Second, ther e was a process o f bein g overwhelmed b y terror an d by th e events tha t evoke d o r coul d b e expecte d t o evok e terror . Th e therapis t observed tha t thes e tw o model s appeare d t o b e incompatible o r contra dictory, bu t tha t they coul d bot h b e making contribution s t o th e break down process . Sh e notice d a t one point , whil e h e talked abou t al l thes e things, that, for the first time, he was talkin g from the point of view tha t there might b e some possibility of a moderate, compromisin g lifestyl e i n which he migh t be able to live with a limitation like panic disorder. This was th e first tim e tha t th e patien t ha d give n voice , o n hi s own , t o th e

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idea o f limitation s an d t o th e ide a o f bein g abl e t o adap t t o a lifestyl e that too k thos e limitation s int o account . Th e therapis t recalle d an d recounted a scen e i n The Right Stuff i n whic h Charle s Yaege r take s th e X-15 s o high that i t conks out an d crashes, describing this as a metapho r for hi s trouble . By likening him t o a famou s an d courageou s man , whil e alluding t o th e danger s o f exceedin g th e limitation s o f one' s "equip ment," th e therapis t wa s preparin g a fram e o f referenc e that , i f incorpo rated b y th e patient , woul d enabl e hi m t o protec t hi s dignit y whe n coming up agains t hi s own limits . Choosing t o Mov e Betwee n Phase s In the nex t session , th e patient agai n talke d exclusivel y abou t th e break down process . Thi s wa s beginnin g t o fee l t o th e therapis t lik e a regula r bill o f far e now ; sh e n o longe r wondere d whethe r h e woul d permi t he r to tak e a growth-oriente d stance . In thi s session , h e seeme d t o hea r her , almost fo r th e first time , on th e concept o f th e reversibility o f movemen t between th e phases. He remarke d tha t bein g abl e t o mov e fro m phas e 3 to phase 1 to phase 2 t o phase 1 to phase 2 an d s o forth wa s a new ide a and allowe d tha t i t was worth explorin g further . Roger di d no t appea r fo r th e nex t session . Durin g th e hour , th e therapist calle d th e hous e an d foun d tha t Roge r ha d forgotte n th e ap pointment an d tha t h e wa s disappointe d becaus e ther e wa s somethin g he wante d t o discuss . Reasonin g tha t thi s wa s hi s wa y o f askin g fo r a n extra session , th e therapis t foun d tim e t o se e him th e nex t day , when h e indicated tha t h e wanted t o try tranylcypromine, "t o se e if I can stabiliz e myself a t phas e 2 . " I n discussin g th e us e o f thi s medication , the y re viewed hi s experienc e a t anothe r hospital , whe n tranylcypromin e ha d been use d t o trea t depressio n becaus e h e wa s claimin g t o b e extremel y suicidal. H e no w reveale d tha t h e ha d no t bee n a t al l suicida l a t tha t time an d tha t h e ha d claime d t o b e s o onl y t o se e to i t tha t h e staye d i n the hospital fo r a long time. His hospital docto r ha d turne d t o th e use of tranylcypromine a t thi s point , alon g wit h a neuroleptic , resultin g i n a severe toxi c reaction . Th e therapis t reviewe d ver y carefull y th e dietar y restrictions, including the absolute restriction agains t th e use of cocaine . In th e nex t session , the y agai n brok e ne w groun d a s th e patien t tol d the therapis t tha t h e wa s acceptin g th e validit y o f th e ide a o f bein g abl e to shift betwee n phas e 1 an d phas e 2 . I n thi s context , an d becaus e i t

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appeared tha t his interes t i n evoking a shift wa s mainl y centere d o n th e ability t o shif t up , the therapist aske d hi m how h e was doin g a t shiftin g down fro m phas e 2 to phas e 1 . Roger indicate d that he had real troubl e doing thi s becaus e h e woul d los e face , a repor t suggestin g that , fo r th e moment, th e idea o f a n underlying defici t wa s no t operative. The thera pist replie d emphatically that , i n her view, he was entitled f t o shift fro m phase 2 t o phas e 1 an y tim e h e wante d an d tha t h e coul d d o s o wit h dignity, becaus e i t too k suc h tremendou s courag e fo r hi m t o mak e an y attempt a t al l t o g o fro m phas e 1 to phas e 2 i n the face o f a n unforget table strin g o f breakdown s an d thei r consequen t humiliations . H e starte d on tranylcypromin e tha t week. At th e tim e o f th e nex t session , Roge r calle d sayin g that , o n a n impulse, h e ha d decide d t o g o t o Florid a agai n t o joi n hi s parents . H e was takin g th e tranylcypromine , alon g wit h enoug h chlorpromazin e t o guarantee goo d sleep , an d observe d tha t h e migh t b e feelin g a littl e bi t better. In summarizing the developments o f thi s part of th e work, we see this as a perio d whe n th e patient' s emergin g interes t i n other s le d hi m t o confront hi s illnes s fro m a new perspective . Now , fo r th e first time, h e endorsed th e concep t o f self-regulatio n an d certai n idea s critica l t o th e development o f copin g skills relevant to his social need s and commensurate with his known vulnerabilities. He gave at least provisional credenc e to the following theses : 1. Movin g betwee n involvemen t an d disengagemen t i s normativ e an d therefore respectable . 2. Res t i s a necessary preparatio n fo r an d seque l t o activ e involvemen t with people. 3. I require mor e res t pe r uni t o f activit y tha n other s becaus e I have a proneness to panic anxiety that is not shared by other people. 4. I f I rest as soon a s I become awar e of th e need, I am less likely to ge t stuck in the resting state for a long time. 5. The capacit y t o mov e towar d involvemen t afte r a perio d o f res t requires that I learn to cue in to my actual readines s for involvement , rather tha n relyin g o n genera l societa l injunction s abou t whe n I should b e ready for involvement .

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LEARNING TO USE THE NEW PARADIGM As indicated a t the beginning of this chapter, the majority o f the materia l to thi s poin t wa s writte n contemporaneousl y wit h th e development s described i n th e previou s section . W e wil l no w chronicl e subsequen t developments i n th e treatmen t tha t ar e relevan t t o reformulatin g th e phasic natur e o f th e illness . O f specia l interes t i n thi s sectio n i s th e interplay betwee n th e patient' s yearning s fo r involvement , hi s effort s t o make socia l contact , shift s betwee n th e thre e characteristi c state s o f mind, an d preoccupation s wit h th e CIA . Heretofore , eac h tim e th e pa tient retreated t o phase 1 , he experienced a decrease in the very relationa l skills h e hope d t o regai n and , i n th e absenc e o f competin g evidenc e o f his rea l valu e t o rea l people , expose d himsel f t o a relentles s barrag e o f depreciatory an d intensel y humiliatin g globa l self-representations . Thus , each effor t t o recove r hi s capacit y t o b e aliv e ende d i n failur e and , o f greater long-ter m consequence , furthe r decrease d hi s capacit y t o antici pate pleasurabl e outcome s fro m futur e strivings . Th e resul t wa s a self enforced apath y tha t ha d al l th e marking s o f th e negativ e syndrome , punctuated b y occasional burst s o f excessiv e an d undirecte d activation . Beginning i n th e twenty-eight h mont h o f treatment , th e therapis t strove t o foste r th e developmen t o f th e patient' s capacit y t o mov e elec tively an d wit h dignit y betwee n phas e 1 and phas e 2 . Sh e conceive d o f phase 1 as a recuperativ e an d preparator y state , a psychologica l "hom e base" fro m whic h th e patient coul d mak e explorator y move s int o phas e 2, whic h sh e sa w a s the stat e tha t supporte d involvemen t an d participa tion with rea l objects. She believed the patient's capacit y fo r involvemen t would b e strengthened throug h practic e an d repetition , provided patien t and therapis t devise d way s t o aver t th e advers e effect s o f prolonge d withdrawal. The first opportunit y t o practic e th e ne w orientatio n occurre d durin g the patient' s tri p t o Florida , note d above . Te n day s int o th e trip , h e phoned th e therapis t t o sa y tha t h e ha d spen t mos t o f hi s tim e i n phas e 2, goin g ou t ever y nigh t t o discotheques . H e was , however , concerne d because th e da y befor e h e di d no t ge t dresse d an d di d no t shave , whic h suggested t o hi m tha t h e wa s slidin g bac k int o phas e 1 . Sh e recom mended tha t h e thin k o f thos e behavior s a s example s o f th e kin d o f temporary regressio n t o phas e 1 tha t the y ha d bee n talkin g abou t re -

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cently. He immediately confirme d tha t she might be right. He added that he was finding it hard to carr y on conversations with women, which th e therapist suggeste d wa s t o b e expecte d becaus e h e wa s ou t o f practic e and becaus e hi s min d woul d kee p defensivel y shuttin g dow n o n hi m until i t sa w tha t n o terribl e thing s woul d happe n whe n h e venture d forth. Fiv e day s later , h e returne d fro m Florid a lookin g confiden t an d relaxed, clean-shaven, tanned , wearing a blue blazer and boat shoes. The therapist conclude d provisionall y tha t o n thi s occasio n he r effort s t o represent hi s retrea t favorabl y ha d prevente d th e usua l cycl e o f with drawal an d humiliation.

Using the Hospital a s a Social Club Within two weeks of hi s return home, the patient asked for admission t o the hospital , havin g becom e discourage d b y th e isolatio n o f "lif e i n th e woods" withou t hi s parent s an d wit h n o acces s t o othe r people . I n contrast t o al l previou s admissions , thi s hospita l sta y seeme d barel y justifiable, occurrin g i n th e absenc e o f crisi s o r deterioration . Indeed , when th e therapis t visite d hi m o n th e uni t th e da y afte r hi s admission , she found hi m activel y i n conversation wit h a female patient. The therapist mad e not e o f thi s development , emphasizin g i n a n acceptin g wa y that Roger was usin g the hospital a s a social club . They joked abou t the fact tha t h e ha d com e t o th e hospita l thi s tim e wit h hi s bes t clothes , almost a s if he were headed for a stay at a resort. Fiv e days later, he was optimistic abou t havin g com e int o th e hospita l electivel y an d read y t o socialize an d eve n allowe d tha t hi s presenc e wa s value d b y som e othe r patients. H e spok e o f hi s desir e t o hav e a girlfriend—someon e t o hol d hands wit h an d si t besid e an d watc h televisio n with , nothin g mor e complicated than that. He was conflicted abou t going home. Much a s he was read y t o g o afte r les s tha n a wee k i n hospital , h e ha d becom e interested i n a ver y attractiv e femal e patien t wh o ha d showe d ope n disappointment o n learnin g o f hi s pla n t o leav e th e unit . Th e therapis t supported th e ide a o f hi s remainin g i n th e hospita l a bi t longer , repre senting this as an opportunity fo r him to drink in some contact of a kind that he had not had in a long time. She validated the patient's view that , if presented wit h th e choice betwee n medicatio n an d a kiss a s treatmen t for depression, most people would benefit mor e from the kiss treatment.

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Beginnings of Satisfying Relationship s with Women He did stay, spendin g hours in the presence o f thi s woman, late r reveal ing wit h unqualifie d pleasur e tha t the y ha d ha d som e goo d physica l contact, som e brie f moment s o f kissin g an d hand-holdin g whil e i n th e unit. Afte r returnin g hom e a week later , Roge r calle d this woma n dail y and went ou t on severa l date s with he r after he r discharge. H e spok e o f a futur e an d o f a developing relationshi p wit h he r for tw o week s there after, indicatin g tha t h e wa s livin g a t phas e 2 plus . I n a fe w days , however, h e wa s openl y ambivalen t abou t th e relationship , revealin g that, althoug h h e wante d a girlfriend , som e sexua l release , an d som e companionship, sh e was not the right person for him. He then broke of f with he r when , o n severa l conversations , sh e di d no t see m totall y sup portive o f hi s complaint s abou t hi s parents . Thre e week s later , h e re ported a drea m i n whic h h e wa s married , an d i n th e discussio n tha t followed, th e therapist took a developmental perspective : R: A t first I didn't like being married, but then I got used to it. T: See ? You're practicing, even in your dreams! R: Bu t then a girl named Linda Love came along and murdered both o f us. T: S o you'r e conflicted . Conside r th e possibilit y tha t yo u ar e gettin g ready for something. Not in any dramatic way, but gradually. The matter-of-fac t optimis m o f th e therapist' s response s i n thi s inter change wa s a n importan t elemen t o f he r continuin g effort s t o compet e with th e patient' s tendenc y t o negat e positiv e developments . Further more, th e focu s o f th e drea m interpretatio n wa s i n keepin g wit h th e priority o f providin g th e patien t wit h way s i n whic h t o experienc e himself a s bein g lik e othe r people. Rathe r tha n ope n a n inquiry regard ing th e sourc e o f th e self-destructiv e elemen t embodie d i n Lind a Love , she chose to emphasize how ordinary , how norma l it is to fee l conflicte d when opening up a new line of development . In th e nex t session , Roge r note d that , i n contras t t o al l previou s relationships in which he had grown to care about a woman, he had not felt smothered b y this woman. He allowed that, while this was probabl y because th e relationshi p hadn' t laste d lon g enoug h fo r i t t o happen , i t might als o b e becaus e o f som e maturationa l move . T o thes e optimisti c remarks, th e therapis t responde d b y pointin g agai n t o th e favorabl e

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implications of his having had a marriage dream . In the very next sessio n Roger wa s pessimistic , reminiscin g abou t th e beeper s an d th e CIA . H e seemed pressure d t o d o somethin g wit h hi s life , t o tr y t o ge t a job, an d yet full y anticipate d tha t h e would fail . Th e therapis t place d hi s discour agement i n th e contex t o f hi s yearnin g fo r a woman , pointin g ou t tha t he wanted t o hav e a girlfriend bu t fel t h e coul d no t kee p u p hi s end o f a relationship. Beginning a Productiv e Involvemen t wit h Da y Treatmen t During thi s sam e hospita l stay , Roge r accepte d a referra l t o a da y treatment progra m situate d i n hi s ol d neighborhoo d i n th e city . Hi s willingness t o ente r thi s progra m wa s linke d t o hi s desir e t o ge t bac k t o his apartmen t i n th e city . H e preferre d livin g b y himsel f t o livin g wit h his parents , bu t di d no t kno w wha t h e woul d d o wit h hi s time . I n thi s context, th e therapis t suggeste d tha t h e conside r thi s particula r da y program, whic h sh e ha d visite d informall y severa l month s earlie r o n hi s behalf. His initial reaction, while negative, did not sto p him fro m attend ing. Withi n a shor t time , h e ha d mad e severa l friend s i n th e progra m and wa s regularl y meetin g wit h the m fo r dinne r afte r hours . Th e thera pist place d thi s developmen t i n th e contex t o f Roger' s striving s ove r th e previous fifteen month s t o find som e companionship , deemphasizin g th e extent t o whic h h e woul d otherwis e hav e bee n adversel y affecte d b y being mor e involve d i n the role of a psychiatric patient tha n eve r before . The connectio n t o peer s a t th e da y progra m cam e unde r intens e pressure earl y i n the sixt h mont h o f hi s day program sta y an d th e thirty fifth mont h o f treatment , i n the fac e o f a n unanticipate d invitatio n fro m a forme r femal e acquaintance . Sinc e ther e ha d bee n littl e affection , i t would b e overstatin g thei r relationshi p t o describ e he r a s a girlfriend . There ha d been , however , som e ver y satisfyin g sex , an d no w h e wa s anticipating th e possibility o f a physical encounter . In this context Roge r reported feelin g th e urg e t o g o into phas e 1 , in anticipatio n o f failur e o n the upcomin g date . Th e therapis t discusse d th e nee d fo r hi m t o accep t the regressiv e pus h a s a legitimat e wa y t o forestal l a drasti c collapse . A t a sessio n tw o day s later , whe n Roge r reporte d h e had cancele d th e dat e and no w claime d t o b e crackin g up , th e therapis t insiste d that , i n poin t of fact , h e was constructivel y runnin g fo r cover . There followe d a profoundl y intens e an d confrontationa l discussio n

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in which th e therapis t wa s abl e to distinguis h tw o parts o f th e patient: a vulnerable par t tha t struggle d t o b e involve d an d retreate d whe n over whelmed, an d a vicious , punitive , perfectionisti c par t tha t wa s a prim e cause of the self-shaming tha t led to extensive, prolonged demoralizatio n of psychoti c proportions . Roge r accepte d thi s formulatio n an d th e ide a that hi s experienc e i n a dru g rehabilitatio n progra m ha d amplifie d th e latter t o hi s detriment . Th e therapis t gav e him a prescription fo r loraze pam, recommendin g tha t h e us e u p t o 4 milligram s pe r da y t o trea t hi s panic anxiety . Th e patien t fel t tha t i f h e wen t t o th e progra m i n hi s present stat e of mind , he would surel y lose face with hi s peers, making a fool o f himsel f an d destroyin g th e goo d wil l tha t h e recognize d a s existing ther e fo r him . Th e therapis t offere d t o cal l th e staf f t o validat e his temporar y retrea t fro m th e program , provide d tha t th e patien t als o contract th e staf f directl y t o explai n th e nee d fo r a temporar y absence . Roger gladl y agree d t o thi s interventio n an d remaine d ou t o f th e pro gram fo r a tota l o f five weeks . B y th e en d o f th e first week , h e ha d rebounded substantially , playin g roc k musi c an d recruitin g th e CI A toward th e en d o f mendin g hi s self-esteem . H e wa s abl e t o say , bot h a t home an d i n session , that h e was no t leadin g the worst possibl e lif e an d was abl e t o agre e that th e bi g problem generatin g th e suicidalit y was hi s vicious superego. He indicate d tha t h e was thinking o f goin g back t o th e day program . Th e therapis t cautione d hi m no t t o g o bac k to o soo n an d suggested tha t h e shoul d remai n ou t unti l h e ha d regaine d hi s yearnin g to b e with others . Four weeks later, he returned t o the program . Considering a Mov e t o a Halfwa y Hous e In additio n t o th e movemen t towar d increase d socia l contact , tw o month s after joinin g th e da y treatmen t program , Roge r bega n t o voic e a n inter est i n leavin g home . Sinc e h e continue d t o hav e rea l doubt s abou t hi s capacity t o manage lif e b y himself, he volunteered on e day, in the thirty second mont h o f treatment , tha t h e was considerin g makin g applicatio n to a halfwa y hous e i n th e city . H e foun d i t difficul t t o conside r thi s option i n th e ligh t o f th e intens e conflic t tha t ha d emerge d thre e year s earlier betwee n himsel f an d hi s parent s ove r th e issu e o f th e hospita l staff's recommendation : Goin g to a halfway hous e would b e like admit ting tha t the y an d hi s parent s wer e correct . Thus , h e discusse d th e ide a of a halfwa y hous e i n th e contex t o f th e increasin g conflic t an d resent -

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ment h e wa s experiencin g i n hi s relationshi p wit h hi s father . H e coul d not continu e t o liv e unde r th e sam e roo f wit h th e man . Th e therapis t encouraged hi m t o decid e th e questio n solel y o n th e basi s o f it s place i n his long-term effor t t o fin d a more companionabl e nich e fo r himself .

