Downloaded by [New York University] at 12:41 13 August 2016 the Interactive World of Severe Mental Illness

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Downloaded by [New York University] at 12:41 13 August 2016 The Interactive World of Severe Mental Illness

In our society, medication is often seen as the treatment for severe mental illness, with psychotherapy a secondary treatment. However, quality social interaction may be as important for the recovery of those with severe mental illness as are treatments. This volume makes this point while describing the emotionally moving lives of eight individuals with severe mental illness as they exist in the U.S. mental health system. Offering social and psychological insight into their experiences, these stories demonstrate how patients can create meaningful lives in the face of great difficulties. Based on in-depth interviews with clients with severe mental illness, this volume explores which structures of interaction encourage growth for people with severe mental illness and which trigger psychological damage. It con- siders the clients’ relationships with friends, family, peers, spouses, lovers, co-workers, mental health professionals, institutions, the community, and society as a whole. It focuses specifically on how structures of social interaction can promote or harm psychological growth, and how interaction dynamics affect the psychological well-being of individuals with severe mental illness. Diana Semmelhack is Professor of Behavioral Medicine at Midwestern Uni- versity and a Board Certified Clinical Psychologist. She has done extensive research on group work. Larry Ende received his MSW from the Jane Addams College of Social Work in Chicago and specializes in psychodynamically oriented therapy with children and adolescents and with severely mentally ill adults. He has a Ph.D in Literature from SUNY Buffalo. Arthur (Art) Freeman is Professor of Psychology and Executive Program Direc- tor of the Clinical Psychology programs at Midwestern University (Downers Grove, IL, and Glendale, AZ). He has published seventy five professional books and over one hundred book chapters, reviews, and journal articles. Clive Hazell operates a private practice in Chicago and teaches at the School of the Art Institute of Chicago, and the National College of Naprapathic Medicine. Downloaded by [New York University] at 12:41 13 August 2016 Colleen L. Barron, M.S. is a mental health professional working with severely mentally ill adults. She graduated Magna Cum Laude from Domin- ican University in River Forest, IL. She received her Master of Science in Clinical Psychology at Benedictine University in Lisle, IL. She pursued her college education after working in the corporate arena for 20 year. Garry L. Treft, MA. is the Administrative Coordinator for the Department of Behavioral Medicine at Midwestern University in Downers Grove, IL. He has a B.S. from Union College in Lincoln, NE, and a M.A. from Andrews Univer- sity in Berrien Springs, MI. Garry has written for local, national and international publications with experience in the corporate and non-profit sectors. Explorations in Mental Health Series

Books in this Series:

New Law and Ethics in Mental The Philosophy, Theory and Health Advance Directives Methods of J. L. Moreno The Convention on the Rights of Persons The Man Who Tried with Disabilities and the Right to Choose to Become God Penelope Weller John Nolte

The Clinician, the Brain, and I Psychological Approaches Neuroscientific Findings and the to Understanding and Subjective Self in Clinical Practice Treating Auditory Tony Schneider Hallucinations From Theory to Therapy A Psychological Perspective on Edited by Mark Hayward, Joy and Emotional Fulfillment Clara Strauss, and Simon Chris M. Meadows McCarthy-Jones

Brain Evolution, Language and Primitive Expression and Psychopathology in Schizophrenia Dance Therapy Edited by Paolo Brambilla and When Dancing Heals Andrea Marini France Schott-Billmann

Quantitative and Qualitative A Theory-based Approach Methods in Psychotherapy Research to Art Therapy Edited by Wolfgang Lutz and Sarah Implications for Teaching, Knox Research and Practice Ephrat Huss Downloaded by [New York University] at 12:41 13 August 2016 Trauma-Informed Care How Neuroscience Influences Practice The Interactive World Amanda Evans and Patricia Coccoma of Severe Mental Illness Case Studies from the Learning about Emotions in Illness U.S. Mental Health System Integrating Psychotherapeutic Diana J. Semmelhack, Larry Teaching into Medical Education Ende, Arthur Freeman, and Edited by Peter Shoenberg and Clive Hazell with Colleen L. Jessica Yakeley Barron and Garry L. Treft The Interactive World of Severe Mental Illness Case Studies from the U.S. Mental Health System

Diana J. Semmelhack, Larry Ende, Arthur Freeman, and Clive Hazell with Colleen L. Barron and Garry L. Treft Downloaded by [New York University] at 12:41 13 August 2016 First published 2015 by Routledge 711 Third Avenue, New York, NY 10017 and by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2015 Taylor & Francis The right of Diana Semmelhack, Larry Ende, Arthur Freeman, and Clive Hazell to be identified as authors of this work has been asserted by them in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data The interactive world of severe mental illness : case studies of the U.S. mental health system / Diana Semmelhack [and five others]. pages cm. — (Explorations in mental health series) Includes bibliographical references and index. 1. Mentally ill—Rehabilitation—United States—Case studies. 2. Mental illness—Treatment—United States—Case studies. 3. People with disabilities—Rehabilitation—United States—Case studies. I. Semmelhack, Diana. RC439.5.I58 2015 362.20973—dc23 2015005690 ISBN: 978-0-415-74301-3 (hbk) Typeset in Sabon by Apex CoVantage, LLC Downloaded by [New York University] at 12:41 13 August 2016 To Marge and Goldie: and all others who have endured the struggle and succeeded. Downloaded by [New York University] at 12:41 13 August 2016 “Untitled” by Chelsey Wood Downloaded by [New York University] at 12:41 13 August 2016 Contents

Introduction 1

1 Institutional Interaction Structures 12

2 Social Interactions With Families 34

3 Social Interactions With Friends 50

Introduction to the Cases 79

4 The Depersonalized Musician 81

5 The Woman Who Couldn’t Get Her Abuser Out of Her Head 89

6 The Depressed Man in Chronic Pain 108

7 The Last Train Out of Berlin 122 Downloaded by [New York University] at 12:41 13 August 2016 8 The Woman Who Believed She had No Heart 135

9 Monster Woman 146

10 The Woman Who Never Mourned 158

11 The Man Who Lived in a Dumpster 170 viii Contents 12 The Tavistock Method: A Growth-Promoting Form of Group Interaction 187

13 Synthesis: Reflections on the Structure of Interaction 212

14 Conclusion 218

Epilogue 225 Index 229 Downloaded by [New York University] at 12:41 13 August 2016 Figures and Illustrations

Illustration “Untitled” by Chelsey Wood vi 12.1 Hill Interaction Matrix 191 13.1 Institutional structures that hinder and promote growth 212 13.2 Family structures that hinder and promote growth 212 13.3 Friendship structures that hinder and promote growth 213 13.4 Interaction structures that tend to promote psychological damage for clients 214 13.5 Interaction structures that tend to promote psychological growth for clients 214 Downloaded by [New York University] at 12:41 13 August 2016 This page intentionally left blank Downloaded by [New York University] at 12:41 13 August 2016 Foreword

It was with great pleasure that I accepted Dr. Semmelhack’s offer to write a foreword for this exceptional book. It is a rare opportunity to have in one volume the results of over 20 years of clinical practice and research on the ways that institutions, families, and friends work with individuals who experience severe mental illness. Through careful analysis of significant stories of clients, the authors provide not only valuable information regarding the interaction of clients with the system, but also the opportunity to see both the intended and unintended consequences of prevailing methods of care for those with psychiatric disabilities. This book demonstrates how to move from a medically oriented or “pathologizing” paradigm to a recovery-oriented one. To validate this paradigm shift, and to show how it can improve the quality of life for the client, the authors present examples of therapy that responds to the specific experiences and worldview of the client, instead of treatment that is based on the perspective of “mental illness.” The focus is on success, and the case studies bring client-therapist interaction, the specific client-therapist interaction, into the foreground, thus demonstrating its centrality in fostering recovery and healing. The book exemplifies an attitude of respect and understanding toward the client that is similar to that of another doctor who worked with the severely mentally ill in Europe, Carl Gustav Jung. The great Swiss analyst C. G. Jung was adamant that the symptoms of severe mental illness must be seen from multiple perspectives. While recognizing the necessity of acknowledging the presence of deep psychopathol-

Downloaded by [New York University] at 12:41 13 August 2016 ogy primarily for the purpose of establishing prognosis and determining the level of containment needed for effective treatment, Jung believed it was important to look at the meaning being expressed by the specific behaviors of individuals diagnosed with schizophrenia (or, in his terminology, dementia praecox), not only functionally, but also from traditional Freud- ian perspectives and from the perspective of the collective unconscious. Jung relativized the importance of pathologization; to label an individual as sick in effect stops the search for meaning behind the presentation of the client. It was in the meaning, the underlying messages being sent by the sufferer to those who are charged with their care, that clues to healing could be found. xii Foreword Differential diagnosis requires a careful tabulation of symptoms, including their frequency, intensity, context, and duration, so that a more or less clear clinical picture can emerge. This process usually results in a label, or some other expression that categorizes the individual with respect to the nature and severity of their psychological situation. Jung felt that it was just as important to note in detail the specific ways in which “severe mental illness” manifested in each particular man or woman with whom he worked, because it was in the specificity of the symptoms that true therapy could begin. If a client was having hallucinations or hearing voices, it was considered important to note the details of the hallucinations and the voices, not just accepting these as evidence of psychopathology, but also seeing them as pointing to ways to support the client through therapeutic interventions. In this way, Jung was able to show that psyche, just like soma, has an innate tendency towards wholeness, a predisposition to health. While the body’s reactions to invasions by viruses and bacteria can look frightening and at times beyond hope, patience and careful care often show that these frightening aspects of illness are actually the body’s way of mounting a healing response to the invading pathogen. So too with psychological symptoms: Although challenging in their manifestation, these symptoms reveal the psyche’s healing power in action, and treatment must be guided by these symptoms, not conducted in spite of them. It is hoped that this volume, as the authors’ previous one, also published by Routledge, will contribute to a much-needed paradigm shift within the field of psychological care for the severely mentally ill. It is a challenging text, one that will bring even seasoned therapists to question tried-and-true methods and perhaps empower all of us to focus on the specific relationships that develop between our clients and ourselves, because it is in the realness of that relationship that all participants will experience recovery.

Dr. Kenneth James, Ph.D., Diplomat, Jungian Analyst, Chicago Society of Jungian Analysts Downloaded by [New York University] at 12:41 13 August 2016 Preface

Sometimes an unruly patient being forcibly admitted into a psychiatric ward, strapped tightly onto the gurney by those who range from the outright hostile to gentle practitioners of coercive trickery, feels a bit like he is helplessly surrounded by a pack of hungry wolves. An empathic and gentle response to a patient who angrily loses control can contain what might otherwise lead to a damaging interactive experience. We need to learn how to evoke in our clients, not nightmarish images of beasts, but those of caring people who can help to neutralize their inner demons. This book reaches out to the wolves that inhabit us all with the hope of containing them and coaxing ourselves into more humane social interactions so that people become people again. Downloaded by [New York University] at 12:41 13 August 2016 This page intentionally left blank Downloaded by [New York University] at 12:41 13 August 2016 Interactions Can Be Lethal

Dear Miss Lonelyhearts— I am sixteen years old now and I don’t know what to do and would appreciate it if you could tell me what to do. When I was a little girl it was not so bad because I got used to the kids on the block making fun of me, but now I would like to have boy friends like the other girls and go out on Saturday nites, but no boy will take me because I was born without a nose—although I am a good dancer and have a nice shape and my father buys me pretty clothes. I sit and look at myself all day and cry. I have a big hole in the middle of my face that scares people even myself so I cant blame the boys for not wanting to take me out. My mother loves me, but she crys terrible when she looks at me. What did I do to deserve such a terrible bad fate. Even if I did do some bad things I didn’t do any before I was a year old and I was born this way. I ask Papa and he says he doesn’t know, but that maybe I did something in the other world before I was born or that maybe I was being punished for his sins. I don’t believe that because he is a very nice man. Ought I commit suicide?

Sincerely yours,

Desperate

Downloaded by [New York University] at 12:41 13 August 2016 This letter is from Miss Lonelyhearts, a novel by Nathanael West, 1933 (pp. 5–6). We have left mistakes as they have been depicted in the original. This page intentionally left blank Downloaded by [New York University] at 12:41 13 August 2016 Acknowledgments

First of all, the authors would like to thank the individuals with mental illness who participated in this project. Special acknowledgment needs to be given to Eva Rest, who early on in this project devoted much time to editing and formatting initial drafts, which led to the final product. We also thank Chelsey Wood, MFA, the artist who created the featured drawing and Dr. Kenneth James for writing the foreword. Several others have contributed to the international commentary in this text, including the late Dr. Antony Kidman and Dr. Rachael Murrihy (Australia); Dr. Wing Wong (Hong Kong); Dr. Andrzej Kokoszka (Poland), Dr. Daniel David (Romania); Dr. Tullio Scrimali (Italy); Dr. Young Hee Choi (South Korea); and Mehmet Sungur (Turkey). Dr. Bradford Czochara made a significant contribution to the chapter on the Tavistock method, enhancing it with his ongoing research on large group process. Other individuals whose contribution is greatly appreciated include James Christopher, Allen Ende, Charles Semmelhack, Joe Lunini, Robert Semmelhack, Jon Doeden, Blode, Tricia Treft, Emma Siglinsky, Toni Kissel, Jerilyn Miripol, Aurelia Alonzo Lopez, Neringa Stat- uleviciene and the thoughtful comments of Eric Ornstein and Karen Far- rell. Our team thanks everyone at Routledge who provided strong support, including Merritt Duncan, who provided information and assistance in a timely manner whenever needed. Grace Sullivan deserves special thanks for her support during the early phases of compiling the document. We thank the library personnel who have assisted us. We are grateful for the support received from the National Alliance on Mental Illness and the Clinical Psy-

Downloaded by [New York University] at 12:41 13 August 2016 chology Department at Midwestern University, including Dr. Richard C. Ney and Fay Alvarado. Special thanks are given to Deanna Dang, MA, for her support and advice as a nursing home administrator and art therapist. We greatly appreciate the assistance of the staff at the facilities where our research was carried out. We also thank everyone at New Foundations for their contribution. Additionally, our team thanks the many graduate students who assisted in this project, including Hillary Linderman, Clin- ton Lewin, Mary Rizzo, Roshni Patel, and Zina Peters. Lastly, we wish to acknowledge and thank the many clients who have help shape our viewpoint in perspective to the treatment of the severely mentally ill. We also wish to thank Dr. Larry Ende, who is an author, but also a central contrib- utor to the development of the ideas for this book. This page intentionally left blank Downloaded by [New York University] at 12:41 13 August 2016 Introduction

From their [the writers’] perspective the same woman who looks like a helpless and ‘deteriorated’ patient in the traditional medical or mental health clinic may look and act like a “strong survivor” in a sheltered environment where her experience is validated and strengths are recognized and encouraged (Herman, 1997, p. 134).

This book describes the moving lives of eight people with severe mental illness as they exist in the U.S. mental health system. The cases we provide offer, to a degree, success stories, showing how clients manage to create meaningful lives in the face of great difficulties. Our work with these individuals informs the conclusion that underlies this book: the social interaction of people diagnosed with severe mental illness plays a fundamental role in their mental health and treatment. Psychotropic medication, it is true, is important in the treatment of severe mental illness. However, pills are not enough to recover from the devastation of a psychotic break. As a parallel, a person cannot recover from the suicide of her 12-year-old daughter solely through a psychiatrist’s prescription of an anti-depressant. The social interaction surrounding a person can facilitate recovery, or play a major role in her mental illness. In writing this volume, we hope that mental health professionals and other interested parties will reflect on the tremendous importance of growth-promoting communication in the lives of the “severely mentally ill,” individuals who tend to be alienated from our society. Professionals in the U.S. primarily treat severe mental illness with medication and, at times, secondarily psychotherapy. We are saying that a third Downloaded by [New York University] at 12:41 13 August 2016 factor in recovery, which is as important as these two, is the social interaction that influences the client’s psychological well-being. Interpersonal psychoanalysis, and the humanistic movement in psychology, among other sources, suggests the importance of such interaction. This research often tends to be marginalized or forgotten (Rogers, 1961; Sullivan, 1974). Based on the review of transcripts of therapy sessions (compiled over the last 20 years of treatment) and in-depth interviews with clients diagnosed with severe mental illness, we explore the question: what structures of interaction encourage growth for people with severe mental illness, and what 2 Introduction kind promote psychological damage? Throughout the text, when interaction dynamics or structures are discussed, we are referring to interaction as a process and attending to how this process works as opposed to purely focusing on its content. An example of an interaction dynamic is the use of projection that devalues a person diagnosed with severe mental illness. We consider the clients’ overall relational worlds, including their relationships with friends, family, peers, spouses, lovers, co-workers, mental health professionals, institutions, the community, and, finally, society as a whole. This vignette, based on the experience of a colleague of ours, suggests the importance of interaction dynamics in the lives of people with severe mental illness:

Working in a poor quality long-term care center for years as an art therapist, I saw the elderly man, identified as a “schizophrenic,” sitting quietly in a wheelchair by the first floor nurses’ station. This man looked hopelessly withdrawn. In the morning, we would sometimes nod at each other, or engage in some other form of non-verbal acknowledgment, and I would move on with my day. Then one day the acknowledgment was replaced by an outburst: “Metamorphosis, metamorphosis, metamorphosis!” he kept repeating in a loud and deliberate voice. I stared at the man, perplexed. “What do you mean “metamorphosis”?” I asked. The man screamed “Kafka!” He was referring to Kafka’s short story “Metamorphosis.” This story tells of a man who awakes one morning to find that he has been transformed into a gigantic insect. A few days later I gave the man the story. He looked at it briefly and gave it back to me. “I can’t read this story,” he said, “because it is my story.” “How so?” I asked. “Don’t you see,” he said, “I am a schizophrenic . . . nothing but a huge insect by societal standards.” It quickly became apparent to me that there was much more depth to this man than I had realized. Further inquiry revealed him to be an educated musician, an artist, a brother, and a son. This information was not in his chart. It was obtained from the client and other reliable

Downloaded by [New York University] at 12:41 13 August 2016 sources. Further conversation with the elderly gentleman, Tim, revealed that the mental health system had depersonalized him to the point that he felt less than human—“Crazy,” he said, “an outcast.” ’

