Essay No 3. “Talking Therapy” Alternatives for Psychotic Disorders

Introduction

Many colleagues are not aware of authors who write and train in methods appropriate for psychotic disorders. Senior staff have told me they cannot believe that psychosis can be resolved without medication. Drug therapy dominates any talk of treatment for these disorders. This perpetuates the idea that these difficulties are somehow especially biologically caused and require medication. (Essay 5 will raise questions about the claimed efficacy of psychiatric medications.) This essay says there are approaches that could be included in the treatments offered by mental health services.

Apart from references to a few authors at the end, this paper is chiefly an extract of 10 pages from one book, detailing 2 case examples. They were enough to make me buy the book, which deals with a wide array of psychological disorders.

This essay is longer than the others, but is essential reading to understand that even psychotic disorders are changeable through talking therapy. Reading many examples from different family therapists has made me truly wonder why antipsychotics are ever tried first.

In the extract below, some information from previous chapters is assumed, so a greater understanding is gained by reading the whole book, which I heartily recommend.

Comment: Some may criticise the use of case studies such as those below, preferring “hard science.”  Elsewhere I refer to scientific studies. Here I offer the case studies to advertise that there are alternatives to medications, approaches that have theoretical underpinnings which are written down and taught. As colleagues do not talk about them, I presume they are not widely known.

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Extract from “Knowing Through Changing: The Evolution of Brief Strategic Therapy,” by Giorgio Nardone & Claudette Portelli (Crown House Publishing, Wales, UK, 2005)

Presumed psychosis

We use the term presumed psychosis because we believe that often a wrong diagnosis of psychosis is conducted, and that it is this labelling that eventually “invents” the illness (Nardone and Portelli, 2005). From our point of view, to assume from the very beginning that a patient is psychotic means, to be caught up in a prophecy that sees no or very little possibility in treating the patient. We strongly believe that a therapist should always try to do something to alleviate the suffering of the patient and his / her loved ones, even when the case is considered clinically untreatable.

By saying it is a psychotic case, the therapist, like all the other agents around the patient, can be easily caught up by a consequential overwhelming feeling of helplessness. As Watzlawick used to say “Words are like bullets” — and they are, without doubt, responsible for the construction of one’s reality.

The word “presumed” sheds a ray of hope and thus one feels that something might still be done. Then, if the treatment works well and “the patient recovers from his psychotic symptoms, we can affirm that it was no case of psychosis, if not, at least we have tried our best to better the situation and often small positive changes still take place that help the patient and his beloved ones adjust better. But, again, we come to discover a problem by means of its solution: “Knowing through changing.”

At our Center we have had many diagnosed psychotic patients who have completely overcome their presumed psychosis. In saying this, we do not mean that we have healed psychotic patients, but only shown through successful therapies that these persons were not afflicted by a real psychosis but by invalidating symptoms defined as signs of psychosis in traditional nosographic classifications.

Having clarified this fundamental assumption, we can now proceed in presenting the phases of therapy in the treatment of these highly intimidating patients.

In the first stage of treatment, the most important therapeutic action is the complete acceptance of the distorted reality presented by the patient, as if it were actually real. In order to do this, the therapist needs to trace the logic of the patient and use his language. At a communicative, relational, and strategic level, the therapist needs to follow the patient’s narration of his reality, without alienating himself to what the patient is saying, and thus openly show that he acknowledges his suffering. This permits the therapist to establish a good and suggestive relationship with the patient and also with his family.

Once this is accomplished the first session goes into the second stage of therapy: to construct and introduce an invented reality, which realizes concrete results. In other words, the therapist must build a therapeutic representation usually followed by a ritual prescription that fits with the pathological patient’s perception and reaction, which drives it toward self-destruction.

This amounts to a strategic form of art on the therapist’s part, because he first has to follow the logic and structure of the patient’s representation of reality, then invent and introduce something tailored to patient’s non-ordinary logic, capable of achieving an effective change. This normally takes up the entire first session, so as to be able to make this new representation, based on the patient’s logic, more credible, more artistic and ”real” for the patient. The representations of reality, or the delusions, of patients with presumed psychosis follow a non-ordinary logic. To be able to alter their dysfunctional balance, we cannot disregard the patient’s delusions but, in devising therapeutic strategies, we need to use the non-ordinary logic that underlies these specific delusions. In other words, the therapist needs to follow the seemingly crazy logic that underlies the patient’s ideas and actions by inexplicitly showing the patient that what he is thinking and doing makes sense, while gently intervening by sowing seeds of doubt in what the patient has always held as absolute. This should be done with great caution so as not to dispel his delusions.” On the contrary, the therapist should make use of counter-delusions to introduce some different aspects that serve to divert the delusion toward a new, more functional balance but without driving out the old convictions.