DISCUSSION By the tim e Roge r introduce d th e ide a o f movin g t o a halfway house , h e and th e therapis t ha d com e ful l circle . The y bega n thei r wor k i n th e context o f a dramati c worsenin g i n hi s clinica l state , apparentl y evoke d by th e hospita l staff' s recommendation , endorse d b y th e family , tha t h e live i n a halfwa y house . H e wa s violentl y oppose d t o th e recommenda tion, t o th e indignities o f lif e a s a supervised menta l patient . No w Roge r was placin g th e ide a o n th e agend a fo r thei r work . Fro m thi s poin t forward, th e session s wer e characterize d increasingl y b y th e patient' s direct expression s o f lonelines s an d narcissisti c injur y an d b y th e thera pist's rejoinder s tha t hi s isolatio n wa s n o longe r servin g him an d tha t h e must, i n du e time, find a living situation that , while accordin g him som e dignity, include d peer s wit h who m h e coul d find som e meaningfu l com panionship. The work continue d t o b e punctuated b y occasional "visits " from th e CIA , an d h e wa s stil l haunte d b y th e beepe r experience , con vinced tha t a t leas t thi s was a rea l event . Bu t b y the thirty-eight h mont h of treatment , eve n whil e h e woul d no t altogethe r relinquis h th e hop e o f having a rol e i n "their " plan s an d eve n whil e h e woul d no t permi t th e therapist t o assum e a n interpretiv e stance , Roge r wa s abl e himsel f t o give the interpretatio n that , whateve r "their " plans , the CI A represente d for hi m a possible wa y ou t o f th e unbearabl e sens e of insignificanc e tha t his life had take n on . Despite thes e continuin g ruminations , th e patien t wa s abl e t o mak e use o f th e flexibilit y o f th e ne w paradig m i n orientin g himsel f towar d involvements wit h peers . The hig h poin t cam e i n th e thirty-sixt h mont h of treatmen t an d represente d clea r evidenc e o f hi s increasing capacit y t o cue i n t o th e sign s o f overloa d an d retrea t momentarily . I n a grou p a t the da y program , Roge r confronte d anothe r patien t abou t bein g cliquis h and arrogan t an d wa s in turn confronte d b y other grou p member s abou t his ow n obnoxiou s ways . H e lef t th e progra m feelin g shaky , observe d that h e was afrai d t o liste n t o musi c on th e way hom e ( a familiar sig n of

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an impendin g breakdown) , wen t ou t t o dinne r wit h hi s parent s an d a friend, too k som e lorazepa m t o cur b th e anxiety , an d then , recallin g recent time s whe n crackup s ha d bee n short-lived , foun d tha t instea d o f wanting t o crac k an d retreat, h e wanted t o g o ou t dancing . H e wen t t o a loca l discotheque , approache d a woman standin g b y herself , danced , broke a sweat , bough t som e drink s fo r himsel f an d th e woman , staye d with her , kisse d a little , the n kisse d mor e i n earnest , aske d he r home , "gave it the old colleg e try, " and weathered her refusal. H e wen t home, felt truly tired, and slept without dreams, or at least without dreams that he coul d recall , an d awok e i n a stat e o f serenit y th e nex t morning . I n session, h e reporte d feelin g prou d o f himsel f an d optimistic , havin g taken more responsibility for himself than in years and having weathered a rejection with more resilience than he thought he had. This cas e demonstrates ho w a therapist, takin g an interest in identifyin g the patient' s prioritie s an d the n incorporatin g thos e prioritie s int o he r approach, wa s abl e t o establis h a n activ e collaboratio n wit h th e patien t in the service of eventual, incremental increases in the patient's flexibilit y in managin g interpersona l relationships . The patien t presente d wit h ex treme sensitivit y t o emotiona l contac t and , a t th e sam e time , wit h pro found injur y t o hi s self-estee m emanatin g fro m th e continua l flow o f evidence o f deficiencie s i n hi s capacit y t o perfor m ordinar y task s an d functions u p t o conventiona l standards . H e use d psychi c numbin g t o attenuate hi s interes t i n involvement s and , simultaneously , a s a way t o diminish hi s capacit y t o experienc e th e pai n o f hi s situation . Ye t hi s continuing objec t hunge r le d hi m t o undertake , a t first i n delusiona l ways, an d then later in more realisti c ways, t o creat e satisfyin g involve ments with people . H e had evolve d a model o f hi s condition tha t incor porated th e numbin g proces s o n on e en d o f a spectru m an d desire d forms o f alivenes s o n th e other . Afte r man y year s o f experienc e wit h a range o f therapist s an d modalities , h e ha d littl e patienc e wit h conven tional diagnostic and psychotherapeutic frameworks. H e specifically disallowed th e us e o f th e diagnosi s o f schizophreni a o r an y o f th e para digms tha t ar e commonl y i n us e i n th e understandin g an d treatmen t o f schizophrenia. H e would no t permit the therapist to assum e an interpretive stance. The therapist' s stanc e demonstrate s ho w th e framewor k describe d i n this book , whe n brough t t o bea r o n a comple x clinica l reality , lead s t o the gradua l unfoldin g o f a n increasingl y detaile d understandin g o f th e

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interplay betwee n a patient's conflict s an d deficits. If , ou t of disgust , th e patient spurned conventional psychiatri c frameworks , a t least he offere d one o f hi s own . A s bafflin g an d uncomfortabl e a s workin g withi n tha t framework migh t hav e been , th e therapis t recognize d immediatel y tha t the goa l o f establishin g a n allianc e require d tha t sh e lear n t o d o so . A s she demonstrate d respec t fo r an d curiosit y abou t hi s paradigm , th e patient wa s increasingl y willin g t o revea l hi s centra l priorities—over coming loneliness , bein g admire d b y peopl e whos e opinio n h e valued , and abov e all , protectin g hi s dignit y agains t th e onslaugh t o f hi s ow n and others ' realizatio n o f hi s infirmities . Arme d wit h a bette r under standing o f th e way s i n whic h thes e principle s organize d hi s inne r lif e and hi s behavior , sh e wa s abl e t o offe r modification s o f th e patient' s model o f illnes s tha t modestl y enhance d hi s capacit y t o ente r int o in volvements wit h selecte d peer s whil e enablin g hi m t o buffe r himsel f against the risk of the massive collapse of self-esteem tha t had commonl y occurred in the past and that had uniformly le d to complete inaccessibil ity an d psychosis. Building on the therapist's apparen t acceptanc e o f hi s priorities, th e patien t wa s abl e t o revea l that , fa r fro m bein g a passiv e victim, h e wa s activel y regulatin g hi s menta l stat e i n accor d wit h th e extent o f sensor y an d emotiona l flooding h e wa s experiencing . Whil e herself seein g thi s regulator y proces s a s a response t o deficien t stimulu s barrier functioning , t o th e patien t sh e responde d mor e concretel y an d within his paradigm b y recommending th e use of psychi c numbing (whic h he was alread y doing by going into phase 1 in his paradigm) a s a means to achieve rest between involvements. While the therapist recognized th e need fo r thi s copin g device , sh e increasingl y sa w tha t it s us e triggered a catastrophic for m o f demoralization . Th e patien t harbore d a n idealize d view o f manhoo d i n whic h suc h res t wa s no t permissibl e an d wa s therefore th e occasio n fo r dee p self-stigmatization . Whil e keepin g aliv e in the dialogue his needs for companionship an d respect, she offered hi m a soothin g an d dignifie d orientatio n b y normalizin g th e nee d fo r inter vals o f recuperatio n betwee n period s o f involvement . Operatin g withi n his ow n paradig m modifie d b y thi s orientation , th e patien t wa s abl e t o increase hi s capacit y t o bot h ente r int o an d adaptivel y retrea t fro m involvements wit h desire d objects. The modes t successe s h e experience d in socializatio n enable d hi m t o accep t th e therapist' s representation s o f him a s having a vulnerability t o intens e interpersona l interaction . Even tually, th e patien t bega n t o tal k abou t movin g fro m th e parenta l hom e

The Case of Roger 34 3 to a supervised community residence, in which access to peers would be enhanced, an d hinte d a t th e possibilit y o f eventuall y relinquishin g a valued delusion . Th e wor k wit h th e patien t continues , centerin g o n working through the loss of his valued capacity to socialize at will, the acceptance of illness-related limitations, and the formation of a realistic life structure. To summarize , th e wor k wit h thi s patien t demonstrate s th e process , through the initial an d intermediate phases of treatment , of identifyin g the patient's own priorities and shaping and reshaping a treatment strategy that is extensively customized to those priorities. Conventional clinical method s o f interviewing , observation , cas e formulation, an d intervention were considerably modified and , in some ways, put aside in the service o f developin g th e kin d o f relatednes s tha t th e patien t woul d accept. The progress permitted through thi s method of working , while modest, ha s brough t thi s patien t t o a stat e o f mind , attitud e towar d illness, and degree of social involvement he could not otherwise attain.

8 Beyond Psychoeducation: Raising Family Consciousness About the Priorities of People with Schizophrenia

Work wit h families of the mentally ill has been transformed in the last decade i n way s tha t ar e both favorabl e an d problematic fo r clinician s treating th e most seriousl y mentall y il l patients. Before th e mid-1970s, the prevailing clinical orientations to the family were based on interpersonal theories of th e pathogenesis of schizophrenia (1-5 ) tha t shared a common emphasi s o n famil y interactio n a s a n essential elemen t in the pathogenesis o f schizophrenia . Emergin g fro m an d consonan t wit h a distinctly American belief in the primacy of environmental influence s in human personality development, these theories possessed such powerful apparent validity that they were quickly adopted as fundamental clinical tenets, dominatin g famil y therap y wit h hospitalize d patients . Familie s often complaine d tha t encounter s wit h clinician s workin g unde r th e assumptions espoused by these theories were guilt-invoking and did not help the family to understand or accommodate to the behavior of the ill family member (6). By the late 1970s , the whole group of famil y interaction theorie s of schizophrenia ha d falle n int o disfavo r a s a resul t o f thre e interactin g forces. First, no compelling, internally coherent, and comprehensive body of empirical evidence had been developed to confirm any of the specific hypotheses (7—8). Second, biological paradigms began to gain the ascendancy i n model s o f schizophrenia , beginnin g wit h th e discover y tha t phenothiazines had specific effects o n the symptoms of schizophrenia— symptoms that had heretofore bee n seen as manifestations o f interpersonal operations within the family. The biological revolution went on to yield increasingly cogent and empirically based models for the principal manifestations o f th e disorder . Third , th e tren d awa y fro m lifelon g institutional care had thrust clinicians into direct contact with the fami347

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lies o f thei r patient s t o a degre e unparallele d durin g th e er a o f asylu m treatment. A s patient s move d fro m hospital-base d t o predominantl y community-based care , familie s cam e t o accep t a n increasingl y centra l role i n supportin g patients . The increase d burde n experience d b y fami lies le d man y t o see k mor e contac t wit h clinician s an d t o as k fo r les s blame-invoking, mor e information-providin g method s o f workin g wit h families. The work o f th e British group a t the Maudsley Institut e of Psychiatr y led th e wa y towar d a for m o f famil y therap y tha t overcame , a t leas t partially, the limitations of the previous paradigm. Beginning in the early 1970s, thi s grou p demonstrate d a stron g correlatio n betwee n certai n family attitude s an d short-term morbidit y (a s measured by relapse rates) from schizophreni a (9-10) . Patient s discharged fro m hospita l treatmen t fared bes t amon g relative s wh o showe d hig h toleranc e fo r th e patient' s lack of everyda y conversation an d detachment from family life . Subsequent studie s b y othe r groups , designe d t o tes t th e effect s o f family intervention s aime d a t promotin g understandin g o f illnes s an d tolerance o f illness-relate d behavior , hav e show n tha t familie s ca n ac quire mor e toleran t way s o f relatin g t o th e patien t wit h schizophrenia , with attendan t decline s i n short-term morbidit y fo r the patient (11—12) . Because o f thei r emphasi s o n famil y educatio n abou t schizophrenia , these approache s ar e ofte n referre d t o a s "psychoeducational " pro grams. (Althoug h thes e program s frequentl y hav e a broader scop e tha n this ter m implies , w e wil l us e th e ter m here. ) Familie s find informatio n about th e natur e o f schizophreni a usefu l i n understandin g th e behavio r of th e patient , th e treatment s applied , an d th e prospects fo r th e future . In addition, specialize d trainin g i n problem-solvin g everyda y famil y sit uations helps family member s cope with the behavioral an d communicational ambiguitie s an d variation s i n functionin g tha t ar e inherent i n th e illness. While th e psychoeducational famil y program s have, on balance , produced mor e affirmativ e orientation s t o th e familie s o f patient s wit h schizophrenia, amon g treating clinicians, certain difficulties hav e become apparent a s thes e approache s hav e increase d i n popularity . Foremos t among th e difficultie s i s that , whil e man y familie s no w understan d th e aspects o f schizophreni a tha t aris e fro m disorder s o f th e brain, manifes tations o f th e illnes s tha t aris e fro m th e patient' s persona l reaction s t o symptoms, t o functiona l disability , an d t o los s o f vita l connection s t o

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others ar e no t alway s satisfactoril y deal t wit h i n psychoeducationa l programs an d are not well recognized, understood, o r accepted b y fami lies. I n thi s chapter , w e wil l focu s o n difficultie s presente d b y thi s pro grammatic gap as they relate to the tasks of treatment within the frame work develope d in earlier chapters. A clinical example will illustrate the dilemma now commonly encountered in work with families o f individuals with schizophrenia . A 26-year-ol d ma n with schizophreni a wa s hospitalize d fo r th e sixth time for increasing delusions, disorganization, irritability, and socially inappropriat e behavior . Whil e receivin g neurolepti c medi cation an d participating in the hospital milieu , his psychotic symptoms abate d significantly . A t thi s point , hi s father , a professiona l man who ha d consistentl y denie d that the son ha d ever bee n ill o r required medicatio n t o remai n well , bega n t o pressur e th e so n t o come hom e an d retur n t o college . The son' s condition i n th e hos pital uni t worsened, with a return of delusiona l ideation , includin g the delusion that he was not his father's son but rather was the son of a well-known roc k star . Th e patient's mother , wh o ha d openl y acknowledged fo r severa l year s tha t he r so n ha d a serious menta l illness, describin g th e conditio n a s a n imbalanc e o f brai n chemis try, aske d tha t th e so n b e place d o n highe r dose s o f neurolepti c medication. Clinician s workin g wit h th e so n becam e awar e tha t father and mother, operating fro m divergent perspectives, shared a diminished understandin g tha t the son's conflic t abou t the father' s renewed expectation s wa s contributin g t o th e recen t clinica l exac erbation. Durin g a family sessio n i n which thi s linkage was identi fied to th e parents , th e son , i n a rare momen t o f clarity , wa s abl e to reveal that he did not believe he could function in school becaus e of th e effect s o f schizophreni a o n concentratio n an d reading . H e declared tha t he wanted nothin g mor e tha n to take his medicatio n and return to far m life. H e kne w fro m recen t and past experience s that suc h a life offere d considerabl e satisfaction . H e turne d t o hi s father an d pleade d wit h hi m t o accep t tha t h e ha d schizophreni a and neede d medicatio n t o sta y wel l an d aske d tha t h e b e allowe d to return to living on a farm. The son's clinical exacerbation can be seen in part as an attempt to teach his father abou t the illness and remind him of its impact on his function -

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ing, al l i n th e servic e o f gainin g suppor t fo r discharg e t o a settin g i n which h e coul d functio n adaptively . Fo r hi s part, th e fathe r ha d no t ye t developed a wa y o f copin g wit h th e impac t o f th e son' s illnes s o n hi s own imag e o f himsel f a s fathe r an d o n hi s dream s fo r hi s son' s future . He ha d no t ye t mourne d th e los s o f th e idealize d son . Hi s prioritie s demanded tha t th e so n retur n t o a lif e structur e tha t wa s normativ e fo r his ag e peers . Fo r he r part , th e mothe r ha d no t recognize d th e son' s active contributio n t o hi s clinica l state . In he r view , th e illnes s an d th e son's regresse d behavio r wer e simpl y th e result s o f a brai n disorder . T o her, th e conflic t betwee n fathe r an d so n wa s n o mor e tha n a distressin g sidelight; th e correc t approac h wa s a n increas e i n psychotropi c medica tion. While psychoeducationa l program s hav e gon e a lon g wa y towar d alleviating familie s o f th e guil t tha t i s commonl y a n advers e effec t o f psychodynamic famil y orientation s an d whil e famil y member s ar e in creasingly cognizant of th e biological sid e of schizophrenia , man y do no t appreciate th e extent to which the symptoms an d the course of the illnes s are shape d b y th e patient' s ow n priorities—hi s o r he r goal s an d aspira tions, fear s o f deficien t performance , grie f an d rag e ove r los t functiona l capacity. Increase d emphasi s o n th e biologica l aspect s o f schizophreni a may occlude recognition o f these human reaction s to the illness. Without substantive modification , th e current psychoeducationa l orientatio n fall s short o f promotin g specific , individualize d famil y understandin g o f th e patient's persona l reaction s t o hi s o r he r predicament . Failin g t o giv e sufficient weigh t t o th e patient' s prioritie s an d t o th e likelihoo d o f con flicting priorities withi n th e patient, famil y member s hav e no perspectiv e through whic h t o giv e meanin g t o som e o f th e mos t prominen t clinica l manifestations o f schizophreni a i n th e ope n community . The y ar e ofte n left baffle d an d confuse d b y thes e behaviors , a t a t los s t o connec t em pathically wit h th e ill member's predicament .

BEHAVIORS FAMILIE S FIN D DIFFICULT TO UNDERSTAND Three examples , representin g frequen t relatives ' complaint s abou t pa tient behavio r tha t w e believ e represen t persona l reaction s t o illnes s rather tha n primar y manifestation s o f schizophrenia , serv e t o illustrat e this problem .

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Noncompliance wit h Psychotropi c Medicatio n Families ofte n hav e grea t difficult y comprehendin g noncomplianc e wit h psychotropic medication , especiall y when , a s i n th e cas e describe d be low, th e patient show s significan t improvemen t wit h th e us e of medica tion. During a n intake interview, th e mother of a 29-year-old ma n with schizophrenia recounte d th e patient' s lif e histor y i n grea t detail , emphasizing how , fo r thirtee n years , sh e ha d sough t a t grea t personal sacrifice, an y and all forms of treatment that might be of help to him . She had no lif e apar t fro m he r efforts t o help him, and yet no treatmen t tha t wa s applie d seeme d t o offe r benefit . The n thre e years ago , th e patien t wa s give n a tria l o f depo t neuroleptic . H e showed a decreas e i n delusions , a virtuall y complet e remissio n from though t disorde r tha t ha d bee n s o sever e a s t o b e describe d as "wor d salad, " and ceased hi s us e of abusive , fou l language . H e was in the best clinical stat e that she had seen in all the time of hi s illness an d wa s discharge d home . However , h e refuse d t o permi t the continuation o f th e depot neuroleptic an d within thre e month s suffered a recurrenc e o f symptoms . Now , thre e year s later , sh e described hersel f a s shu t of f fro m he r son , n o longe r allowin g herself t o car e about him, and on some occasions sayin g openly t o his clinicians that it would b e better for him to be dead rather than continue on in this state. As lon g a s th e patient wa s il l wit h n o remed y i n sight , thi s mothe r wa s able t o accep t hi s conditio n an d freel y subordinate d he r own lif e t o th e endless pursui t o f a remedy . Wit h th e arriva l o f a n effectiv e treatment , she lost her capacity t o b e sympathetic t o his predicament. Sh e regarded his refusal t o take medication a s willful an d unnecessary, becam e angry , and withdrew . Sh e lacke d a perspectiv e throug h whic h t o understan d this behavior a s a manifestation o f hi s struggle to preserve autonom y o r to ward off psychi c deadness. This vignett e exemplifie s typica l situation s tha t en d i n a n impass e when psychoeducationa l intervention s tha t d o no t dra w o n specifi c knowledge abou t th e patient' s interna l worl d ar e used . Resolvin g suc h an impass e require s carefu l attentio n t o th e creatio n o f a n unusual an d highly individualize d for m o f famil y empathy—tha t is , empath y fo r th e

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patient's preferenc e fo r a specific delusiona l worl d view. T o accomplis h this goa l i n th e cas e describe d above , th e famil y therapis t woul d first make a n allianc e wit h th e mother' s ow n disappointmen t relate d t o th e loss o f a normal son , communicatin g understandin g an d acceptanc e o f the mother' s frustratio n an d sens e o f loss . Goin g further , th e famil y therapist woul d access , eithe r directl y o r throug h consultatio n wit h th e patient's individua l therapist , knowledg e abou t th e experience s th e pa tient wa s prioritizin g b y refusin g medicatio n and , ideally , som e under standing o f th e patient' s ow n sens e o f conflic t an d frustratio n i n th e matter of taking medication. The latter knowledge could help the mother to appreciat e tha t there i s an active struggl e takin g place entirely within the patient an d therefor e outsid e o f th e mother's experience— a struggl e that i s analogous t o th e observable (t o the mother) on e betwee n mothe r and son, in which she completely favor s the use of medication , while her son is totally opposed t o it. In this case, individual wor k with the patient revealed that, i n response t o a series of rejection s b y women, the patient had develope d th e highl y erotize d vie w o f himsel f a s a ma n o f "fata l charms," b y whic h h e mean t tha t h e wa s th e cente r o f desir e o f man y women who , shoul d the y com e int o contac t wit h him , would die . Suc h information allowe d th e famil y therapist , workin g i n concer t wit h th e patient's individua l therapist , t o facilitat e th e mother' s capacit y t o em pathize wit h he r son' s dilemm a and , i n th e process , t o appreciat e tha t taking medicatio n mean t losin g th e capacit y t o kee p aliv e hi s sens e o f importance, howeve r delusional . Give n acces s t o thi s information , th e mother could appreciat e how disconfirmin g conventiona l socia l encoun ters ha d ofte n bee n fo r he r so n an d ho w unappealin g suc h encounter s would b e i n the future , unles s supplemente d b y a special an d sustainin g (even i f delusional ) sens e o f importance . Finally , sh e wa s helpe d t o se e that this delusional elaboratio n was not entirely a safe haven for the son, since hi s perception wa s colore d b y th e convictio n tha t ultimatel y wome n would leav e him . Detaile d an d highly individualize d parallel s wer e the n identified—between th e son' s nee d fo r hop e (o f bein g desired ) an d th e mother's need for hope (o f recovery)—that furthere d th e development of maternal empathy . O f equa l importance , th e famil y therapis t then highlighted the nature of their very different orientation s toward medication : The mother saw it as a solution to the son's frightening and demoralizing (for her ) behaviora l disorganization , wherea s fo r th e so n i t interfere d