Once Tim became part of a small supportive art therapy group it could be seen that his extreme withdrawal had been a defense against an environment this sensitive man found wholly unbearable, the harsh, punitive, depersonalizing environment of the nursing home. This supportive group became a safe holding environment where Tim came to build relationships with others based on a modicum of safety and trust. A holding environment Introduction 3 is a safe setting where an individual can feel free to share his thoughts and feelings without the fear of retribution (Basham, K., Heller, N., Mattei, L., Méndez, T., Northcut, T., Schamess, G., . . . & Shilkret, R. (2011)). The depersonalizing environment at the nursing home represents an interaction structure that hinders the growth of a person with severe mental illness; the holding environment is one that facilitates the client’s growth. Especially in the first few chapters of the book we describe interaction dynamics that aid or impede client growth. We link these descriptions of structures with important interactions in the eight case studies. Following this introductory chapter, chapters 1–3 explore important structures of interaction for clients with psychiatric problems in three major areas: their worlds in institutions (chapter 1), families (chapter 2), and friendships (chapter 3). This exploration is informed by the analysis of the book’s case studies. Chapters 4–11, the eight case studies, form the heart of our data. In commenting on structures of interaction evident in each case study, we refer to interaction dynamics discussed in the first three chapters. After briefly referring to the earlier vignette about Tim, we introduce two other case studies included in the book. Chapter 4, “The Depersonalized Musician,” presents the case we began to describe in the introduction. Tim, with the help of a holding environment, engages in a metamorphosis. Unlike in Kafka’s short story, Tim’s metamorphosis is from “the schizophrenic” to a functioning individual integrated into a holding environment—a therapeutic community. Chapter 5, “The Woman Who Couldn’t Get Her Abuser Out of Her Head,” shows how a history of severe sexual, physical, and emotional abuse can be ignored by professionals for decades and dismissed with a diagnosis of psychosis. The use of diagnosis to obscure a client’s experience is an interaction dynamic that emerges a number of times in the case studies. For years no one interacted with Anna in such a way that she was given the opportunity to describe the nature of her auditory hallucinations or her childhood history. The auditory hallucinations were hostile and degrading. An open dialogue with a mental health professional could have allowed Anna to communicate the nature of these voices—that they represented the voice of her abuser and were very likely auditory flashbacks. In addition, the diagnosis of schizophrenia could have been substituted

Downloaded by [New York University] at 12:41 13 August 2016 with post-traumatic-stress-disorder—a more accurate description of Anna’s psychopathology. An accurate diagnosis could have led to healing interactions with mental health professionals and others that could have expedited her recovery. Anna was eventually able to tell her story to a therapist. By telling her story through group, peer, and family interactions characterized by empathy, unconditional positive regard, and congruence (sometime referred to as “genuineness”) (Rogers, 1961) she was able to recover and reclaim her life. In chapter 8, “The Woman Who Believed She Had No Heart,” Shirley engages in therapeutic interactions with a psychologist utilizing an integrated Kleinian and Rogerian therapeutic framework. Institutionalized as a 4 Introduction very young child, Shirley was in a sense “raised by” toxic institutionalized settings where interactions depersonalized and dehumanized her. Shirley was put away from an early age and institutionalized. She was in a sense amputated from society and was reduced to a psychiatric diagnosis. Ampu- tating containment (or the attempt to contain an individual by dismissing her unique experience) is an interaction dynamic that is mentioned in many of the cases and is relevant to Shirley’s case. The interactions in five pivotal sessions are analyzed in which therapist and client experienced a breakthrough that leads to the assembly of a coherent narrative of abuse that contributes to her recovery. From a cognitive behavioral perspective, this narrative approach could be viewed as a reframing of her experience. The case emphasizes the importance of how interacting with a caring individual (therapist) who actively listens can be profoundly psychologically healing. While medication helped, the caring interactions with others greatly contributed to Shirley’s becoming a more integrated and interactive person. In chapter 12 we look at structures of interaction in the context of group work with psychiatric clients. We draw on our earlier work, Group Ther- apy for Adults with Severe Mental Illness: Adapting the Tavistock Method (Semmelhack, Ende, & Hazell, 2013), which pointed at the key role of growth-promoting group interactions in recovery from severe mental illness. Chapter 13 synthesizes and integrates the book’s findings. The conclud- ing chapter emphasizes our theme about social interaction and its role in mental illness. A perspective is offered on the manner in which different countries utilize various interaction dynamics differently than the U.S. in facilitating therapeutic change—a topic we will elaborate on in future research. Finally, in the epilogue, Dr. Semmelhack shares comments on her interactions with mental health professionals following the psychotic break of a family member during the completion of this manuscript. This experience gave her first-hand insight into how the quality of interactions by mental health professionals contributed to and inhibited therapeutic change in the designated patient. There are further issues we wish to discuss briefly before moving to chapter 1. One issue involves professionals’ tendency to systematically undervalue the role of non-professional relationships in recovery. The word “treatment” assumes that professionals are largely the ones who are respon-

Downloaded by [New York University] at 12:41 13 August 2016 sible for recovery. The word obscures a central fact: the social world of the client plays a fundamental role in recovery. Social life doesn’t just provide assistance to treatment that is based on medication or psychotherapy, when that is available. Rather, it provides a basis for recovery, a psychosocial process that engenders a psychosocial transformation. The way that professionals speak about treatment tends to deny this partly because we wish to think of “treatment” as something that we do. This makes us feel needed and in control—we believe that people without training and a degree cannot be responsible for “treatment.” This belief in ourselves as the sole providers of treatment supports our way of making a living. And it results in Introduction 5 professionals’ failure to acknowledge that successful recovery is based, to a large degree, on the nature of one’s interactions with non-professionals as well as professionals. This includes, for example, interactions with family, friends, peers, co-workers, and various types of groups. Professionals do not sufficiently help clients to cultivate social lives that support their recovery. People cannot talk to, be validated by, or feel loved and understood by their medications—people require quality interactions in order to facilitate recovery from a severe mental illness. Another issue is that it is very likely that a large number of mental health professionals in the U.S. will at some time provide or oversee the care for individuals diagnosed with a severe mental illness. To work with this population, one needs to significantly expand one’s empathic capacity. These clients experience the world in ways that differ greatly from what most mental health workers have experienced. This is due not only to the nature of the clients’ symptoms, but also to the devastating social situations they have experienced—homelessness, multiple hospitalizations, long-term institutionalizations, and jail—sometimes for decades. Many individuals with severe mental illness obtain little treatment other than medication management in the U.S. healthcare system. This book, especially the case studies, can help readers in the process of developing the empathic ability to treat, to respond to, or simply to understand these individuals. Mental health professionals and laypeople alike can gain a better understanding of the importance of interaction structures in the recovery of severely mentally ill individuals. We have also considered the issue of how to identify the individual with severe mental illness. Sometimes we label a person as a patient, a client, or someone diagnosed with a severe mental illness. Thomas Szasz (1960) in his famous essay “The Myth of Mental Illness” would question whether there is such a thing as mental illness at all. Using the word “illness” also may suggest a medical model that we do not necessarily endorse. Given the complexity of this labeling issue, we chose to use those terms typically used in the settings that we discuss in this book—hospitals and nursing homes. Hence, we interchangeably use the terms “client,” “patient,” and “severely mentally ill person” depending on the context discussed in the text. Other considerations of context also result in different ways of labeling this population at different places in the text. However, it is the position of these

Downloaded by [New York University] at 12:41 13 August 2016 authors that, above and beyond the labels, we are talking about human beings. Great effort has been taken to identify the illnesses—schizophrenia, major depression, borderline personality disorder, etc.—as something separate from who the person is in the world—brother, sister, mother, artist, father, friend, teacher, etc. The next issue involves our rationale for selecting the specific cases highlighted in this book. We selected the cases for a number of reasons: 1) These cases represent people with a range of psychopathologies. 2) The therapists treating the clients use a broad range of treatment modalities including psychodynamic, cognitive behavioral, and family systems therapy. 3) The 6 Introduction longevity of the therapy with the clients is unusual in that all cases span at least four years and one case terminates after 12 years of treatment. 4) Detailed case histories of psychodynamic treatment provide information that many professionals seek. 5) We provide case histories of older clients in long-term care facilities, another area in which more case histories are needed. 6) Our choices also act as a convenience sample, since we had access to clients in long-term care. All of the cases take place in either long-term care facilities (nursing homes) or state mental institutions. The rationale for the selection of cases being treated in these localities is relevant to the subject matter, interaction dynamics. Treatment that occurred in these locked institutions allowed for frequent observations of clients interacting with mental health professionals in different contexts in the milieu throughout the day. Concurrently, the long-term nature of these institutionalizations allowed for extended therapeutic involvement with clients. Another issue addresses the relation of our book to others on a similar topic. While related works exist, our book appears to be the only one that focuses specifically on the question of how structures of social interaction can promote psychological growth or harm in clients diagnosed with severe mental illness. We examine client interaction in a variety of contexts. Studies of such interaction tend to focus on one context: for example, the family. We consider clients’ interaction from the perspective of their subjective worlds, while also considering each client’s entire relational world. One more issue concerns the history of the quality of the interaction dynamics with people designated as severely mentally ill. Many texts have been devoted to the history of the treatment of mental illness. For the purpose of this book, we wish to touch on a few key points. Dating back to Neolithic times, interactions included interventions that were largely physically based. They often included barbaric attempts to rid the mentally ill person of “evil spirits” that possessed him: for example, trephining—a procedure that requires a hole to be formed in the mentally ill person’s skull, through which the evil spirit causing the psychopathology could be released, thus curing the individual (Foerschner, 2010). In some ways, trephining in its brutality does not appear to be very far removed from the twentieth-century procedure known as a lobotomy—where the patient’s frontal lobe was scraped

Downloaded by [New York University] at 12:41 13 August 2016 with an ice pick. This procedure, another form of “treatment,” produced damage that cut off all interactions between the mentally ill individual and society through institutionalization in often cruel and barbaric settings. The insane asylum has for centuries served as a place to rid society of this highly stigmatized population (Foerschner, 2010). It wasn’t until the late 1700s and early 1800s that more humanitarian ways of interacting with mentally ill individuals emerged. Philippe Pinel in Paris hypothesized that mentally ill patients would improve if they were treated with kindness and consideration (Butcher, Mineka, & Hooley, 2007). Under Pinel’s care, patients were no longer treated like animals but Introduction 7 unchained and encouraged to interact like human beings. The humanitarian approach reached the U.S. in the early 1800s. However, this form of treatment interaction was rare. Up until the introduction of psychoanalysis, physical interactions and isolation of the mentally ill person dominated, with staff frequently using restraints (e.g., straightjackets), spinning chairs, magnetism, and incarceration in harsh insane asylums largely devoid of positive human interactions. In the early part of the twentieth century, Freud’s “talking cure” highlighted the treatability of mental illness through therapeutic dialogue. Rather than advocating locking up the mentally ill person, Freud’s followers suggested that making the unconscious conscious through verbal interactions could lead to the remission of symptoms. Various forms of the “talking cure” evolved from Freud’s ideas, including the work of Carl Jung, Harry Stack Sullivan, Melanie Klein, Carl Rogers, Wilfred Bion, Alfred Adler, Aaron Beck, Marsha Linehan, David Foy, and others. Even with the evolution of many forms of individual, group, and family therapy, largely intrusive and at times brutal forms of treatment thrived during the early part of the twentieth century, including lifetime institutionalization in asylums where “therapy” involved physically invasive procedures including lobotomies, electroconvulsive therapy (ECT), insulin coma induction, and ice baths, with ECT being used extensively even today (Fink, 2001). The introduction of psychotropic medications in the mid-twentieth century greatly advanced the treatment of individuals with severe mental illness. Julius Axelrod’s work pertaining to the interaction among neurotransmitters (reuptake hypothesis) formed the basis for the development of modern psychotropic drugs (Rubin, 2007). His work ultimately led to the development of thorazine, the first anti-psychotic, which produced many side effects, including tardive dyskinesia—which can permanently impair gross and fine motor movement in patients (Jones, Barnes, Davies, Dunn, Lloyd, Hayhurst, & Lewis, 2006). The popularity of these drugs has skyrocketed since then, with millions prescribed annually (Götzsche, 2013). Today, the U.S. mental health system has institutionalized the provision of medication as the treatment of choice for severe mental illness—obscuring the role of social interaction in clients’ treatment. Despite much evidence to

Downloaded by [New York University] at 12:41 13 August 2016 the contrary, the mental health system tends to deny the possibility of recovery, treating severe mental illness as a chronic disease that can only be managed through the use of medication. Professionals use the word “illness” in a way that suggests that “mental illness” is solely a biological problem. This perspective encourages many professionals to ignore or inadvertently invalidate the client’s experience. Professionals often take minimal interest in their clients’ narratives and often neglect psychosocial issues—including histories riddled with abuse, neglect, and loss. Medication often takes the place of trying to solve the fundamental problem of how to interact therapeutically with those diagnosed with severe mental illness. 8 Introduction PSYCHOTHERAPY

The final issue to address involves the use of psychotherapy. While we analyze interaction dynamics in eight case studies, the therapies used in these cases are themselves forms of social interaction. The therapy used emphasizes contemporary approaches of psychodynamic therapy and Rogers’s conditions for growth-producing therapy. Marsha Linehan’s work in Dia- lectical Behavior Therapy (DBT) is also given emphasis from both a psychosocial and therapeutic standpoint. Additionally, other forms of cognitive behavioral techniques are mentioned throughout the cases from an integrative perspective. All of these schools of therapy on some level place interaction at the center of recovery. As indicated earlier, psychotherapy (or the “talking cure”), made its formal debut with the introduction of psychoanalysis. The psychoanalytic movement, which started in the early 1900s, gained popularity. The analyst and the analysand engaged in dynamic interactions, which included free association, interpretation, dream analysis, etc. These interaction dynamics ideally led to a remediation of symptoms. Psychoanalysis was based on drive theory or the importance of libido in motivating behaviors. The process of classical analysis would require daily sessions between therapist and analysand over the course of many years. The cure involved the client gaining an understanding for the latent meaning of manifest symptoms—making the unconscious conscious—and ultimately the resolution of childhood conflicts (Brenner, 1973). Freud’s psychoanalysis proliferated into various schools of thought, many de-emphasizing libido and focusing more on interaction dynamics. Sullivan’s (1974) interpersonal psychoanalysis foregrounded interaction dynamics. In object relations therapy, the quality of introjected interactions with “objects” (other people) greatly determines the quality of an individual’s mental health (Fairbairn, 1952; Guntrip, 1992; and Klein, 1946). In self psychology, there is a focus on interaction dynamics between self and others that emphasize empathy, self-objects, mirroring, idealizing, and introspection in enhancing development (Kohut, 1977). The frequency of interactions with the therapist in psychodynamic therapies is less than in psychoanalysis (one or twice a week) and the emphasis is on interactions that contribute to “exploring those

Downloaded by [New York University] at 12:41 13 August 2016 aspects of self that are not fully known, especially as they are manifested and potentially influenced in the therapy relationship” (Shedler, 2010, p. 98). Humanistic therapies entered the picture in the 1960s and 1970s. One of the most prominent members of this genre, Carl Rogers (1961), emphasized the importance of the quality of interactions between therapist and client in his work “The Six Necessary and Sufficient Conditions for Therapeutic Change.” Of the six conditions listed in this article, three are considered to be central to the therapeutic process. These three include 1) being in a relationship where one person is incongruent (the client) and the other person (the therapist) is in a state of congruence; 2) unconditional positive regard (UPR); and 3) empathy, with these three conditions to a degree being Introduction 9 understood by the client. Empathy stands alone as one of the most important ingredients to successful therapeutic outcomes in all schools of psychotherapy today (Feller & Cottone, 2003; Rogers, 1975). In the last few decades, psychodynamic and humanistic treatments have been overshadowed to some extent by shorter-term cognitive behavioral techniques or CBT (Bandura, 1961; Beck, 1995; Ellis, 1962; and others). Academicians, policy makers, and others in the medical profession have emphasized that more long-term psychodynamic and humanistic treatments lack empirical support, highlighting the efficacy of medication and cognitive behavioral therapies in outcome studies (Butler, Chapman, For- man, & Beck, 2006). In many cases, CBT therapies the importance of human interactions are de-emphasized in the treatment of psychopathology. CBT highlights the teaching of various techniques such as thought stop- ping, de-catastrophizing, psycho-education, and engaging in positive events to reduce psychopathology. CBT at least initially shows a more immediate positive therapeutic outcome; however, this outcome is not always long-lived (Shedler, 2010). With the influx of managed care and psychotropic medications, insurance companies have looked for quick cures to longstanding psychopathologic illnesses stemming in some cases from years of intense abuse, neglect, and loss. The brevity of individual therapy endorsed by managed care companies and the limited statewide funding devoted to mental health services have reduced the capacity to effectively utilize an integrative approach based on more than cognitive behavioral therapies with institutionalized severely mentally ill individuals. Medication continues to be viewed as the most appropriate means of abating symptoms. The introduction and enhanced sophistication of psychotropic medications have in many cases undermined the importance of the therapeutic relationship (or interpersonal relationships in general) in facilitating change. Even modern psychotropic medications produce serious side effects, including dramatic weight gain, diabetes, metabolic decompen- sation, and other serious side effects (Antipsychotic U, 2004). Shedler (2010) and others (Bateman & Fonagy, 2000; Leichsenring, Rabung, & Leibing, 2004; Shedler, 2002) have challenged the notion that psychodynamic treatments are not effective in treating personality disorders and other mental health conditions. Concurrently, evidence suggests that

Downloaded by [New York University] at 12:41 13 August 2016 the basic premises of a person-centered approach have influenced the practice of most therapeutic systems (Cain, 2010). Rogers (1980) states that as persons are empathically heard, they become more real and genuine, thus more openly expressing how they feel. The therapeutic efficacy of Rog- ers’s approach has been confirmed by many researchers (Kirschenbaum & Jourdan, 2005). Human interaction is tantamount to healthy psychological functioning, and good therapeutic interaction dynamics—as pointed out in the cases highlighted in this book—can be as central to the cure as psychotropic medications. Finally, we wish to mention that, although we spend a great deal of time highlighting weaknesses within the U.S. mental health system, we must also 10 Introduction acknowledge that many institutions that utilize medications in the allevi- ation of symptoms also employ caring workers, utilize useful groups, and offer good psychological support.