Furthermore, we need to modify the dynamics within the patient’s interactive system with others and the world. This is carried out by the prescriptions such as the Conspiracy of Silence, the Nightly Family Ritual (both prescriptions have been already described in previous sections) and others, which help frustrate the secondary advantages offered by the symptoms.

The third and fourth stages of therapy are the same as previously described treatment protocols: guiding the person and the family to build a new balance based on the new reality after an often dramatic change. For the sake of clarification, we will use real clinical examples.

Riccardo, a shabbily dressed, bearded twenty-year-old, was brought to therapy by his father for his bizarre attitude, which had been diagnosed as “monomaniac behaviour.” Two years earlier he started attending university, where he joined the Socialist Revolutionary Political party, which became his sole and exclusive interest and encapsulated his entire existence. He left home, because he was truly convinced that the family was a social constriction that suffocated personal growth and self-fulfilment, to join party comrades at the university campus, but failed to attend lectures. His entire existence whirled around political issues and debates. He would isolate himself for days to study political treatises and texts.

[The classical definition of delusion is a false, personal belief, based on incorrect inferences regarding external reality, which is firmly upheld by the individual despite everyone else’s contrary beliefs.]

His conversations with family members and flatmates were monothematic. He would passionately lecture and try to convince others of his political ideologies, while losing his temper when others objected. He was hospitalized a number of times because he had undergone critical moments when his behaviour had gone out of control. His father tried to talk sense into him while his party comrades avoided him, annoyed by his bizarre behaviour and repetitive speeches. He came to therapy depressed but not defeated by his failed attempts to be taken back by the party.

This was a fundamental aspect that we recognized as useful so as to be able to divert the patient’s delusion to a more functional balance. This was the right lever to exploit, since he wanted, more than anything else in the world, to be taken back by the group. But the patient was convinced that to be reaccepted by the group he had to find more persuasive words. Thus, his attempted solutions were to study more about his ideology and then preach his knowledge to show his full commitment to the revolution and to the party. This was his conviction, his delusion. During the first session, it became clear that the patient would have done anything to be taken back by his party. We showed him that we could help him. And yet, following the logic of his delusion, we started sowing doubts about whether finding more persuasive words was actually the right way to be accepted back into the group.

Therapist: So the group does not want you anymore?

Patient: No, no.

Therapist: OK. But what are you doing so that you can get back to your group, so that you are accepted once more?

Patient: Yeah, in fact, that is what I need to understand.  I need to understand better what I need to do.

Therapist: Hmm, but what have you done till now so that they would take you back?

Patient: No, I mean, that is no…continuing in this way, for example, I don’t know, doing my best to diffuse the left-wing ideology in all schools, however, within normal limits, like others do, within normality…

Therapist: Hmm [nodding], and this is all that interests you? There is nothing else in your life?

Patient: Right now, no.

Therapist: So, when you can’t meet people, you have your texts, which you study in great depth so that you will be well up in them? Do you speak about your texts with anyone or you keep them to yourself?

Patient: Yes, I do, but then people speak less to me, they become rubber walls (an Italian expression meaning words just bounce back off people; people do not understand)  I come to face rubber walls.

Therapist: So, you try to speak to them but they refuse you, therefore the more you speak the more they refuse you.

Patient: It’s a great mess.

Therapist: So, correct me if I’m wrong but trying to convince them with words is the best way to draw them always more away from you?!

Patient: Yes, in fact

Therapist: However, for you, the desire to profess your faith, your ideology is uncontrollable or else you have come to understand that the more you speak the more this distances you from them. What do you think is best now?

Patient: Now it’s best to calm down a bit.

Therapist: Are you able to do so?

Patient: Yes. However, I manage quite poorly.

Therapist: Well, I’ll help, OK? [Pause] Well, when they keep you away, this provokes in you depressive moments, i.e. you feel bad that they ignore you or you get angry?

Patient: I get angry and bury myself in my books.

Therapist: As if like saying, “Since you people are like that, I’ll isolate myself and read, or else …”

Patient: Look for others.

Therapist: Others?

Patient: Yes, others, who knew what was happening in my life but who led their own tranquil life

Therapist: But these people listen to you for five minutes and then they send you away and tell you to go to hell.

Patient: Yes, they greet me, “Hi, Riccardo”—and that’s it.

Therapist: Or maybe even if they see you around, they would try to avoid you.

Father: He’s monothematic.