Beyond Psychoeducation 35 3 with necessary (for him) access to a self-affirming inne r world. A conventional famil y therap y intervention , coachin g the mother t o refrain fro m struggling wit h hi m abou t medication , wa s the n invoked , creatin g a more neutral interpersona l field and thereb y preparing th e son, in individual an d famil y sessions , t o identify , revea l directl y t o mother , an d resolve his own internal conflict abou t compliance with medication. Rejection o f Rehabilitation Treatment Program s Many famil y member s ar e awar e that , followin g a remission o f symp toms with psychotropic medication, th e most productive work o f treat ment i s buil t aroun d th e goa l o f promotin g recover y o f interpersonal , social, and vocational functioning. Psychoeducationa l interventions provide an understanding of the patient's needs during the immediate postpsychotic phase , durin g whic h increase d activity , especiall y increase d social interaction , ma y interfer e wit h convalescenc e an d provok e a return of psychotic symptoms. However, many family members find themselves at a loss to understand why the patient will not participate in lowstress activitie s tha t ar e recommended b y treating clinician s durin g th e convalescent phase . Not uncommonly , i f famil y member s expres s thei r reasonable concern s t o th e patient' s clinicia n persistentl y enough , th e clinician may , unconsciously, rais e his or he r ow n expectation s fo r th e patient. Experiencin g thi s shif t a s th e clinician' s disappointment , th e patient, in turn, may respond with anger, fear, or demoralization, while the famil y ma y tak e th e clinician' s increase d expectation s a s confirma tion of the validity of their own excessive expectations, as evidence that the patient coul d have been more functional al l along. This in turn may trigger famil y resentmen t towar d th e patient fo r no t havin g bee n mor e active. A vicious downward spiral then ensues. Disruptive Behavio r Directed Toward Family Members As patient s wit h schizophreni a spen d mor e tim e livin g i n th e ope n community, some families are increasingly exposed to abusive, threatening behavior . Familie s ofte n as k clinician s ho w t o dea l wit h thi s problem, manifestin g a belie f tha t i t constitute s evidenc e o f a retur n o f th e primary symptoms of the illness and just as often revealin g that they are

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permitting burdensom e level s o f disruptio n o f famil y life . Whil e th e psychoeducational orientatio n usuall y include s specifi c famil y guidanc e for limitin g abusiv e behavior , littl e attentio n i s give n t o it s psychody namic basis . Th e resul t i s tha t familie s ofte n mov e t o sto p th e abus e without possessin g a n understandin g o f th e behavio r tha t woul d enabl e them t o d o s o with empathy . Familie s los e patience wit h thi s manifesta tion o f th e illnes s an d ceas e supportiv e interactio n wit h th e patient . These problems typif y th e limitations o f existin g psychoeducational pro grams in fostering famil y understandin g o f the human reaction s to illnes s that underli e man y manifestation s o f schizophrenia .

PROMOTING FAMIL Y EMPATHY FOR THE PATIENT'S DILEMMA In attemptin g t o addres s th e problem s pose d above , w e hav e foun d i t useful t o conduct a form o f sensitivity training for th e families o f individ uals with schizophreni a a s a part o f a comprehensive packag e of service s provided withi n a psychoeducationa l fram e o f reference . Th e followin g presentation i s excerpte d fro m a worksho p give n t o familie s o f peopl e with schizophrenia . Modele d afte r th e Surviva l Skill s Worksho p devel oped b y Anderson, Hogarty , an d Reis s (12) , the workshop begin s with a description o f th e clinica l manifestation s o f schizophrenia , th e inne r experiences o f th e illnes s a s reporte d b y patients , an d th e prevailin g treatments fo r schizophrenia . Th e final sectio n o f ou r workshop , whic h goes beyon d th e usua l psychoeducationa l workshop , center s o n experi ences o f narcissisti c injur y a s experience d b y peopl e wit h schizophreni a who ar e attemptin g t o reintegrat e int o society . Structure d a s a guide d fantasy, it s goa l i s t o increas e th e family' s realizatio n that , despit e th e biological root s o f th e disorder , th e cours e o f illnes s an d muc h o f th e day-to-day behavio r o f th e patient ar e drive n b y the patient's struggl e t o maintain self-estee m i n th e fac e o f hi s o r he r attempt s t o regai n a nich e in a communit y o f peers . W e repor t thi s sectio n her e substantiall y a s i t is presented i n the famil y workshop . In th e discussio n t o follow , genera l principles ar e elucidated tha t ar e relevant t o work wit h familie s aime d a t enhancing famil y sensitivit y t o th e human sid e of th e illness.

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The Humiliation Workbook Workshop Leader : Fo r th e nex t few minutes , I' m goin g t o as k yo u t o come wit h m e int o th e experienc e o f peopl e wh o hav e falle n il l wit h schizophrenia. I should tel l yo u a t ih e outse t that , walkin g wit h m e o n this pat h an d identifyin g wit h th e positio n o f a n il l person , ma y b e disagreeable, even painful i n some measure. I offer the exercise nevertheless, believin g that there is a great deal of trut h here, and that no matte r how painful , thi s trut h ultimatel y promote s th e well-bein g o f peopl e suffering fro m schizophrenia . For the sake of illustration, I will as k you to follow the story of a man named Bill (no t his real name) . As we se t out, Bil l is 28, ha s bee n ill fo r ten years , was livin g i n a halfway hous e an d attendin g a da y treatmen t program until he was rehospitalized a week ago . Just before entering the hospital, Bill was due to be transferred fro m da y treatment to a rehabilitation program,.i n whic h h e woul d star t a transitiona l job . I t woul d have bee n a simple assembl y job , but it would hav e been a way fo r hi m to get going after a decade away from the job market. Bill neve r mad e th e transfe r t o th e rehabilitatio n progra m because , two day s afte r agreein g t o ente r th e program , h e secretl y discontinue d all hi s medication . Withi n te n days , h e wa s to o disorganize d t o remai n in a communit y residence . Whe n I visite d hi m i n th e hospita l shortl y after admission, he revealed, with a wide smile of immense pleasure, that he stopped the medications a s an experiment—to establis h onc e an d fo r all whether he really needed it. I noticed that on the wall o f hi s room h e had hun g a drawin g complete d i n hig h school . I t wa s a smiling , full faced picture of himself . Abov e the face was the inscription "Bil l Turner for President. " I learned tha t Bil l ha d use d thi s poster durin g a n actua l campaign fo r th e presidency o f hi s high schoo l class . I was immediatel y struck by the contrast between this image and another that he had given me a fe w month s earlie r t o han g i n m y office : Tha t drawin g show s a n unshaven, unkempt man hunkered down i n a cluster of garbage cans o n a city street corner. It doesn' t tak e a maste r clinicia n t o realiz e tha t thes e tw o image s speak fo r th e tw o side s o f a central lif e conflic t tha t Bill wa s livin g out . His dilemma , lik e th e dilemm a o f thousand s o f othe r youn g me n an d women afflicted wit h a psychiatric illness that does not go away and that leaves th e suffere r partiall y disabled , i s a s follows : After coming to

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believe, on the basis of his cumulative childhood and adolescent experience, that he is going to become a citizen, perhaps even an important citizen, he finds that he has become a mental patient instead. Profession als can poin t optimisticall y t o th e evidence of recoveries in the long-ter m outcome studies , an d som e kno w fro m direc t persona l experienc e o f patients wh o wer e onc e brough t lo w b y schizophrenia an d hav e gone o n to recover . However , Bil l di d no t hav e acces s t o thes e source s o f opti mism. In fact , ther e wa s n o evidenc e directl y availabl e t o him tha t h e would eve r have a life tha t h e would wan t t o b e a part of . Tha t i s not t o say tha t Bil l wil l alway s b e incapacitate d o r tha t h e wil l alway s requir e protection an d supervision . Rather , i t i s a n acknowledgemen t o f hi s experience—of lon g an d seemingl y endles s stretche s o f tim e ahea d i n which h e will exis t mor e a s a menta l patien t tha n a s a citizen . And wit h this anticipation , i t i s n o wonde r that , b y surreptitiousl y rejectin g dru g treatment, h e chos e to retur n himsel f t o th e statu s of a n institutionalize d mental patien t rathe r tha n suffe r th e large r blow s t o prid e tha t woul d come wit h being , i n hi s view , a substandar d citizen : Bein g insan e wa s less o f a n attac k o n hi s self-respec t tha n bein g wel l thi s way—a s a n employee i n a sheltered workshop . Wounds to the Self Now I' d lik e t o as k yo u t o ente r int o Bill' s positio n an d imagin e tha t i t is yo u wh o ar e caugh t o n th e horn s o f hi s dilemma . Imagin e yoursel f realizing tha t soo n afte r yo u wen t of f you r medication , yo u los t contro l of you r mind : • Yo u couldn' t contro l you r behavio r anymore . • Yo u di d thing s tha t yo u ar e now ashame d of . You'r e no t sur e you ca n live with th e realization tha t yo u di d thos e things . Imagine realizin g tha t eve n thoug h yo u ar e bette r now , you r min d doesn't see m th e same : • Yo u canno t thin k a s straigh t o r a s sharpl y no w a s yo u di d te n year s ago. You don' t see m to be able to remember thing s very well anymore , even very simpl e things . • Mos t o f th e time , you ar e to o exhauste d t o d o ver y muc h o f anythin g anymore. Nearly everythin g you tr y t o d o lead s to boredo m o r failure ,

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Even thinkin g abou t undertakin g a ne w activit y leave s yo u confuse d or exhausted. • Yo u wonde r wha t ha s becom e o f th e person yo u onc e were , an d yo u wonder i f yo u wil l eve r b e tha t perso n again . Sometime s i t seem s a s though al l yo u hav e lef t o f tha t perso n i s a memory ; you'r e no t sur e you even want to hol d onto th e memory, bu t you're terrified o f losin g it. Now, stayin g wit h tha t position , imagin e yoursel f a s see n b y other s after yo u wen t of f you r medication . Imagin e realizin g that , whe n yo u stopped your medication, other people noticed that you were "losing it." Imagine realizing that people treat you as if you were an invalid: • The y speak slowly to you or loudly, as if you were retarded or deaf. • Whe n you do some really simple thing—like taking out the garbage or taking a shower—your famil y rejoices , a s i f wha t yo u ha d don e wer e a major accomplishment . • Peopl e avoi d yo u a s the y woul d a leper , a s i f the y coul d catc h wha t you have if they stayed around you too long. • Whe n yo u revea l you r unusua l experience s t o ordinar y people , the y get frightene d o r offended . Whe n yo u revea l the m t o professionals , they tell you that you have something called symptoms. Judging fro m th e reaction s o f th e people—th e ordinar y peopl e an d th e clinicians—whom yo u encounte r in the course of you r days living in the community, yo u hav e cease d t o b e a desirable , value d membe r o f tha t community. Imagine realizin g that , wit h increasin g frequency , you r ol d friend s can't seem to find time for you: • Th e people wh o d o make time fo r yo u ar e people who m yo u thin k o f as more ill than you are. • Yo u sometime s wis h the y woul d leav e yo u alone , becaus e yo u ar e embarrassed to be seen in public with someone who looks mentally ill. Imagine realizing that even when you are putting in a maximal effort , nothing tha t yo u d o an d nothin g tha t yo u produc e evoke s prid e o r pleasure i n your family. Imagin e realizing that in all likelihoo d your lif e will never turn out the way you thought it would:

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• Othe r peopl e d o no t appea r t o tak e you r dream s an d you r plan s fo r the future seriously . • Whe n yo u as k i f yo u wil l eve r b e oka y again , peopl e fal l silent , loo k away, an d change the subject. In the cours e o f you r day s i n th e community , yo u hav e dail y experiences tha t remind you o f wh o yo u migh t have bee n if not fo r th e illnes s and other experiences tha t suggest a bleak, disaffirmin g future : • Yo u wai t on a street corner for th e minibus that will tak e you to you r day hospita l program . O n th e opposite corner , you se e boy s an d girls talking an d laughing , waitin g fo r anothe r bu s t o tak e the m t o you r former high school. • Yo u liste n t o you r docto r encouragin g yo u t o tak e a jo b staplin g plastic bags shut—a job that in your most desperate dreams you never imagined would b e a part of your life. As if al l this were not enough , you ar e also more or less continuousl y confronted b y th e los s o f you r persona l sovereignty . Yo u d o no t hav e control ove r you r ow n thoughts , you r ow n feelings , you r movements , whom yo u choos e t o spen d tim e with , who m yo u liv e with . I n short , your life is no longer your own: • Ever y da y yo u g o t o th e da y program , yo u pas s th e hospital . Yo u remember tha t yo u wer e force d bodil y int o tha t place . Peopl e yo u trusted called in the police in response to your expressed desire to take to the road for a while. • Whe n yo u wal k i n th e city , yo u se e othe r peopl e goin g t o wor k o r walking wit h thei r friends . Yo u realiz e tha t yo u d o no t hav e thei r mobility. Yo u can't imagine that you ever will have their mobility. • Yo u watc h othe r peopl e makin g decision s fo r yo u a s i f yo u wer e 6 years old. They care about you. This you know. But they make plans for you r lif e withou t eve n thinkin g tha t yo u migh t hav e opinion s o r preferences o f your own. • Whe n yo u tal k t o th e staf f i n the da y program abou t your life , whic h you fee l i s goin g nowhere , yo u realiz e tha t thei r live s ar e goin g jus t fine. It doesn' t mea n tha t thei r live s ar e reall y goin g fine. Bu t fro m th e perspective of a person suffering fro m the disabling effects o f schizophre nia, clinicians' lives are just wonderful .

Beyond Psychoeducation 35 9 Protecting Yourself Against Wounds Now I want yo u t o hol d ont o Bill' s perspective fo r a while longe r an d think abou t what you migh t do if you were in his position. In this part of the exercise, I'm going to be describing behavior that we have all been taught to think of as symptoms of schizophrenia. But I'm suggesting that at leas t som e o f thes e behavior s ar e bette r though t o f a s th e externa l manifestations of certain strategies used by patients to insure the survival of the self Thin k fo r a moment about how you migh t try to cope with the injury t o your self-respect and how you would respond to the loss of a desirable personal future. Yo u might make an attempt on your life, of course, for your daily experience has become an endless string of assaults on your will to endure. But more likely than that, or at least long before taking that route, you will do other things. Blame and Recrimination You will ruminat e abou t you r curren t existence , reviewing all tha t ha s happened t o yo u an d concludin g tha t someone , mayb e som e specifi c person or persons, is at fault for this endless series of humiliations: • Yo u search your past in a blameful reverie . You remember some things that your mother—or you r father o r other people—did t o you a long time ago. You conclude that they made you sick. You plan ways to get even with them. • Yo u set out t o giv e your very successful ki d brother , wh o is now th e pride of the family, a hard time. You think up ways to embarrass him in fron t o f hi s friends . Yo u sidl e up t o hi s fiancee, knowing tha t sh e can tel l yo u haven' t ha d a bat h i n weeks . You notic e your brother' s discomfort, an d you are pleased that he does not challenge you. Noticing the pleasure in these moments, you begi n to devote part of every day to thinking up ways to get even with other people: • Yo u thin k u p way s o f behavin g tha t produc e discomfor t i n you r doctor and in the day hospital staff. • Yo u focu s you r vengefulnes s especiall y o n anyon e wh o presume s t o make recommendations as to how you can improve your life.

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Numbing Out Vengeance ma y diminis h you r pain . Bu t yo u pa y a pric e inasmuc h a s you realiz e yo u ar e hurting people wh o car e abou t you . S o you explor e other ways of killing your pain: • Yo u discove r tha t whe n yo u hav e a drink , yo u don' t fee l muc h o f anything fo r a while. S o yo u tak e t o drinkin g a couple o f beer s ever y time yo u anticipat e a humiliatin g encounter . An d the n yo u drin k t o stop yoursel f fro m eve n thinkin g abou t th e possibilit y o f humiliatin g encounters. • Yo u tak e to experimentin g wit h drugs , like speed and downers, to see if they will shut out the agony. • Yo u notic e tha t sometimes , eve n withou t drug s o r alcohol , yo u ar e able t o shu t down th e parts of you r mind that remember th e past an d dream about the future. Yo u are not quite sure how you'r e doing this, but th e mai n thin g i s tha t whe n yo u sto p you r min d fro m thinking , you als o succeed in stopping the pain. • Yo u realiz e that it is wanting things tha t causes the pain. You put this observation t o wor k i n you r dail y life , killin g of f an y an d al l forme r interests an d declinin g t o becom e intereste d i n anythin g new . Yo u learn t o liv e b y a ne w versio n o f a n ol d maxim . Th e ne w maxi m i s "No gain , no pain." • Yo u avoi d an y ongoin g activit y tha t migh t remin d yo u o f wh o yo u would hav e been if not fo r the illness. You certainly d o not let anyon e talk you into going to a rehabilitation program . Handling Loneliness Through Withdrawal and Anonymity Whether throug h th e us e o f drug s o r alcoho l o r jus t b y havin g learne d to num b out , yo u no w ar e abl e t o abolis h a grea t man y o f th e experiences o f humiliatio n tha t wer e you r dail y bil l o f fare . Certai n problem s become apparent , though. Yo u notice that you are often lonel y fo r some sort o f companionship . Yo u ar e stil l attracte d t o th e opposit e sex . Yo u still loo k forwar d t o conversatio n wit h a friend , eve n i f it' s jus t smal l talk. Yo u notice tha t you loo k forwar d t o seeing certain people. I n spite of yourself , yo u hav e becom e attache d t o them , an d yet yo u kno w tha t any one of thes e people can—at any moment, without an y warning, an d without i n any way wanting to hurt you—become a source of injury .

Beyond Psychoeducation 36 1 • Yo u tak e t o stayin g hom e fro m th e place s wher e yo u ru n int o th e people you like the most. You stay away from the day hospital. You take to your room. • Yo u decide to go on the road, moving from place to place, reasoning that if you can just get into an anonymous, nomadic life-style you will succeed i n gettin g th e bes t of thi s apparentl y automati c tendenc y t o get attached to people. Repudiating Conventional Reality And if, afte r al l this , you ar e still i n pain, there are yet other ways to shield yourself against the humiliation, ways that involve not only letting go of involvement with other people but also relinquishing your commitment to what we call reality. You will be drawn to these ways of coping because, in the final analysis, truth and accuracy and realistic thinking are only usefu l s o lon g a s the y lea d t o som e degre e o f rewar d i n the moment, or at least point to the possibility of future reward: • Yo u sto p takin g your medicines , realizin g tha t they ar e maintaining your sanity. • Onc e of f th e medicines, yo u ar e too confuse d t o thin k th e thought s that are the source of your pain. • Yo u find yoursel f thinkin g tha t yo u hav e becom e all-powerfu l o r famous, and you come to prefer these dreams to "reality," even though others seem to think that these beliefs are evidence of illness. • Yo u make believe you are secretly a member of a powerful organiza tion, lik e th e CI A o r th e FBI . Yo u fill your day s wit h fantasie s o f daring missions. • Yo u realize that you are no longer on earth, but now reside secretly in a satellite, circling the globe, in complete control of everything below. • Yo u make believe that you are not ill, convincing yourself that you are just fine and that it is everyone else, and especially you r adversaries, who require psychiatric attention. You try to convince them to go for help. • Yo u convinc e yoursel f that , althoug h yo u wer e onc e ill , yo u ar e all better now. • Yo u ignor e an y evidenc e o f continuin g impairments , an d yo u repudiate observation s mad e b y others, who i n their helpfulness, see k t o convince you that you are still a mental patient.