REFERENCES

Antipsychotic, U. (2004). Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care, 27(2). Bandura, A. (1961). Psychotherapy as a learning process. Psychological Bulletin, 58(2), 143–159. Basham, K., Heller, N., Mattei, L., Méndez, T., Northcut, T., Schamess, G., ... & Shilkret, R. (2011). Inside out and outside in: Psychodynamic clinical theory and psychopathology in contemporary multicultural contexts. J. Berzoff, L. M. Fla- nagan, & P. Hertz (Eds.). Rowman & Littlefield Publishers. Bateman, A. W., & Fonagy, P. (2000). Effectiveness of psychotherapeutic treatment of personality disorder. The British Journal of Psychiatry, 177(2), 138–143. Beck, J. S. (1995). Cognitive therapy. New York: John Wiley & Sons, Inc. Brenner, C. (1973). An elementary textbook of psychoanalysis. New York: Interna- tional Universities Press. Butcher, J.N., Mineka, S., & Hooley, J.M. (2007). Abnormal psychology. Boston: Pearson Education, Allyn & Bacon. Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clinical Psy- chology Review, 26(1), 17–31. Cain, D. (2010). Person-centered psychotherapies. Washington, D.C.: American Psychological Association. Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Carol Publishing Group. Fairbairn, W. R. D. (1952). Psychoanalytic Studies of the Personality. In Psycho- analytic Studies of the Personality (pp. 1–297). London: Tavistock Publications Limited. Feller, C. & Cottone, R. (2003). The importance of empathy in the therapeutic alliance. Journal of Humanistic Counseling, Education and Development, 42(1), 53–61. Fink, M. (2001).Convulsive therapy: A review of the first 55 years. Journal of Affec- tive Disorders, 63(1), 1–15. Foerschner, A. M. (2010). The history of mental illness: From ‘skull drills’ to ‘happy pills’. Student Pulse, 2(9), 1–4. Götzsche, P. (2013). Deadly medicines and organised crime. London: Radcliffe. Guntrip, H, (1992). Schizoid phenomena, object relations and the self. London:

Downloaded by [New York University] at 12:41 13 August 2016 Karnac Publishing. Herman, J. (1997). Trauma and recovery: The aftermath of violence—from domestic abuse to political terror. New York: Basic Books. Jones, P. B., Barnes, T. R., Davies, L., Dunn, G., Lloyd, H., Hayhurst, K. P., & Lewis, S. W. (2006). Randomized controlled trial of the effect on quality of life of second-vs first-generation antipsychotic drugs in schizophrenia: Cost utility of the latest antipsychotic drugs in schizophrenia study (CUtLASS 1). Archives of General Psychiatry, 63(10), 1079–1087. Klein, M. (1946). Notes on some schizoid mechanisms. The International Journal of Psychoanalysis, 27, 99–110 Introduction 11 Kirschenbaum, H. & Jourdan, A. (2005). The current status of Carl Rogers and the person-centered approach. Psychotherapy: Theory, Research, Practice, Training, 42(1), 37–51. Kohut, H. (1977). The restoration of the self. Chicago: University of Chicago Press. Leichsenring, F., Rabung, S., & Leibing, E. (2004) The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: A meta-analysis. Archives of General Psychiatry, 61(12), 1208–1216. Rogers, C. R. (1961). On becoming a person. Boston, MA: Houghton Mifflin, Co. Rogers, C. R. (1975). Empathic: An unappreciated way of being. The Counseling Psychologist, 5(2), 2–10. Rogers, C. R. (1980). A way of being. Boston, MA: Houghton Mifflin, Co. Rubin, R. P. (2007). A brief history of great discoveries in pharmacology: In celebration of the centennial anniversary of the founding of the American Society of Pharmacology and Experimental Therapeutics. Pharmacological Reviews, 59(4), 289–359. doi:10.1124/pr.107.70102. Semmelhack, D., Ende, L., & Hazell, C. (2013). Group psychotherapy with severely mentally ill adults: Adapting the Tavistock method. London, UK: Routledge. Shedler, J. (2002). A new language for psychoanalytic diagnosis. Journal of the American Psychoanalytic Association, 50(2), 429–456. Shelder, J. (2010). The efficacy of psychodynamic psychotherapy.American Psychol- ogist. 65(2), 98–109. Sullivan, H. S. (1974). Schizophrenia as a human process. New York: W.W. Norton. Szasz, T. S. (1960). The myth of mental illness. American Psychologist, 15(2), 113–118.

NOTE: For works cited from the World Wide Web, the links were accurate at the time of publication. With time however, they may have changed and might not be accessible in the same way as referenced here. Downloaded by [New York University] at 12:41 13 August 2016 1 Institutional Interaction Structures

In writing the first three chapters of this book, we reflected on the available literature on our topic—the social interaction structures that promote or hinder growth for psychiatric clients. (See the introduction of this volume for a definition of interaction structures/dynamics.) These reflections took into account an analysis of the structures of interaction in the eight case studies presented in chapters 4 through 11. (See chapter 13 for a list of major structures described in the case studies.) Our examination of the available literature and our analysis of the case studies informed each other. Integrating these two sources of information, we formulated common interaction structures that affect the psychological well-being of clients diagnosed with severe mental illness. We consider the structure of social interactions in three major areas: clients’ families, their friendships, and the institutions they belong to. This first chapter focuses on institutions. We consider mainly the types of institutions most relevant to the case studies: long-term care centers and state hospitals.

INSTITUTIONAL INTERACTION STRUCTURES THAT TEND TO DAMAGE CLIENTS

Institutional interaction structures are particularly important to focus on in that each individual described in the case studies resides in a locked institutional setting. This section describes interaction structures that tend to

Downloaded by [New York University] at 12:41 13 August 2016 impede growth for those with psychiatric issues. The locked nature of most long-term care centers and hospitals intensifies the importance of staff interactions with clients. On a locked unit there is no escape from the staff members who manage the care (including medical and mental health workers). Therefore, the quality of the matrix of interactions within the environment, if primarily growth-impeding, could contribute to the psychopathology.

Creating a Culture of Obedience Institutions for people diagnosed with severe mental illness often exert on residents a great pressure for obedience and at times can be coercive (Miller, Institutional Interaction Structures 13 2003; Szasz, 2002). A culture of obedience can undermine clients’ ability to grow psychologically. The inherent potential for the misuse of power by human beings (when put in authority positions over others) is best evidenced in the Stanford Prison Experiment (Zimbardo, 1971). We are not, however, opposing a hierarchical model of mental health treatment. Depending on the given staff, clients, and circumstances, a relatively hierarchical model may or may not be most effective. We aim here to explore a relatively non-hierarchical framework which operates in a nonjudgmental manner. D. Martin (1955) captures a sense of the role of obedience in mental health facilities in a moving quotation. He cites a passage about the shock many European psychiatrists felt when they looked at their mental institutions from the perspective of reconstruction and renewal present after World War II:

. . . the patient has ceased to rebel against, or to question the fitness of his position in a mental hospital; he has made a more or less total surrender to the institution’s life . . . He is co-operative. Here ‘co-operative’ usually implies that the patient does as he is told with a minimum of questioning or opposition. . . . [The] patient, resigned and co-operative . . . too passive to present any problem of management, has in the process of necessity lost much of his individuality and initiative (pp. 1188–1190).

Wing and Brown (1970) in a prominent critique showed how mental institutions actually produced what were mistakenly thought to be negative symptoms of schizophrenia. While obedience and passivity in these institutions were considered to be symptoms of schizophrenia, these writers demonstrated that these characteristics of residents in reality were related to the phenomenon of “institutionalization,” a gradual acquiescence to a state of life that precludes participation in the community outside the hospital (Wing & Brown, 1970). The first institutional structure we consider is aptly titled “Creating a Cul- ture of Obedience.” A culture of obedience may cultivate an unquestioned compliance with an institution’s rules. Some rules are explicit and others are implicit. The structure for creating a culture of obedience, for both residents and staff, has two major components, which are unconsciously integrated: 1) the use of reward and punishment to support adherence to the institu-

Downloaded by [New York University] at 12:41 13 August 2016 tion’s explicit and implicit rules; and 2) an implicit cultural value system that encourages compliance with these rules. Institutions use reward and punishment to encourage resident obedience. In addition to instituting rules for the facility as a whole, the staff designs plans that function as rules for individual clients. When a client enters the system, a psychological expert examines and diagnoses the individual. Staff develops a treatment plan for the client. This plan provides a basis for the application of reward and punishment. Diagnostic formu- lations and treatment plans, as official documents, carry a lot of weight. They not only have a clinical function, but also play a role in maintaining client obedience. 14 Institutional Interaction Structures The staff, for example, psychiatrists, psychologists, nurses, social workers, and certified nursing assistants, track each client’s behavior. An environment is created wherein client behaviors are constantly monitored and evaluated by staff (Goffman, 1961a). They evaluate client behavior in regular meetings and make plans for future behavior. In between these meetings, ‘bad’ behavior is written up and punished. At other times, clients may be rewarded. What may seem to an outsider to be relatively minor rewards and punishments can become extremely significant for residents, in part due to the deprivations they endure in institutional life (Goffman, 1961a; Weinstein, 1994). Such deprivations include, but are not limited to, lack of privacy, poor quality food, and lack of opportunities for social interaction or pleasure. For example, residents may have to wait an entire day for a cup of coffee. Punishments and rewards may involve whether one receives small items purchased for clients, coffee, passes to leave the facility, privileges to smoke, or permission to go on trips in the community. Sometimes the staff makes these privileges part of behavior plans (and at times the clients have some input). At other times, the presence or absence of these privileges functions as a more general means of encouraging ‘good’ behavior. Describ- ing the use of punishment and privileges in mental institutions, Goffman (1961a, p. 52) says, “The over-all consequence is that co-operativeness is obtained from persons who often have cause to be unco-operative.” More implicit rewards and punishments play a decisive role in the management of resident behavior (Taylor, 1979). The institution has power over the fulfillment of the most cherished wish—the wish to be released from the facility. This is a major source of obedience. Residents often feel like inmates condemned to living out their lives under prison-like conditions. Yet, at the same time, the residents fear being expelled from the institution. If expelled, they may become homeless (Hopper, Jost, Hay, Welber, & Haugland, 1997), end up in jail (Teplin, 1984), or be placed in a much worse facility—such as a nursing home, perhaps in an unknown location where they have no relationships (Simon, Lipson, & Stone, 2011). Past experiences with being homeless, abandoned, hungry, or unsafe can make the threat of being expelled terrifying. This is especially the case since many of these clients already are vulnerable to feeling paranoid. The threat of expulsion functions as an important motivation for compliance with the explicit and implicit

Downloaded by [New York University] at 12:41 13 August 2016 rules within the facility. Additionally, events that appear to have no link with reward and punishment can be perceived as punitive by the client. Hospitalization often functions in this manner. Clients sometimes hide the expression of their intense emotions due to fear that they will be hospitalized, or placed in a locked ward. Similar threats result from the practice of using ECT, isolation, or physical restraints. The use of force, including the ability to affect whether clients remain in the facility, ultimately lies behind the less intimidating dynamics (such as reinforcement of positive behaviors) that encourage resident compliance. This is partly because the residents, to a significant extent Institutional Interaction Structures 15 correctly, see themselves as having few choices in the day-to-day management of their survival outside of a facility. Another powerful implicit form of reward and punishment comes from staff attitudes toward clients. At times, the staff offers clients affection and understanding. This can have a great impact given clients’ isolation and social deprivation. In addition, clients generally want to please the staff. At other times, staff members explicitly or subtly adopt demeaning, punitive, or condescending attitudes toward residents. This is often conveyed through word choice or tone of voice. Without being aware, staff can at times be outright cruel or physically abusive, and clients may feel helpless and unable to defend themselves. The threat of being demeaned and chewed out for undesired behavior makes for a constant source of obedience. A vulnerable client’s whole day can be ruined by an abusive interaction with a staff member. One client in a nursing home, for example, became furious for more than a day over a fairly common incident:

I had a horrible flashback, and I urinated twice in my bed. I told the nurse what happened. She said I was trying to manipulate staff. I got written up for it. Why did she do that? I couldn’t help what happened to me!

However, after strongly criticizing abusive behaviors by staff, Barton (1966) says:

Before judging staff too harshly it must be remembered that mentally ill and elderly people can be maddening and exasperating and the chronic shortage of staff in most situations results in all but the most saintly employees becoming irritable and short tempered at times. (p. 14)

The self-righteous critic, Barton (1966) adds, “should work eight hours a day ‘with his hands in excreta’ for a few days before exploiting these tragic incidents with harsh criticism . . .” (p. 14). Barton is suggesting that one needs to look at staff’s actions from their perspective—working for a low wage, in a pressured environment with little admiration for the work that they are doing. The work of caring for institutionalized individuals could

Downloaded by [New York University] at 12:41 13 August 2016 be viewed as demeaning by society as a whole. The actions of staff are part of a system that includes clients, job conditions, clients’ families, the staff members’ colleagues and superiors, and the dependence of these factors in various ways on the larger social system within which the treatment center is embedded. Another aspect of reward and punishment involves the client’s family, friends, guardians, pastor, or other caring persons who may visit. Many residents manage to retain few links to those in the community. They depend on these visitors for a number of things, including advocacy, or having someone to get them out of the institution for a little bit of time. Since connecting with 16 Institutional Interaction Structures those outside the facility is so crucial for residents, and may not happen often, residents may feel obligated to maintain the expected behaviors of these visitors. The expectations of family members, of course, can have an especially powerful effect on residents’ behavior. Growth promoting expectations of family members allows the individual to feel connected to society as a whole. On their own, actions that function as punishments and rewards might not have a strongly coercive effect on the residents, or residents might rebel. The more or less acknowledged practice of reward and punishment, however, is integrated into an implicit cultural value system. This system creates a culture in the facility that encourages residents to take for granted the institution’s chosen practices. Behaviors are (mostly unconsciously) divided into ‘good’ and ‘bad.’ These categories are implicitly defined by the institution. The word ‘good’ implicitly associates compliant behavior with desirable qualities, making the behavior seem to be naturally and unquestioningly desirable. Other words do a similar job, including ‘appropriate’ versus ‘inappropriate’ and ‘healthy’ versus ‘unhealthy.’ Connotations of goodness or badness can also work in the same manner, as when a staff member says that a client ‘needs to’ take a shower—implying that taking a shower at that time is ‘good’—or when a client is described as being ‘late,’ which is ‘bad.’ ‘Good’ and ‘bad’ and related words can obscure the basis for the judgments they convey. They leave the impression that this judgment is obvious and agreed upon. The words can seem to suggest generally accepted social meanings and norms. In reality, however, the basis for the judgments underlying the use of the words ‘good’ and ‘bad’ is quite complex. The institution’s policymakers establish the rules behind many of these judgments. Many factors, however, play a role in determining the behaviors that come to be thought of as ‘good’ or ‘bad,’ including the funding available for carrying out practices; state pol- icies; mental health theories, opinions, and practices; socially dominant community attitudes toward mental illness; client needs; the threat of lawsuits; social norms; the wishes of the client’s relatives; and the attitudes of the institution’s personnel, especially those directly responding to the client behavior (who are most often low-level employees with high-stress jobs, low pay, and little or no training in the field). For the most part, the clients themselves are not involved in determining which of their behaviors are considered ‘good’ or

Downloaded by [New York University] at 12:41 13 August 2016 ‘bad,’ although in some cases clients can give some input into their treatment plans. Most of the factors listed above, moreover, include various parties whose opinions conflict with each other, sometimes at a fundamental level. The apparent simplicity and general agreement about values suggested by the use of the word ‘good’ is, therefore, an illusion. The word can take everything for granted. ‘Good’ and ‘bad’ tends to obscure exactly who determines that a behavior is good or bad, or how this determination is made. In a bureaucracy, it often occurs that no one is responsible for the institution’s rules. They just seem to somehow exist. One is left with the feeling that there is no need to reflect on what lies behind the judgments being made, or to consider the question of the client’s own judgment of his behavior. Institutional Interaction Structures 17 When one does reflect on the underlying value system of institutions for those diagnosed with severe mental illness, one might find that what is valued most is efficiency (especially as financially defined), the reproduc- tion of the institution itself, the meeting of various regulations imposed on the institution from outside, compliance in taking medication, orderliness, obedience, punctuality, cleanliness, and politeness (Gammonley, Zhang, & Paek, 2010). Significantly less valued is the experience and the emotional lives of the residents, their standard of living, a systemic view of their behavior (rather than one that focuses only on individuals’ behavior), initiative, responsibility for one’s own treatment and way of living, privacy, the physical beauty of the environment, connection with the community, stimulation, meaningful and purposeful work and other activities, autonomy, community, relationships, social interaction, collective responsibility, therapy, self-actualization, empathy, caring and compassion, and respect for the dignity of the residents (Kayser-Jones, 1990). If staff and clients regularly reflected on the meaning of behaviors rather than blindly accepting them as ‘good’ or ‘bad,’ they might consider the experiences and motivations behind their behaviors, the systemic causes and consequences of their behaviors, and how the clients and staff might want to change these things. Staff and clients might cultivate ideas about what they would consider most valuable in an institution and what to do about it. Later in this chapter we will consider the dynamics of ‘therapeutic communities.’ In these therapeutic community settings, staff and clients reflect on the meaning of behavior rather than simply identifying behaviors as good or bad. Staff and clients think about the results of their institution being the way it is and how they might go about changing it (Main, 1977). The implicit value system is turned into an explicit one (Pestalozzi, Hin- shelwood, & Houzel, 1998). Together with clients, staff may engage in a non-judgmental unpacking of meaning that would be impossible in a judgmental atmosphere. An environment in which such things take place encourages critical thinking rather than obedience. Such an environment might in part be characterized by Rogers’s necessary and sufficient conditions for therapeutic change, including empathy, unconditional positive regard, and congruence. The cultivation of obedience discourages agency and initiative (Milgram,

Downloaded by [New York University] at 12:41 13 August 2016 1963, 1974). It contributes to resident apathy and lethargy. In facilitating compliance, the institution itself encourages residents to maintain a false self (Miller, 1980; Winnicott, 1971). The constant judgment of behavior has a severe effect on people in institutional environments (Goffman, 1961a). For example, residents learn to avoid self-disclosure out of fear of being criticized or punished. This results in the opposite of a therapeutic environment, which is an environment that would encourage clients to grow. It results in the opposite of a holding environment, in which residents do not feel accepted and do feel judged. This lack of a holding environment creates a place where clients do not possess the ability to take risks without being judged and, therefore, are not free to explore their true selves. 18 Institutional Interaction Structures We imagine several objections that might emerge in response to this section of the book:

1. Words like ‘good’ might be thought of as being merely symbols representing ideas, or words used as a shorthand for an explanation. If the word ‘good’ is used as shorthand and an explanation of it is provided, then in that situation the word may not have the detrimental effects described. However, the word ‘good’—like all words, in fact—tends to be a slippery meaning-creating device, not merely a representation of ideas. We have attempted to present here some of the possible effects and connotations of the word ‘good.’ 2. The use of words like ‘good’ is necessary for the efficiency of the institution. If staff and clients often stopped to reflect on the ideas underlying the judgments of their behaviors, this would greatly slow down the institution’s operations (Menzies-Lyth, 1960, 1988). This is accurate. By avoiding such reflection, employees keep their minds clear for other more practical matters. The slowing down process, however, is crucial for humanizing institutions. There are programs that do this—we will discuss some of them further in the chapter—and these programs allow clients not only to survive, but also to thrive! 3. The behavioral rules in institutions for those diagnosed with severe mental illness may seem benign. They involve such things as taking showers, eating meals, taking medication on time, not begging or stealing, and not touching or harassing others. The rules that are significant, however, concern the maintenance of hierarchical relationships between staff and clients and the maintenance of a hierarchical organizational structure. These rules are implicit and rarely questioned. Another important rule consists of the need for compliance with one’s treatment plan. The general attitude of compliance in the institution tends to result in compliance in this area as well. However, the need for collaboration in treatment is widely known by professionals. In many cases, the staff is willing to adopt a more collaborative model, especially when clients speak up for this (Menzies-Lyth, 1960, 1988). 4. With the population in question, a certain amount of coercion may be advisable to ensure that the standards of the institution are upheld.

Downloaded by [New York University] at 12:41 13 August 2016 The elimination of all forms of coercion may be difficult. There are programs, however, that attempt to eliminate or at least minimize coercion (Gale, Realpe, & Pedriali, 2008). 5. Sometimes obedience makes a relationship efficient, effective, and even inspiring. We will not take on the complex and important question of when obedience functions as a desirable client behavior.

