Beyond Medication

Therapeutic Engagement and the Recovery from Psychosis

David Garfield, Daniel Mackler, David Garfield, Daniel Mackler

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781317723554
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Beyond Medication focuses on the creation and evolution of the therapeutic relationship as the agent of change in the recovery from psychosis.

Organized from the clinician's point of view, this practical guidebook moves directly into the heart of the therapeutic process with a sequence of chapters that outline the progressive steps of engagement necessary to recovery. Both the editors and contributors challenge the established medical model by placing the therapeutic relationship at the centre of the treatment process, thus supplanting medication as the single most important element in recovery.

Divided into three parts, topics of focus include:

• Strengthening the patient
• The mechanism of therapeutic change
• Sustaining the therapeutic approach.

This book will be essential reading for all mental health professionals working with psychosis including psychoanalysts, psychiatrists, psychologists and social workers.

Part 1
Engaging the patient

Chapter 1
Strengthening the patient

David Garfield and Daniel Dorman

Introduction — into psychosis: the case of K.

There are many roads into psychosis and there are many key ingredients to the road out. When the emotional pain of living becomes unbearable and internal and external support begins to lose its ability to hold things together, a profound new and different reality sets in. In the midst of this "falling apart," at the center of this "going crazy," the patient has, in a way, lost his or her mind. Yet, what does that really mean? What is it that is lost?

K. had struggled since she moved to her new wealthy suburb at the age of 11. As the oldest of four girls and one youngest boy, K. had set the pace. She excelled in soccer, was considered creative and verbally advanced by her teachers, and enjoyed the respect of both her parents. Yet, in the new school, she was a "duck out of water." There were many talented children there. Her family was at the low end of the income bracket in this town. She had left her close friends, and found it difficult to make new friends. Girls in her grade made excuses as to why they could not sleep over. K.’s mother also felt out of place. She drove a Mercedes but felt that others would see that they did not live in a big house and would think that she drove it for "show." When cut off by nasty drivers in town, K.’s mother would think that she was being targeted because she drove a Mercedes – that people were jealous of her.

K. felt her old self-confidence slipping away. To compensate, she made up elaborate fantasy stories in her own mind about Dalia, a mythical 30-year-old artist who was talented and known for her creativity. Dalia also possessed secret physical powers that allowed her to fend off and deter would-be assailants. Dalia was not only a painter but also a writer and K., in real life, would emulate Dalia’s style as she imagined it in her fantasies. After 2 years in the new junior high school, K. had no good friends. Luckily, she had her little sisters to play with, but she began to worry about her body as she was going through puberty. When she was younger, K. had always felt good about her body. She was a good athlete. At the new junior high, K. had not tried out for the soccer team. Her father, a hardworking, "never home" attorney, pushed her to play sports in school. She tried lacrosse but was quite self-conscious. Her body image oscillated dramatically. Was she too fat? Was she too tall? K. could not get a fix on her own body during this time. She would have spurts of being quite good at lacrosse and at other times her self-confidence would give way to intense self-consciousness and awkwardness. She took refuge in her fantasy world with Dalia.

K. found herself "dissociating" at times during class. She had no seizures or medical problems, but she would lose track of time and would feel like she was "not in her own body." She tried to adjust her eating to make her body "come out right." She would command and direct her little sisters so she could feel like she had something to offer. As she entered high school, K. kept away from boys. She went to church frequently, which gave her some sense of belonging. Yet, she continued to have disturbing "dissociative" experiences at school and sometimes at home. There was no history of abuse. She felt like she was not doing well with her life; she knew there was something "wrong" with her but did not know what it was. She found herself becoming more and more anxious.

Louis Sass (1992) described how normal emotionality is replaced by a certain kind of anxiety as psychosis sets in. He divided the process into four stages. First, a period of "unreality" sets in where things just do not seem the same. Here is where we find our patient K. The second stage is what Sass calls "mere being." In this state, nothing has any more emotional value than anything else and "significance" evaporates. A devastating car accident may carry the same weight as dropping a turkey sandwich on the ground. The third stage is called "fragmentation" and involves the inability to compare one thing with another. The cow and the calf are not seen as mother and offspring – these kinds of relationships are not noticed anymore. It is just two different sizes of cow. A tire is not seen as part of a car but rather as two separate unrelated items. Finally, in a desperate search for meaning, the fourth stage of "apophany" appears. Apophany is the Greek word for "to become apparent." Now, everything has meaning. Each little noise, each little word, each glance, each opening of a door all become terribly meaningful, but the patient cannot figure out how. The patient is forced to remain on guard at all times to try to make sense of it.