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• Yo u convinc e yourself tha t you have some condition les s dreadful tha n the on e yo u ar e suppose d t o have . I f yo u ar e sai d t o hav e schizophre nia, yo u see k evidenc e tha t i t i s reall y manic-depressiv e illnes s o r alcoholism. • Yo u tak e t o behavin g lik e a bad perso n s o that nobody , includin g yo u yourself, can notic e how impaire d yo u are . • Yo u ente r a timeles s reverie , remembering forme r time s when lif e wa s good t o you . Yo u eve n inven t remembrance s o f thing s tha t neve r actually occurred . Throug h thes e remembrances , yo u ar e abl e t o be lieve that you wer e somebody befor e yo u becam e a nobody. In thes e ways , an d i n a myria d o f others , you d o you r bes t t o surviv e the onslaugh t o f th e man y moment s o f injur y t o you r dignit y tha t ar e yours b y reaso n o f you r presenc e i n an d acces s t o th e ope n community . You lear n first and foremos t t o protect you r sou l from annihilation . Yo u do thing s i n th e servic e o f tha t goa l tha t other s canno t understan d an d do no t support . Yo u d o thes e thing s o n th e premis e tha t sanit y withou t dignity, withou t a sens e o f bein g valued , i s n o bargain . Yo u ar e tellin g your famil y an d an y other s wh o encourag e yo u t o sta y ou t o f th e hospital an d t o get better tha t th e price you ar e paying for wha t the y cal l community car e is greater tha n yo u ca n bear . Principles Derived

from the Humiliation Workbook

Now, i f yo u ca n disengag e fro m th e exercise , I' d lik e t o commen t o n some o f th e principle s tha t ca n b e derived fro m wor k wit h patient s wh o tell us, directly an d indirectly , about th e injuries t o the self that ar e their s because the y attemp t t o retur n t o usefu l lives . Firs t an d foremost , w e must addres s th e principl e o f recover ability. No t s o lon g ago , i t wa s preposterous t o thin k tha t mos t peopl e wit h schizophreni a coul d ge t better. We mus t underscor e a t thi s junctur e ho w muc h th e belief s o f th e psychiatric profession—belief s abou t th e outcom e o f schizophrenia — have bee n challenge d b y recen t scientifi c studie s o f th e long-ter m cours e of schizophrenia . Just i n the last five years, it has become clear that mos t of th e expectation s w e wer e taugh t t o hav e fo r ou r seriousl y il l patient s were undul y pessimistic . Al l o f thes e studie s repor t tha t betwee n one half an d two-third s o f patient s wit h ver y sever e an d prolonge d schizo phrenic illnesse s experienc e complet e recoverie s o r ver y marke d im -

Beyond Psychoeducation 36 3 provement when provided with access to decent housing and community services over long enough periods of time. Yet the time frame of these studies is an issue for some people, who observe that the studies took i n observations over periods of twent y to thirty years and say that is too long for people with schizophrenia and for thei r familie s t o b e expected t o wai t fo r improvement. Indeed , the time until recovery begins is often very long, but it should be noted that all the long-term outcome studies employed clinical treatment methods that were available in the 1950s and 1960s. In the intervening years, we have learned a few thing s about drug treatment and psychosocial programming that increase the prospects for social recovery. All the same, there are still large numbers of people who, despite their efforts and our own, will continue to exist more as mental patients than as citizens. So, we cannot ethically proceed as if there were the promise of recovery in all cases. Then we are faced with the need for a definition of recovery as applied to prolonged mental illness. In this context, recovery is not just a matter of leaving one's condition behind . Rather, I prefer to think of recovery as meanin g th e rebuilding of a life and o f meaningful and rewarding involvements in particular. It is from this vantage point that we can most readily comprehen d th e reluctance o f man y people with schizophreni a to participate willingly i n conventional form s o f communit y treatment. While we succeed with these treatments in removing symptoms, we do not at the same time do very well at restoring the person to a niche that provides acces s t o evidenc e of hi s or her importance an d to a sense of belonging somewhere to somebody. This brings us directly to a third principle, which is the phenomenon of interindividual variability, or, more plainly, the notable differences in the paths taken by different peopl e in rebuilding their lives. Many patients mount a recovery in some domains of functioning while continuing t o manifes t limitation s i n others . Many , fo r example , ar e u p and about—working, livin g with famil y o r friends—even thoug h the y continue to experienc e the primary symptom s o f thei r illness. This should not surpris e us , fo r peopl e wh o hav e schizophreni a ar e a s varie d a s everyone else in their basic humanity. We see individuality manifestin g itself i n the paths people choose in the face of an y adversity, including that presente d b y schizophrenia . Ther e i s grea t nee d fo r respec t fo r individual preferences i n our work wit h peopl e wit h schizophrenia . In

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1974, th e psychiatris t Aaro n Lazar e recommende d tha t eac h patien t b e asked, a s one elemen t o f ou r efforts t o develo p a treatment plan, "Ho w would yo u lik e t o b e treated? " He calle d th e approac h implie d b y th e question th e "custome r approac h t o patienthood " (13) , forecastin g th e emergence o f th e curren t era , i n whic h a patien t shop s fo r th e mos t attractive path, for the program or activity that is most affirmative o f his or her basic human dignity. "Bill, how woul d yo u lik e to be treated here? What do you thin k wil l work bes t for you?" For a variety of reasons , we d o not often ge t usefu l answers immediatel y i n respons e t o suc h questions . Peopl e wh o ar e veterans o f th e menta l healt h syste m ar e use d t o bein g regimente d an d having thei r individua l preference s ignore d o r disaffirmed . A t best , the y are simpl y no t prepare d fo r thi s for m o f curiosit y fro m clinicians . A t worst, the y ar e war y o f suc h a n inquiry , takin g i t a s jus t on e mor e attempt a t diagnosi s o r a s a set-up fo r frustratio n o r disappointment . We shoul d no t b e surprise d tha t th e vetera n decide s i t i s bes t t o b e circumspect an d replie s i n a n uninformativ e manner . W e mus t b e pre pared t o as k th e questio n repeatedl y an d t o affir m preference s tha t th e patient elects to reveal t o us, no matter how outlandis h the y may at first appear. W e mus t b e o n th e lookou t fo r indirec t evidence , fo r clue s tha t point towar d preferences . W e mus t sho w th e patien t ou r attempt s t o guess how h e or she prefers t o b e treated, ready to be told that we got it wrong, but representing b y the act of guessin g openly an d in front of th e patient tha t w e genuinel y wan t t o discove r hi s o r he r opinion s s o tha t we may take them seriously. Finally, ther e i s th e importanc e o f dignity a s a basi c principl e fo r program development . Lif e fo r thos e wit h persisten t psychiatric impair ments i s replete with opportunitie s fo r injur y t o th e soul an d offers ver y few balancin g opportunitie s fo r dignifie d an d rewardin g involvements . In thes e circumstances , apath y an d despai r ar e th e obvious , ordinary , reasonable choices of the afflicted. I recall now one young man, a veteran of eigh t relapse s an d a s man y hospita l stays , wh o announce d i n a da y program cas e conference, "I' d rathe r no t g o t o thes e activities. " An d after a moment, a s if to explai n himself , h e added , " I think o f mysel f a s being i n justifiabl e retirement. " The n ther e i s th e woma n whos e sol e genuine satisfactio n was , fo r som e time , he r sexua l encounter s wit h several me n an d wh o eventuall y contracte d a for m o f venerea l diseas e not easil y treated . He r eviden t distres s i n th e fac e o f thi s diseas e le d m e

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to inquir e whethe r sh e wa s thinkin g o f it s implication s fo r th e future . She replie d i n a low , desperat e voice , " I hav e n o future . I hav e n o future." The traged y o f thi s situatio n i s that , wit h enoug h imaginatio n an d enough public commitment, much of the injury can be avoided. Not that we coul d altogethe r abolis h th e injury . Schizophreni a damage s th e suf ferer's dream s i n som e way s tha t hav e littl e t o d o wit h th e attitude s o f others o r wit h th e availabilit y o f countervailin g positiv e involvements . But we ca n do bette r at providing acces s t o circumstance s tha t promot e quality of life . Above all, there is the need for a dignified place to live. To o often, w e deliver peopl e wit h schizophreni a int o th e ver y wors t o f physica l set tings. There was a time when we could get by with this practice, becaus e the people we sent to such places had lived for s o long in the regimentation of large institutions that they jumped at the chance to live anywher e in th e ope n community . Increasingly , however , th e vast majorit y o f th e mentally ill have not lived for decades in institutions. Consequently, they do no t kno w ho w t o b e gratefu l fo r a nich e i n a slu m neighborhood . They spurn the very same quarters that the previous generation clung to. The ne w generatio n reject s excessiv e constraint s o n thei r movements . They tak e t o th e roa d i f the y experienc e to o muc h regimentation , to o much loss of sovereignty. They do so even at the expense of losing acces s to services they need. Second, there is the need for acces s to activity that makes a contribution to the life of the community —not a contribution t o a large, imper sonal world , bu t t o a communit y o f person s know n t o th e patien t an d about who m h e ha s com e t o care . On e youn g man , livin g i n a stat e hospital an d stil l man y year s awa y fro m returnin g t o th e ope n commu nity, sai d t o hi s parents , "Wha t I need i s someone t o tak e car e of!" H e was givin g voice t o th e need t o b e valued. Peopl e suffering fro m schizo phrenia ar e capabl e o f contributin g t o th e communitie s i n whic h the y reside, i f onl y w e ca n thin k o f thei r sometime s shor t an d inconstan t workdays as having value. Too often, we impose timetables for improvement o n suc h person s tha t mak e participatio n i n treatmen t program s untenable for them. Third, there is the need for contact with persons who can legitimately claim to have recovered, peopl e who were once incapacitate d b y schizophrenia but who no w ar e up and about, having recovered their capacity

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for involvemen t an d mad e a lif e fo r themselves . I n virtuall y al l othe r walks o f life , yo u wil l find readil y a t han d graduate s o r alumni , peopl e who hav e bee n wher e yo u ar e an d wh o hav e gon e o n t o bette r things . Not s o wit h forme r patients . Th e publi c fea r an d revulsio n attache d t o the condition ar e so intense that practically a s soon a s a person recover s a nich e amon g th e citizenry , h e o r she cease s al l contac t wit h thos e stil l suffering wit h th e illness. Some courageous formerl y il l men and wome n maintain a degree o f publi c visibility , remainin g accessibl e t o thos e stil l down an d ou t wit h th e illness . Bu t most peopl e wit h schizophreni a wil l go throug h a lifetim e withou t eve r havin g acces s t o suc h a person . Without thi s kin d o f persona l testimonial , withou t a living , breathing , credible example , al l ou r statistics abou t recover y ar e for naught . Whe n we find way s t o provid e acces s t o forme r sufferers , thos e stil l sufferin g have reaso n to believ e in the future an d can sustain hope o f bette r times ahead, even in their darkest moments. And finally, there is great need for respite fro m time to time. It is clear from day-to-da y clinica l wor k tha t on e doe s no t procee d straightfor wardly fro m illnes s t o recovery . Th e pat h i s virtuall y alway s character ized b y advance s an d retreats , eve n unde r th e mos t optima l o f circum stances. I n the presen t era , i n whic h car e i n th e ope n communit y i s th e prevailing orientation, an accumulation o f wounds to the self sufficientl y weighs dow n th e recovering patient fro m tim e to time, so tha t he or she asks fo r refug e fro m lif e i n that ope n community . Withou t ou r support for th e legitimac y o f refuge , withou t occasional , brie f acces s t o refuge , the weary an d demoralized patien t will achiev e it just the same, throug h an aggravatio n o f th e illnes s an d it s symptoms , i n th e for m o f a majo r relapse. Jus t thi s week , th e ma n wh o describe d himsel f a s bein g i n justifiable retiremen t decided, after two years of isolation, to risk coming around to a day program and daring to hold hands there with a woman, also a veteran . Feelin g th e pressur e ver y directl y an d anticipatin g ye t another humiliation , h e exclaime d i n m y office , "I' m dyin g fo r anothe r breakdown!" He ma y yet see k refug e fro m thi s newfound alivenes s an d its attendant risks. And if he does, I will immediatel y endorse his elective and presumably brie f retur n t o hi s favorit e hospita l unit . There , h e wil l smoke cigarette s an d tel l jokes . H e wil l hid e ou t fro m th e risk s o f wanting things and yearning for contact. His desire to hold hands again, to reac h ou t fo r som e life , wil l retur n i n shor t orde r because , throug h the us e o f brie f respite , h e wil l hav e averte d a mor e massiv e an d mor e

Beyond Psychoeducation 36 7 prolonged regression. And when his desire does return, he will ask to go home and to go back to that day program and to that girl. He will have learned t o mak e us e o f wha t w e cal l "regressio n i n th e servic e o f th e ego." He will have learned, as we do, to take a vacation t o avoid burn out. Together, the two of us will have learned how to cycle between rest and involvemen t an d throug h thi s cyclin g t o kee p aliv e th e long-ter m movement toward rebuilding a life of belonging. Thank you for your attention. Discussion o f the Humiliatio n Workbook We have presented this excerpt from ou r model workshop in an attempt to illustrate one way that clinicians treating individuals with schizophrenia ca n wor k t o increas e families ' understandin g o f patients ' prioritie s having to d o with self-estee m regulation . Centra l t o th e presentation i s the primac y o f th e ris k o f narcissisti c injur y amon g patient s wh o ar e attempting to recover a niche in the community. Far from bein g simply manifestations o f schizophrenia, such frequently observabl e phenomena as noncompliance with medication, rejection o f therapeutic and rehabilitation treatments , and disruptio n o f famil y lif e are seen as the external representations o f th e patient's struggl e to maintai n som e semblance of dignity i n th e fac e o f disaffirmation , stigmatization , an d exposur e t o failure i n th e ope n community . Workin g fro m withi n th e perspectiv e offered i n the workshop, we are able to respond to the mother who was at a loss to understand he r son's rejection o f depot neuroleptic that he r son i s attempting t o ward of f a neuroleptic-induced los s of a treasure d sustaining fantasy . Goin g further, w e can suggest that, i n time, he may come to appreciat e th e value of medication , provide d som e affirmativ e real experience s wit h wome n ca n b e mad e availabl e t o hi m throug h which he can achieve a sense of being valued. In his case, a communit y nurse wa s assigne d t o mak e frequen t visit s t o hi s home followin g dis charge. At first, he preferred t o think o f her a s his English teacher, an d only after si x months was he able to acknowledge that she was a nurse. He rejecte d al l medication s fo r man y month s followin g discharge , bu t finally, throug h activ e coaching from th e nurse, he was able to agree to take medication temporarily durin g a relapse and thus to avoid a return to hospital treatment. More than the avoidance of hospitalization, however, it was the ready access to the nurse as a community-based compan -

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ion tha t mad e i t possible fo r hi m t o accep t medication . Additionally , h e chose t o resum e medicatio n o n hi s ow n terms , so that , fo r th e first tim e in thirtee n year s of illness , he coul d experienc e medicatio n a s somethin g within hi s control rathe r tha n seein g it as the emblem o f his subjugation . To th e famil y o f th e patien t represente d b y Bil l Turner, w e wer e abl e to say that h e required a longer stay in hospital treatment , preparing hi m through repeate d confrontatio n wit h hi s deficit s t o accep t hi s status a s a mental patien t an d thu s eventuall y fo r a mor e stabl e reinvolvemen t i n community life . "Bill " staye d o n a specia l long-ter m uni t fo r patient s with schizophreni a fo r eightee n month s an d wa s the n discharge d t o liv e with hi s family whil e continuing with da y treatment . On e year followin g discharge, h e wa s workin g par t tim e i n a bakery , hi s first sustaine d employment sinc e the onse t o f th e illness. To familie s wh o presen t question s regardin g violenc e an d abuse , w e are abl e t o poin t t o th e them e o f vengeanc e a s a primar y copin g devic e for patient s wh o canno t bea r th e damag e t o thei r self-estee m evoke d b y the confrontatio n wit h wel l sibling s an d othe r famil y member s no t af fected b y th e illness . I n n o wa y doe s thi s perspectiv e sugges t tha t th e patient's behavio r shoul d b e tolerated . Bu t i t doe s offe r familie s a wa y to vie w th e agon y tha t drive s th e patien t unde r som e circumstance s t o turn agains t love d ones . We are reminded o f th e comment o f a recovere d patient who, on hearin g the presentation, wrot e to us that i t was the first time sh e fel t trul y understoo d an d offere d th e observatio n tl\at , i n he r experience workin g wit h formerl y mentall y il l people , thos e wh o fight often hav e the best prospects fo r th e future .

COUNTERPOINT: THE FAMILY'S PRIORITIES In this chapter, we have attempted t o describ e som e methods o f workin g with familie s tha t promot e empath y fo r th e perso n wit h schizophrenia . In th e cours e o f thei r work , famil y therapist s universall y becom e wit nesses t o anothe r aspec t o f thes e situations—th e prioritie s o f individua l family member s an d o f th e famil y a s a whole . Thes e priorities , a s the y become known t o th e family therapis t an d t o othe r clinician s who spen d time interactin g wit h famil y member s i n th e cours e o f thei r wor k wit h the patient , represen t a n importan t counterpoin t t o th e focu s o n th e patient's priorities . W e wil l en d thi s chapte r wit h a brie f discussio n o f

Beyond Psychoeducation 36

9

this aspec t o f th e work, whic h ha s bee n describe d mor e full y elsewher e (14). In work directe d towar d teachin g familie s abou t schizophrenia , i t i s common t o observ e tha t on e o r mor e member s o f th e famil y ar e no t prepared t o accep t th e informatio n provide d i n psychoeducational pro grams. Thes e famil y members , wh o ofte n sta y awa y fro m forma l psy choeducational program s becaus e the y rejec t outright the basi c assumption tha t th e patien t i s il l an d require s psychiatri c treatment , becom e involved, albei t reluctantly, in interactions with front-lin e clinicians . For this grou p o f famil y members , acceptanc e o f illnes s constitute s a too painful assaul t o n thei r ow n sens e o f dignity , o n thei r ow n identit y a s parents, o r o n thei r internalize d representation s o f th e il l member . I t is our observation tha t many family members, perhaps the majority, begi n with a very extensive denia l o f illness , which the n gives way t o recogni tion an d acceptanc e onl y wit h repeate d exposure s t o th e extreme s o f disorganization an d mor e ofte n onl y whe n the y begi n t o perceiv e som e hope o f recovery . Fo r thes e relatives , th e clinician' s tas k i s t o wor k diligently t o preserv e th e family' s capacit y t o envisio n a n alternative , more hopeful future , even when, or perhaps especially when, the current clinical pictur e look s thoroughl y bleak . Thus , rathe r tha n makin g re peated attempt s t o brea k throug h th e family' s denia l o f illness , th e clinician seek s t o find in the patient's curren t behavio r evidenc e observable to th e family tha t the patient is more than an illness, that he or she continues to have a soul, continues to dream about and look fo r satisfaction i n dail y life , an d stil l ha s som e determinatio n t o becom e a whol e person again . B y givin g voic e t o th e family' s wis h fo r recovery , b y keeping aliv e i n th e min d o f th e famil y th e possibilitie s fo r a n eventua l recovery, th e clinicia n ca n a t time s creat e a n allianc e wit h th e famil y through whic h som e accommodation , som e recognitio n o f illness , an d some collaboratio n wit h clinician s i s allowable . A final exampl e illus trates th e rol e o f th e famil y therapis t a s a n interprete r o f th e favorabl e aspects of a patient's symptoms : The famil y o f a 25-year-ol d ma n wit h schizophrenia , wh o ha d led a n isolate d lif e i n anothe r city , denie d th e exten t o f hi s illnes s for man y years , believin g tha t h e suffere d fro m a borderlin e per sonality disorder . A t on e point , th e patien t wa s arreste d fo r a n attempted rap e tha t too k plac e i n broa d dayligh t an d tha t oc -