Basing an Environment on Projections In harmful institutions for people diagnosed with severe mental illness, residents and staff do not understand one another. Residents often note that Institutional Interaction Structures 19 staff does not understand them. The failure of residents and staff to understand each other, however, is not incidental, but part of the environment’s design. The institution, in fact, depends on the ability of residents and staff to misunderstand each other. The staff exaggerates how passive and helpless the residents are; residents have an exaggerated conception of how active and powerful the staff is (Hinshelwood, 2001). This dynamic functions as a defense against anxiety in the case of both parties (staff and residents). These misunderstandings legitimize the social hierarchy that puts staff in power. They also facilitate the hierarchy’s operation. If the residents and staff saw each other as whole people, what would legitimize one group’s (the staff’s) control over the other? Projection and hierarchy can work together to demean residents and aggrandize staff. The structure of this basic misunderstanding involves two steps. The first step concerns the use of projection in the pre-institutional life of the subject. At some point in their lives, probably in their infancy, people begin to project onto those who later become described as ‘mentally ill’ the idea that something is the matter with them. At a certain point, these people come to be seen as ‘crazy’ or ‘intolerable.’ Others (such as family or friends) find interacting with them (the designated patients) to be disturbing and through the use of projection—and projective identification—the others (family, friends, etc.) attempt to ward off their experience of being disturbed. This is what the “the others” learn from the social norm. As a further benefit, the projecting party gets to be seen as ‘normal.’ This use of projection depends on the mechanisms of splitting and introjection. The projecting person splits off the part of himself or herself that feels disturbed and projects this part into the ‘mentally ill’ person. The designated patient then tends to introject this projected part into themself, thereby becoming ‘crazy.’ Moreover, the ‘crazy’ party tends to project normality onto the friend, family or other party, who introjects the idea of her normality. The second step of this interaction structure describes how this projection becomes transformed in the context of the institution. In the institution, these projections become exacerbated. This is because the pervasive explicit and often implicit social hierarchy systematically demeans the residents, setting them up to be seen as inferior beings. The degree of projection also occurs because this hierarchy assigns staff the responsibility to manage and

Downloaded by [New York University] at 12:41 13 August 2016 oversee the lives of the residents, who are seen as being incapable of taking care of themselves. In American society, mental health staff in institutions often take for granted the ability to infantilize their residents. While describing the humiliating use of punishment in such institutions, Goffman (1961a, p. 51) notes that “Whatever their severity, punishments are largely known in the inmate’s home world as something applied to animals and children . . .”. Americans unquestioningly accept the existence of practices in institutions for those with psychiatric problems that they would never allow to exist in their own lives. Perhaps most of all, the projections are so intense in these institutions because the residents’ disturbing affects are so hard to bear. Before they 20 Institutional Interaction Structures came to the institution, the residents’ projection is often “so extreme the family ejects the culprit to a distance that lessens the impact of those projections. Families protect themselves from a kind of psychic assault, this intrusive, explosive action upon their minds” (Hinshelwood, 2001, p.140). The process of projection both helps the staff to ward off this unbearable affect by projecting its disturbing quality onto the ‘crazy’ residents and helps the residents avoid dealing with this affect by projecting their active selves onto the staff. The residents feel relieved of the need to address their unbearable affect because they have placed their responsibility in the staff. The residents thus take on the character of being passive and helpless, while the staff takes on that of being active and helpful. Projecting their weakness and vulnerability onto the residents, the staff feel like they are ‘the healthy ones.’ Another factor affecting the staff’s demeaning projections onto residents results from the great stress of managing a number of difficult residents at once in a highly time-pressured unit. Such projection can be seen in a textbook describing such a unit in a hospital, where there is great time pressure on staff. Sharfstein, Dickerson, and Oldham’s (2008) Textbook of Hospi- tal Psychiatry at one point describes the milieu with a string of demeaning connotations. The book speaks of “agitated, disorganized, needy, attention-seeking, and aggressive patients, which can result in a contemporary state of bedlam” (p. 129). The demeaning connotation of these words reflects the kind of projections that occur when staff is unable to handle stressful situations with residents. And in a real-life situation between client and staff, demeaning words are often much more pejorative. For example, staff may use pejorative terms such as bitch, bastard, or asshole to identify a disruptive patient. Later, the book suggests “a dictionary of patient-specific target behaviors” that can help staff track patients in the busy milieu. This list includes “yelling, cursing, threats, sexual self-stimulation, inappropriate touching of others, intrusive attention seeking, failure to get out of bed, or medication refusal” (Sharfstein et al., 2008, p. 129). The time pressure in such a milieu results in a systematic pigeonholing of patients into these categories so that the staff image of patients results not from an understanding of the person, but from one-word descriptors of the trouble the patients cause. The use of such a system guarantees that patients are seen in terms of projections.

Downloaded by [New York University] at 12:41 13 August 2016 Menzies-Lyth (1960, 1988) highlighted the objectification of patients in a British teaching hospital as a way of warding off intense anxieties that emerge in staff when life and death anxieties are prevalent. This objectification manifested in nurses who referred to patients in the hospital as part objects, such as “the heart patient in bed five.” Staff treated patients as if they had no existence before or outside of the hospital. In contrast to such objectification, a calm and containing environment can reduce clients’ acting-out behaviors before they escalate. Projection works in conjunction with more explicit social dynamics such as social hierarchy. Psychological writers sometimes write about projection Institutional Interaction Structures 21 as though it accounts for the whole social dynamic of an institution by itself. While writers deny the importance of projective identification because it is threatening to face it, they may also focus only on projection to avoid addressing explicit power dynamics. Discussing therapeutic communities, Thomas Main (1977) has written a very thoughtful critique of how attention to social structure can ignore the dynamics of “how people relate to each other” (such as through projection) (p. 14). He differentiates formal structure (rules, regulations, and designated hierarchy) from an institution’s “culture.” Main suggests that “culture” (in a milieu) transcends formal rules and regulations organically emerging in response to interpersonal interactions and relationships between all members of the community (staff and residents included). Yet his focus only on dynamics of projection (cultural dynamics) can obscure the powerful role that “social structure” plays in therapeutic communities, as well as elsewhere. This happens in the similar situation in which clinical professionals view psychoanalysis as the sole basis for analyzing social dynamics (Spandler, 2006).

The Fundamental Use of Amputating Containment R.D. Hinshelwood’s (2001) foreword to a book on psychiatric institutions stresses the difficult emotions involved when working with the residents: “Patients who have to be admitted into institutions for treatment are the most difficult” (Pestalozzi et al., 1998). Hinshelwood states that:

. . . these people who are more than society can cope with, often exhibit violent or self-harming behavior and threaten the psychological balance both of themselves and of those whom they interact with. He describes their communication as “a kind of acting-upon the mind of others . . . a kind of “psychic” action, as it were, which invariably has a violent effect on the receiver of these actions—and that is what we have to contain in our institutions (Pestalozzi et al., 1998, p. xvii).

The fundamental distortions (or dislocations) of projection provide a means by which institutions try to avoid the experience of these highly disturbing affects. The institutions also try to deal with these affects using another

Downloaded by [New York University] at 12:41 13 August 2016 means that is in a sense even more extreme. This is the interaction structure of amputating containment, a structure that attempts to contain disruptive affect by seeking to rid the institution of it altogether. The staff medicates residents, soothes them, punishes them, hospitalizes them, evicts them, places them in isolation or restraints, or adopts cognitive approaches to addressing their issues that ignore emotions. This behavior often derives from a damaging concept of the need for detachment from residents’ problems. Many staff members believe in uses of detachment that become a basis for avoiding experiencing residents’ affects. Mental health professionals will often say that this detachment enables staff to effectively serve clients. Residents may 22 Institutional Interaction Structures endorse this approach to their experience because it protects them from having to address emotional pain that may be attached these experiences. Yet this approach can amputate the very experience that needs to be addressed. Mental health workers often have a general idea of containment that blurs the distinction between amputating containment and Bion’s (1970) theory of containment, which is its opposite. The general idea of containment suggests providing safety or sanctuary, setting limits, and keeping a disturbance from causing damage, spreading, or leading to acting out. Bion’s (1962) concept can include these suggestions, but focuses specifically on other things: 1) The therapist seeks to experience, understand, detoxify, and transform an affect that the client finds unbearable. 2) The therapist returns this transformed affect to the client in a more manageable form, a form in which the client can think about it. By experiencing containment over time, the client learns to act as the container for her own difficult emotions. 3) This process depends on the therapist’s receptivity to his or her own unconscious thoughts, feelings, and fantasies, and in particular on their receptivity to their own unconscious response to the client’s disturbing affect. (The therapist explores their reverie—such as their free associations towards the client—as a way of becoming aware of this unconscious response. This processing of the reverie may take quite a bit of time to unfold, at times over the course of many therapy sessions. Given the disturbing nature of the affect, a supervisor may provide a holding environment that helps the therapist to explore her reverie.) 4) Finally, in order to work with the resident’s experience, the therapist needs to tolerate and to process rather than to avoid the resident’s suffering. Eaton (2005) suggests that therapists need to learn to become “projective identification welcoming objects” in which this process can take place. The efficiency-focused practices of a typical institution do not support the kind of a holding environment conducive to Bionian containment, but the practice has been effectively applied in long-term care centers or other locked institutions (Hazell, 2005). Mental health professionals, then, often use the word ‘contain’ in a way that blurs together two opposite processes—one that explores a painful experience, Bion’s containment, and another that covers over it, amputating containment. Mental health professionals would benefit from gaining an understanding of the ethical and therapeutic ramifications of these processes

Downloaded by [New York University] at 12:41 13 August 2016 and how they negatively and positively impact recovery. An analogy may further clarify the dynamics of amputating containment. This method of interaction resembles the approach of a local muffler shop to faulty exhaust systems. Upon being asked to repair an exhaust system, the owner of this shop indicated that the business did not repair exhaust systems, but only replaced them. He could not answer any questions about the broken system. It was as though this muffler shop man knew nothing about exhaust systems, but only about how to replace them. This resembles the attitude of mental health workers who use only amputating containment in response to clients’ distress. It is as if the staff knows nothing at all about the client’s emotional wounds, but only about how to replace a distressed Institutional Interaction Structures 23 mental state with another mental state (for example, by providing medication). Unlike mufflers, however, damaged emotions, though they may be numbed, soothed, or ‘quieted down,’ cannot be actually addressed through mechanical actions. A psychotic client reported an experience he had in a treatment program that carefully attended to most of his needs, while at the same time completely ignoring his strong feelings. A busy psychiatrist met with the client to see whether there was any need for changes in his treatment. The psychiatrist listened to him, but when the client began using difficult imagery involving a boiling lagoon inhabited by fierce monsters, the doctor would suddenly turn away from him and tend to his high stacks of paperwork. Discussions with the client showed that the unusual imagery that the psychiatrist ignored, as is frequently the case with such imagery, expressed in a partially obscured (and thus protected) form the client’s deepest and most important feelings. The psychiatrist had apparently felt that he could better use his time catching up on his paperwork because the strange imagery, in his view, was to be treated simply as a standard symptom of psychosis, rather than as an important expression of the client’s concerns. It frequently occurs that mental health practitioners focus on conventionalized schemas for what constitutes a particular ‘mental illness’ and pay minimal attention to the unique features that make up the individual’s experience. Sometimes the formula is as simple as DSM criteria plus ‘stressors’ (stressful life events) that are thought to trigger psychotic episodes. Programs designed to contain individuals who have psychosis are often based on such thinking, which amputates the emotional states of these individuals. An astonishing example of such amputating containment took place in a long-term care center. The center was well kept, and the staff seemed friendly and caring. A new therapist working at this facility was asked to familiarize himself with some of the residents. He proceeded to read through an enormous file on a fairly new resident who was diagnosed with major depression. The file contained the results of many different tests and examinations, a number of them physical, though many psychological, and various kinds of reports, evaluations, and background information on the client. It took some time to work through all the information. Professionals had put great care into collecting, presenting, and organizing all this information. Yet

Downloaded by [New York University] at 12:41 13 August 2016 when the therapist finally finished reading the chart, he noted an astounding omission. Not one item in the file said anything regarding why this man was depressed! Thinking there must be an error, the therapist found the professionals who had been working on the case and respectfully asked for further information. The resident had been interviewed, diagnosed with major depression, given medication, and now was participating in groups, much like the other residents. He had a dedicated therapist, who was very concerned about the resident’s well-being. It was a busy department, the resident’s therapist said, and there was neither time nor need for more in-depth therapy. The previous therapist did admit that failing to ask the resident what he was depressed about was an unfortunate omission, but this did not 24 Institutional Interaction Structures interfere with the diagnosis and treatment, and the resident’s treatment in general was little different from that of anyone else in the facility. One of the most radical forms of amputating containment is hospitalization. Often, hospitalization will blast away the mental state of the patient through powerful medications and displacement of the patient from his usual circumstances. Often, the hospitalization covers over the patient’s experiences prior to entering the hospital and her reflections on these experiences. The individual often leaves the hospital with less truly useful information about her problems than when she was admitted to the hospital. A person may enter the hospital with a complex, painful, psychosocial problem, and leave with a ‘biological’ one that is considered to a large degree outside of the individual’s control. Although there may be a limited, rushed attempt to address psychosocial concerns in the hospital, the focus on medication sends the message that psychosocial concerns are secondary, if relevant at all. Painful social experiences that played a key role in leading to the hospitalization may be ignored or forgotten by the time the patient leaves. Earlier, we showed how The Textbook of Hospital Psychiatry (edited by Sharfstein et al., 2008) described the practice of projecting negative qualities onto patients in the high-pressure hospital environment. This textbook also makes statements that emphasize the hospital’s basis in amputating containment. Discussing the time squeeze in contemporary psychiatric units, the book rather casually states that “hospital staffs often forget to talk to the patient” (Sharfstein et al., 2008, p. 30). The book also does little to suggest that it would be in the interest of clients to pursue psychotherapy even once they leave the hospital. This gives the impression that medication (to be provided by psychiatrists) is the only treatment for serious psychological issues. This book presents psychiatric treatment for those diagnosed with severe mental illness as a treatment that works. When such treatment does not produce the intended results, it is often said that the patient is ‘treatment resistant’ or ‘non-compliant.’ The fact that the majority of patients remain severely impaired and socially limited after years of psychiatric treatment does not stop the authors of this textbook from conveying the impression that the treatment “works.” This viewpoint, as articulated by Sharfstein and colleagues, dismisses treatment that would help patients live meaningful and fully

Downloaded by [New York University] at 12:41 13 August 2016 functioning lives. The textbook serves the psychiatric profession’s interests by minimizing any acknowledgment that other treatments exist and can help. In stark contrast to the aforementioned viewpoint, Bertham Karon (2003) cites the work of Frieda Fromm-Reichmann (1939) and takes the position that treating schizophrenia without psychotherapy is tragic. According to Karon (2003), Fromm-Reichmann:

. . . made clear that schizophrenia is a human experience with meaning, meaning that is hard to uncover, but it only takes patience, kindness, a tolerance for not understanding as well as for the patient’s desperate Institutional Interaction Structures 25 defenses, and a willingness to understand the human condition at its most painful and to take psychoanalytic ideas seriously when patients talk about them. Understanding persons with schizophrenia means facing facts about ourselves, our families, and our society that we do not want to know, or to know again (in the case of repressed feelings and experiences). (p. 1).

Karon goes on to state that one-third of individuals diagnosed with schizophrenia fully recover within 25 years and another third have social recoveries with or without treatment. She says that “psychological treatments before the neuroleptic era, from “moral treatments” to psychoanalytic therapies, produced superior results, but we are not using them” (p. 1).

Depersonalization The process of depersonalization involves an individual being divested of human characteristics or their sense of individuality. According to Goffman (1961a), the process of depersonalization is common in many institutions that facilitate the “treatment” of those with severe mental illness. It is a process in which one becomes depersonalized as one adopts the identity of a diagnosis. For the most part, in various institutions the patient becomes their diagnosis. For example, a woman whom we shall call Sarah has many roles prior to her psychiatric hospitalization—teacher, mother, and wife. Upon hospitalization for a psychotic episode, staff depersonalized her by referring to her as “the schizophrenic” in Room 230. In this case, Sarah is deposed of her normal social roles and stripped of her usual identities (Menzies-Lylth, 1960). The process of being hospitalized and the common experience of depersonalization that accompanies it may lead patients to feel as if they have been deserted by society. Stigmatization contributes to the depersonalizing process. According to Corrigan (2004), “Stigma yields two kinds of harm that may impede treatment participation: It diminishes self-esteem and robs people of social opportunities” (p. 614). Years of stigmatization can lead to the internalization of stigma. In this case the person sees himself or herself as nothing but a label and becomes devoid of humanness. The person, in fact, becomes

Downloaded by [New York University] at 12:41 13 August 2016 “employed” as a full-time severely mentally ill person.

INSTITUTIONAL INTERACTION STRUCTURES THAT TEND TO FOSTER GROWTH

This section describes interaction structures that tend to foster growth for those with psychiatric issues. In the process, a bit further on, we describe two psychiatric institutions focused on interaction structures that promote growth: first, therapeutic communities and, second, the Open Dialogue 26 Institutional Interaction Structures Program (Seikkula & Olson, 2003), a specific psychiatric program developed in Finland.

Containment Many institutions for severe mental illness make use of interaction structures that support growth. The use of containment and the holding environment are important examples of interaction structures in many institutions that promote growth. Both Wilfred Bion (1962) and D.W. Winnicott (1965) identified the importance of these structures based on observations of early childhood development. According to Bion (1962), containment is a process linked to early infancy where the caregiver hears and absorbs the cries of pain, hunger, and discomfort exhibited by the infant and in turn reflects them back to the child in such a way that these feeling states can be tolerated. The consistent use of the containment of otherwise unbearable emotional states by the caregiver contributes to a child’s ability to think and manage experiences and emotional states. This early capacity to manage emotional states becomes paralleled in how a therapist responds to a client in therapeutic adult interactions.

Holding Environment Similarly, a holding environment is linked to “good enough mothering” and involves the caregiver’s capacity to provide a safe and secure haven for the developing child (Winnicott, 1960). Actions that facilitate the development of a safe holding environment include physically holding, feeding, bathing, and caring for the infant in a consistent and loving way. Winnicott (1965) extrapolated the idea of holding environments to therapeutic milieus and the treatment of adults, suggesting that the therapist, like the original caregiver, must through their actions (i.e., interpretations, interventions, empathy, etc.) provide a safe environment where therapeutic change can occur. Even in institutions that appear to provide growth-inhibiting interactions, holding environments and containment can occur that facilitate positive therapeutic change. In a seemingly toxic treatment environment, a single mental health care provider who shows empa-

Downloaded by [New York University] at 12:41 13 August 2016 thy and genuine care for a patient in great emotional distress can make a difference in the patient’s recovery. Likewise, group therapy that facilitates supportive peer interactions can elicit a holding and containing environment wherein members can openly share and express their thoughts and feelings and ultimately grow psychologically.