The developing self

Defining one’s self, one’s unique identity, is a central part of human psychological development. That developing self is challenged throughout our lives, but more at some ages and under some circumstances. For example, if K. had a stronger sense of her self, she might not have felt like a "duck out of water" at the new school. A move would be a challenge to any child, since he or she depends on the consistency of the external world, but K. did not have enough confidence in herself to accommodate the change. The demands of the external world increase as we grow older, which is why K. experienced increasing problems. Her self, her "I," was not able to keep up with the increasing demands. Her lack of confidence led her to construct Dalia, a fantasy self who had strength and power. K.’s dependence upon a fantasy identity, vicariously living through Dalia’s secret powers, added to her increasing sense of unreality. But the cost of constructing an identity is that further growth is impeded. Actual growth is the accumulation of actual experience. K. was freezing herself in place. She experienced a gradual erosion of her "I," adding to her sense of unreality. As her "I" eroded, she no longer had a reference point for her emotionality, thus she gradually slipped into a life without meaning. The awareness of a diminutive "I" accounts for much of the pervasive anxiety referenced by Sass. As she retreated into a solipsistic state, K. lost the ability to confirm or validate her sense of self. Thus she experienced herself in fragments. She then desperately searched for meaning, for what was real and what was not real, which resulted in paying attention to every little sensation and every little detail of her life. She desperately sought solutions, such as declaring with certainty that her changing body was the problem, or that she needed to join a group to secure an identity. But these efforts did not fix her gradual self-dissolution. K.’s overwhelming anxiety caused her to try to shut down her mind, resulting in periods of dissociation. Some people shut themselves down to such an extent that they become catatonic.

To the outside observer K. is psychotic. But her experiences are not just "delusions," or misrepresentations of reality. Life was becoming unreal. K.’s anxiety was, in fact, overwhelming. Her experience of herself in fragments can be understood, since she no longer experienced herself in a cohesive way. Even her efforts to shut herself down make sense, since she did not know what else to do. The psychotic person is not so strange or so different from anyone else. His struggles, even his solutions to his difficulties, are entirely human. He can be understood.

The road out of psychosis demands addressing the problem at the core: K.’s diminutive "I," her lack of self, must be strengthened. A therapist who tries to understand the psychotic person will find that he or she always has a remnant of self. It may be buried, but it is there. It is possible to help affirm his or her remaining self, and to help him build a stronger self. The remnant of self is not a static thing, but rather it has a nascent vitality. Although this remnant is a result of a significant developmental arrest (Stolorow and Lachmann, 1980), it is constantly seeking to re-engage. Marian Tolpin (2002), the Chicago self-psychology psychoanalyst, labeled this alive remnant the "forward edge of development," and notes that it is the therapist’s job to attend to its manifestations and to provide the kind of responsive environment that can facilitate its developmental trajectory. Let us turn to the example of Ms. C. for an initial understanding of how this happens.

Engaging the sequelae of psychosis: the case of Ms. C. — looks can be deceiving

Ms. C. had been in a halfway house for about 15 years. She had been married to a terribly abusive alcoholic man to whom she had devoted herself. She had been an active little girl, the only child of a beautiful mother who was a housewife and a father who was a wealthy attorney and an abusive, alcoholic husband. Ms. C. reported that as a little girl she was constantly told, by her father, how she was pretty like her mother. Her mother was described as sweet but quiet and unengaged. Later, Ms. C. would relate that she was sure her father had been consistently unfaithful to her mother and that caused her mother to be depressed. She grew up in a big house in the Hamptons on Long Island.

Ms. C. had done well in school and had become something of an environmentalist before it was fashionable. She was an avid birdwatcher and took over her mother’s gardening when her mother was too depressed to keep it up. She had many boyfriend suitors and she dated in high school. She wanted to go away to college but her mother wanted her nearby, so Ms. C. went to junior college. She was "swept off her feet" by a charismatic young man who was in law school and who wanted to go into politics. At the age of 22, she married and quickly had two children in the span of 3 years. Her husband was elected to the state senate and she entertained regularly. She was the "belle of the ball" and delighted in her role as the "woman behind the man." Ms. C. ignored reports that her husband was "a bit like Jack Kennedy with the women." She, in fact, adored Jackie Kennedy, so she was initially pleased by the comparison. But her husband’s infidelity became more difficult to ignore. On top of that, he became very demanding of how she should dress and what she should serve to guests, and he would come home very late, drunk, and smelling of another woman’s perfume. When she confronted him about this, he would deny it, become furious, and hit her.