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curred, b y th e patient' s subsequen t account , i n respons e t o a n auditory hallucinatio n i n which h e hear d a woman's voic e saying , "Take me, take me." During the ensuing months, while the famil y was stil l absorbin g th e implication s o f th e attac k fo r thei r son' s future, th e therapis t wa s abl e t o interpre t th e ac t a s th e firs t indi cation o f th e son's wish fo r a relationship wit h a woman. U p until this point , despit e thei r espouse d belie f tha t th e so n di d no t hav e schizophrenia, the parents had never given evidence that they thought of hi m a s a man who migh t want the companionship o f a woman. The therapis t referre d frequentl y i n th e ensuin g tw o year s t o thi s incident, confrontin g th e famil y no t s o muc h wit h hi s illnes s a s with hi s aliveness . Gradually , th e parent s bega n t o tal k i n famil y meetings abou t hi s lonelines s an d his attractio n t o wome n a s indications o f hi s underlying health , an d th e patient, wh o wa s presen t in man y o f thes e meeting s was , i n thi s way, a witness t o hi s bein g talked abou t an d though t o f b y hi s parent s a s a sexual bein g i n a constructive sense . A yea r later , h e me t a woma n i n a loca l da y hospital progra m an d began dating her. The family wa s concerne d about this liaison because they did not favor their son developing a romantic relationship with a mental patient, fully expecting, a t this time, tha t h e woul d on e da y mee t a norma l gir l an d ge t married . However, th e therapist reminded them that there was a time whe n the ide a o f an y relationshi p wit h an y woma n seeme d ou t o f th e question t o thi s youn g ma n an d challenge d the m t o affir m th e developing relationship . Thre e year s later , th e mothe r sen t th e therapist, wh o wa s n o longe r workin g wit h th e family , a n an nouncement o f th e marriage of th e young man to this same woman, signifying he r acceptance o f bot h th e legitimacy o f th e son's statu s as a mental patient and his movement toward recovery . Left t o thei r ow n devices , thi s famil y woul d hav e remaine d s o focuse d on the dangerousness of the son's behavior that they would have avoided altogether th e subjec t o f hi s sexuality , hopin g t o discourag e hi m fro m any furthe r act s of violence . I n this way, crucia l evidenc e o f hi s vitality , of hi s strivings, even his psychotic strivings, would have gone unnoticed . Perhaps th e resul t woul d hav e bee n a repetitio n o f th e attack , thereb y moving hi m close r t o a caree r a s a mentall y il l offender . Additionally , though, the parents would have persisted in their denial of his illness, for

Beyond Psychoeducation 37 1 there wa s n o basi s i n th e attack , a s perceive d b y them , o n whic h t o assemble the hope for an acceptable future that was the crucial ingredient i n thei r acceptanc e o f th e illnes s i n th e present . Th e therapist' s representation of the son as a person who yearned for the company of a woman broke open a new line of thought, constituting the basis for the family's seeing him once again in hopeful terms. In conclusion, while the task of the clinician who relates to the patient's family member s includes , i n part , promotin g a n appreciatio n o f th e patient's priorities and how these become manifest in observable behavior, th e clinicia n soo n discover s tha t famil y member s hav e thei r ow n legitimate priorities that profoundly shape the extent and quality of their participation in the work with the patient. If schizophrenia is frightening and if life in the face of the illness often seems unbearable to the patient, it is equally true that the illness and the attendant loss of function in the patient represen t a crisi s o f majo r proportio n t o th e family . Famil y responses to schizophrenia, including some responses that are helpful to the patient and others that interfere with the patient's attempts to cope constructively wit h the illness, are central to the course of th e disorder over time. A full appreciatio n of th e family's experienc e of schizophre nia, whic h i s beyon d th e scop e o f thi s book , prepare s th e clinicia n t o work at the interface between patient and family in ways that maximize the likelihoo d o f restorin g th e patient's capacit y fo r productiv e socia l and vocational involvements in community life.

Notes

INTRODUCTION a. W e d o no t mea n t o impl y tha t th e clinicia n wil l endors e action s tha t ar e harmful t o sel f o r others . O n th e contrary , th e ai m i n suc h circumstance s i s to contai n o r mediat e agains t har m whil e a t th e sam e tim e conveyin g a n understanding o f th e inten t o f th e patient' s contemplate d actio n a s wel l a s the clinician's own inten t in providing containment . 1. A MODEL FOR UNDERSTANDING SCHIZOPHRENI A a. A n importan t corollar y i s tha t th e caregiver' s respons e t o thes e behaviors , often characterize d b y confusion, anger , fear , or withdrawal, ca n compoun d the patient's difficulty wit h relatedness and communication . b. Indeed , w e shal l see , th e pattern s o f adaptatio n i n schizophreni c individual s do appea r t o follo w comprehensibl e an d expectable courses , consistent wit h the principle s o f psychodynamic s an d cognitiv e theories . I t i s th e conse quences o f this proces s o f adaptation , whic h ar e s o disablin g an d defeatin g

373

374 Notes to th e schizophreni c individual , tha t w e inten d t o study , and , ultimately , t o treat. c. Th e manner i n which treatment s ar e "applied"—that is , the way i n which th e clinician present s th e treatmen t t o th e patien t an d th e discussion s tha t g o o n around it—ar e crucia l t o th e effectivenes s o f th e treatment . I t is not a simpl e matter t o appl y somati c treatment s i n wor k wit h schizophreni c patient s because o f th e wa y i n whic h the y perceiv e th e treatmen t proces s an d thei r interaction wit h th e clinician . d. Fo r example , a n extremel y paranoid , angr y mal e wa s aske d t o hea d th e ward's tas k force , petitionin g th e hospita l t o allo w th e war d t o hav e a poo l table. Hi s demanding , litiginou s stance , fuele d b y hi s belie f tha t figures i n authority wer e inherentl y malevolent , mad e hi m a powerful , albei t a t time s eccentric, spokesperson . A t th e sam e time , h e wa s formin g a n allianc e wit h the ward throug h thi s activity . e. Thi s distinction i s related t o a classic controversy i n the area o f schizophreni c phenomenology—whether th e patien t simpl y suffer s fro m a "deficit " i n per ception an d cognitio n o r i s "i n conflict " abou t hi s vie w o f th e world . Ou r model allow s fo r a putative physiologi c role , but assert s the importance , an d indeed th e essentia l contribution , o f psychologica l response s t o th e illness . Thus, we see that th e patient's convictio n abou t a delusional vie w of sel f and / or other s is , i n part , an d significantly , motivate d an d sustaine d b y hi s diffi culty i n toleratin g th e psychologica l alternative : confrontin g th e disturbe d nature o f hi s experience , an d th e fac t o f hi s illness, of whic h h e is, in spit e of the delusion, aware—thoug h tha t awarenes s include s doubt . The delusion is an alternativ e view that "satisfies " th e individual's psycho logical priorities . Th e unconsciou s min d is , i n som e sense , awar e o f it s conflicting representation s o f reality . The delusiona l vie w can the n b e said t o be a t odd s wit h th e individual' s rationa l vie w o f experience . We do no t full y understand ho w o r why th e conscious min d select s one or th e other view . W e do kno w tha t suc h conflic t ca n b e identifie d an d tha t patient s can , over time , change th e wa y the y interpre t events , eve n i n th e fac e o f ongoin g psychoti c stimuli.

2. UNDERSTANDIN G TH E SUBJECTIVE EXPERIENCE OF THE PERSON WITH SCHIZOPHRENI A a. Th e lengt h an d complexit y o f thi s commen t illustrate s th e principl e tha t "giving advice " canno t b e though t o f a s straightforwar d an d simple . Advic e may stil l be given, but the complexity o f th e patient's experience of the advic e must be anticipated .

Notes 37 5 3. FRO M UNDERSTANDING TO ACTION: THE ALLIANCE AND THE TREATMENT PROGRAM a. Ho w remarkable that we wish to insulate patients from th e ritual of trial and failure through which learning proceeds and with which we all struggle daily! What is more, the activity coordinator's remarks repeat the common error of asserting authorit y wher e reflectio n an d recommendatio n base d o n experi ence would suffice. This tendency is quite common in health care settings for a variet y o f reasons : Patients ar e infrequently gratefu l o r complimentar y t o staff member s an d usuall y (defensivel y du e to thei r unconsciou s frustratio n or shame ) demea n th e activitie s an d othe r intervention s offere d them ; i n addition, mos t hospitals—an d ironicall y psychiatri c hospital s an d depart ments are no exception—are remis s in their efforts t o sustain morale among health car e workers, who in our experienc e have been generally competent , caring, overworked, underpaid, and unappreciated. The staff members ' frustration an d lack of contro l (an d insecurity abou t th e value of their work) is then expressed in authoritarian responses.

4. TH E MAN WITH A BUG IN HIS BRAIN: AN INITIAL INTERVIEW a. Man y patients , b y contrast , presen t suc h bizarr e o r primitiv e attitude s o r reactions tha t th e clinicia n lack s acces s t o analog s withi n him - o r hersel f (perhaps, becaus e the y woul d b e too threatening) , making i t mor e difficul t for th e clinicia n t o find commo n groun d wit h th e patien t an d therefor e making it harder to identify way s to be helpful. b. Fo r example , i n th e cas e allude d t o i n chapte r 1 , th e clinicia n refuse d t o devote his time to defending th e patient against the CIA. He and the patient could, however, both agre e that the patient's sense of being unjustly treate d was an issue worthy of their collaboration. c. Naturally , th e patient' s attitud e towar d involvemen t i s fa r mor e comple x than the interviewer's comments suggest. The interviewer is not here addressing th e patient' s ambivalenc e abou t contact , onl y tha t par t o f th e patien t that, as he has indicated, wishes to be involved.

7. TH E CASE OF ROGER: OUTPATIENT PSYCHOTHERAPY— FROM APATHY TO COMMUNITY INVOLVEMENT a. Th e patient ha d bee n investigating his options while in the hospital, mostly by talkin g wit h fello w patient s wh o ha d bee n t o othe r institution s o r ha d heard about them from others who had been there.

376 Notes b. Th e delays were long enough to set the therapist to wondering whether this was psychomotor retardation and thereby evidence of depression. c. Th e therapist often referred openly to her struggle to listen without prejudice. She would say, "This is where a real psychiatrist would say to you . . ." She would tell him how difficult, ho w disorienting, and even how frightening it was to absorb his story without the protection accorded by the usual psychiatric perspective. d. Th e patient covertly discontinued the use of lithiu m carbonate in about the eighteenth month of therapy, having insisted from the beginning that it never had had any appreciable effect on his condition. e. H e was, by this time, taking chlorpromazine o n a self-directed basis , using sleep disturbance as the target symptom, with an average daily dose of 40 0 mg. pe r da y a t bedtime . Al l effort s t o educat e hi m a s t o th e benefit s o f dopamine blockade for overstimulation had been met with a wall of irritable denial: He did not have an illness; all he required was something to promote a good night's sleep, and chlorpromazine was good for that purpose. f. Th e patient echoed thi s sentiment a t several point s a s the work proceeded. On one occasion a year later he declared, "I earn the food that I eat, just by being able to bite it!"

References and Suggested Readings

This is not intended to be an exhaustive referenc e list. We have selected a few illustrative article s tha t ca n b e use d a s guide s t o furthe r exploration . Som e chapters hav e references , som e hav e suggested readings , an d some hav e both. The former are used either to substantiate the text or to acknowledge a source. Suggested readings are included to illuminate or extend what has been presented. In addition , ther e is a brie f lis t o f genera l reference s tha t offe r excellen t overviews o f som e o f th e mai n theme s o f th e book . I t i s ou r hop e that , b y making this list concise, we encourage readers to pursue the references.

CHAPTER REFERENCES AND SUGGESTED READINGS

Introduction References 1. Rothman , D. J. The discovery of the asylum: Social order and disorder in the new republic. Boston: Little, Brown and Company, 1971.

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378 References and Suggested Readings 2. Chamberlin , J. On our own: Patient-controlled alternatives to the mental health system. New York: McGraw-Hill, 1978. 3. Estroff , S . E. Making it crazy: An ethnography of psychiatric clients in an American community. Berkeley: University of California Press, 1981. 4. Runions , J., an d R . Prudo . Proble m behaviour s encountere d b y familie s living wit h a schizophreni c member . Canadian journal of Psychiatry 2 8 (1983):382-86. 5. Va n Putten, T. Why do schizophrenic patients refuse to take their medications? Archives of General Psychiatry 31 (1974): 67-72. 6. Marder , S . R . Lo w an d conventional-dose maintenanc e therapy wit h Fluphenazine Decanoate. Archives of General Psychiatry 44 (1987):518-21. 7. Carpenter , W., an d D . Heinrichs . Targeted medicatio n strategies . Schizophrenia Bulletin 9, 4 (1982):533-42. 8. Herz , M., H. Szymanski, and J. Simon. Intermittent dose strategies. American journal of Psychiatry 39 (1982):918-22. 9. Kane , J., G. Honigfeld, J. Singer, and H. Meltzer . Clozapin e fo r the treatment-resistant schizophrenic. Archives of General Psychiatry 45 (1988):789 97. 10. Blackwell , B. The drug defaulter. Clinical Pharmacology and Therapeutics 13 (1972):841-48. 11. Strauss , J. S. , W . T . Carpenter , an d J. Bartko . Th e diagnosi s an d understanding of schizophrenia: Part III. Speculations on the processes that underlie schizophrenic signs and symptoms. Schizophrenia Bulletin 1 1 (1974):6175. 12. Andreasen , N. C. Negative symptoms in schizophrenia: Definition an d reliability. Archives of General Psychiatry 39 (1982):784-88 . 13. Crow , T . J. Two syndrome s i n schizophrenia? Trends in Neurosciences 5 (1982):351-54. 14. Crow , T. J. Positive an d negative schizophrenic symptoms an d the role of dopamine. British Journal of Psychiatry 139 (1981):251-54. 15. Mackay , A. V. Positive and negative schizophrenic symptoms and the role of dopamine: I. British Journal of Psychiatry 137 (1980):379-86. 16. Angrist , B., J. Rotrosen, and S. Gershon. Differential effects of amphetamine and neuroleptics o n negative vs. positive symptom s in schizophrenia. Psychopharmacology 72 (1980):17-19. 17. Andreasen , N. C, S . A. Olsen, J. W. Dennert, and M. R. Smith. Ventricular enlargement in schizophrenia: Relationshi p to positive and negative symptoms. American Journal of Psychiatry 139 (1982):297-302. 18. Allen , H . A . Dichoti c monitorin g an d focuse d versu s divide d attentio n in schizophrenia. British Journal of Clinical Psychology 21 (1982):205-12. 19. Frieswyk , S . H. , J . G . Allen , D . B . Colson , L . Coyne , G . O . Gabbard , L. Horwitz, and G. E. Newsom. Therapeutic alliance: Its place as a process and outcome variable in dynamic psychotherapy research. Journal of Consulting and Clinical Psychology 54, 1 (1986):32-38.

References and Suggested Readings 37 9 20. Hartley , D. Researc h on the therapeutic alliance in psychotherapy. American Psychiatric Association Annual Review 4 (1985):532-49. 21. Horowitz , M . J. , an d C . Marmar . Th e therapeuti c allianc e wit h difficul t patients. American Psychiatric Association Annual Review 4 (1985):573 85. 22. Allen , J. Therapeuti c allianc e an d long-ter m hospita l treatmen t outcome . Comprehensive Psychiatry 26 (1985):187-94. 23. Greenson , R. R., an d M. Wexler. The non-transference relationshi p in the psychoanalytic situation . International Journal of Psycho-Analysis 50 (1969):27-39. 24. Pious , W . L . A hypothesi s abou t th e natur e o f schizophreni c behavior . Psychotherapy of the psychoses, A . Burton , ed . Ne w York : Basi c Books, 1961. Pp. 43-68. 25. Donlon , P. , an d K . Blacker . Clinica l recognitio n o f earl y schizophreni c decompensation. Diseases of the Nervous System 36, 6 (1975):323-27. 26. Freeman , T. The pre-psychotic phase and its reconstruction in schizophrenic and paranoia c psychoses . International Journal of Psycho-Analysis 6 2 (1981):447-53. 27. Docherty , J. P., an d D. P . Van Kammen, et al. Stages of onse t o f schizophrenic psychosis. American Journal of Psychiatry 135 (1978):4. 28. Andreasen , N. C. The broken brain: The biological revolution in psychiatry. New York: Harper and Row, 1985. 29. Crow , T. J. The continuum of psychosis and its implication for the structure of the gene. British Journal of Psychiatry 149 (1986):419-29. 30. Andreasen , N . C , an d S. Olsen . Negativ e vs . positiv e schizophrenia . Archives of General Psychiatry 39 (1982):789-94. 31. Lewine , R . R. , L . Fogg , an d H . Y . Meltzer . Assessmen t o f negativ e an d positive symptoms in schizophrenia. Schizophrenia Bulletin 9 (1983):368 76. 32. Kay , S. R., L. A. Opler, and A. Fiszbein. Significance of positive and negative syndromes i n chroni c schizophrenia . British Journal of Psychiatry 14 9 (1986):439-48. 33. Frank , A. F., J. G. Gunderson, and B. Gomes-Schwartz. The psychotherapy of schizophrenia: Patient and therapist factors related to continuance. Psychotherapy 24, 3 (1987):392-403. 34. Lin , I. F., R. Spiga, and W. Fortsch. Insight and adherence to medication in chronic schizophrenics. Journal of Clinical Psychiatry 40 , 1 0 (1979):430 32. 35. Barr , M. A . Homogeneou s group s wit h acutel y psychoti c schizophrenics . Group 10,1 (1986):7-12 . 36. Pao , P . Schizophrenic disorders: Theory and treatment from a psychodynamic point of view. New York: International Universities Press, 1979. 37. Carpenter , W . T. , an d D . W . Heinrichs . Treatmen t relevan t subtype s o f schizophrenia. Journal of Nervous and Mental Disease 169 (1981): 113-19.

3 8 0 References

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I. A Model fo r Understandin g Schizophreni a References 1. Wallace , E . R . Wha t i s truth?: Som e philosophica l contribution s t o psychi atric issues. American Journal of Psychiatry 145 , 2 (1988):137-47 . 2. Faust , D. , an d R . A . Miner. Th e empiricis t an d hi s ne w clothes : DSM-II I i n perspective. American Journal of Psychiatry 14 3 (1986):962-67 . 3. Crow , T . J . Positiv e an d negativ e schizophreni c symptom s an d th e rol e o f dopamine. British Journal of Psychiatry 13 7 (1980):383-86 . 4. Crow , T . J. Molecula r patholog y o f schizophrenia : Mor e tha n on e diseas e process? British Medical Journal 28 0 (1980):l-9 . 5. Andreasen , N . C , an d S . Olsen . Negativ e vs . positiv e schizophrenia : Defi nition an d validation . Archives of General Psychiatry 3 9 (1982):789-94 . 6. Jackson , J . H . Selected writings, J . Taylor , Jr. , ed . London : Hodde r an d Stoughton, Ltd. , 1931 . 7. Johnson , E . C, e t al . Mechanism o f th e antipsychoti c effec t i n the treatmen t of acut e schizophrenia. Lancet 1 (1978): 8 4 8 - 5 1. 8. Wing , J . K . Psychosocia l factor s affectin g th e lon g ter m cours e o f schizo phrenia. Psychosocial treatment of schizophrenia, J . Strauss, W. Boker , an d H. D . Brenner, eds . Toronto: Han s Huber , 1987 . 9. Carpenter , W . T . Approache s t o knowledg e an d understandin g o f schizo phrenia. Schizophrenia Bulletin 1 3 (1987) : 1-8. 10. Ciompi , L. Toward a coherent multidimensiona l understandin g an d therap y of schizophrenia : Convergin g ne w concepts . Psychosocial treatment of schizophrenia, J . Strauss , W. Boker , an d H . D . Brenner, eds . Toronto: Han s Huber, 1987 . I I . Opler , L . A., et al. Positive and negativ e syndrome s in chronic schizophreni a in patients . The Journal of Nervous and Mental Disease 17 2 (1984):317 25. 12. Levin , S. : Fronta l lob e dysfunction s i n schizophrenia-11 : Impairment s o f psychological an d brai n functions . Journal of Psychiatric Research 1 8 (1984):57-72. 13. Weinberger , D . R. , e t al . Physiologi c dysfunctio n o f dorsolatera l prefronta l cortex i n schizophreni a I : Regiona l cerebra l bloo d flo w evidence . Archives of General Psychiatry 4 3 (1986):114-25 . 14. Goldberg , T . E. , e t al . Further evidenc e fo r dementi a o f th e prefronta l typ e of schizophrenia ? Archives of General Psychiatry 4 4 (1987) : 1008-14. 15. Chaika , E . Though t disorde r o r speec h disorde r i n schizophrenia ? Schizophrenia Bulletin 8 (1982):587-91. 16. Crosson , B. , an d C . W . Hughes . Rol e o f th e thalmu s i n language : I s i t related t o schizophreni c though t disorder ? Schizophrenia Bulletin 1 3 (1987):605-21. 17. Freedman , R. , e t al . Neurobiologi c studie s o f sensor y gatin g i n schizophre nia. Schizophrenia Bulletin 1 3 (1987):669-77 .