The Therapeutic Community Some institutions go further in terms of altering interaction structures in order to promote growth. One of these is the therapeutic community (Ken- nard & Roberts, 1983). This kind of community has been described as a Institutional Interaction Structures 27 kind of laboratory for examining the dynamics of interpersonal relationships (Bloom, 1997). The term “therapeutic community” has been applied to institutions ranging from mainstream ones (such as a typical group home) to those that depart significantly from the mainstream (to be discussed later in this chapter). Therapeutic communities, like the Tavistock method discussed in chapter 12, developed based on the group work of Wilfred Bion. Bion (1961) studied psychological problems in a group as problems of the group itself, rather than as the problems of individual members (Bion, 1961). Therapeutic communities also consider individual behavior in terms of its function in the group. The therapeutic community movement gained steam in the 1960s in response to the widespread critique of large state mental hospitals for treating patients in inhumane and ineffective ways. Over time, different kinds of therapeutic communities developed in different situations based on need. An example of a therapeutic community is a home in which therapists live with residents who have serious emotional problems. The community of therapists and residents frequently meets to discuss house dynamics, and much group work takes place, as well as intensive individual integrative therapy with a psychodynamic base. Supervisors meet frequently with staff to examine how the psychotherapy, community meetings, and informal house activities taking place relate to each other. Supervision might consider, for example, how a resident’s actions in the home reflect this resident’s transference, as discussed in individual therapy. Therapeutic communities rely a great deal on integrative approach. Kernberg (1982) summarizes the three central features of a therapeutic community. The first is Community Treatment. Staff and clients work together in an organized community, where both parties are co-responsible for the treatment. Next is Therapeutic Culture. All interactions and activities relate to clients’ education and social rehabilitation. Last, but not least, is Living-Learning Confrontation. Clients and staff openly respond to behaviors and reactions to them, in the Here and Now, and explore how these behaviors function.

Creating a Culture of Enquiry

Downloaded by [New York University] at 12:41 13 August 2016 The therapeutic community focuses on an interaction structure: Creating a culture of enquiry. Thomas Main (1977) developed the concept of the culture of enquiry in response to what he saw as the routinized thinking characteristic of social institutions. He believed that institutional workers tend to forget the purpose behind their actions, yet continue to perform them in an unthinking way. A culture of enquiry requires members (staff, family members, and clients, etc.) to constantly reflect on why the institution does things the way that it does. All members reflect on all the systems (including the personal systems and other sub-systems) that form the system of the institution as a whole (Main, 1977). They reflect on their own behaviors and their 28 Institutional Interaction Structures relationships with others. Members of the group—as in psychodynamic therapy—keep asking themselves: “What is going on between us?” (Hin- shelwood, 2001, p. 113). They reflect on underlying transferences and countertransferences. An institution with a culture of enquiry, such as a therapeutic community, does not leave individuals to address the institution’s dynamics on their own. The institution may pressure clients to reflect on interpersonal relations to assist them through this process. Frequent, regular meetings including staff and residents are scheduled for this reflection. Staff model interpersonal reflection for residents. These meetings create a containing space for interpersonal reflection, and this increase in interpersonal reflection contributes to a more effective healing environment. The usefulness of these meetings depends on their “quality of emotional linking” which is described above (Hinshelwood, 2001, p. 106). Group members need to respond to each other’s comments with emotional understanding and connection. When responses in the interaction proceed in a dismissive or fragmenting way, this discourages emotional growth or understanding of group dynamics. A therapist can help members become aware of group processes that prevent linking. The therapist can assist in making the emotional and intellectual connections for the group, and this helps the group develop the ability to function as a container (Hinshelwood, 2001). The culture of enquiry locates the source of wisdom in the discussion in all the members of the group, not simply in the professionals. All involved “are encouraged to be curious about themselves, each other, the staff, the management structure . . . the institution and everything else pertinent to events and relationships within the community” (Campling, 2001, p. 365). This encourages members to re-think their roles, to see themselves as responsible for everything and therefore as initiators, not as passive members of a predetermined structure. The culture of enquiry works against the culture of obedience that characterized our large state mental institutions from the past and continues, although to a lesser degree, in today’s institutions (Main, 1977). The community as a whole comes to think and care about itself. While therapeutic communities focus on creating a culture of enquiry, elements of this culture occur at various times and places in traditional institutions as well. Downloaded by [New York University] at 12:41 13 August 2016 Sharing Power Another interaction structure at the heart of the therapeutic community is sharing power. This structure played a key role in the roots of the therapeutic community, Bion’s therapeutic work at the Northfield Military Hospital during World War II (Harrison, 2000). Bion was put in charge of a ward full of undisciplined soldiers that the hospital considered neurotic. Bion, however, refused to ‘treat’ them. While expressing to the soldiers his critical view of their behavior, Bion made it Institutional Interaction Structures 29 clear that he himself would do nothing about it and left it to the soldiers to take responsibility for their own behavior. After an initial chaotic period, this strategy proved to be very successful, and the soldiers’ behavior changed. Bion’s refusal to exercise power over the soldiers, however, disturbed his superiors, and they decided to dismiss him. Nonetheless, Bion’s practice of working with groups whose members themselves take responsibility for the group made a significant impact at Northfield Hospital. His experiment was considered Northfield I. His ideas were later taken up in another experiment in group work referred to as Northfield II. Tom Main (1977), who helped to create Northfield II, described the role of the psychiatrist in the “therapeutic community” as a sharing of power. He thought that psychiatric hospitals centered too much on the doctors’ interests and required the full participation of the whole hospital community:

The anarchical rights of the doctor in the traditional hospital society have to be exchanged for the more sincere role of member in a real community, responsible not only to himself and his superiors, but to the community as a whole . . . He no longer owns “his” patients. They are given up to the community which is to treat them . . . Patients are no longer his captive children, obedient in nursery-like activities, but have sincere adult roles to play, and are free to reach for responsibilities and opinions concerning the community of which they are a part . . . [The patients help] formulate the conditions . . . of group life. (Main (1977) quoted in Bridger, 1990, p. 21)

In terms of structure, sharing power may involve shared decision-making, staff negotiating their roles with residents, increased flexibility of roles, or letting residents create their own structures. Therapeutic communities have varied greatly in terms of the degree to which power has been shared. For example, in the U.S., a number of substance-abuse-focused therapeutic communities have strict hierarchical orientations. Whereas the crippling effects of obedience have been noted, power sharing can have many benefits, such as increasing residents’ self-esteem, motivation, initiative, and responsibility (Jones, 1976). The therapeutic alliance is frequently strengthened by the therapeutic community. And power sharing may greatly improve commu- Downloaded by [New York University] at 12:41 13 August 2016 nity cohesion—a key therapeutic factor (Main, 1977). Some common objections to sharing power are its inefficiency, inef- fectiveness, or that power relations are pervasive in our society and cannot be avoided (Gale et al., 2008). There is research, however, suggesting that therapeutic communities (which generally include sharing power) can work effectively and in a cost-effective manner (Gale et al, 2008; David & Mak-Pearce, 2001). As regards to the pervasiveness of power relations, it is true that power runs through our society, interactions, and personal attitudes. Institutions cannot magically transform this by setting up a particular 30 Institutional Interaction Structures kind of structure. There is evidence, however, suggesting that residents and staff who are used to working in hierarchies can gradually learn how to act as partners (Gale et al., 2008).

Open Dialogue Like the therapeutic community, the Open Dialogue program is also focused on an interaction structure that facilitates growth for clients with psychiatric issues. Open Dialogue, a program developed in Finland, has been noted for its unusual success. Impressive research suggests the effectiveness of this approach to therapy (Haarakangas, Seikkula, Alakare, & Aaltonen, 2007, p. 222), which is also cost effective. In Open Dialogue, a therapeutic team responds to psychiatric crises immediately and flexibly, preferably at the client’s home. Such flexibility continues throughout the treatment, which may last for years. The therapeutic team remains in place for the length of the treatment. The team uses medication sparingly and they also avoid hastily resorting to hospitalization. Rather, they tolerate uncertainty and emotional distress. This helps the team to be receptive to the experiences of those present. The group’s focus is on creating a dialogue among the various parties, both professionals and non-professionals, who play a role in the client’s treatment. Staff members seek to involve important members of the client’s social network in the treatment. The professionals involved may include therapists, psychiatrists, nurses, or social workers. The main focus of the treatment takes place in meetings that include all participants. These meetings seek to bring about open dialogue, which helps to create mutual empathy, insight, and cooperative work. The group develops “a new collective understanding about the nature of the problem” (Haarakangas, et al., 2007, p. 224).

Multi-Voiced Conversation (This section is based on the essay “Healing Elements of Therapeutic Con- versation: Dialogue as an Embodiment of Love” (Seikkula & Trimble, 2005)). Multi-voiced conversation, a key element of the Open Dialogue program, is designed to draw out the voices of everyone present. Each group member

Downloaded by [New York University] at 12:41 13 August 2016 presents her unique perspective—the client, the family, the psychiatrist, the nurse, the therapist, the client’s close friends, the employer, etc. The therapist seeks to ensure that everyone—and above all, the client—“feels heard, responded to, and ultimately understood” (Seikkula & Trimble, 2005). No single voice or perspective is allowed to dominate. There is no hierarchy in the room. Other components of the structure include the following: Staff members make no attempt to arrive at one ‘true’ description. There is no attempt to hurry. Enough time is allowed so that everyone can have her say, expressing her emotions fully. Ideally, everyone responds to a multiplicity of voices. Institutional Interaction Structures 31 Multi-voiced conversation helps to create strong group cohesion and community. The group respects and takes seriously the client’s psychotic perspective, as it does all the other voices present. The client’s behavior is not the sole focus of the meeting. This assists the client in not feeling stigmatized or scapegoated. In addition, families do not tend to feel blamed, as they have at times in family therapy. Families feel listened to by the others who are present. They play a key role in helping to link the client’s psychosis with life events. In a situation where a client experiences psychosis, relationships are often strained, if not severely damaged. Open Dialogue can help to restore these damaged relationships. This can play a significant role in a psychotic person’s recovery. Open Dialogue shows that institutionalized interaction does not have to be alienating; it can have a healing function. We will suggest that therapeutic communities, the Open Dialogue program, and Tavistock groups (chapter 13) help to counteract the negative dynamics we have discussed in this chapter: the culture of obedience, projection, amputating containment, and depersonalization.

REFERENCES

Barton, R. (1966). Institutional neurosis (2nd ed.). Oxford, UK: Butterworth- Heinemann. Bion, W. R. (1961). Experiences in groups. London: Tavistock. Bion, W. R. (1962). Learning from experience. London: Heinemann. Bion, W. R. (1970). Attention and interpretation: A scientific approach to insight in psychoanalysis and groups. London: Tavistock. Bloom, S. L. (1997). Creating sanctuary: Toward the evolution of sane societies. New York: Routledge. Bridger, H. (1990). The discovery of the therapeutic community: The Northfield experiments. In E.E. Trist, H.E. Murray & B.E. Trist (Eds.). The social engagement of social science: A Tavistock anthology (Vol. 1, pp. 68–87). London: Free Association. Campling, P. (2001). Therapeutic communities. Advances in Psychiatric Treatment, 7(5), 365–372. Corrigan, P. W. (2004). How stigma interferes with mental health care. American Psychologist, 59(7), 614–625. David, E., & Mak-Pearce, G. (2001). Is the Arbours Crisis Centre cost-effective? In J. H. 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New York: Anchor Books/Doubleday. Goffman, E. (1961b). On the characteristics of total institutions. In R. Keith Cannan (Eds.), Symposium on preventive and social psychiatry (pp. 43–84). Washington, DC: Government Office Printing. Haarakangas, K., Seikkula, J., Alakare, B., & Aaltonen, J. (2007). Open dialogue: An approach to psychotherapeutic treatment of psychosis in Northern Finland. In H. Anderson & D. Gehart (Eds.), Collaborative therapy: Relationships and conversations that make a difference (pp. 221–223). New York: Routledge. Harrison, T. (2000). Bion, Rickman, Foulkes, and the Northfield experiments: Advancing on a different front. London: J. Kingsley. Hazell, C. (2005). Imaginary groups. Bloomington, IN: Authorhouse. Hinshelwood, R. (2001). Thinking about institutions: Milieux and madness. Lon- don: Jessica Kingsley Publishing. Hopper, K., Jost, J., Hay, T., Welber, S., & Haugland, G. (1997). Homelessness, severe mental illness, and the institutional circuit. Psychiatric Services, 48(5), 659–665. Jones, M. (1976). Maturation of the therapeutic community: An organic approach to health and mental health. New York: Human Sciences Press. Karon, B. P. (2003). The tragedy of schizophrenia without psychotherapy. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 31(1, Special issue), 89–118. Kayser-Jones, J. S. (1990). Old, alone, and neglected: Care of the aged in the United States and Scotland (Vol. 4). Oakland, CA: University of California Press. Kennard, D., & Roberts, J. (1983). An introduction to therapeutic communities. London: Routledge. Kernberg, O. F. (1982). Self, ego, affects, and drives. Journal of the American Psy- choanalytic Association, 30(4), 893–917. doi:10.1177/000306518203000404 Main, T. (1977). The concept of the therapeutic community: Variations and vicissi- tudes. Group Analysis, 10(2), S2–S16. doi:10.1177/05331647701000212 Martin, D. (1955). Institutionalisation. The Lancet, 266(6901), 1188–1190. Menzies-Lyth, I. (1960). A case in the functioning of social systems as a defense against anxiety: A report on a study of nursing service of a general hospital. Human Relations, 13, 95–121. Menzies-Lyth, I. (1988). Containing anxiety in institutions: Selected essays (Vol. 1). London: Free Association Books. Milgram, S. (1963). Behavioral study of obedience. The Journal of Abnormal and Social Psychology, 67(4), 371–378. Milgram, S. (1974). Obedience to authority. New York: Harper & Row. Miller, A. (1980). The drama of the gifted child: The search for the true self. New York: Harper Collins. Miller, J. B. (2003). Work in progress: Telling the truth about power. Wellesley, MA: Wellesley Centers for Women (Stone Center). Retrieved from http://www.jbmti. Downloaded by [New York University] at 12:41 13 August 2016 org/pdf/100sc.pdf Pestalozzi, J., Frisch, S., Hinshelwood, R. D., & Houzel, D. (Eds.). (1998). Psycho- analytic psychotherapy in institutional settings. London: Karnac Books. Seikkula, J., & Olson, M. E. (2003). The open dialogue approach to acute psychosis: Its poetics and micropolitics. Family Process, 42(3), 403–418. Seikkula, J., & Trimble, D. (2005). Healing elements of therapeutic conversation: Dialogue as an embodiment of love. Family Process, 44(4), 461–475. doi:10.1111/15455300200500072 Sharfstein, S., Dickerson, F., & Oldham, J. (Eds.). (2008). Textbook of hospital psychiatry. Arlington, VA: American Psychiatric Publishing. Institutional Interaction Structures 33 Simon, S. E., Lipson, D. J., & Stone, C. M. (2011). Mental disorders among non-elderly nursing home residents. Journal of Aging and Social Policy, 23(1), 58–72. Spandler, H. (2006). Asylum to action: Paddington day hospital, therapeutic communities and beyond. London: Jessica Kingsley Publishing. Szasz, T. S. (2002). Liberation by oppression: A comparative study of slavery and psychiatry. Piscataway, NJ: Transaction Publishers. Taylor, S. E. (1979). Hospital patient behavior: Reactance, helplessness, or control? Journal of Social Issues, 35(1), 156–184. Teplin, L. A. (1984). Criminalizing mental disorder: The comparative arrest rate of the mentally ill. American Psychologist, 39(7), 794–803. Weinstein, R. M. (1994). Goffman’s asylums and the total institution model of mental hospitals. Psychiatry: Interpersonal and Biological Processes, 57(4), 348–367. Wing, J. K., & Brown, G. W. (1970). Institutionalism and schizophrenia. London: Cambridge University Press. Winnicott, D. W. (1960). The theory of the parent-infant relationship. International Journal of Psychoanalysis, 41(6), 585–595. Winnicott, D. W. (1965). The maturational processes and the facilitating environment: Studies in a theory of emotional development. New York: IUP. Winnicott, D. W. (1971). Playing and reality. London: Tavistock Press. Zimbardo, P. G. (1971, October 25). The power and pathology of imprisonment. Congressional Record (Serial No. 15). Hearings before Subcommittee No. 3, of the Committee on the Judiciary, House of Representatives, Ninety-Second Con- gress, First Session on Corrections, Part II, Prisons, Prison Reform and Prisoner’s Rights: California. Washington, DC: U.S. Government Printing Office.

NOTE: For works cited from the World Wide Web, the links were accurate at the time of publication. With time, however, they may have changed and might not be accessible in the same way as referenced here. Downloaded by [New York University] at 12:41 13 August 2016 2 Social Interaction With Families

The next interaction structures we analyze consist of family interactions. Family interactions deeply affect the well-being of clients with psychiatric problems (Dixon, Adams, Lucksted, 2000). But treatment tends to leave them out of the therapeutic process. Instead, professionals offer medication and at times psychosocial treatment without family involvement (Bedell, Hunter, & Corrigan, 1997; Miklowitz, 2004). For a long time, professionals have adopted a critical or detached position with regard to the families of clients with serious psychological disorders (Miklowitz, 2004). The families have often been seen as detrimental to treatment. The “experts”, who tend to believe that they have the answers, have often looked down on families, seeing themselves as the professionals, as being at the center of treatment (Burbach & Stanbridge, 1998; Mosher, 1969). Families may lack professional knowledge, but their commitment and compassion to the client embody a kind of knowledge that at times is more important than the professionals’ detached form of knowledge. Most of the research on families with a disturbed member has focused on their negative effects on the client. A few studies, however, have examined families’ resilience, pointing out their “acceptance, hardiness, hope, mastery, self-efficacy, sense of coherence, and resourcefulness” (Zauszniewski, Bekhet, & Suresky, 2010). Professionals often do not appreciate the endless sacrifices that families make trying their best to help a family member with a psychiatric disability. Many professionals seem to forget the battles that families may engage in year after year trying to help their afflicted child or family member survive.