Ms. C. felt that she could not tell her mother about the situation. Her own father died and Ms. C. noted "I didn’t cry at the funeral." Ms. C. became depressed. She felt that her mother needed Ms. C.’s "belle of the ball" lifestyle as something that kept her mother from being depressed. Ms. C. became anxious. She began to believe that she was ugly and disgusting. She voiced the delusion that her face had changed and she was deformed. One night when her husband did not come home, she could not sleep the whole night. He did not call or return in the morning either. She called his office and he had come in but was in a meeting. Ms. C. went into the kitchen, found a plastic bottle of liquid bleach, poured it over her head and face, and lit herself on fire. Her mother was to come over for lunch and found Ms. C. whimpering in a corner of the kitchen.

Ms. C. was completely disfigured from the self-inflicted immolation. She refused plastic surgery. After her wounds had healed, she was transferred to a psychiatric inpatient unit. Her husband insisted that she stay there for 6 months. She came home and she knew that he would not be able to tolerate her. She had a difficult time explaining what had happened to her two little girls. She became withdrawn. Ms. C. had covered her hands with the bleach as well, so they were completely disfigured, as were her neck and upper chest. Many of her caregivers at the hospital found it hard to look at her. Ms. C. understood this. She retreated into a world of her own. Every time she attempted to return home in the first 2 years, she found it impossible to return to "my old life. I was now as ugly and disgusting on the outside as I felt on the inside." She entered a halfway house associated with the hospital.

Her husband sought a divorce and remarried quickly. He took custody of their children although she wrote to them and called them several times a week. They would visit her in the halfway house on holidays. Ms. C. settled into a life "amidst outcasts." She routinely participated in all the group sessions, made insightful comments to the other patients and to staff, and she volunteered in the hospital gift shop. Her social interactions, however, were difficult because staff were sometimes disturbed by her grotesque appearance, and since she did not want to cause them distress she would leave the group. Sometimes, patients would sense that she was hiding behind her wounds and they would address this, which would be difficult for her and would cause her to leave the group.

After 15 years in the halfway house and many staff therapists, one of us (D.G.) was assigned as her therapist. Warnings had been issued by the staff as to what the initial reaction might be. What was memorable was exactly how startling it was to find that Ms. C. had beautiful, brilliant blue eyes.

Ms. C. was worn down by her years on trifluoperazine (Stelazine) and her routine in the hospital and halfway house. She had never heard voices, never had persistent delusions, and yet had been labeled with schizoaffective disorder for several years. The new therapist focused on her blue eyes and over a period of weeks of twice-a-week therapy became more comfortable with her disfigurement. Ms. C. was somewhat startled that the therapist was not repulsed by her appearance. She did not know quite what to make out of the suggestion to meet twice a week but she was happy for the conversation. She related the entirety of her story and her terrible remorse about her life without her daughters.

The patient was confused by other aspects of the therapist. He did not push medication and, in fact, suggested that maybe she did not need it. It took several months to taper her dose down and she was fine. Although he had in mind that her act of self-immolation was not only a peak experience of masochism and "turning against the self," he also was aware of the amount of rage and self-hatred that accompanied it. Both realized that this was not going to be the "status quo" infrequent medication management/no change therapy that had taken place over the last 15 years.

Over the first year, Ms. C. reported having more feelings. She missed her daughters, she was annoyed with the hospital, and she pitied and was very angry with her mother. The therapist’s modest office at the State Hospital became a kind of refuge for her to talk. It was in the second year that something small but remarkable occurred.

One day Ms. C. came in and made a comment about how the pathos ivy plant in the office needed more water. Although it was a brief, off-the-cuff observation, she had never made a comment, critique, or observation like this before. The therapist latched onto it and said that he thought that one was supposed to soak them and then let them dry out a lot. She then went into a small treatise on plant watering. She also touched upon a Boston fern as well. This was about more than her becoming a teacher in that moment. Here she was expressing something important to her that she was now fully sharing. It was no longer just her blue eyes that were impressive, it was the breadth of her knowledge of and passion for plants.

How the little “I” becomes a bigger “I”: engaging affects

A person’s internal perception of what feels organic or real is his authentic self. Ms. C. developed a false self a...

Table of contents

• Cover Page
• Half-Title Page
• Series Page
• Title Page
• Copyright Page
• Table Of Contents
• Contributors
• Foreword by Bertram Karon and Ann-Louise Silver
• Acknowledgements
• Part 1 Engaging the patient
• Part 2 The elements of change
• Part 3 Listening to the patient: stories of what really works
• Part 4 Concluding chapter
• Index