Therapist: Monothematic. However, you have come to comprehend that the more you run after them, the more they run away.

Patient: The more they run away.

Therapist: You said that you would like to speak up, state your case, but nobody is now willing to listen to you

Patient: Yes.

Therapist: Or else they listen to you for five minutes and then they tell you to go to hell? On the other hand when you talk to your dad, your dad discusses it with you? But after a while you will start to quarrel, true?

Father: We do not quarrel: we discuss.

Therapist: You start to quarrel because you [toward the father] are not so much in agreement with his ideas. You get into a sort of political debate and you clash

Father: [Nods.]

Therapist: OK, we would like you to follow our indications to the letter, that is, we would like you to allow a precise period of time for your orations. We would like you to give out a speech every day while [speaking to the father] you and your wife are in his presence. Therefore, what we would like you to do during the coming two weeks, every evening, you get together in your living room, you and your wife seated in absolute silence, you [pointing to the patient] standing. You set an alarm clock to ring after half an hour, because your speech should be managed within an adequate period of time and you, for half an hour, should carry out your speech on a chosen argument regarding  your ideology and for half an hour you have to stand there and give, out your speech—talk and talk.

You and your wife [referring to the father] should remain the entire half an hour in absolute silence. When the alarm rings, stop, it’s all over until the following evening you have to avoid to speech about your ideology and studies  you have to keep what we call conspiracy of silence: you [to the father] have to really avoid it if it happens that he starts speaking. Tell him, “Tell us about it this evening during the half an hour.” Postpone it. Riccardo, this goes for everyone. I mean, during the coming two weeks we would like you to restrict your need to speak about this important thing to the half-hour. Therefore, we would like you to avoid speaking about it with anyone–after all nobody really listens to you, they avoid you! But since you feel the need to express your faith, your belief, you will do so with them [pointing at the parents]; for now let us limit ourselves to at least educate them. Let us start off from this first stage so that we can then move onto the rest, you agree?

Patient: Yes, yes.

The following session, Riccardo reported that he followed the prescription and that every evening, in just half an hour, he managed to develop his speech and bring it to a closure. He also declared that, besides the half-hour oration, he did not try to persuade the world of the revolution. He said he kept at heart what we had said the previous session. So, on meeting his friends, especially a female friend, he avoided speaking about his revolutionary ideology and he noticed that people started to hang around with him more.

The prescription also changed the family dynamic. Both Riccardo and his dad said that they had more tranquil days, when they spoke about sport, cinema, university, and other topics that had hitherto always been put aside to leave space for their usual political debates. At the end of the second session Riccardo was invited to continue giving out his speeches during the half-hour once a day, underlying their fundamental didactic purpose, while keeping a silence throughout the rest of the day just as he had managed to do so far. Furthermore, he was asked to carry out an experiment. We told him, “At a specific hour of the day, which you are free to choose, we want you to ask yourself, ‘What would I do with my time if I were no longer interested in my revolution project? How would I spend my time differently from what I do now, if I were no longer interested in the revolution?’ And for an hour every day, not more than an hour, carry it out. Let’s see what you would choose to do for an hour a day, just an hour, not more, as if you were no longer interested in the revolution.”

The patient arrived at the third session gladly itemizing all the new things he managed to do during the past two weeks. He confessed that he even had a date with a girl he liked, when they spent a pleasant evening talking about sweet nothings. Furthermore, during the last Week, he felt the need to start reading other books such as novels.

Even though the as-if prescription was limited to just an hour a day, it triggered off what Thom (1990) has called the “butterfly effect” (which we touched on earlier) throughout the patient’s entire daily routine. At the end of the session he claimed that, even though he was still loyal to his ideals, he thought that, every now and then, one had to take one’s mind off things.

Patient: Well, observing other people’s daily activities, even though they have not taken big life decisions-—however, they have chosen their life—each one of them has an occupation or something else .. . but they try to take their minds off it by doing something else. For me life was just commitment to my ideals and that’s it. Then I tried to understand what other people do in their free time, go to the cinema, read novels and magazines…

Therapist: Therefore, what you are saying is that what you previously considered as anti-revolutionary miseries now you look at them differently?

Patient: That is, not as anti-revolutionary but as a form of distracting, uninterested attitude;  now I’m trying to be more interested in art, there are so many beautiful things here in Tuscany, even in Arezzo, Piero della Francesca…

Therapist: Not only, Poliziano and others.

Patient: I know. In fact this brings to mind even linking this to the commitment of certain historical leaders such as Trotsky and Lenin when they visited London. Lenin said, “Look, Westminster, it is wonderful.” But Trotsky showed no interest: “No, I want to look at Russia… just let me be.” He did not want to see…

Therapist: He did not want to see beyond his ideology. Therefore, you mean that your boundaries are getting elastic, more flexible?