Downloaded by [New York University] at 12:41 13 August 2016 Moxon and Ronan (2008) describe the problems faced by such families:

Relatives may feel anxious or helpless because they do not know what to expect. Relatives may also feel other forms of negative affect because they cannot change the illness or feel they can help. Additionally, they may feel angry at the difficult behavior of the patient or resentful at having to provide more care than is usually required for a person of the patient’s age. Relatives may then also feel guilty for these feelings. Addi- tionally, patients and family members may feel stigmatized or ashamed, and socially isolate themselves (p. 47). Social Interaction With Families 35 Given families’ love, compassion, and sense of responsibility for a family member suffering from psychiatric problems, unavoidable exhaustion often results in inner conflict that produces even more strain. This stress can often exacerbate the patient’s psychopathology which is discussed in greater detail later in the chapter. An article on a family intervention for schizophrenia by Moxon and Ronan (2008) introduces the world of family interventions. The article mentions that many of these interventions have been created over the past 20 years and explains how important they are. However, it proceeds to say that applications of these interventions “have been limited largely to research settings [emphasis ours]” (Moxon and Ronan, 2008, p. 48). This reflects a tragic situation: Families that have members with schizophrenia badly need help from the mental health system. Ways of helping are available, and yet these families receive little help. This partly results from professionals’ reluctance to help. This reluctance to help contributes to a vicious cycle in which a hospitalized psychotic family member gets discharged from the hospital after being “stabilized” into their care. The family is often left helpless with little access to available resources to intervene in the treatment of their family member upon discharge—the lack of support may result in the client’s relapse and ultimately re-hospitalization. A therapist’s critical or detached relation to the family acts as a defense mechanism. Is it too much to say that families are often left out of treatment precisely because their involvement is so central to the issues at hand? It is true that professionals not only doubt the productiveness of involving families, but also fail to advocate for more family involvement because they believe that mental health agencies simply lack the resources to provide much family intervention. The financial viability of some programs, however—such as Open Dialogue—suggests that resources may not be an insurmountable problem (Seikkula & Olsen, 2003). Family involvement in therapy has been shown to be a very effective and potentially cost-effective approach to solving psychiatric problems (Seik- kula & Olsen, 2003). The research just cited suggests that family intervention contributes to the well-being of both client and family when certain variables and/or conditions exist in the relationship. The lack of professional advocacy for family involvement seems to be part of an underlying

Downloaded by [New York University] at 12:41 13 August 2016 unconscious reluctance—on the part of mental health staff, administrators, family, and clients—to confront the central issues that may emerge given family participation, issues considered potentially explosive, such as deeply rooted relational conflicts. Such central issues could include, for example, rage about a parent’s failure to attend to a child’s needs in her younger years (Moxon & Ronan, 2008). Everyone involved in the patient’s treatment (professionals, staff, and family) may tacitly agree not to have open discussions of these central issues. Professionals often face, in the presence of both family and client, the deep emotional conflicts often underlying the relationship between the 36 Social Interaction With Families two (family and clients). To maintain a distanced, hierarchical, perhaps critical view of the family makes it easier for professionals to talk about these conflicts. Yet it may be crucial to respond to these conflicts openly and directly while empathizing with and respecting the viewpoints of both family and client (again, as in the Open Dialogue program) (Seikkula & Olsen, 2003). Using this kind of interactive approach, family therapy can reduce the defenses of all three parties—the professionals, the family, and the client—helping each party to develop empathic perspectives of the others. This can result in much healing (Seikkula, Aaltonen, Haarakangas, & Lehtinen, 2006; Seikkula & Trimble, 2005).

INTERACTION STRUCTURES THAT STIFLE GROWTH

Early Childhood Discord Genetics, without question, contribute much to the development of schizophrenia. The social interaction of early childhood, however, we believe plays a role as well—in fact, a very large role. Much research supports this conclusion (McGuffin, Asherson, Owen, & Farmer, 1994; Van Os & McGuffin, 2003). The expansive literature on the therapy of schizophrenia, according to Gabbard (2014), shows a clear consensus: An important causal factor of schizophrenia is disturbance between the infant and caretaker relationship. Moreover, recent research indicates that childhood trauma plays a causal role in psychosis and schizophrenia (Larkin & Read, 2008; Varese et al., 2012). Finally, a fairly recent study suggests that when children who are genetically at risk for schizophrenia are brought up in a well-functioning family, their risk factors for schizophrenia diminish (Hooley, 2007). Mainstream psychology appears to act as though this research does not exist. In fact, it goes further and fosters what might be referred to as the “illnessization” of psychiatric disturbances. This tendency represents certain psychological features (for example, hallucinations) as components of a biologically framed “illness” by speaking of them in isolation from the social dynamics that, therapy shows, are inherent in them. Portrayals of schizophrenia tend to emphasize hallucinations, delusions, and disorga-

Downloaded by [New York University] at 12:41 13 August 2016 nized speech and behavior. These positive symptoms stand out, and they are unusual and dramatic (DSM-IV-TR; Owen, 2012). The most horrify- ing component of the disorder, however, and perhaps the core component of it, may be the sufferer’s radical estrangement from her fellow human beings (Lipton, Cohen, Fischer, & Katz, 1981). This characteristic, however, is difficult to measure, painful to face, and time consuming to address. Yet addressing this interactional component of the disturbance may be at the heart of effective treatment. Our society’s focus on biology in the treatment of schizophrenia partly constitutes a reaction against earlier portrayals that stressed environmental causes without providing sufficient evidence to support this emphasis. Social Interaction With Families 37 Writers in the field of psychology, for example, have strongly rejected Freida Fromm-Reichmann’s concept of the “schizophrenigenic mother,” whom she represented as the chief cause of schizophrenia (Fromm-Reichmann, 1948). Many have expressed anger about this explanation of schizophrenia for its false and negligent blaming of mothers. Unfortunately, this criticism, while valid, has contributed to the current tendency to simply overlook the environment’s role in the development of schizophrenia. Meanwhile, our society’s focus on biology and medication reinforces the idea that the social environment of the disorder does not warrant much attention (Lewis & Levitt, 2002). Part of the trouble in acknowledging the role of social interaction in severe mental illness is that we have not established exactly how this interaction leads to psychiatric disability. Sullivan (1974) vehemently described schizophrenia as a problem of social interaction. He described the problem as a result of faulty mothering that made an infant anxious and prevented the mother from fulfilling the infant’s needs (Gabbard, 2014). The mother was unable to provide a workable holding environment for the infant, an explanation that still makes sense despite what is believed about the biological etiology of severe mental illness today (Gabbard, 2014). Gabbard (2014) also proposes that, due to a problem of the caregiver, the child, or both (or indeed the fit between mother and child), some caregivers cannot function to contain an infant’s projective identifications. The caregiver therefore cannot modify the child’s distressing psychic material and then return it to the infant in more manageable form (Gabbard, 2014). This basic disruption in the caregiver’s relationship with the infant may contribute to the development of schizophrenia when certain risk factors exist and are not adequately addressed. Larkin and Read (2008) present a cognitive model for how the environment, or more specifically trauma, can lead to psychosis. According to this model, an experience of trauma may lead to “negative beliefs about the self, world, and others” that are linked with psychosis. One may come to believe that “I am vulnerable;” “others can’t be trusted;” “the world is dangerous.” Thoughts which reinforce these negative beliefs about intense interpersonal conflict can be transformed into psychotic thinking. This negative ideation can damage not only the client’s sense of self, but also his relationship with

Downloaded by [New York University] at 12:41 13 August 2016 those around him. Thus, dealing with a person experiencing a psychotic break can be tremendously stressful for his caregivers, who are left to deal with this negative ideation—potentially directed at them. The stresses of caregiving for psychotic individuals can lead to intense emotional reactions (Wearden, Tarrier, Barrowclough, Zastowny, & Rahill, 2000). In 1972, researchers presented a concept called “Expressed Emotion” (EE), which describes a damaging form of interaction between a family and its schizophrenic member (Brown, Birley, & Wing, 1972). The family develops a high level of criticism, hostility, and over-involvement towards the client. This concept has undergone a great deal of research, which has affirmed its validity (Moxon & Ronan, 2008). Now the workings of this 38 Social Interaction With Families well-received concept bear a striking resemblance to the dynamics involving the firmly rejected description of the schizophrenigenic mother—a popular concept in psychodynamic literature from the 1940s to the 1970s (Neill, 1990). As in EE, the schizophrenogenic mother was described as an emotionally overly involved, critical, and at times abusive family member. Frieda Fromm-Reichman (1948) was the first to identify disordered maternal relationships as the cause of schizophrenia. Why is this resemblance between Frieda Fromm-Reichman’s (1948) concept and EE barely noticed? This occurs partly because of the current disinterest in examining the basis of present-day behavior in early childhood events. We are not calling for a revival of the schizophrenigenic mother concept, but raising the question of whether the characteristics of Expressed Emotion that exacerbate schizophrenia could also be related to the dynamics of the schizophrenigenic mother.

Expressed Emotion Caring for a family member with severe mental illness can be very difficult, frustrating, and annoying, and caregivers can and often do burn out. It is not surprising, therefore, that caregivers sometimes react to the family member in a critical, hostile, or emotionally over-involved manner. These interactions may often demean or invalidate the person with the severe mental illness, and have been extensively studied by Butzolff (1998) and Hooley (2007). Numerous studies have shown that these interactions often reach a level of negativity that can have damaging results both for the individual with the emotional disorder and for the family (Kavanagh, 1992). Researchers initially developed the concept of Expressed Emotion to explain relapses in schizophrenia. When clients with schizophrenia returned home from a hospitalization to a high EE family environment, their chances of relapse more than doubled compared with those of other clients (Brown et al., 1972; Hooley, 2007). According to Barrowclough and Terrier (Moxon & Ronan, 2008, p. 28), relatives who rate high at EE “tend to be locked into a series of negative interactions” with the client, while “low EE family members appear to be more able to ‘go with the flow.’ ” Family members rating high in EE may act intolerantly, intrusively, or inflexibly, thus depriving a client of a sense of autonomy (Moxon & Ronan, 2008, p. 29).

Downloaded by [New York University] at 12:41 13 August 2016 Family members who receive high EE ratings, however, may have quite good intentions. In fact, Hooley (2007) stated that those given high EE ratings may be people who tend to play a more active role in addressing life’s challenges, while those who receive low ratings might be more likely to simply let things take their course. Far from being unusual, those with high EE ratings are actually more normative in most of the industrialized world than those countries with low EE ratings (Hooley, 2007). In fact, as the stress of caring for a client increases over time, the majority of relatives end up with high EE ratings (Hooley, 2007). Despite the caregiver’s good intentions, Expressed Emotion can have serious consequences. Relapses for people with psychotic disorders can be Social Interaction With Families 39 devastating. The relapses can undermine an individual’s employment, housing, education, and relationships. They can bring on psychosis, disorgani- zation, isolation, emotional numbing, and severe problems with motivation and self-esteem. Sometimes, a relapse leads to suicide attempts. It can further stigmatize the individual, which may interfere with a whole range of opportunities that may no longer be available to them. Finally, a relapse can exacerbate the neurological damage already brought about by earlier bouts with psychosis, making recovery more problematic. Negative interactions, therefore, are not minor events. They can help initiate a chain of events that ultimately shatters a person’s life. Brown, et al. (1972) noted that clients with schizophrenia discharged from institutions tended to relapse more often when they returned to their families than when they would live alone. These researchers designed a study to find out what in the family environment could have led to this higher level of relapse. Research led to the focus on the family’s hostility, criticism, and emotional over-involvement in reaction to a family member with schizophrenia. Their research showed that a high level of Expressed Emotion in family interactions strongly predicted the psychiatric relapse of the family member with schizophrenia. For the last 50 years, extensive evidence supporting the predictive value of EE in a variety of cultures has accumulated. Based on their meta-analysis of studies examining EE and outcomes for individuals with schizophrenia, Butzlaff and Hooley (1998) found “that EE is a significant and robust predictor of relapse in schizophrenia” (p. 547). Other studies (Hooley, 2007) have also shown that high EE levels predict worse clinical outcomes for individuals with mood disorders and other serious psychological conditions. The research has also been extended to apply to social environments beyond the family. Stud- ies have shown that mental health professionals themselves exhibit high EE levels, a significant problem for the profession (Van Humbeek & Van Audenhove, 2003). Based on our clinical experience, Expressed Emotion appears to char- acterize the defense mechanism of projection. Projection serves as perhaps the most central defense mechanism for families with a psychotic member. The family member’s disturbed feelings in response to the client become projected onto the client, who is denigrated or criticized, per-

Downloaded by [New York University] at 12:41 13 August 2016 haps as a “crazy” person. Disturbance in the family becomes projected onto the client, who in turn becomes the “designated patient” (Bowen, 1978). Expressed Emotion is not just a means of coping with stress. It defends against a family member’s unconscious feelings toward the psychotic member and is related to the caregiver’s transference and to the feelings of the family as a whole. The client as well tends to project her painful feelings onto the caregiver. Using projective identification, the caregiver projects her suffering onto the client in the form of criticism and hostility. Caregivers also use emotional over-involvement in the attempt to reduce their own suffering, trying to control what seems to be the source of their suffering (Farber, 2008). A circular situation 40 Social Interaction With Families develops wherein each party unconsciously tries to unburden herself of painful emotion by projecting it onto the other, only to find it directed back at her. This leads to a viscous cycle of EE and damaged relationships within the family. The caregiver’s penchant for projecting emotions onto the client derives in part from the hierarchical role that the caregiver plays. When the relationship between the caregiver and the client is a mutual one, there is more respect for the client, and this reduces the level of the caregiver’s projections. Family therapy programs responding to the problems caused by EE tend to emphasize the need for caregivers to show tolerance and empathy for the person with the psychiatric disorder. Research demonstrates that these programs can reduce EE from high to low levels, thus significantly reducing the likelihood of relapse (Falloon et al., 1982). Unfortunately, our society makes little use of these programs (Moxon & Ronan, 2008).

Non-Mutual Interaction The interaction between an individual with a psychiatric disability and her family tends to be non-mutual. By non-mutual interaction we are referring to communication that is not characterized by autonomy and reciprocity. Interactions lacking in mutuality can be harmful for individuals with psychiatric disabilities. The concept of mutuality in relationships is very important because the quality of an individuals’ relationships with others impact on their mental health. The notion of non-mutuality (or mutuality) in relationships is very important in that the quality of relationships an individual is involved in ultimately has some impact on her mental health. As discussed earlier, these individuals’ lives involve a great deal of interactions with people who see themselves as their superiors. People who act as helpers in particular, as noted, often speak as individuals who occupy a position above the client in a hierarchy (Laugharne & Priebe, 2006). The heavy presence of hierarchical relationships in the lives of those with psychiatric disabilities takes a toll on them (Rosenhan, 1973), and these hierarchical relationships can often make them feel inferior, demeaned, dependent, disconnected, and powerless. They may feel unable to voice their opinions which creates a lack of authenticity in their relationship with

Downloaded by [New York University] at 12:41 13 August 2016 others. The experiences of both parties (helper and helpee) may become deeply buried inside. Both parties may keep authentic parts of themselves outside of the relationship, thus limiting their ability to grow. Painful feelings may be kept out of the relationship, which they are then unable to change from experience. People with psychiatric issues may feel a need to be compliant with their relatives in order to preserve the familial relationship. This resembles a crucial interaction pattern described by Miller and Stiver (1998): the individual stays out of connection with the family member in a desperate attempt to preserve a connection with her and avoid painful affect. Social Interaction With Families 41 Emotional Cutoffs In addition to projection, families often use another defense to try to get rid of their disturbed feelings toward the client: the “emotional cutoff” (Bowen, 1978). The emotional cutoff is a more radical form of distancing, and it is practiced universally in families (Titelman, 2014)—unlike Bowen, we do not see emotional cutoffs as inherently negative. While at times taking a break from family interactions can be necessary— allowing for self-reflection and insight into heightened emotional reactions that can allow for the rational processing of conflict—emotional cutoffs are more extreme and can perpetuate conflict and destructive emotional states. The emotional cutoff is the ultimate amputating containment. The defense (emotional cutoff) can take many forms, from ignoring an emotionally disturbed relative in an interaction to maintaining a large physical distance from the person that facilitates emotional distance. The family member doing the emotional cutoff often feels that she cannot deal with her distressing feelings anymore, or is outraged with the behavior of the person with the disability. After a major emotional cutoff, a caregiver’s love for and attention to the client may gradually, imperceptibly become increasingly muted. The caregiver may fantasize that their disturbed relative no longer exists or is well taken care of by the long-term care facility or group home where they may be residing. Again, emotional cutoffs are most often reflected in the caregiver’s failure to visit, call, or make any attempt to contact the emotionally disturbed relative. Often, the family member who facilitates the emotional cutoff does not reflect on the impact of her actions on the disabled individual. Since people with emotional disabilities tend to have few social connections, a significant emotional cutoff can devastate them. This can contribute to depression, wounded self-esteem, and perhaps further a withdrawal from social contact. In severe cases, it may facilitate an emotional breakdown (Kayser-Jones, 1990). Distance at times can have beneficial consequences, not only for the caregiver, but for the emotionally disturbed person as well. Sometimes, the tem- porary use of distance may relieve anxiety sufficiently to make reflection possible on the relationship. This can easily be taken too far. The relief afforded by distance may be treasured and then the distanced relationship may ossify to the point that one is oblivious to the dangers that can occur if a cutoff of communication lasts too long. By the time there are attempts at Downloaded by [New York University] at 12:41 13 August 2016 restoring communication, it may be too late. In this way, a relationship may be silently killed off. Sometimes, an emotional cutoff is accomplished almost instantaneously. Following a painful and devastating interaction, a family member may make a drastic effort to get some peace of mind, such as taking a vacation, during which the specific contents of the interaction and the feelings associated with it may become obliterated, sometimes permanently (Titelman, 2014). One of the keys to evaluating the effects of an emotional cutoff may be whether it makes possible the processing of an emotional difficulty or simply avoids the difficulty, leaving the actual meaning of this distancing unconscious. 42 Social Interaction With Families Over the years, many obstacles interfere with family members’ abilities to maintain their level of assistance for a relative diagnosed with severe mental illness. This may include burn out, the exhaustion of resources, or frustration with having many times struggled to provide assistance that was then rendered useless or squandered by the relative in need. The mental health system often offers family little help when they need it very badly. Eventu- ally, a family may reach the threshold where they can no longer manage to take care of a psychologically disabled relative, and the family may be faced with institutionalizing the individual (Pejlert, 2001). This form of distancing may reduce the family’s suffering, and the result may be tragic and perhaps permanent for the family member with the disability (Kayser-Jones, 1990). It is hard to grasp the deep loneliness and isolation that exists in residential institutions for the severely mentally ill. Families often use another common defense to alleviate their difficult suffering: denial. The family with the member diagnosed as having a severe mental illness more or less denies there is a problem. The family may make strenuous efforts to compensate for the difficulties of having a member with a psychiatric disability, while simultaneously denying or ignoring the underlying problem as if it doesn’t exist. Such families may act as closed systems, with rigid boundaries, trying to keep away outsiders who might interfere with the dynamics of the family system that perpetuate the problem (Hinshaw, 2005).