References and Suggested Readings 38 1 18. Patterson , T. Studie s toward th e subcortica l pathogenesi s o f schizophrenia . Schizophrenia Bulletin 1 3 (19$7):555-76. 19. Holzman , P . Recen t studie s o f psychophysiolog y i n schizophrenia . Schizophrenia Bulletin 1 3 (1987):49-75 . 20. Nasrallah , H . A. , an d D . R . Weinberger . The neurology of schizophrenia. New York : Elsevier Science, 1986 . 21. Harding , C . M. , e t al . Vermon t longitudina l stud y o f person s wit h sever e mental illness (Parts I and II). American Journal of Psychiatry 14 4 (1987):718 35. 22. Kraepelin , E . Dementia praecox and paraphrenia. Huntington : Rober t E . Krieger, 1971. 23. Bleuler , E . Dementia praecox or the group of schizophrenias. Ne w York : International Universitie s Press, 1950 . 24. Brenner , H . D . O n th e importanc e o f cognitiv e disorder s i n treatmen t an d rehabilitation. Psychosocial treatment of schizophrenia, J. Strauss , W. Boker , and H. D. Brenner, eds. Toronto: Hans Huber, 1987 . 25. Weinberger , D. R . Implications of normal brai n development fo r the pathogenesis o f schizophrenia . Archives of General Psychiatry 4 4 (1987):660 69. 26. Michels , R. , an d J. O . Cavenar , Jr. , eds . Psychiatry. Philadelphia : Lippin cott, 1987 . Vol. 1 , pp. 14-26; vol. 3, pp. 3 - 8 . 27. Rifkin , A. , ed . Schizophrenia and affective disorders: Biology and drug treatment. Boston : Wright, 1983 . 28. Andreasen , N . The broken brain: The biological revolution in psychiatry. New York : Harper and Row, 1985 . 29. Karown , F. , e t al . Preliminar y evidenc e o f reduce d combine d outpu t o f dopamine an d its metabolites i n chronic schizophrenia. Archives of General Psychiatry 4 4 (1987):604-7 . 30. Sandler , M . Th e dopamin e hypothesi s revisited . The biological basis of schizophrenia, G . Hemmings an d W. Hemmings, eds . Baltimore: Universit y Park Press, 1978. Pp. 79-85 . 31. Ingvar , D . H. , an d Franzen . Distributio n o f cerebra l activit y i n chroni c schizophrenia. Lancet! (1974):1484-86 . 32. Jaskiw , G . E. , e t al . Media l prefronta l corte x lesion s i n th e rat . Abstract , New Researc h Section , America n Psychiatri c Associatio n Annua l Meetin g Proceedings. May 1988 . 33. Grossberg , S. , an d G . Stone . Neura l dynamic s o f wor d recognitio n an d recall: Attentiona l priming , learnin g an d resonance . Psychological Review 93 (1986):46-74 . 34. Oke , A . F. , an d R . N . Abrams . Elevate d thalami c dopamine : Possibl e lin k to sensor y dysfunction s i n schizophrenia . Schizophrenia Bulletin 1 3 (1987):589-604. 35. Lishman , W. A. Organic psychiatry. Oxford : Blackwell Scientific, 1987 . 36. MacLean , P . D . A triun e concep t o f th e brai n an d behavior . Lectur e I .

382 References and Suggested Readings Man's reptilia n an d limbi c inheritance. Lecture II . Man's limbi c brain an d the psychoses. The Hincks Memorial Lectures, T. Boa g and D . Campbell, eds. Toronto: University of Toronto Press, 1973. 37. Falloon , I., D. C. Watt, and M. Shepard. The social outcome of patients in a tria l o f long-ter m continuatio n therap y i n schizophrenia : Pimozid e vs . Fluphenazine. Psychological Medicine 9 (1978):265-74. 38. Marder , S. R., et al. Low and conventional-dose maintenanc e therapy with fluphenozine decanoate . Archives of General Psychiatry 44 (1987):518-21. 39. Siris , S. G., et al. Adjunctive imipramin e in the treatment of post psychotic depression. Archives of General Psychiatry 44 (1987):533-39. 40. Hirsch , S. R., A. G. Jolley, R. Manchanda, and A. McRink. Early intervention medicatio n a s an alternativ e to continuou s depo t treatment i n schizophrenia: Preliminar y report . Psychosocial treatment of schizophrenia, J. Strauss, W. Boker, and H. D. Brenner, eds. Toronto: Hans Huber, 1987. 41. Docherty , J. P., D. P. Van Kammen, S. G. Siris, and S. R. Marder. Stages of onset o f schizophreni c psychosis . American Journal of Psychiatry 13 5 (1978):420-26. 42. Lacan , J. The case of Aimee, or self-punitive paranoia . The clinical roots of the schizophrenia concept, J. Cuttin g an d M . Shepherd , eds . Cambridge Cambridge University Press, 1987. Pp. 213-226. 43. Rogers , R . W. , an d C . R . Mewborn . Fea r appeal s an d attitud e change : Effects o f a threat's noxiousness, probability o f occurrence, and the efficac y of copin g responses . Journal of Personality and Social Psychology 3 4 (1976):54-61. 44. Rippetoe , P . A. , an d R . W . Robers . Effect s o f component s o f protection motivation theory on adaptive and maladaptive coping with a health threat. Journal of Personality and Social Psychology 52 (1987):596-604. 45. Gum , G . A. , e t al. Informatio n an d locu s o f contro l a s factor s i n th e outcome of surgery. Psychological Reports 45 (1979):867-73. 46. Poll , I. B., et al. Locus of control an d adjustmen t t o chronic hemodialyses. Psychological Medicine 10 (1980):153-57. 47. Miller , S. M., et al. Preference fo r contro l an d the coronary prone behavior pattern: "I'd rather do it myself." Journal of Personality and Social Psychology 49 (1985):492-99. 48. Nowack , K. , et al. Coronary-prone behavior , locus of contro l an d anxiety . Psychological Reports 47 (1980):359-64. 49. Rotter , J. B. Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs 80,1, no. 609 (1966). 2. Understandin g the Subjectiv e Experienc e of the Person with Schizophrenia References 1. Bowers , M. Retreat from sanity: The structure of emerging psychosis. Balti more: Penguin Books, 1974.

References and Suggested Readings 3 8

3

2. Freedman , B. The subjective experience of perceptual and cognitive disturbances in schizophrenia. Archives of General Psychiatry 30 (1979):333-40. 3. Johnson , D. Representation of the internal world in catatonic schizophrenia. Psychiatry 47 (1984):299-314. 4. Landes , D., and F. Mettler. Varieties of psychopathological experience. New York: Holt, Reinhart and Winston, 1964. 5. Morgan , R. Conversations with chronic schizophrenic patients. British Journal of Psychiatry 134 (1979):187-94. 6. Reed , G. The psychology of anomalous experience. London : Hutchinson, 1972. 7. Sechehaye , M . Autobiography of a schizophrenic girl. New York : Ne w American Library, 1970. 8. Mahler , M. S . On human symbiosis and the vicissitudes of individuation. New York: International Universities Press, 1968. 9. Schultz , C . Th e contributio n o f th e concep t o f self-representation-object representation differentiatio n t o th e understandin g o f th e schizophrenias . NIMH3(1980):453-70. 10. Feinstein , D. The symbiotic block. International Journal of Psychoanalytic Psychotherapy 6 (1977):131-44. 11. Lichtenberg , J. The development of the sense of self. Journal of the American Psychoanalytic Association 23 (1975):453-84. 12. Bion , W. Differentiation o f the psychotic from the non-psychotic personalities. International Journal of Psycho-analysis 38 (1957): 266-75. 13. Hatan , M. The importance of th e non-psychotic part of the personality in schizophrenia. International Journal of Psychoanalysis 35 (1954): 119-28. 14. White , R . Th e experienc e o f efficac y i n schizophrenia . Psychiatry 28 (1965):199-211. 15. Davie , J. Observation s o n som e defensiv e aspect s o f delusio n formation . British Journal of Medical Psychology 36 (1963): 67-74. 16. Cassimatis , E. G. The "False self": Existential and therapeutic issues. International Review of Psycho-analysis 11 (1984): 69—77. 17. Beavers , W . Schizophreni a an d despair . Comprehensive Psychiatry 1 3 (1972):561-72. 18. Sandler , J. The background of safety. International Journal of Psychoanalysis 41 (19>60):352-56. 19. Burnham , D. , A . Gladstone , an d R. Gibson . Schizophrenia and the needfear dilemma. New York: International Universities Press, 1969. 20. Modell , A . Object love and reality. New York : Internationa l Universitie s Press, 1968. 21. Searles , H. The schizophrenic individual's experience of his world. Psychiatry 30 (19 67):119-31. 22. Winnicott , D. W. The capacity to be alone. International Journal of Psychoanalysis 39 (1958):416-20.

384 References and Suggested Readings 3. Fro m Understanding lo Action: The Alliance and the Treatment Program References 1. Selzer , M . A. , M . Carsky , B . Gilbert , W . Weiss , M . Klein , an d S . Wagner . The shared field: A precursor stage in the development of a psychotherapeutic allianc e wit h th e hospitalize d chroni c schizophrenic patient . Psychiatry 47 (1984):324-32 . 2. Selzer , M . A . Preparin g th e chroni c schizophreni c fo r explorator y psycho therapy: The role of hospitalization . Psychiatry 4 6 (1983):303-11 . 3. Brown , L . J . A short-ter m hospita l progra m preparin g borderlin e an d schizophrenic patients for intensive psychotherapy. Psychiatry 44 (1981):327 36. 4. Volkan , V. The introjection o f a n identification wit h the therapist as an egobuilding aspect in the treatment of schizophrenia. British Journal of Medical Psychology 4 1 (1968):369-80 . 5. Lidz , T . Th e developin g guideline s t o th e psychotherap y o f schizophrenia . Psychotherapy of schizophrenia, J . Strauss , M . Bowers , T . Downey , e t al. , eds. New York : Plenum, 1980 . Pp. 217-26 . 6. Boyer , L . B. Offic e treatmen t o f schizophreni c patients : Th e us e of psycho analytic treatment with few parameters. Psychoanalytic treatment of schizophrenic, borderline, and characterologic disorders. L . B . Boyer , P . L . Gio vacchini, eds. New York : Jason Aronson, 1980 . Pp. 129—70. 7. Schulz , C . G . A n individualize d psychotherapeuti c approac h wit h th e schizophrenic patient. Schizophrenia Bulletin 1 3 (1975)-.46-69 . 8. Kohut , H . Th e analysi s o f th e self . Ne w York : Internationa l Universitie s Press, 1971. 9. Selzer , M . A. , H . W . Koenigsberg , an d O . F . Kernberg. The initia l contrac t in the treatment of borderlin e patients. American Journal of Psychiatry 14 4 (1987):927-30. 10. Benedetti , G. Individual psychotherapy o f schizophrenia. Schizophrenia Bulletin 6 (1980):633-38 . 11. Frosch , J. , J . Gunderson , R . Weiss , an d A . Frank . Therapist s wh o trea t schizophrenic patients. Psychosocial intervention in schizophrenia: An international view, H . Stierlin , L. C. Wynne, an d M. Wirsching, eds. New York : Springer-Verlag, 1983 . 12. Schulz , C . G . Sel f an d objec t differentiatio n a s a measur e o f chang e i n psychotherapy. Psychotherapy of schizophrenia, J . G. Gunderso n an d L. R. Mosher, eds. New York : Jason Aronson, 1975 . Pp. 305—16. 13. Searles , H . F . Psychoanalyti c therap y wit h schizophrenic patient s i n a private practic e context . Countertransference and related subjects: Selected papers. Ne w York : International Universitie s Press, 1979. Pp. 582-602. 14. Feinsilver , D. B., and J. G. Gunderson. Psychotherapy o f schizophrenia: I s it indicated? Schizophrenia Bulletin 6 (1980): ! 1-23.

References and Suggested Readings 38 5 15. Grinspoon , L. , J. Ewalt, an d R. Shader . Schizophrenia: Pharmacotherapy and psychotherapy. Baltimore: Williams and Wilkins, 1972. 16. Gunderson , J., A . Frank , H . Katz , M . Vannicelli , J. P . Frisch , an d P . H . Knapp. Effect s o f psychotherap y i n schizophreni a II : Comparativ e out come o f tw o form s o f treatment . Schizophrenia Bulletin 10 (1984):564 99. 17. Klerman , G . L . Ideolog y an d scienc e i n th e individua l psychotherap y o f schozophrenia. Schizophrenia Bulletin 1 0 (1984):608-12. 18. Rosenfeld , H . Note s o n th e psychoanalytic treatmen t o f psychoti c states . Long term treatments of psychotic states, C. Chiland ed. New York: Human Sciences Press, 1977. Pp. 202-16. 19. Will , O . A. Schizophrenia: The problem o f origins . The origins of schizophrenia, J. Romasin, ed. Amsterdam: Excerpta Medica, 1967. Pp. 214-27. 20. Anthony , W. J., and R. P. Liberman. The practice of psychiatric rehabilitation. Schizophrenia Bulletin 12 (1986):542-59. 21. Frey , W . D . Functiona l assessmen t i n th e 80's : A conceptua l enigma , a technical challenge. Functional assessment in rehabilitation, A. Halpern and M. Fuhrer, eds. New York: Brooke, 1984. Pp. 11-43. 22. Presly , A. J., A. B. Gribb, and D. Semple. Predictors of successful rehabili tation in long stay patients. Acta Psychiatrica Scandinavica 66 (1982):83 88. 23. Carpenter , W . T. , an d D . W . Heinricks . Earl y intervention , time-limited , targeted pharmacotherap y o f schizophrenia . Schizophrenia Bulletin 9 (1983):533-43. 24. Falloon , I., and R. Liberman. Interactions between drugs and psychosocial therapy in schizophrenia. Schizophrenia Bulletin 9 (1983): 543-55. 25. Hogarty , G . E. , N . R . Schooler , R . Ubrich , F . Mussare , P . Ferr o an d E. Herron. Fluphenazine and social therapy in the aftercare of schizophrenic patients. Archives of General Psychiatry 36 (1979):1283-95. 26. Anderson , C. M., G. E. Hogarty, and D. J. Reiss. Family treatment of adult schizophrenic patients. Schizophrenia Bulletin 6 (1980):490-506. 27. Greenley , I. R. Familial expectations, post-hospital adjustmen t and the societal reactio n perspective o n menta l illness . Journal of Health and Social Behaviour 20 (1975):217-27 . 28. Vaughn , C. E., and J. P. Leff. The influences of family and social factors on the course of psychiatric illness. British Journal of Psychiatry 129 (1976): 12537. 29. Vaughn , C. E., and J. P. Leff. The measurement of expressed emotion in the families o f psychiatri c patients. British Journal of Social and Clinical Psychology 15 (1976): 157-65. 30. Leff , J. P., L. Kuipers, R. Berkowitz and D. Sturgeon. A controlled trial of social interventio n i n the families of schizophrenic patients: Two year follow-up. British Journal of Psychiatry 146 (1985):594-600. 31. Leff , J. P., L. Kuipers, R. Berkowitz, C . E. Vaughn, and D. Sturgeon. Life

386 References and Suggested Readings events, relatives' expressed emotion and maintenance neuroleptics in schizophrenic relapse. Psychological Medicine 13 (1983):799-806. 32. Goldstein , M . J. , an d A . M . Strachan . Th e impac t o f famil y interventio n programs o n famil y communicatio n an d th e short-ter m cours e o f schizo phrenia. Treatment of schizophrenia: Family assessment and intervention, M. J. Goldstein, I. Hand, and K. Hahlweg, eds. Heidelberg: Springer-Verlag, 1986. Pp. 185-92. 33. Giovacchini , P. C. Countertransference wit h primitive mental states. Countertransference: The therapist's contribution to therapeutic situation, L . Epstein and H. Feiner, eds. New York: Jason Aronson, 1983. Pp. 235-67. 34. Grinberg , L. On a specific aspect of countertransference du e to the patient's projective identification . International Journal of Psycho-analysis 4 3 (1962):436-40. 35. Searles , H. The schizophrenic's vulnerabilit y t o the therapist's unconsciou s processes. Journal of Nervous and Mental Disease 12 (1958):247-62. 36. Winnicott , D . W. Hat e i n th e countertransference. Collected Papers. Ne w York: Basic Books, 1958. Pp. 229-42. 5. Th e Case of Sharon: A Hospital Sla y Involving Noncompliance, Violence, an d Staff Conflic t References 1. Selzer , M. Preparing the chronic schizophrenic fo r explorator y psychother apy: The role of hospitalization. Psychiatry 46 (1983):303-11. 2. Schwartz , D. Aspects of schizophrenic regression. Psychotherapy of Schizophrenia. Amsterdam: Excerpta Medica, 1979 . Pp. 79-87. 3. Searles , H. Countertransference and related subjects. New York : Interna tional Universities Press, 1979. 4. Gunderson , J. Patient-therapist matching : A research evaluation. American Journal of Psychiatry 135,10 (1978): 1193-97. 5. Auerhahn , N., and M. Moskowitz. Merger fantasies i n individual inpatien t therapy wit h schizophreni c patients . Psychoanalytic Psychology 1 , 2 (1984):131-48. 6. Feinsilver , D., and B . Y. Yates. Combined us e of psychotherapy an d drug s in chronic , treatment-resistan t schizophreni c patients . Journal of Nervous and Mental Disease 172, 3 (1984):133-39. 7. Kernberg , O. Object relations theory and clinical psychoanalysis. Ne w York: Jason Aronson, 1976. 8. Munich , R., M. Carsky, and A. Appelbaum. The role and structure of longterm hospitalization: Chronic schizophrenia. The Psychiatric Hospital 16, 4 (1985):161-69. 9. Ogden , T . Projectiv e identificatio n i n hospita l treatment . Bulletin of the Menninger Clinic 45, 4 (1981):317-33. 10. Schulz , C. Technique with schizophrenic patients. Psychoanalytic Inquiry 3, 1 (1983):105-24 .

References and Suggested Readings 38 7 11. Selzer , M., M. Carsky, B. Gilbert, W. Weiss, M. Klein and S. Wagner. The shared field:Aprecursor stage in the development of a therapeutic alliance with th e hospitalize d chroni c schizophreni c patient . Psychiatry 47 , 4 (1984):324-32.

6. Th e Case of Maryann: Psychotherapy and Community Management, Rehabilitation, and Rehospitalization References 1. McGlashan , T., J. Docherty, and S. Siris. Integrative and sealing-over recoveries fro m schizophrenia : Distinguishin g cas e studies . Psychiatry 3 9 (1976):325-38. 2. Searles , H . Phase s o f patient-therapis t interactio n i n th e psychotherap y o f chronic schizophrenia. 1961 . Collected papers on schizophrenia and related subjects. New York: International Universities Press, 1965. Pp. 521-59.

Suggested Readings Goering, P. N., and S. K. Stylianos. Exploring the helping relationship between the schizophrenic clien t an d rehabilitation therapist . American Journal of Orthopsychiatry 58, 2 (1988):271-80. Roberts, R. The outpatient treatment of schizophrenia: An integrated and comprehensive management-oriented approach . Psychiatric Quarterly 52 (1984):91 112. Strauss, J. S., and W. T. Carpenter. Schizophrenia. New York: Plenum, 1981. Wing, J. K. The management of schizophreni a i n the community. Research in the schizophrenic disorders: The Stanley R. Dean Award Lectures, R . Cancr o and S. R. Dean, eds. New York: Spectrum, 1985. Vol. 2, pp. 113-54. Wing, J. K., and B. Morris, eds. Handbook of psychiatric rehabilitation practice. Oxford: Oxford University Press, 1981.

7. Th e Case of Roger: Outpatient Psychotherapy— From Apathy to Community Involvement References 1. C . C. Beels. Personal communication, 1974. 2. Zelin , M . L. , S. B . Bernstein, C . Heijn , R . M . Jampel, P . G . Myerson , G . Adler, D. H. Bule, Jr., and A. M. Rizutto . The sustaining fantasy questionnaire: Measurement of sustainin g functions o f fantasie s i n psychiatric inpatients. Journal of Personality Assessment 47 (1983):427-39. 3. McGlashan , T. H. Aphanisis: The syndrome of pseudo-depression in chronic schizophrenia. Schizophrenia Bulletin 8,1 (1982): ! 18-33.

