Imagine visiting Mary with me; she’s a housewife in a poor area. She’s hardly showering; she’s not shopping, cooking, cleaning, or tending her children. She had been hospitalised following a psychotic experience where she believed her children were in danger from poison and people were after her. She’s been on medications for 18 months for Schizo-Affective disorder. She is anxious, defensive, denying any problems, and hopes I will stop my home visits.

Imagine her husband, working fulltime, doing a double load of running the household as well, wondering how long before his wife returns to normal, if she ever will.

Think about the context of therapy we face. We work amongst clients who can behave in bizarre ways. They can confuse us and their families; they can frighten. We can be under pressure to fix these situations. We care and want to do our best. With a psychotic individual, possibly without exception a diagnosis is made and antipsychotic medication is commenced. This would be considered “Best Practice.” Is Mary’s treatment really best practice?

Three months after first meeting Mary, her husband, Dave, phoned asking to meet. I was pleased to do so. After meeting him, I stopped seeing her. I planned with him to change his behaviour, so she would change. Her medications continued but I said I had no faith in them working. But if he did what I asked I felt we could help her. He listened enthusiastically. I understood it would be hard, but he probably didn’t.

The general plan was simple. Instead of patiently waiting for her to get better, I wanted Dave to demand she act better immediately. I coached him how to pressure her, insist, and remain determined. For example, instead of cooking tea when he arrived home from work, he should make her do so! This demonstrates a belief she can do things, rather than conveying ideas she is ‘ill.’ Rather than organise and put the children to bed, he should insist she do this.

I motivated Dave by forecasting that the marriage would eventually end if things continued as they were. Although he seemed very committed to his wife and family, he agreed that it could not last like that for ever. And I forecast that this approach would make changes happen quickly.

We met weekly to review his actions and the responses it generated. Understandably he acted firm for a bit and then stopped. He was naturally soft and accommodating and I was asking very different behaviour of him. I took note of any success or partial success he mentioned following his actions. I kept a record of these so I could remind him later when he faced tough times. If she helped a bit with the food and then returned to bed, I would point out that she was giving evidence that she was able. I used this to encourage him to persist.

He would report some things that were obvious positive signs – they were at a parent-teacher night; he said she acted normally for 2 or 3 hours; “No-one there would know she had a problem.” Then at home she reverted to her non-coping behaviour. If I was not meeting with Dave, discussing and recording, he would not have accorded significance to such behaviours. So these and Mary’s many small efforts encouraged him to continue.

I coached him how to speak to her; I did not encourage abusive language, but I was encouraging firm insistence so that he could be effective. I did not want him to ask, but expect, insist, require responsible behaviour. It was a challenge to tread a good line. I did not want him to encourage her with praise or gratitude, but when she did something just say a simple, “Thanks,” as anyone would normally say. I did not want him to ‘lecture’ her about what being a good mother meant. I was concerned that could make it difficult to get started, as she might ‘lose face.’ I just wanted him to consistently and unequivocally communicate his expectation, which also communicated his belief she was able to do these things.

He did get frustrated and after a number of weeks felt worn down. I suggested that he take a mental holiday; for a week or two, just look after the children and himself, stop trying to influence Mary, and then start again. This was around Christmas. He was taking the children shopping for presents, when Mary asked to join them. He declined, informing her she could when she behaved properly again. Similarly he made meals for the family but did not include her, indicating she had to get her own.

At Christmas there was a large gathering of the extended family. One relative with a history of depression had a conversation with Mary and said, “You can’t just rely on the medication; you have to make an effort.” Three days later Mary told her husband that she was going to do things again. She began and within a week, Dave reported she was behaving normally. [Christmas was 7 weeks after I first met Dave.]

I saw him a month later and he was very happy. A further month passed and he was still happy, and we agreed we did not need to meet again. I rang Mary briefly, my first contact for more than 4 months. Her voice was totally different to the woman I had known. She concurred she was better. She said she was past her problems. Her outpatient doctor had stopped her antipsychotics, but she remained on her antidepressant.

Fourteen months after that Christmas conversation I rang to follow up. Mary answered. Her voice was normal. She referred to her “depression” in the past, and told me about her family. She was living a normal life. Dave spoke later and reiterated that the changes had lasted. He was happy that he had his wife back. He was keen that people know about “my approach.”

This is not my approach, of course. It follows from my understanding of what Jay Haley (family therapist) and others have written. Haley does not want people to be regarded as ‘ill,’ as that implies they need medical intervention. Rather he emphasises firm direction from the family members, regardless of whether the official diagnosis is Schizo-Affective disorder, Schizophrenia, or heroin addiction, or anorexia. Haley wants the important people in the client’s life to use their influence, which can be much more powerful than strangers (professionals) that clients often do not care about and do not want to see.

There is no reason to think the medications suddenly began to work for Mary. There were numerous reports in the 7 weeks of her responding to Dave’s actions. He saw she could do things, but then she would stop. He came to doubt she was ‘ill,’ and expected different behaviour from her. This created a context where she had to think about what she was going to do. Without this she quite likely would still be languishing as a mental patient, as many do.

She had been hospitalised and told she was ‘ill;’ she lost confidence that she could behave effectively. We turned this around.

All people can turn their lives around quickly, but labelling them as ill can tremendously hamper them. They may need compassion and care, but also expectation. It helps immensely when families are involved to help steer them forward.

So many believe they have to wait for the medication to work; but so often it does not. Months go by, which can stretch into years. Haley has advocated taking people off psychiatric medications as soon as possible (but preferably never starting it.) He wants to avoid the dulling and sedating side-effects which can justifiably hamper recovery; and he wants people to think of themselves as normal, and needing to solve a problem.

Even when medication appears to work, does it? Would they have got better without it, with firmness and appropriately high expectations? Many clinical trials show no significant difference between the active drug and placebo; these will seldom make it into psychiatric journals and thus a false impression of efficacy is created.

[Most readers will know of some cases where medication has made remarkable changes. I do too. I do wish to acknowledge that some people have been helped enormously, and there are some contexts where talk therapy has not worked, nor is likely to.]

Haley’s approach is not easy. It often creates family conflict before resolution. But imagine if you can get them back to work or school within days and weeks, rather than months and years. What a saving in money, and lost living.

Imagine if you didn’t have to tell them they are sick and coerce them into taking medications that they often resist, not to mention serious side-effects (eg diabetes, kidney damage, heart damage, thyroid impairment, weight gain.) These risks may seem acceptable to some, but are they really necessary?

Is it fair to leave patients like Mary on medications that give results she was getting? She was existing, not functioning. Her marriage was fragile. The future was bleak. Is it really “Best Practice” to tell people they are ill?

The ‘Mental Illness’ Metaphor

I favour telling people they “have problems” rather than being ill. Is it clear that ‘mental illness’ is only a metaphor, a way of describing Mary’s behaviour? This metaphor implies that mental problems are like physical illnesses. However there are rarely any measurable signs of a biological ailment.

If Mary can change through redeciding, what does it say about the message of mental “illness?” Should we create an environment of normal expectation, or lowered expectation that follows from believing the person is ill?

In the future I hope patients and families will routinely be told there are solutions that do not necessitate medications. There are alternatives.

The end.