INTERACTION STRUCTURES THAT FACILITATE GROWTH

Interaction Structures That Help Foster Love Families can play a central role in treatment because they have a decisive advantage over most people who assist the client: They love the client. This may translate into caring and commitment way beyond what staff can offer, as well as the satisfaction of emotional needs that others are unable to sat- isfy. Our mental health system does not appreciate the key role that love plays in treatment. This partly results from the fact that the professionals generally are not the ones who provide it. Often, families express their love for the client indirectly by providing

Downloaded by [New York University] at 12:41 13 August 2016 concrete and practical assistance. The family’s love for the client often is intertwined with painful feelings related to their difficult relationship with the client. Expressing love concretely allows them to express the love while keeping a distance from the relationship. The concrete and practical assistance that families provide contributes a great deal to clients’ psychological growth but at the same time does not address the emotional pain experienced by the family. Individuals with psychiatric disabilities tend to be impoverished, isolated, and limited in their practical skills. Frequently, clients live meager lives under dreary circumstances and may come to feel that they deserve to live in such harsh conditions. Therefore, concrete and practical support contributes to their self-esteem. Having a relative take a Social Interaction With Families 43 client out from a residential institution for a visit every week can mean a tremendous amount to the client, on many levels. Family visits and phone calls—or the lack of them—affect residents deeply. Residents may often treasure small gifts, or even being offered a little bit of quality food. Individ- uals with psychiatric disabilities also rely on families’ “strengths, expectations and knowledge” (Topor et al., 2006, p. 22). In addition, families often play crucial roles as advocates. The staff’s awareness that a family monitors treatment in itself can result in better care. Overall, the family’s presence carries great symbolic meaning for clients. And it carries a lot of weight. It contributes to clients’ strength, stability, and resourcefulness. A family’s love helps them (the family) to provide emotional nurturance. Often, infrequent interactions with their families of origin are the only loving interactions that clients experience. Family members’ defenses against experiencing their painful relationship with the client may hinder their ability to directly express love, but many families do manage to respond directly to clients’ emotional needs through concrete and practical acts. Often, it is simply the family member’s presence that the client needs (Topor et al., 2006). In this case, the non-verbal aspect of caring may be more important than what is said. This is because a great deal depends both on the family member’s authenticity and on her emotional receptivity to the client. Families also play a crucial role in treatment by providing warmth and unconditional positive regard. These qualities too, as in the widely accepted principles of Rogerian psychotherapy, greatly depend on the authenticity of expression. Verbal effectiveness also plays a significant role in emotional nurturance. This is central, for example, in empathy (Rogers, 1961). Families accomplish a good deal in treatment by providing clients with empathy. Empathy is not simply an attitude, for achieving it depends to a significant degree on the spe- cifics of one’s verbal expression (Bonvicini, Perlin, Carroll, Rouse & Gold- stein, 2009). This applies as well to another key element of family nurturance: validating the client. Families often validate clients’ strengths and abilities. Given the tendency to stigmatize these clients, validating them often requires some verbal facility. Validating the clients’ personhood is especially important in a depersonalizing environment such as long-term care (Freeth, 2007). Mental health workers should partner with family members in helping them to better understanding their mentally ill member. A greater understanding

Downloaded by [New York University] at 12:41 13 August 2016 of the person’s illness could help in generating more empathic interactions between family members and the diagnosed individual (Leggatt, 2002). Authenticity is just as important in providing empathy and validation. When coming from the heart, empathy and validation work against the depersonalizing effects of a residential institution. A simple example of validation during a visit by a family member might be complimenting the client on how nice he looks or how neat and clean his room appears. It might also involve recognizing the person for some accomplishment, such as acquiring a volunteer job at the institution. Simple positive remarks like the ones just discussed go a long way in frequently stark institutions where very few validating interactions occur. 44 Social Interaction With Families A family’s love for a member with a psychiatric disability can help them to tolerate what might otherwise be very annoying behavior. Often, these families intuitively create a low stress environment for the member. This helps the family member to function better, thereby reducing the family’s burden. The decreased stress for caregivers also reduces their need to project painful affect onto the client. This need to decrease stress is emphasized in the research on how to reduce Expressed Emotion (Brown et al., 1974; Hooley, 2007). Moreover, tolerance for the client’s behavior helps caregivers to stay grounded in their affectionate feelings toward the individual, which improves the quality of the relationship. Often, caregivers’ ability to be tolerant depends on how well they take care of their own well-being which allows them to remain more engaged with family members (Baronet, 1999). Caregivers own well-being can be enhanced by owning their own projections. Their enhanced sense of well-being allows them to cultivate empathy which research supports as the greatest antidote (empahsis ours) to Expressed Emotion. Winnicott’s (1994) essay “Hate in the Counter-Transference” provides insight on this topic. The essay portrays hatred toward the person one is helping not as a negative quality to be avoided, but as an understandable emotion for a caregiver under difficult circumstances, an emotion that needs to be understood rather than shunned. Shunning the emotion often results in repressing it and then unconsciously projecting it onto the person cared for. Exploring the hostility that inevitably emerges, on the other hand, helps caregivers to be more empathic. A family’s love sometimes helps the family to create intimacy with a psychiatrically disturbed member who others believe to be hopelessly incapable of communication. Part of this involves the willingness to avoid role-playing, which is another common defense against pain. People who speak to someone with a mental disability frequently play roles, such as the role of caregiver. This role-playing creates a distance that helps the speaker avoid dealing with her discomfort when interacting with the mentally ill person. The person with the psychological disability in turn often plays the role of being compliant, not trusting that she can open up with the caregiver. Family members often avoid role-playing, however, and connect with a

Downloaded by [New York University] at 12:41 13 August 2016 disturbed individual through the interplay of honesty and empathy (Rosen- berg, 2003). One of the conversation partners says something empathic to the other. This encourages the other to speak honestly. This honesty in turn encourages further empathy. When such honesty and empathy build and become mutual, this creates an authentic connection. Such conversation may help the individuals accept each other as they are, with less need for distance. Distance may need to be increased when the stress become too great or to gain perspective. Alternatively, distance needs to be decreased when sensitivity to the patient’s feelings are paramount. The conversation partners may become more in touch with their love for each other and better able to experience and process difficult emotions. The connection may grow Social Interaction With Families 45 over time; however, the family member must be willing and able to maintain a mutual relationship with the troubled family member. Families, in summary, may express their love to members with psychiatric disability through concrete and practical assistance, caring, warmth, unconditional positive regard, empathy, validation, tolerance (including acceptance and respect), and the establishment of connection. A theme of attachment runs through these qualities. These ways of expressing love, which are often present, can help individuals move from the depths of emotional breakdown into recovery and perhaps beyond. Love in this way can help to repair, solidify, or create loving internal objects that individuals can rely upon in times of need. People in recovery can experience the effects of a holding environment, in which they can take risks, explore their true feelings, and move forward.

Family Interventions Our mental health system does little to make families feel comfortable with family interventions, or to make families aware of how they can benefit from them (National Alliance on Mental Illness, nd). This adds to the basic problem that the profession does not often make family interventions available. In many locked institutions a family “intervention” takes the form of a monthly care plan meeting that does not consist of therapy (Personal communication, Deanna Dang, MA, Nursing Home Administrator, June 10, 2014). There are many different schools of family therapy that are evidence-based, including Salvador Minuchen’s Structural Therapy (1974), Jay Haley’s Strategic Therapy (1987), and Murray Bowen’s Systemic Therapy (1978). When they are repeatedly unable to solve their problems on their own, families may seek family therapy. Often, the issues may be practical ones such as how to obtain a psychiatrist. They also may include problems areas just discussed: emotional support, tolerance, or connecting with a psychiatrically disabled family member. A psychiatrically disabled individual and her family often have harmful underlying conflicts with one another that they are unaware of, or feel unable to address. Family therapy can create a supportive environment that makes it possible to address these issues (Leszcz, Yalom, & Norden, 1985). This can help to heal the family fractures

Downloaded by [New York University] at 12:41 13 August 2016 that often exist. Family therapy helps families better access their natural strengths and provides a scaffolding towards identifying and strengthening weaknesses. Family members have tremendous insight into the patient that often gets overlooked. The mental health system typically ignores the possibility that the illness of a single member may represent problematic interaction dynamics within the family (Bowen, 1978). Family therapy creates a holding environment that helps members to gain better insight into how interactions within the system as a whole may be manifesting in the “designated” patient. The goal of the intervention becomes making family members more aware of their role in the patient’s recovery. The interpretation of family 46 Social Interaction With Families interactions can open up a closed family system so that change can occur (Minuchen, 1974). Studies show that long-term family intervention for schizophrenia low- ers relapse rate, reduces Expressed Emotion, and improves client outcome (Gabbard, 2014; Hogarty, Anderson, & Reiss, 1986). As for preventing relapse, many studies have demonstrated that adding family intervention to medication makes the treatment three times as effective (Gabbard, 2014). Finally, a notable research team recently has strongly affirmed the usefulness of family interventions for schizophrenia. The Agency for Health Care Policy and Research, and the National Institute of Mental Health (NIMH) formed the Schizophrenia Patient Outcomes Research Team (PORT) to determine evidence-based treatments for schizophrenia. PORT then exhaus- tively reviewed the literature evaluating treatment outcomes. Their conclusion: the evidence supports the need for family intervention. “Persons with schizophrenia who have ongoing contact with their families” they recommend, “should be offered a family intervention that lasts at least 6–9 months” (Dixon et al., 2009, p. 53). The PORT document lists family interventions the researchers consider effective, including “illness education, crisis intervention, emotional support, and training in how to cope with illness symptoms and related problems” (Dixon et al., 2009, p. 53). These interventions also often include behavioral problem solving and work on family communication. In addition, the extensive research on Expressed Emotion has led to many studies of psycho-educational interventions intended to reduce Expressed Emotion (Dixon et al., 2009). Professionals consider psycho-education a best practice for the treatment of schizophrenia and can help families manage Expressed Emotion. Psycho-educational programs often provide information on the nature of schizophrenia, treatment for the condition—including family management—prognosis, and strategies to calm the emotional cli- mate in the home (Moxon & Ronan, 2008, p .48). The National Alliance on Mental Illness (NAMI) offers a free, highly regarded psycho-education program on mental illness called “Family to Family” (National Alliance on Mental Illness, n.d.). In this program, trained family members of individuals diagnosed with mental illness teach other such family members how to deal with issues that emerge when one

Downloaded by [New York University] at 12:41 13 August 2016 has a severely mentally ill relative. The United States Substance Abuse and Mental Health Services Administration (SAMHSA) includes this program on its National Registry of Evidence-Based Programs and Practices. The 12-session NAMI course addresses various forms of mental illness, medication issues, evidence-based treatment, problem solving, communication techniques, strategies for responding to crisis situations, self-care for the caregiver, available supports and services, and mental health advocacy. The program is partially based on the presenters’ familiarity with the “lived experience” of a person with mental illness (A. Adkins, personal communication, National Alliance on Mental Illness DuPage County, December 17, 2014). Social Interaction With Families 47 The Open Dialogue program further explained in Chapter One offers a different way of helping families with a psychotic member to transform the interaction patterns that impede growth. This program, as noted earlier, has had extremely positive results. The research supporting these results is very solid, and this approach in general might be considered network therapy rather than family therapy because it may include non-family members and does not necessarily include the family. The program, however, can also function as family therapy (Seikkula & Trimble, 2005). The focus on multi-voiced conversation in Open Dialogue makes it different from most family therapy (Seikkula et al., 2006). While the majority of family therapies may stress the need for therapists to collaborate with the family, multi-voiced conversation goes further. It is centered on drawing out and foregrounding in the session the voices of everyone present. The success of this approach is in part related to the respect that is accorded to all voices (all parties), including voices that may be “delusional.” This facilitates an openness that results both in greater connection among the parties and a greater ability to take in others’ perspectives. Participants come to experience, process, and empathically understand each other’s emotions, which helps families grow.

REFERENCES

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We have found in programs for people with psychiatric disabilities that friendships, like families, play a fundamental role in their treatment. Yet the curative power of positive interaction dynamics with friends is somehow not recognized as “treatment” (Davidson, Chinman, Sells, & Rowe, 2006). Professionals often undervalue both the family’s role and the role of friends in recovery. Friends and family are supposed to provide merely “social support,” not “treatment” (Bellack & Mueser, 1993; Bowling, 1994). While the family role is foundational, friends can be part of the recovery in ways that families cannot. Families often provide great practical assistance, advocacy, and support. However, friendship contributes a good deal to the individual’s social life and psychological well-being (Sullivan, 1974). Friendship is a very flexible structure, more so than families or institutions. This flexibility allows friends to meet each others unique needs. Family relationships are more complicated and volatile than friendships due to their depth as well as the sacrifices, responsibilities, and power struggles involved in family dynamics (Cuijpers & Stam, 2000; Sullivan, 1974). Friendships therefore tend to meet emotional needs for people with psychiatric disabilities in less conflicted ways than families. This benefit of friendship is supported by the Wan-Yuk, Harley, Board- man and Craig (2011) study where individuals with schizophrenia rated their friendships as being of importance and of high quality. This is often not the case with their family relationships, which tend to be more mixed. People with psychiatric disabilities frequently turn to friends for acceptance

Downloaded by [New York University] at 12:41 13 August 2016 and understanding, although these qualities can also be found in their families. Finally, people diagnosed with severe mental illness often have a close bond with each other because of their common problems and their shared oppression by the community at large (Davidson, Chinman, et al., 2006). Friendships offer an opportunity to remake our social nesting (Evans, 2006; Mitchell, 1982; Perese & Wolf, 2005; Sullivan, 1953). Like everyone else, those with psychiatric diagnoses have entrenched behavioral patterns or schemas derived from their childhood relationships with family. These patterns, often rooted in early childhood, can be difficult to change. This is partly because while the client may be attempting to change, the family may remain frozen in patterns that perpetuate the client’s thinking and behavior. Social Interactions With Friends 51 Parents, for example, may curtail their children’s social lives out of fear of losing their familial bond (Lefley, 1989). Clients often seek out friendships that foster alternatives to the historical patterns embedded in family relationships (Brumbaugh & Fraley, 2006; Davidson, Chinman, et al., 2006; David- son, Shahar, Lawless, Sells, & Tondora, 2006). New relationships provide the mentally ill person with an opportunity to explore new ways of relating which challenges otherwise entrenched patterns. This may be especially helpful to those diagnosed with severe mental illness, who tend to have troubled relationships with their families. Friendships (often with the assistance of a therapist with a psychodynamic base) offer excellent forums for remaking transference patterns (Schön, Denhav, & Troper, 2009). Likewise, working with a cognitive therapists, individuals can reformulate relationships by reworking dysfunctional schemas. One may discover aspects of a ‘true self’ (Winnicott, 1956; Winnicott, 1994) that had previously been constrained through various therapeutic models. This redoing of the transference patterns tends to happen most fundamentally in romantic partnerships (Zelizer, 2010). The intensity of passion in these relationships parallels that of the original relationship with primary caregivers, but in this case partners have the opportunity to apply what they have learned from experience. It is widely noted that love heals, in this case more intensely than in other friendships (Sharfstein, 2005). Because people choose friends, whereas they are born into their families of origin, people often choose as friends or as lovers those who complement their past experience with their families. Choosing friends appears to help people to create a context in which they can foster the psychological growth that they wish to obtain. Many accuse mental health professionals of blaming clients’ psychiatric issues on their families, especially on their mothers (Falloon et al., 1982; Hartwell, 1996). At times, mental health workers try to keep clients’ families out of the treatment because they see the families as perpetuating the clients’ problems (Falloon, Boyd, & McGill, 1984). To generally accuse families of causing clients’ problems is a grave mistake. However, early interactions in childhood (if conflictual) between future psychiatric clients and their family members (who, like anyone, have their own issues) do contribute significantly to clients’ problems (Lyons-Ruth,1996). This applies to later interactions (as adults) between clients and their fami-

Downloaded by [New York University] at 12:41 13 August 2016 lies as well. This is not to “blame” families, but to acknowledge their roles in clients’ mental health (Mishler & Waxler, 1965; Muller, Sicoli, & Lemieux, 2000). Friendships offer clients a context in which to reshape their psychological and social development (Sullivan, 1974). Friendships also offer a helpful context in which to change the dynamics learned in one’s family of origin (Davidson & Strauss, 1992; Sageman, 2004). This transformative nature of friendships contrasts with family dynamics that (linked to the family history) can evoke very intense reactions. These intense emotional reactions can act as obstacles to changes in behavior (Perese & Wolf, 2005; Reiss, 1976). We believe that friendships provide a calmer environment for pursuing interpersonal change in certain circumstances. 52 Social Interactions With Friends Despite family members’ love for each other, interacting with a family member diagnosed with severe mental illness over time tends to become very stressful. After a while, this stress can result in family members interacting with the client less out of love and more out of duty. The caregiver may become somewhat detached or even resentful. The client may feel guilty, angry, and unwanted. Friendship provides a context in which people interact more out of desire than out of a sense of obligation (Caqueo-Urizar, Gutierrez-Maldonado, & Miranda-Castillo, 2009). Friendships have advantages that relationships with mental health professionals as well as families do not provide. Mental health professionals and family members often have condescending attitudes towards the individuals diagnosed with severe mental illness. This occurs because while trying to help these clients, family and professionals often unconsciously feel a need to distance themselves from the clients (Nordt, Rössler, & Lauber, 2006). The relationship has become difficult or too painful. This condescension also derives simply from our society’s tendency to stigmatize people diagnosed with severe mental illness (Nordt et al., 2006). One might expect therapists to dismiss such stigmatizing, yet studies indicate that mental health professionals tend to stigmatize these clients as much as the general population does (Corrigan, 2004; Gray, 2002). Our society, with its emphasis on hierarchical relationships, tends to view helpers as superior to those they help. The provision of help, therefore, often is accompanied by condescension, although at times this may not be visible or clearly perceived by the person being helped. Clients often feel hurt and demeaned by condescending help, but do not voice their feelings because they are extremely dependent on the care of the helper, or because they feel they have no power in the relationship (Doty & Sullivan, 1983; Taylor, 1979). Compared with mental health workers and family, friends offer help in a manner that is less likely to be based on a hierarchical view of the relationship. This makes possible more of a relationship of mutuality. Parents and partners often fixate on playing the ‘helper’ role, not encouraging autonomy and reciprocity. Thus the relationship with family and partners may be both helpful and detrimental to patients (Schön et al., 2009). Friendship offers the greatest opportunity for clients to engage in mutual relationships (Davidson, Shahar, et al., 2006). Mutuality in clients’ relation-

Downloaded by [New York University] at 12:41 13 August 2016 ships plays a key role in their recovery. Most people involved with these clients, both professionals and non-professionals, overlook the importance of mutuality in their relationships. Yet, mutuality in relationships contributes to clients’ dignity, self-esteem, and sense of self-efficacy. Mutual empathy in relationships contributes greatly to their sense of closeness (Miller & Sti- ver, 1998). It is unfortunate that in our society the helping of others tends to occur in hierarchical relationships (Lauber, Nordt, Braunschweig, & Rössler, 2006; Lazarus, 1994). Mutuality in the relationships of those with psychiatric disabilities, most evident in their friendships, can contribute a great deal to their psychological wellbeing. Social Interactions With Friends 53 While therapists have experience in attempting to bring about growth promoting relationships, therapists spend a small amount of time with the client. They are not present for the important events in clients’ lives. Friends do not have these limitations (Bickman, 1999; Earley, 2007; Rosenhan, 1973; Watzlawick, 1990). They can be there for a client in times of great need. They can interact with the others involved in the client’s life. They can observe the client in her everyday relationships (Etherington, 2007; Gurdin, 1986; Gurdin, 2007). The fact that therapists are paid for their services makes their concern feel less authentic than a friend’s concern (Szasz, 1994). The friend, after all, has chosen to be with the client (Sullivan, 1953). Not only are therapists paid to spend time with the client, but since clients with serious psychiatric problems tend to be impoverished, they have little influence over the choice of the therapist (Arnstein, 1969; Murali & Oyebode, 2004).