3 8 8 References

and

Suggested Readings

Suggested Readings Cassel, E . J . Th e natur e o f sufferin g an d th e goal s o f medicine . New England Journal of Medicine 30 6 (1982):639-45 . Josephs, L . Witnes s t o tragedy : A self-psychologica l approac h t o th e treatmen t of schizophrenia . Bulletin of the Menninger Clinic 5 2 (1988) : 134-45. Venables, P. , an d J . F . Wing . Level s o f arousa l an d th e subclassificatio n o f schizophrenia. Archives of General Psychiatry 7 (1962):114-19 . Wynne, L . C . A phase-oriente d approac h t o treatmen t wit h schizophrenic s an d their families . Family therapy in schizophrenia, W . R. McFarlane, ed. New York : Guilford Press , 1983 . Pp. 2 5 1 - 6 5. 8. Beyon d Psychoeducation : Raisin g Famil y Consciousnes s Abou t the Prioritie s o f Peopl e wit h Schizophreni a References 1. Bateson , G. , D . D . Jackson, J. Haley , an d J. Weakland . Towar d a theory o f schizophrenia. Behavioral Sciences 1 (1956):251-64 . 2. Bowen , M . A famil y concep t o f schizophrenia . The etiology of schizophrenia, D . D. Jackson, ed . New York : Basi c Books, 1960 . 3. Lidz , T., A. R. Cornelison , D . Terry, and S . Fleck. Intrafamilial environmen t of th e schizophreni c patient . VI . The transmissio n o f irrationality . Archives of Neurology and Psychiatry 7 9 (1958):305-16 . 4. Wynne , L . C. , I . Ryckoff , J . Day , an d S . Hirsch . Pseudo-mutalit y i n th e family relation s o f schizophrenics . Psychiatry 2 1 (1958):205-20 . 5. Singer , M . T. , an d L . C . Wynne . Communicatio n style s i n parent s o f nor mals, neurotic s an d schizophrenics . Psychiatric Research Reports 2 0 (1966):25-38. 6. Terkelsen , K . G . Schizophreni a an d th e family : II . Adverse effect s o f famil y therapy. Family Process 2 2 (1983):191-200 . 7. Hirsch , S . R., an d J. P. Leff, Abnormalities in parents and schizophrenics: A review of the literature and an investigation of communication defects and deviances. London : Oxfor d Universit y Press , 1975 . 8. Leff , J . P . Development s i n famil y treatmen t o f schizophrenia . Psychiatric Quarterly SI (1979):216-32 . 9. Brown , C . W., J. L . T. Birley , and J. K . Wing. Influence o f famil y lif e o n th e course o f schizophreni c disorders : A replication. British Journal of Psychiatry 12 1 (1972):241-58 . 10. Vaughn , C . E. , an d J . P . Leff. The influenc e o f famil y an d socia l factor s o n the cours e o f psychiatri c illness : A compariso n o f schizophreni c an d de pressed neuroti c patients. British Journal of Psychiatry 12 9 (1976) : 125—37. 11. Falloon , I . R . H. , J. L . Boyd , an d C . W . McGill . Family care of schizophrenia. New York : Guilfor d Press , 1984 . 12. Anderson , C . M. , G . E . Hogarty , an d D . J . Reiss . Schizophrenia in the family. Ne w York : Guilfor d Press , 1986 .

References and Suggested Readings 38

9

13. Lazare , A. , S . Eisenthal , an d L . Wasserman . Th e custome r approac h t o patienthood: Attendin g t o patien t request s i n a walk-in clinic . Archives of General Psychiatry 32 (1975):553-58. 14. Terkelsen , K . G . Evolutio n o f famil y response s t o menta l illnes s throug h time. Families of the mentally ill, A. B . Hatfield an d H . Lefley , eds . New York: Guilford Press , 1987. GENERAL REFERENCES Anderson, C. M., G. E. Hogarty, and D. J. Reiss. Schizophrenia and the family. New York: Guilford Press , 1986. Black, B . J. Work and mental illness: Transitions to employment. Baltimore : Johns Hopkins University Press, 1988. Bowers, M. B. Retreat from sanity: The structure of emerging psychosis. New York: Human Sciences Press, 1974. Ciardiello, J . A. , an d M . D . Bell . Vocational rehabilitation of persons with prolonged psychiatric disorders. Baltimore: John s Hopkin s Universit y Press , 1988. Falloon, I. R., J. L. Boyd, and C. W. McGill. Family care of schizophrenia. New York: Guilford Press , 1984 Freeman, T . The psychoanalyst and psychiatry. New Haven : Yal e Universit y Press, 1988. Hafner, H. , W. Gattaz , an d W. Janzarik, eds . Search for the causes of schizophrenia. Berlin: Springer-Verlag, 1987. Sechehaye, M . Autobiography of a schizophrenic girl. New York : Grun e an d Stratton, 1951. Strauss, J. S., and W. T. Carpenter. Schizophrenia. New York: Plenum, 1981. Wing, J. K., and G . W. Brown. Institutionalism and schizophrenia. Cambridge : Cambridge University Press, 1970.

Index

Adaptive inten t o f patient' s belief s an d actions, 5 , 6 , 14 , 35 , 45 , 46 , 47 , 51 ; empathy for , 96 ; expresse d i n delusions , 3 2 - 3 3 , 361-62 ; identifying , wit h th e patient, 32 , 60 ; an d manifes t commu nication, 78 , 80 , 81 ; and socia l with drawal, 38 , 3% 45 , 47 , 360-6 1 Affect, 125 , 226—27 ; an d countertransfer ence, 246 ; an d relatedness , 70 ; restricted, 3 8 Affective flooding , 328 , 329 , 34 2 Age o f onset , 4 1 Aggression, 38 , 178 ; an d boundar y distur bances, 85 ; distance create d by , 103 ; and manifes t communication , 80—81 . See also Violenc e Agitation, 18 , 3 8 - 3 9 Alcohol an d drugs , 330, 36 0 Aliveness, 310-14 , 320 , 329 , 332 , 341 ;

absence of , 2 ; an d treatmen t alliance , 6 . See also Vitality , los s o f Allies, potential , 20 0 Amotivation, 12 , 38, 39 ; an d boundar y disturbances, 85 ; an d demoralization , 57, 60 ; and interactio n o f physiolog y and psychology, 43 , 45 ; an d psycholog ical discontinuity , 9 3 - 9 4 ; an d treatmen t alliance, 19 , 23; and treatmen t pro gram, 160-6 5 Anderson, C . M. , 35 4 Andraesen, N. , 3 7 Anger, 8 , 39 , 5 1 - 5 3 , 133 , 134 , 161 , 178 , 226, 227 , 241 , 315; i n resigne d pa tients, 162 , 164 , 16 5 Anhedonia, 39 , 328 ; an d demoralization ,

57,60

Antidepressants, 24 , 250-5 1 Antipsychotic medication . See Medicatio n

391

392 Index Anxiety, 25 , 61 , 89 , 92 , 109 , 121 , 136 , 160, 172 , 178 ; and depersonalizatio n and derealization , 84—85 ; and los s o f old self , 106-7 ; managing , 26 ; an d manifest communication , 80—81 ; and physiological factors , 3 8 - 3 9 , 42 ; an d psychic numbing , 312 ; reducing , 102 , 139; an d treatmen t alliance , 30 , 3 4 Apathy, 8 , 38 , 39 , 71 ; as activ e attemp t to avoi d pain , 5 ; an d demoralization , 57, 60 ; illustrate d i n cas e o f Roger , 307, 3 1 0 - 1 1 , 328 , 335 ; an d interactio n of physiolog y an d psychology , 43 , 45 ; and treatmen t alliance , 19 , 2 3 Aphanisis, 31 1 Assessment interviews , 169—23 2 Autonomy issues , 66, 156 , 298 ; contro l issues relate d to , 101-2 , 104-5 , 235 ; explored i n assessmen t interview , 1 8 6 87, 217 ; an d noncompliance , 235 , 237 ; and psychologica l response s t o illness , 39; an d rehospitalization , 289 , 290 , 294; an d safet y needs , 111 ; and violence, 26 5 Avolition, 19 , 38 , 39 , 71 ; and interactio n of physiolog y an d psychology , 43 , 4 5 Behavioral interventions , 102 , 139 , 143 , 144 Biological mode l o f schizophrenia , 13 , 19 , 59, 347 , 354 ; an d delusions , 50 ; impac t of, 1 , 2 , 3 , 9 - 1 0 , 11 ; and popula r over simplification o f th e illness , 7 Bleuler, E. , 18 , 3 5 Body awareness , 8 8 Borderline patients , 12 6 Boundary disruption , 84 , 246 , 247 ; an d tolerance fo r intimacy , 10 . See also Self object differentiation , disturbance s o f Brain-imaging studies , 4 1 Brain pathology, 18 , 35 , 4 0 - 4 5 Brenner, H . D. , 3 6 "Bug in th e brain " case, 169—23 2 Buspirone, 33 0 Case management , 149 , 32 4 Catecholamine systems , 4 1

CAT scans, 1 0 Cavenar, J. O. , Jr., 37, 4 0 Cerebral mass , decreased , 10 , 4 0 Chlorpromazine, 311 , 315, 331 , 33 4 Cholinergic deficienc y states , 4 0 Clinical training , 7 - 8 , 9 Cocaine, 330 , 33 3 Cognitive avoidance , 4 8 Cognitive impairment , 10 , 18 , 38 , 4 0 - 4 1 , 61, 71 , 89 , 265 ; intens e affec t associ ated with , 226-27 ; an d interpersona l relations, 47 , 144 ; an d lac k o f insight , 39; fro m medicatio n toxicity , 38 , 42 ; and mesocortica l abnormalities , 42 , 43 ; and psychologica l continuit y an d clarity, 9 2 - 9 9 ; treatmen t of , 97-99 ; an d treatment program , 125 , 128 , 129 , 137 , 140, 144 , 14 9 Cognitive interventions , 102 , 139 , 14 3 Cognitive testing , 5 8 Cognitive therapy , 4 5 Cognitive treatmen t theory , 14 4 Communication, 45—46 , 48, 124 . See also Manifest communicatio n Community care , 1 , 8 , 271-300 , 348 , 362, 363 , 36 6 Compliance, 115 , 152-53 ; experienc e o f control a s predicto r of , 5 5 - 5 7 ; an d insight int o illness , 12 ; and outcome , 5556; passive , 21 , 119 , 133 , 156 , 162 ; and treatmen t alliance , 2 2 Control fantasy , 48 , 5 2 - 5 3 , 102-3 , 14 9 Control issues , 58 , 59 , 66 , 161 , 242, 255 , 264, 280 ; autonom y issue s relate d to , 101-2, 104-5 , 235 ; explore d i n assess ment interview , 186-87 , 217 ; an d locu s of control , 39 , 5 6 - 5 7 , 124 , 186 ; an d manifest communication , 81 , 83 ; and noncompliance, 235 , 237 ; an d outcome , 55-57; i n relationships , 102—4 ; and safety needs , 109 , 111 ; significance of , 101-2; an d violence , 235 , 26 5 Countertransference t o schizophreni c pa tients, 115 , 246-47 , 258 , 283-84 , 296 ; and patient' s contro l needs , 105 ; an d rehospitalization, 293 ; ris k o f actin g on , 128, 134 , 162 ; and treatmen t program , 165-66 Court order , 235 , 255 , 25 6

Index 39 3 Crow, T . J., 1 8 Cultural factors , 7 , 9 Curiosity, patient's , 39 , 228-2 9 Custodial care , 25 9 "Customer approac h t o patienthood, " 364

Dangerous behavior , 58 , 131 . See also Suicide attempt s o r threats; Violenc e Davis, John M. , 3 7 Deja v u experiences , 3 8 Delusions, 9 , 21 , 45, 46 , 5 1 - 5 3 , 225-26 , 285-87, 328 ; adaptiv e function s of , 3 2 - 3 3 , 361-62 ; an d boundar y distur bances, 85 ; an d clinician' s role , 3 1 7 18; diagnosti c emphasi s on , 18 ; as manifest communication , 81 ; and paralle l dialogue, 157-60 ; an d patient's diffi culty i n tolerating self-awareness , 122 ; and patient's subjectiv e experience , 6772, 77 , 81 , 83 , 85 , 89 , 90 , 94 , 101 , 102, 107-10 , 112 , 115 ; and physiologi cal substrat e o f schizophrenia , 39 , 50 ; as psychological respons e t o illness , 19 , 39; psychologica l sustenanc e provide d by, 89 , 90 , 94 , 352 , 367 ; an d related ness, 7 0 - 7 1 , 72 ; self-blame expresse d in, 186 ; structure an d function s of , 4 9 51, 53 ; and treatment alliance , 4 , 5 , 2 2 - 2 5 , 2 7 - 2 9 , 30 , 31 , 3 3 - 3 4 ; an d treatment program , 127-30 , 137 , 1 3 9 40,146, 16 1 Dementia, 10 , 18 , 3 5 Demoralization, 98 , 223 , 224 , 322 , 329 ; aspects of , 5 4 - 5 5 , 57 , 60 ; an d bound ary disturbances, 85 ; combating, 1 2 9 30, 134 , 139 ; an d psychic numbing , 342; a s psychological respons e t o ill ness, 39 ; i n the resigne d patient , 161 , 163; fro m self-shaming , 339 ; source s of, 122 ; and treatmen t alliance , 23 , 26 , 45, 59; an d withdrawal, 47 , 5 7 Denial, 8 , 21 , 59, 74 , 149 , 154 , 281 , 369-71; challenging , 102 ; of depen dency, 287 , 289 ; function s of , 3 8 - 3 9 , 50, 134 ; of losses , 107 , 108 ; as mani fest communication , 81 ; and paralle l dialogue, 157-60 ; a s psychological re -

sponse t o illness , 19 , 3 8 - 3 9 , 5 3 - 5 4 ; and treatmen t alliance , 2 2 - 2 4 , 3 0 - 3 1 , 32, 4 7 - 4 8 Dependency needs , 2 , 218 , 262 , 271 , 283; denial of , 287 , 289 ; gratifying, 29 9 Depersonalization, 38 , 84-8 5 Depot neuroleptic , 351 , 367 Depression, 19 , 38, 4 3 - 4 4 , 45 , 57, 61 , 161, 250 , 309 , 333 , 336 ; an d helplessness, 107 ; an d rehospitalization , 274 , 288 Derealization, 38 , 8 4 - 8 5 Developmental traumas , 1 0 Diagnosis, 18 , 137 , 144 , 309 ; a s discusse d with patient , 127-29 ; an d treatmen t al liance, 3 , 4, 15 2 Dignity, 342 , 367 ; importanc e of , a s basi c principle fo r program development , 364-65; an d living with limitations , 331; los s of, 2 , 3 ; reality principl e sacri ficed to preserve , 5 , 326 , 328 , 36 2 Docherty, J. P. , 4 4 Dopamine activity , 37 , 39 , 4 1 Dorso-lateral prefronta l corte x (DLPFC) , 41 Dream interpretation , 337 , 33 8 Drugs an d alcohol , 330 , 36 0 Drug treatment . See Medication; Neuro leptics DSM III-R , 18 , 37 , 12 9 Dynamic psychotherapy , 142-4 4 Educative paradigm , 125 , 348—5 0 Ego functions , modelin g of , 140—42 , 145-49, 156 , 25 9 Emotional deadness , 310 , 32 9 Empathy, 9 , 32 , 61 , 65, 72 , 92 , 121 , 123 , 215, 254 ; an d clinician' s role , 131 , 134 ; conditions tha t forestall , 7 ; hospitaliza tion presente d a s opportunity for , 239 ; and intervie w techniques , 231 ; for patient's copin g efforts, 96 ; patient's diffi culty with , 132 , 215 ; promoted i n fam ily, 351-52 , 354-68 ; an d treatmen t alliance, 19 4 Environment, patient' s interactio n with , 66, 69, 7 0 - 8 4 , 2 7 8 - 7 9 Epinephrine, 4 1

394 Index Erotic transference , 242 , 247-48 , 28 8 Etiology o f schizophrenia , 9 - 1 0 , 18 , 19 , 35, 49 , 347 ; an d categorizatio n o f symptomatology, 38 , 44 , 45 . See also Model o f schizophreni a Evaluation, 5 8 Experiential deficits , 14 4 Explication, principl e of , 3 3 - 3 6 Expressed emotio n paradigm , 14 9

Failure experiences , 310-1 1 Families o f schizophreni c people , 1 , 61, 67, 304-7 , 321-22 ; an d abusiv e o r violent behavior , 315-16 , 353-54 , 368 , 370; behavior s misunderstoo d by , 3 5 0 54; biologica l mode l champione d by , 3 ; denial by , 8 , 369-71 ; empath y pro moted in , 351-52, 354-68 ; histor y o f work with , 347—48 ; and hospitaliza tion, 239-40 ; an d patient's priorities , 347—71; priorities of , 368—71 ; supervision by , 291-92 ; worksho p for , 3 5 4 68 Family interactio n theorie s o f schizophre nia, 34 7 Family therapy , 149-50 , 347 , 348 , 3 5 2 53, 368 , 36 9 Fantasies, 81 , 94 , 156 ; an d boundar y dis turbances, 85—87 ; of control , 48 , 5 2 53, 102-3 , 149 ; a s copin g strategy , 361-62; o f merger , 34 , 85-87 , 100 , 102, 130 ; a s psychologica l sustenance , 89, 90 , 210 , 352 , 36 7 Fear communication theory , 55 Fear of merger , 88-89 , 10 0 "Flagrant symptom/defici t sympto m model," 3 6 Flexibility, patient's , 66, 76, 113-15 , 22 8 assessing, 23 2 "Flight int o health, " 25 1 Former patients , 365—6 6 Frankness, 132 , 148-4 9 Frontal lob e pathology , 18 , 38 , 144 , 16 1 "Functional deficits, " 12-13 , 18-19 , 36 , 40, 150 . See also Cognitiv e impair ment

Grandiosity, 23 , 38 , 39 , 48 , 50 , 59, 122 , 241, 280 , 287 , 300 ; withdrawa l compli cated by , 4 7 Grief, 22 7

Hallucinations, 22 , 27 , 31 , 38 , 46 , 110 , 121, 128 , 129 , 136 , 146 , 160 , 314 ; de mystification of , 59 ; diagnosti c empha sis on , 18 ; and fantas y o f control , 102 ; managing, 26 ; an d patient' s subjectiv e experience o f medication , 252 , 253 ; an d physiological substrat e o f schizophrenia , 39, 42 , 50 , 6 1 Harding, C . M. , 5 8 Helplessness, 45 , 107 , 109 , 224 , 22 7 Hirsch, S . R „ 38, 4 4 Hogarty, G . E. , 35 4 Hope, 62 , 92 , 133 , 134 , 15 6 Hopelessness, 57 , 16 0 Hospitalization, 318-20 , 362 ; case illustrating issues of , 235-67 ; clinician' s at titude toward , 239-40 ; indication s for , 238—39; and th e outpatient clinician , 240-42; rehospitalization , 271-94 , 30 0 Hospital staff : an d outpatien t therapist , 293—94; hospita l therapist' s relation s with, 256-6 1 Hostility, 38 , 5 1 - 5 3 , 165 ; an d transfer ence, 242 , 247-4 8 Humiliation Workbook , 355-6 8 "Hypofrontality," 4 1

Iatrogenic symptoms , 38 , 61 , 161 ; and "negative" symptoms, 4 3 - 4 4 ; Parkin sonism, 38 , 42 , 43, 61 , 161 , 163 , 304 . See also Sid e effect s Idealizing transference , 18 0 Ideas o f reference , 27 , 3 8 Inaccessible patient , cas e illustratin g wor k with, 303-4 3 "Inciting lesion " hypothesis, 4 0 Information, provisio n of , 138—3 9 Initial interview , 169-23 2 Instrumental rol e functioning , 38 , 43 , 14 4

Index 39 5 Interindividual variability , 363—6 4 Interna] locus o f control , 38 , 56-57, 12 4 Interpersonal therapies , 4 6 Interpretive intervention , 317—18 , 326 , 341 Interview techniques , 169-23 2 Intimacy, 133 , 163 ; and contro l needs , 104, 105-6 ; an d nursin g interventions , 145-49; an d safety needs , 11 0 Introspection, capacit y for , 2 1 8 - 1 9 Invalidism, 33 0 Involuntary patients , 235 , 255 , 256 , 31 5 Irritability, 38 , 44 , 50 , 6 1 Isolation, 57, 71 , 100 , 209 , 213 , 318 , 324, 336 , 340 ; an d boundar y distur bances, 85 , 86 , 87 ; an d contro l needs , 102, 104 . See also Withdrawa l