Patient: Yes, a bit, yes.

During the following sessions, Riccardo reported that he went back to university, that he was dating other girls and that he no longer needed the half-hour podium. At home they finally had pleasant conversations. Every time, we acknowledged Riccardo’s good work but suggested he continue with the prescriptions, each time increasing the length of the as-if session by an hour. This was fundamental at this stage, where we needed not to be blinded by results but work to consolidate the results achieved so far.

At the fifth session, we asked him to continue observing others just as anthropologists do, so that he would get to know more about others, especially about the female world, so that he would come to understand better what to do to enhance his practical capability. We also started working on his appearance, which still had something of the “revolutionary” about it, giving him some problems when he approached others. He was very rather taken by Oscar Wilde’s maxim that it is only superficial people who don’t judge by appearances. A “new” Riccardo arrived at the next session: he had shaved his beard, trimmed his hair and wore a clean T-shirt and a pair of denim jeans; he also looked and behaved his age, as a handsome, pleasant twenty-year-old.

Another exemplary case is of another twenty-year-old (whom we shall call Roberto) who arrived at our centre with his parents after having been to various specialists in the field, who held divergent opinions and diagnoses of his “mental state.” For more than five years, Roberto had segregated himself within a sector of his parents’ mansion because he feared that certain people such as the handicapped, old people, and also his own brother would draw “beneficial energy” out of him. So, he avoided all sort of contact with the outside world and the few times he eventually went out he would perform some sort of “preventive ritual” before leaving the house and then a “repairing ritual” on his return to block the “draining process.” But, since his brother still lived at home with them, for Roberto the danger was also inside the house, so the family—-even though at first they tried to convince him of how much his brother loved him and that he should not be afraid of him—finally gave up and proceeded partitioned the house to prevent the two brothers from meeting.

However, the curious aspect of this case was that therapy began before our first encounter. Before coming to us, Roberto had read various books about our approach and. treatment and so, in the time span between his call to fix the appointment and our actual meeting, he had tried to face his fear and embraced his brother, but this frightened him even more, so he had decided not to do it again.

Once more, our intervention was first to follow the patient’s seemingly “crazy logic,” enter his delusion by utilizing his same language, identify the attempted solutions put into operation by the patient and also by the family that maintained and worsened the situation, and then proceed to block the attempted solutions, by sowing a seed of doubt in the patient’s convictions, and then proceed to find a creative yet credible way of turning the logic against itself.

Therapist: And yet you did something you were afraid to do before: you touched and embraced your brother and he did not drain all your beneficial energy? How do you explain this?

Patient: I don’t know.

Therapist: Therefore, you have, till now, held a wrong idea. Until now, you have protected yourself from him. You could not even stand to see him, thinking that if you touched him he would suck out your beneficial energy. Now you have touched him and nothing happened on the contrary you we able to hold it back, true? Let me explain to you one thing. In such situations as this, when you feel that some sort of osmosis takes place, where beneficial energy passes from you to your brother—OK?—what one tends to rationally do is to think, “I need to defend myself by avoiding such situations; therefore, I need to avoid him; I should avoid to touch him, to even look at him.” Or, better still, you have come to practice total avoidance.

Patient: What?

Therapist: You had come to a point where you had constructed extreme evasion  you could not even stand to see. Unfortunately, this rational reaction does not function. Because, in case of energy influx, the more you run away, the more energy gets lost.  So if you want to learn how to keep your beneficial energy, you need to gradually start doing the very opposite … the more you avoid the feared situation – that is the more you avoid your brother, afraid that he would drain energy from you, the more energy will get lost by itself and passes on to him. In fact, when you embraced your brother, you did not lose all your beneficial energy, true?

Patient: No, I did not lose all my energy.

Therapist: OK.

Patient: But then I decided not to embrace him anymore because when I was in the car getting here, I thought about my brother and energy escaped out of me.

Therapist: Be careful! It escaped without his being present. You have imagined it. Once more you did everything by yourself. Just think that during the past years, in reality, you’ve built your own trap, which you’ve got into but can’t get out of. ln what way? By avoiding confronting something that could have enabled you to hold in your beneficial energy. Instead, running away has made you weaker and weaker, so weak that energy gets lost by itself. Now to fortify yourself we are very glad that we can start doing this with you from today because you have already set in motion a great change while you were waiting to come here. You have spontaneously found your way out. Now we have to proceed without getting frightened and return to the trap. In these days, you have to get used to gradually holding within you your beneficial energy, by gradually coming into contact with your brother. From now till the next time we meet, we would like you, every morning, to wake up and embrace your brother before he goes to work. OK? When he gets back, embrace him once more and then before going to bed. You have to keep in mind that this is the first step, which you discovered spontaneously, in starting to hold in your energy. By running way-

Patient: But I have to give him my energy?