Jackson, J. H. , 3 5 Kraepelin, E. , 10 , 3 5 Lacan, J., 4 9 - 5 0 Lazare, Aaron , 36 4 Limbic dysfunction , 38 , 41—4 3 Lithium carbonate , 31 5 Locus of control , 39 , 56—57 , 124 , 18 6 Lorazepam, 339 , 34 1 Loss, experience s o r anticipatio n of , 39 , 51, 66, 105-9 , 119 , 278 , 312 ; explore d in assessmen t interview , 217 , 219—20 ; and nee d t o mourn , 96 , 252 ; of th e ol d self, 106-9 , 230 ; a s subjective experi ence change s wit h medication , 25 2 McGlashan, T . H. , 31 1 Magical thinking , 34 , 107 , 28 5 Major depression , 38 , 161 , 16 4 Manifest communication , 66, 70 , 279 ; functions an d example s of , 78-84 ; scheme fo r evaluating , 80-8 1 Maryann, cas e of , 271-30 0 Maudsley Institut e o f Psychiatry , 34 8 Medication, 8 , 20 , 21 , 22, 24 , 36 , 59 ,

349, 350 , 355 , 357 , 363 , 367-68 ; an d affective symptoms , 38 ; an d biologica l model o f schizophrenia , 1 , 2 , 3 ; and case of Roger , 304 , 311 , 315 , 325 , 326 , 330, 333 , 334 , 336 , 339 , 341 ; cognitiv e impairment secondar y to , 38 , 42 ; an d conflicting model s o f schizophrenia , 9 ; involuntary, 235 , 255 , 256 ; an d nee d for mode l o f schizophrenia , 12 ; and "negative" symptoms, 12 , 18 , 43; overmedication, 50 , 161 ; patient include d i n decisions about , 124 , 252-54; an d pa tient's contro l fantasies , 53; patient' s subjective experienc e of , 251—54 ; and psychological experienc e o f discontinu ity, 92 ; and rehospitalizatio n issues , 291; an d treatmen t program , 120 , 1 2 1 22, 128 , 135-36 , 150 , 160 ; vitality ad versely affecte d by , 2 . See also Compli ance; Iatrogenic symptoms ; Neurolep tics; Noncompliance wit h medicatio n Memory function , 9 3 Mental patien t role , 2 , 251 , 331-32, 35 6 Mental statu s exams , 66, 15 2 Merger: ambivalenc e toward , 10 ; fantasie s of, 34 , 85-87 , 100 , 103 , 130 ; fea r of , 8 8 - 8 9 , 10 0 Mesocortical pathways , 38 , 41 , 42, 4 3 Mesolimbic system , 38 , 4 1 - 4 2 , 46 , 50 , 6 1 Metapsychological model , 1 3 Michels, R. , 37 , 4 0 Midbrain, 4 1 - 4 2 Milieu therapy , 12 5 Mistrustful patients , 3 3 - 3 4 , 51 , 158 , 159 , 224, 227 ; countertransferenc e to , 2 4 6 47; an d stres s o f interpersona l relations , 47; an d treatmen t program , 126 , 127 , 128, 129 , 135-36 , 137 . See also Suspi ciousness Modeling o f eg o functions , 140-42 , 156 ; by nursing staff, 145-49 , 25 9 Model o f schizophrenia , 124-25 ; biologi cal, 1 , 2, 3 , 7 , 9 - 1 0 , 11 , 13 , 19 , 50, 59 , 347, 354 ; communicatio n of , t o pa tients an d families , 3 4 - 3 6 , 59 , 122-23 , 135—37; essential hypothesi s for , 19— 20; an d famil y therapy , 149-50 ; meta psychological, 13 ; need for , 9 , 11-13 ;

396 Index Nursing interventions , 145-49 , 2 2 1 - 2 2 , 258, 259-6 1

Model o f schizophreni a (Continued ) patient's concern s a s containe d in , 129 ; psychotherapeutic, 9 , 10—11 ; symptom atology a s categorize d in , 3 7 - 6 2 ; an d therapeutic relationship , 17-62 ; an d treatment frame , 135-3 7 Mother-infant interactions , 1 0 Motivational strategies , 14 4 Multidisciplinary treatment , 22 , 121 , 126 ; treatment task s in , 138-5 2

Object relations , 1 0 Organic psychiatrists , 4 9 Outcome, 12 , 22 , 362-63 ; an d compli ance, 55-56; an d contro l issues , 235 , 237 Over-medication, 50 , 15 1

Narcissistic injury , 21 , 39 ; an d denial , 23; educatin g familie s about , 354 , 367; fendin g off , 50 ; medicatio n as , 251 "Negative" symptoms , 2 , 3 , 8 , 12-13 , 22 , 35, 36 , 62 , 335 ; an d demoralization , 57; distinction s among , 4 3 - 4 4 ; iatro genic, 43 ; medication-unresponsiv e symptoms describe d as , 12 , 18 ; and models o f schizophrenia , 10 ; a s neurological deficits , 150 ; a s par t o f psycho logical reactio n t o illness , 19 ; an d phys iological disturbances , 4 0 Neuroleptics: an d affectiv e symptoms , 38 ; and delusions , 50 ; an d iatrogeni c "neg ative" svmptoms, 43 ; an d physiologica l substrate o f schizophrenia , 37 , 41—42. See also Medicatio n Neurologic deficits , 18-19 , 36 , 93 , 150 Noll, Katherin e M. , 3 7 Noncompliance wit h medication , 20 , 21, 24, 30 , 54 , 148 ; advers e effect s o f med ication a s reaso n for , 2 ; cas e illustratin g issues of , 235-67 ; educatin g familie s about, 367 ; families ' respons e to , 3 5 1 53; a s manifes t communication , 81 ; and patient's unrealisti c view s o f control , 53, 102 ; an d psychologica l discontinu ity, 95 , 96 ; a s refutatio n o f conven tional reality , 361 ; sustaining natur e o f delusions a s reaso n for , 89 , 90 , 352 , 367 Noradrenergic neuro n metabolism , 3 9 Norepinephrine, 4 1 Numbing out , 311 , 312 , 332 , 341 , 342 , 360

Panic disorder , 329 , 330 , 331 , 332 , 334 , 339 Parallel dialogue , 140 , 157-6 0 Paranoia, 18 , 21 , 29, 38 , 45 , 109 , 120 , 121; deferenc e to , 127—28 ; and limbi c disturbance, 42 ; an d medication , 2 5 1 52 Parkinsonism, iatrogenic , 38 , 42 , 43 , 61 , 161, 163 , 30 4 Passive compliance , 21 , 119 , 133 , 156 , 162 Passivity, 107 , 131 , 16 5 Patient's priorities , 66, 113-15 , 140 , 218 ; and family' s priorities , 368—71 ; illustrated i n cas e o f Roger , 303 , 306 , 311 , 321, 324 , 326 , 328 , 341 , 342 ; neglec t of, 306 ; raisin g famil y consciousnes s about, 3 4 7 - 7 1 ; subordinatio n o f realit y principle to , 326 , 32 8 Patient's subjectiv e experience . See Subjective experienc e o f th e schizophreni c per son Perceptual distortions , 19 , 23 , 31 , 38 , 46 , 89, 129 , 131 , 137 ; an d delusions , 53 ; and limbi c disturbances , 42 , 61 ; and psychological continuit y an d clarity , 9 2 - 9 9 ; an d relatedness , 7 0 Persecution experience , 21 4 Personality tests , 5 8 PET scans, 4 1 Phasic natur e o f schizophrenia , cas e illustrating, 303-4 3 Phenothiazines, 34 7 Physical settings , 36 5 Physiological factors , 38 , 61 , 101 , 106 , 149, 278 ; an d manifes t communication , 8 0 - 8 1 ; an d psychologica l experienc e o f

Index 39 7 discontinuity, 92 ; and psychological re sponse t o illness , 278-87 ; an d sense o f identity, 10 0 Physiological substrat e o f schizophrenia , 3 7 - 4 9 , 61 , 277-7 8 "Positive" symptoms, 10 , 18-19 , 22 , 35 , 36; an d limbi c syste m disturbances , 42 , 43; an d medication , 1 2 Poverty o f conten t o f thought , 38 , 4 3 Power, them e of , 214-15 , 21 8 Prefrontal brai n regions , 38 , 4 0 - 4 3 , 47 , 61, 140 , 14 4 Premature closure , resistin g pressure for , 227 Privacy, 221-22 , 28 3 Prodromal symptom s o f decompensation , 102 Prognosis, 110 , 139 ; an d patient's atti tudes, 55-57 ; an d patient's flexibility, 228; an d principle o f recoverability , 355-56 Psychiatry, 37 , 4 0 Psychic numbing , 311 , 312 , 322 , 341 , 342, 36 0 Psychoeducational programs , 149-50 , 348-50, 351 , 353, 354 , 36 9 Psychological continuit y an d clarity , 39 , 66, 91 , 92-99 , 109 , 111 , 119 , 229-30 , 242, 28 0 Psychological respons e t o schizophrenia , 17, 18 , 19 , 129 , 137 , 150 , 158 , 160 ; categories of , 3 8 - 3 9 , 43 , 44, 46 ; an d clinician's role , 133—34 ; and cor e physiological deficits , 278—87 ; enlightenin g patients regarding , 125 , 128-29 ; fami lies' failur e t o understand , 350—54 ; maladaptive, 2 3 - 2 4 ; an d manifes t com munication, 78 ; an d productio n o f syn drome, 36 ; an d rehabilitativ e strategies , 144; an d th e resigne d patient, 161-65 ; and treatmen t alliance , 5 1 - 5 3 , 5 9 - 6 0 , 61 Psychological tests , 4 0 Psychological variables , 8 , 9 - 1 0 , 11 ; and "functional deficits, " 1 3 Psychomotor retardation , 38 , 43 , 164 Psychopharmacology. See Medication; Neuroleptics

Psychosocial programming , 36 3 Psychotherapeutic mode l o f schizophrenia , 9, 10-1 1 Psychotherapy wit h th e schizophrenic person, 11 , 12 , 17 , 2 1 - 2 2 , 27 , 125 , 158 ; and communit y an d rehabilitation agen cies, 294-300 ; illustrate d i n cas e o f Roger, 303-43 ; outpatient , 272-300 , 303-43; an d rehospitalizatio n issues , 272-94; rol e of , 138-44 ; therapeuti c goal in , 99 ; an d therapist' s relationshi p with hospita l staff , 256-6 1

Quality-of-life problems , 2 , 3 , 36 5 Quality o f patient' s subjectiv e experience , 66, 8 4 - 9 1 , 279-8 0

Real-object hunger , 318-19 , 34 1 Recoverability, principl e of , 362—6 3 Regression, 71 , 239, 2 4 1 - 4 2 , 292 , 3 6 6 67 Rehabilitation treatmen t programs , 12 , 21, 36 , 125 , 144-45 , 221 ; family's re sponse t o patient' s rejectio n of , 353 ; and outpatien t care , 294—300 ; therapeutic goal in , 99 . See also Therapeuti c activities Rehospitalization, 271-94 , 30 0 Reichman, Fried a Fromm , 1 0 Reiss, D . J., 35 4 Relapses, avoiding , 10 2 Relatedness, 124 , 238 , 279 ; an d cognitiv e disturbance, 47 , 144 ; an d contro l is sues, 102—4 ; and nursin g interventions , 145—49; patient's attitude s toward , 66, 70-78, 215-16 , 21 9 Remission o f symptoms , 2 Repression, 94 , 15 3 Resentment, 23 , 39 , 48 , 152 , 161 , 16 3 Resigned patients , 160-6 5 Respite, nee d for , 36 6 Richelson, E. , 4 0 Rif kin, A. , 3 7 Roger, cas e of , 303-4 3 Rotter, J. B. , 56

398 Index Sacks, Oliver , 9 3 Safety needs , 3 8 - 3 9 , 66, 109-13 , 2 1 6 17, 26 4 Schizophrenia and Affective Disorders, 3 7 Schneider, K. , 1 8 Sealing over , 275 , 27 6 Searles, H., 1 0 Seductiveness, 104 , 13 0 Self-awareness, difficult y i n tolerating, 12 2 Self-blame, excessive , 3 2 - 3 3 , 53 , 122 , 123, 133 , 359—60 ; delusions a s expressions of , 186 ; prevalence an d maladap tive potentia l of , 60 ; a s psychologica l response t o illness , 3 9 Self-disclosing statements , clinician's , 23 1 Self-esteem, 11 , 147 , 156 , 252 , 367 ; di minished, 119 , 129 , 137 ; an d famil y ex pectations, 149 ; an d manifes t commu nications, 80—81 , 83 ; and sustainin g experiences o r expectations, 89-91 ; a s treatment goal , 120 , 122 , 12 4 Self-object differentiation , disturbance s of , 38, 39 , 260 , 279 , 280 , 282 , 285 , 287 ; and autonomy , 100 ; an d contro l needs , 255, 264 , 265 ; an d intervie w tech niques, 171 , 173 , 174-75 , 184 , 216 , 217-18, 226 ; an d patient' s subjectiv e experience, 66, 84—89 ; and rigidit y o f conditions fo r contact , 249 ; an d safet y issues, 109 , 111 ; and therapist' s "pres ence," 130-31 . See also Boundar y dis ruption Selzer, M . A. , 12 6 Serotonergic neuro n hyperactivity , 3 9 Sharon, cas e of , 235-6 7 Side effects, 2 , 251 , 252, 254 . See also Iatrogenic symptom s Social withdrawal . See Withdrawal "Special" relationship, 103 , 104 , 130 , 25 7 Speech production , disorde r of , 45-46 , 4 8 Staff conflict , cas e involving , 235-6 7 Stereotyping, 85 , 131 , 22 7 Stimulus barrie r problems, 19 , 239 , 280 , 328, 34 2 Stress, 19 , 38 , 39 , 61 ; managing, 26 ; nee d to regulate , 71 ; and variabl e degree s o f impairment, 4 1 Stress-diathesis model , 309 , 33 0 Subaffective syndromes , 3 8

Subcortical brai n regions , 38 , 4 0 - 4 3 , 47 , 61, 140 , 144 , 145 , 14 9 Subjective experienc e o f th e schizophreni c person: an d autonom y issues , 66, 1 0 0 105; an d concep t o f transference , 143 ; and contemporar y clinica l training , 8 ; and contro l issues , 66, 101—5 ; and de lusions, 6 7 - 7 2 , 77 , 81 , 83 , 85 , 89 , 90 , 94, 101 , 102 , 107-10 , 112 , 115 ; educating familie s about , 354—68 ; exploring, 139-40 , 152-54 ; illustrate d i n cas e of Maryann , 278-87 ; an d loss , 66, 105-9; an d manifes t communications , 66, 70 , 7 8 - 8 4 ; an d medication , 2 5 1 54; an d patient' s interactio n wit h envi ronment, 66, 69, 7 0 - 8 4 , 278-79 ; priorities an d flexibilit y in , 66, 113-15 ; and psychologica l continuit y an d clar ity, 66, 91 , 92—99 ; psychological symp tomatology a s window into , 51 ; qualit y of, 66, 8 4 - 9 1 , 279-80 ; rehabilitatio n activities designe d around , 264—65 ; as revealed i n assessmen t interview , 1 7 3 90, 214-20 , 225-32 ; an d safet y issues , 66, 109-13 ; an d self-othe r differentia tion, 66, 84—89 ; and sustainin g experi ences o r expectations , 66, 8 9 - 9 1 ; an d treatment alliance , 3 , 4, 65, 66, 1 1 4 15, 152—54 ; and treatmen t process , 65—70; a s use d i n presentin g mode l o f illness t o patient , 13 7 Suicide attempt s o r threats, 87 , 304 , 334 , 339, 359 ; illustrate d i n cas e o f Sharon , 236, 237 , 239 , 242 , 244 , 250 , 251 ; and outpatient psychotherap y an d rehospi talization issues , 272-94 , 300 ; patien t vignettes involving , 24 , 25 , 101 , 146 , 147, 154 , 16 4 Superego, 60 , 33 9 Supportive psychotherapy . See Psychotherapy wit h th e schizophreni c perso n Survival Skill s Workshop, 35 4 Suspiciousness, 38 , 39 , 50, 226 ; an d mesolimbic disturbances, 61 . See also Mis trustful patient s Sustaining experience s o r expectations , 66, 8 9 - 9 1 , 283 , 286 ; delusion s an d fanta sies as , 89 , 90 , 310 , 352 , 36 7 Symptomatology, categorizatio n of , 37—6 2

Index 39 9 Teaching hospitals , 29 3 Thalamic dysfunction , 3 8 Therapeutic activities : th e noncomplian t patient in , 261-62; an d patient's defi cits, 262—64 ; patient's subjectiv e experi ence a s basi s o f desig n for , 264—65 ; range an d importanc e of , 26 1 Therapeutic alliance . See Treatment alli ance Therapeutic ennu i o r despair , 21 , 3 6 Therapist's "presence, " establishing, 130 — 35 Thiothixene, 251 , 31 1 Thought disorder , 38 , 4 5 - 4 6 , 48 , 77 , 128, 129 , 35 1 Time, delusiona l treatmen t of , 94 , 107 , 229-30 Transference, 143 , 165 , 242 , 247-48 ; dis ruptive, 272 , 288-89 ; idealizing , 180 ; and indication s fo r hospitalization , 238 ; predicting, 20 0 Tranylcypromine, 333 , 33 4 Treatment alliance , 13-14 , 144 ; basi s of , 220—22; collaboration a s paradigm for , 4 - 5 , 59, 119 , 120 , 122 , 194 , 205-6 , 341-42; condition s fo r formatio n of , 5 , 20; developmen t of , 5—6, 23, 33-36 , 84, 133 , 152-66 , 281-85 ; dysfunc tional, 59 , 137 ; evaluation of , 248-50 ; and indication s fo r hospitalization , 238 ; and mode l fo r schizophrenia , 17—62 ; obstacles to , 3 - 4 , 6 - 7 , 21 , 2 2 - 2 4, 59; patient's conflic t about , 200-206 ; an d patient's subjectiv e experience , 3 , 4, 65, 66, 114-15 , 152-54 ; a s preeminent fo cus fo r al l clinicians , 20—22 ; and resistance t o acceptin g help , 193-97 ; an d safety issues , 109-10 ; strain s in , 2 0 21, 3 4 - 3 5 ; technique s fo r forming , 152-66; an d treatmen t frame , 126-30 ; and treatmen t goals , 119-25 , 150-52 ; understanding crisi s in , 22—33; and violent behavior , 265—66 Treatment contract , 103 , 126 , 152 ; restatement of , 155-56 Treatment decisions , patient' s activ e inclusion in , 123-24 , 133-34 , 156 , 252-54 , 318-20

Treatment frame , 120 , 126-30 ; clinician' s "presence" established, 130-35 ; mode l of illnes s presented , 135-37 ; treatmen t tasks, 138-5 2 Treatment goals , 4 , 99 , 119-25 , 143 , 150-52, 15 7 Treatment plan , 62 , 144 , 229 , 232 ; an d patient's subjectiv e experience , 114 , 115; presentatio n of , 5 7 - 5 9 Treatment program : treatmen t allianc e techniques, 120 , 152-66 ; treatmen t frame, 120 , 126-52 ; treatmen t goals , 4 , 99, 119-25 , 143 , 150-52 , 15 7 Treatment tasks , 138-5 2 Tricyclic antidepressant , 25 1

Unconscious, 105 , 106 , 130 , 133 , 134 , 166; an d delusions , 4 9

Vengeance, them e of , 36 8 Ventricular brai n ratios , 1 0 Ventricular enlargement , 4 0 Vermont Longitudina l Study , 5 8 Violence, 315-16 , 328 ; cas e illustratin g issues of , 235-67; an d families , 3 5 3 54, 368 , 370 . See also Aggressio n Vitality, los s of , 2 , 3 , 370 . See also Alive ness; Apath y

Weinberger, D . R. , 37 , 4 0 - 4 3 Will, Otto , 1 0 Wing, J. K. , 1 8 Winnicott, D . W. , 1 0 Wisconsin Car d Sort , 4 0 Withdrawal, 3 , 8 , 30 , 43 , 44 , 72 , 125 , 144, 146 , 149 ; a s adaptiv e effort , 38 , 39, 45 , 47 , 3 6 0 - 6 1 ; combating , 139 ; and demoralization, 57; an d loss , 106 ; in the resigne d patient , 160-65 ; an d treatment alliance , 5-6, 19 , 21 , 2 3 "Word salad, " 35 1 Zelin, M. L. , 31 0

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