Therapist: No, you will hold it within you. This will help you keep it for yourself and not give it to him. Before, by running away, by hiding, by avoiding contact, you were always making yourself weaker and weaker and energy passed to him. You are right in wanting to keep your energy and the attention of your parents to yourself. He has his own, he has other things and the same goes for the outside world.  Do the same thing, OK? Besides this ritual, you [addressing the parents] should avoid—from now till the time we meet again—talking or asking about his fears. The more you speak about it, the more you work together to overcome it, the weaker Roberto becomes. So, throughout the day, you should keep what we call conspiracy of silence. You should avoid speaking about his fear and difficulties, or else this will exacerbate them, OK? You will get weaker and beneficial energy will get lost. But in the evenings, after dinner, get together all the family in the living room, get an alarm clock and set it to ring after half an hour, during which you [to the parents] will remain seated in absolute silence, and you, Roberto, standing. You will tell them all about the fears you felt throughout that day, all your worries, all those things that disturbed you. You [referring to the parents] should listen in absolute silence. When the alarm rings, stop—it is all over. Until the following evening avoid speaking about it.

Mother: There has to be his brother too?

Therapist: I would prefer the brother to be present too so that in this way you fortify yourself even more…  OK? And why not? In this way we send him some unbeneficial energy, the other type … no? [Everyone bursts into laughter.] But do not let him know, OK? We won’t tell him.

Patient: OK, we won’t tell him [laughing].

The family arrived the next session overwhelmed by the “miraculous” change that took place. They reported that Roberto carried out the (counter-) ritual three times a day throughout the entire two weeks, without fearing his brother; on the contrary, Roberto starting looking forward to his brother’s return from work, when they spent time chatting, watching TV, playing with videogames, etc. Furthermore, from the following session, Roberto was seen alone in therapy, and reported that he had started going out, going to the gym (with his mum), and to mass, and was eager to go back to school the following academic year. On one of his outings, he had met a disabled child whom he hugged lovingly, and, in therapy, he exclaimed that he could not understand why he used to fear handicapped people – they were so unfortunate and yet so caring. The rest of the therapy focused on establishing a new, more functional equilibrium both for Roberto and for the entire family. It is necessary to consolidate successes that have already been gained, so, by the end of the ten sessions, we had started working with the patient in developing social skills.

These clinical examples show that even such severe disorders can be treated in a short time, without recourse to traditional therapy. We do not “eliminate the delusion” but direct it toward its self-destruction. The principle that forms the basis of our treatment with presumed psychosis is “to add so as to reduce.” Our intervention aims to circumvent the patient’s resistance (Type 4 resistance – patient unable to collaborate) and to lead him to change his perception of reality. We use his own logic and mode of representing reality, and lead him through a series of “corrective” emotional experiences, until he begins to doubt his previously inflexible convictions.

As Goethe wrote, things are actually much simpler than one might think, but much more complicated than one might realize.

A few resources

Elsewhere on my site you will find a case study of a client I assisted – she was diagnosed with Schizo-Affective Disorder. I utilised a systemic approach for psychosis, described by Jay Haley, a prominent American family therapist. [Ref: “Leaving Home: The Therapy of Disturbed Young People,” Second Edition, Brunner/Mazel, 1997.]

[Cloe Madanes also wrote describing that approach: “The Prevention of Rehospitalization of Adolescents and Young Adults,” Family Process, 1980. pp 179-191.]

http://www.isps.org/  This site is “The International Society for the Psychological Treatments of the Schizophrenias and Other Psychoses.” It has many resources, including links to numerous published books for professionals and consumers.

“A Way Out of Madness: Dealing with your family after you’ve been diagnosed with a psychiatric disorder,” by Daniel Mackler & Matthew Morrissey, 2010. This book can be found at the US branch – http://www.isps-us.org/  The stated purpose of the book is a “guidebook to help people diagnosed with psychiatric disorders to deal more effectively with their families…”  The second half has stories from 12 contributors, mostly who have been consumers with diagnoses of schizophrenia or bipolar disorder. All have freed themselves from the psychiatric system and medications, some after very long involvements. For those who do not believe people can do well without medications could benefit from reading these stories. And many clients will find hope from such examples.

(Go to essay 4.)

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