INTERACTION STRUCTURES WITH FRIENDS THAT TEND TO BRING ABOUT DAMAGE

Interaction Structures That Spoil One’s Identity Accepting the Language of “Mental Illness” Many individuals with mental illness are encouraged by friends and peers to accept the phrase “mental illness” as a description of themselves (Goffman, 1961; Ruesch & Phelan, 2004). Individuals diagnosed with mental illness may also embrace this use of language because: 1) they accept the concept of “mental illness” as an accurate description of a problem they have; 2) thinking of their problem as an “illness” encourages them to feel that this problem does not imply a fault or a reason for feeling inferior; 3) the concept of “mental illness” helps to provide them with a realistic sense of their limitations, and 4) “mental illness” is the professional or socially accepted term for their problem. It is useful to point out the work of Thomas Szasz (1960), who argues against the labeling of individuals as mentally ill altogether. He suggests that people who are “disabled by living” are labeled mentally ill. He hypothe- sizes that classifying psychological problems as illnesses and speaking of

Downloaded by [New York University] at 12:41 13 August 2016 “mental illness” involves a conceptual error. According to Szasz, the label “mental illness” is an inappropriate metaphor—there are no true medical conditions of the mind. While we understand that there is a biological basis for mental illness, Szasz’s perspective is an interesting one to contemplate. When a person thinks of her problems as a “mental illness,” however, regardless of how hard she may try to prevent this, the term at times unconsciously continues to stigmatize her. This may result, for example, in a feeling of inferiority when in the presence of others she believes are seeing her as “severely mentally ill.” This is the unconscious power of the term “mental illness” in our society or, rather, the power of the unspoken associations that 54 Social Interactions With Friends tend to accompany the use of the term—even though it is a term institutionalized in the science of psychology (Corrigan, Larson, & Ruesch, 2009). The term “severely mentally ill” acquires such derogatory power because it is unconsciously linked with the severe penalties that our society inflicts upon those given this label. These penalties include being ostracized and scorned by associates (family, friends, employers, etc.) or by the general population. An individual may carefully define her words, yet their meanings are nonetheless influenced by the whole history of their usage—including in this case, related words such “nuts, bananas, twisted, wacko, cuckoo, freak, etc.” (Byrne, 2001, p. 6). In one study researchers identified 250 derogatory labels to identify individuals diagnosed with a severe mental illness (Rose, Thornicroft, Pinfold, & Kassam, 2007). An individual absorbs these usages throughout her life. In one’s unconscious, therefore, the phrase “mental illness” tends to be associated with powerful negative feelings. These feelings are linked with the violent rejection of an individual by society as a whole (Whitaker, 2010). This is one reason why it can be difficult to get rid of stigmas and to avoid having them slip back into one’s consciousness again and again once one believes one has completely gotten rid of these stigmas. Other reasons for the difficulty in ridding the self of stigmas include the social pressure to maintain stigmas, as well as the social use of stigmas to project unwanted feelings onto others. Stigma is based on metonymy. One sees a person, or oneself, as if a single part—an emotional problem—comprises the whole. Thus one calls a person “a borderline” or “a schizophrenic” (Honos-Webb & Leitner, 2001; Markham, 2003). This use of language explains, controls, and creates a boundary around a person, which can reduce the discomfort one feels in her presence. It is a use of language that amputates the individual’s self in the attempt to contain her. Self-stigma can prevent growth; one does not feel capable of acting in accordance with what one truly desires. One loses hope. The loss of hope can destroy the possibility of change. One is beaten back into a debilitating self-image living a compromised existence. One may even feel resigned to a life where “one’s whole identity is enmeshed with the mental patient role” (Slade, 2009, p. 1). Clients may reside in a “mental health (i.e., illness) ghetto”

Downloaded by [New York University] at 12:41 13 August 2016 (Slade, 2009, p. 1). They may consider themselves incapable of being a father, a nurse, a sculptor, of being integrated into the population of the community. As Corrigan (2004) states, the stigma can be as damaging as the illness. To work against self-stigma, to avoid “spoiling” one’s own identity (Goffman, 1961; Wright, Gronfein, & Owens, 2000), one needs to catch oneself experiencing reality in a stigmatized way. One needs to replace (unconsciously) stigmatizing words with others that sufficiently differentiate oneself (unconsciously) from stigmatizing words. For example, the labeled person needs to define herself as a teacher, not as “a person with a mental illness.” Friends need to help create contexts that support clients’ desired identities, not to perpetuate their attachment to the label of being “mentally ill.” Social Interactions With Friends 55 Interaction Structures Naively Employing “Social Support” As suggested in the introduction, when our society does give a role to social interaction in the treatment of psychiatric disability, it tends to be understood as “social support.” Social support is portrayed as a simple and obvious good. Yet research does not even clearly support the conclusion that social support has a positive effect on the well-being of its recipients (Bar-Kalifa & Rafaeli, 2014; Nurullah, 2012). In fact, until recently, the research even tended to find that social support has a negative effect. The myth of the simple and obvious goodness of social support is an offshoot of the nineteenth-century tendency to accept without question the positive role of culture and family (Guggenbühl, 2009). A client support system often strongly encourages, or even pressures, a client to adhere to her treatment plan by taking medication and going to appointments with professionals. This support system appears to be a very useful element of recovery (Warner, 2009). However, the majority of programs in the U.S. focus on medication as treatment, and these programs have a very low standard for what they consider an acceptable outcome (for example, “symptom management”) (Zygmunt, Olfson, Boyer, & Mechanic, 2002). The typical program neglects clients’ deep emotional needs. It appears that among many mental health professionals, clients diagnosed with severe mental illness are considered incapable of addressing deep emotional needs in a profound way. A support system that pressures a client to comply with such a program can lead the client to remain content with the program and not to consider extremely valuable alternative practices that could help her. We believe that social support in effect can (at times) actually help limit a client’s growth. Social interaction plays a key role in recovery. This role, however, is complex, highly variable, and difficult to comprehend. Padgett, Henwood, Abrams, and Drake (2008), describing a recovery study, indicated that “Just as close and supportive ties may be sought as valuable, social distancing may be initiated as a means of enhancing recovery and emotional stability” (p. 338). While study participants valued social ties, like all of us, they wanted “to pursue connectedness on their own terms” (Padgett et al., 2008, p. 335). There is no normative “social support” that helps people (human beings in general). People need to create the kinds of social interaction that they need. The belief in the simple goodness of social support goes along with the

Downloaded by [New York University] at 12:41 13 August 2016 belief that the response and management to “mental illness” should be the ingestion of medication and “a reduction in stress” (Bellack & Mueser, 1993). The idea that one needs to engage in a long-term process of transforming one’s relational framework is typically ignored by the medical establishment. To support recovery, social interaction needs to be part of a plan for clients to develop a new identity, pursue their passions, and develop a satisfying, meaningful life. Recovery is far different than “stabilization”—a term often used to legitimize an empty and lethargic way of life (Falloon, 1991). The accepted ideas about treatment for psychiatric disability are based on a primitive concept of social interaction. Social interaction is not a support for treatment. It is a crucial form of treatment. 56 Social Interactions With Friends What is thought of as social support frequently relies on a hierarchical structure. The phrase “social support” creates an image of a person depending on others. In our society, this suggests that the dependent one is in a subordinate position. In the study mentioned above (Padgett et al., 2008), however, a hierarchical structure of help appeared to interfere with helpfulness. People experienced help as demeaning, invasive, imposed, or demanding. In some cases, this help led to feelings of guilt, or people did not receive the kind of help they desired (Padgett et al., 2008). There was a lack of reciprocity, and reciprocity played a major role in determining whether help was felt to be supportive (Padgett et al., 2008; Schön et al., 2009). Lack of reciprocity frequently compromises the sense of connection that accompanies a helping relationship (Gould, 1990). Reciprocity in interaction is especially important for people with psychiatric issues because of the tendency of others to look down on them or to help them from a position of superiority (Gould, 1990; Jordan, 1986). In relationships, reciprocity shows people respect, supports their self-esteem, helps them to feel—and to be—needed, helps them to feel—and to be—empowered. Through reciprocity, individuals develop a sense of connection between each other. Mutual empathy, as Miller and Stiver (1998) discuss, plays a basic role in “growth fostering connection.” Reciprocity is an integral component of mutual empathy and is especially important in the later stages of recovery. One often hears that those with psychiatric problems need social support (Cobb, 1976; Kaplan, Cassel, & Gore, 1977). Less often one hears that they need social connection. Yet their need for social connection is tremendous. Many obstacles stand in the way of their satisfying this need. Whereas social support often has a hierarchical tone, social connection tends to be more mutual. Our society may think more in terms of social support because of its more hierarchical and utilitarian overtones. More so than social support, social connection provides an end in itself. For what direct purpose does it serve? Social connection flourishes with spontaneous responsiveness. Yet its apparent lack of purpose is merely on the surface. Social connection, for example, involving love, trust, and vulnerability, provides what is foundational for psychological growth (Rogers, 1961; Seligman & Csikszentmi- halyi, 2000; Sullivan, 1974). The frequent emphasis on hierarchy in social

Downloaded by [New York University] at 12:41 13 August 2016 support, on giving in the detached role of superiority, sacrifices a great deal.

INTERACTION STRUCTURES THAT COMPROMISE ATTACHMENT

This section describes some of the most common interaction structures that undermine attachment for people diagnosed with severe mental illness. The structures utilized by family, friends, and mental health professionals, etc. include self-absorption (or narcissistic attachment), withdrawal, role-playing, expressed emotion, and scapegoating. Social Interactions With Friends 57 The traditional notion of schizophrenia emphasizes the interaction traits of self- absorption and withdrawal. These tend to be viewed as characteristic of the disorder that, if they can be treated at all, can only be addressed through medication (Sass & Parnas, 2003). Yet effective psychosocial treatments clearly can modify these behaviors. Self-absorption may include an inward focus, monologue as a style of communication, a narcissistic form of attachment, and a failure of empathy. Withdrawal, which may include self-absorption, can take the form of physical or emotional distance, inattention, numbness, preoccupation, being split off from one’s feelings, or emotional disengagement (Miller & Stiver, 1998). These two forms of interaction severely interfere with psychological growth. Yet these defensive maneuvers can at times make psychological growth possible by preserving a fragile self that is threatened by internal and external forces (Fairbairn, 1952). Despite these defensive behaviors, today more professionals recognize that people with schizophrenia (or “mental illness” in general) tend to value interaction a good deal and to be capable of profound relationships. Wan-Yuk Harley et al.’s (2011) recent study of 137 people with schizophrenia and schizoaffective disorder indicated that, while people with schizophrenia tend to have very few friendships, the quality of their friendships is generally high. Participants found contact with friends to be “warm, enjoyable, and rewarding” (p. 1). Establishing trust, therefore, may pose the largest obstacle in the way of friendship for these individuals. This makes sense given the trauma and rejection these individuals have experienced. When an environment shows itself to be reliably trustworthy—as in established friendships or in effective therapy—people with schizophrenia often pursue fulfilling relationships (Walker & van Der Helm, 2009). People with psychiatric disabilities do a lot of role-playing in institutions (Rosenhan, 1973). They know that the best way to get out may be to be compliant (Braginsky & Braginsky, 1967; Rubin, 1990). They are also used to interacting with staff that treat them in a condescending manner. They learn that failure to be compliant with staff can result in punishment and prevent them from getting what they want or need (Gardner, Hoge, Bennett, Roth, Lidz, Monahan & Mulvey, 1993; Lowry, 1988). In addition, stigmatization, their low position on the social hierarchy, and their various social

Downloaded by [New York University] at 12:41 13 August 2016 difficulties contribute to low self-esteem, which leads to compliant behavior. Finally, to reveal their authentic selves can get them into a lot of trouble. They could be viewed as symptomatic, hospitalized or further medicated if their authentic self is not seen as “normal” by authorities. Role-playing can lead clients to remain out of touch with their feelings, to avoid, of course, authentic communications, and to fail to grow and connect with others. The clients need approval due to their precarious social positions. They fear being abandoned, rejected, or dominated. Staff, parents, partners, and friends often strongly encourage the compliant, role-playing behavior of these individuals. They often act as if they live in an institution when they do not live in one. 58 Social Interactions With Friends Role-playing is related to the family communication style of pseudo- mutuality (Simon, Stierlin, & Wynne, 1985; Wynne, Ryckoff, Day, & Hirsch, 1958). In this form of communication, family members create an illusory harmony by conforming to a rigid pattern of interaction out of fear of conflict or separation. Family members achieve a semblance of unity at the expense of maintaining their identities. In actual mutuality, each party respects the other’s identity. Pseudo-mutuality takes place in friendships as well as in families. The literature shows that friendships of those diagnosed with mental illness, like family relationships, often contain “expressed emotion,” although this seems to be less frequent than in families (Hooley, 2007, p. 30). That is to say, families seem to respond more often to the stresses of caring for a deeply disturbed individual through criticism, hostility, and over-involvement (Anderson, Hogarty, & Reiss, 1980). Friendships are often more tolerant and supportive (Cantor, 1979). But friends do engage in expressed emotion (Butzlaff & Hooley, 1998; Hooley, 2007). This happens more often in distressing situations, or with individuals who present a lot of difficulties or call up painful emotions for their friends. In these situations, people may scapegoat friends diagnosed with severe mental illness, even though one of the important functions that friends serve for individuals diagnosed with severe mental illness is protection from scapegoating. When this protection breaks down, the result can be painful and disruptive for the scapegoated person. Individuals with psychiatric problems often have a long history of rejection or abandonment (Wahl, 1999). When their own friends—their refuge—scapegoat them, this may be difficult to for them to comprehend. They may feel there is no place to turn for comfort.

INTERACTION STRUCTURES WITH FRIENDS THAT FOSTER GROWTH

Fostering Hope Without dreams, Langston Hughes says, “Life is a broken-winged bird/ that cannot fly” (1996). Many have stated thathope brought about the first step

Downloaded by [New York University] at 12:41 13 August 2016 in their recovery. Friends play a major role in encouraging hope. Hope and dreams fuel the engines for change for those with psychiatric disorders. Both the recovery movement and the strengths approach to social work stress that hope plays a central role in recovery (Rapp & Goscha, 2006; Slade 2009). Group therapy is a source of hope and even friendships for patients. Friendships developed in group therapy could be linked with an increased sense of group cohesiveness (Butler & Fuhriman, 1983). When Yalom and Leszcz (2005) explain what makes group therapy effective, the very first principle described is the “instillation of hope” (p. 6). Hope calls for action. Social Interactions With Friends 59 It sustains us in tough times. It opens up a space for creative action where previously there was none. But many forces erode clients’ hope for recovery. Emotional breakdowns lead to depression and despair. People with psychiatric problems internalize society’s stigmas about ‘mental illness’ (Corrigan, Watson, & Barr, 2006). This can destroy hope. Finally, those who suffer from serious emotional problems often become numb to the world, and this too abolishes hope (Murphy, 1998). This may happen because a combination of factors destroyed a person’s life and she is terrified of opening up emotionally and being destroyed again. The terrible suffering of having one’s hopes and dreams crushed cannot happen again if one buries these hopes and dreams. This defense may help a client after a breakdown, but many factors including stigma encourage people to remain frozen in such numbness, perhaps never regaining the strength to live a hopeful life. People with serious emotional disorders greatly depend on our mental health system for hope (Murphy, 1998). Many do not find it there. Although official rhetoric may at times promote the importance ofhope , many professionals, backed by much questionable research, believe that it is not possible to recover from serious mental disorders (Fink & Tasman, 1992; Schulze, 2007). Recovery requires a great deal of persistence. Professionals’ lack of hope often unconsciously supports the clients’ reluctance to try to break out of a safe but deadening resistance to change. Social environments discourage, degrade, and dehumanize these clients, denying their potential (Leigh- ton, 1967), and this makes it difficult to preserve and fosterhope . Friendship offers a contrary force. Friends can help create hope in many ways (Sullivan, 1974). They can empathize, provide advice, evoke positive memories, engage the diagnosed person in positive activities and treat them as a comrade rather than someone with a mental illness. Several factors limit the ability of families to provide such hope. Families may be frustrated by hopes that time and again have been dashed. They may feel exhausted by their history of dealing with the family member’s difficult and stressful problems (Tsang, Tam, Chan, & Chang, 2003). Their relationship with the family member may include dynamics that interfere with the individual’s optimism. The stress of relating to and trying to help the family member over a long period of time leads to highly charged emotions and tends to

Downloaded by [New York University] at 12:41 13 August 2016 result in “expressed emotion”—criticalness, hostility, and over-involvement (Hooley, 2007). This can impede the individual’s ability to respond with enthusiasm. Overly fearful for the individual’s well-being, the family may oppose her attempts to engage in the risky endeavors of change. Friends, on the other hand, can be more tolerant and empathic (Sullivan, 1974). They are less likely to be “burned out” than professionals and family members. They are less likely to hold a critical view, which often accompanies a family member’s or professional’s position of superiority. Especially if they are peers (that is, if they suffer from psychiatric problems themselves), 60 Social Interactions With Friends friends are more likely to function as “insiders,” who may be less apt to stereotype the individual as being incapable of change. Cultivating friendships that support commitment to a person’s dreams promotes growth (Davidson, Shahar, et al., 2006). Friends can bolster the diagnosed individual’s perceived external resources. They can also help to motivate the individual in powerful ways by pursuing mutual passions, showing that they expect the individual’s success, providing encouragement, and showing that they believe in her abilities and strengths (Sullivan, 1994). One friend who believes in a person (providing hope) can make a big difference. A group of friends can make a difference on a different level. Peo- ple with serious psychiatric disorders frequently have experienced trauma. Often this trauma can be damaging to a person’s relationship with friends, family, work, and school; trauma can shatter one’s feeling that a community can to be relied on to support a sense of well-being (Herman, 1997). The ability to trust can be devastated. A group of friends, however, can help to rebuild a supportive sense of community that can help repair a person’s psychological and social damage. This rebuilding happens, for example, in therapeutic communities and the Open Dialogue Program (Shay, 2011). Friends who are also peers can offer a great deal of hope to those with psychiatric problems (Davidson, Bellamy, & Miller, 2012). Those who are not peers help one to connect with the larger community, with all its opportunities (Sells, Davidson, Jewell, Falzer, & Rowe, 2006). Peers provide empathy, a special bond, and they can serve as tremendous role models. Those who are part of peer-run services typically have experience and training that boosts their ability to provide hope for those suffering from psychiatric problems. All of these elements of friendship that foster hope—showing tolerance, pursuing mutual passions, supporting the possibility of change, and so forth—can be part of an interaction structure that promotes growth. People with psychiatric issues need to find and cultivate friends who inspire their hope and encourage them to take actions that support their desired identities while actively pursuing their dreams. Such friends can work together on projects that further both parties’ growth, forming alliances in which each person encourages the other’s growth. Unfortunately, some friends promote hope of a questionable variety.

Downloaded by [New York University] at 12:41 13 August 2016 Hope can support agency; another kind of hope elicits passivity, which is discussed in further detail below. And it is sometimes difficult to tell the difference between these two forms of hope, since they are often mixed and blurred together. Hope that supports agency motivates Davidson et al., 1999). It promotes action to bring about desired change. This kind of hope evokes the imag- ination of new possibilities. It helps bring about new ideas for how to get where one wants to go (Russinova, 1999). The person who develops such hope may suddenly feel that she can do what had previously seemed but had also been deemed impossible. One can promote hope that supports agency Social Interactions With Friends 61 by helping another to increase her “perceived internal resources” and “perceived external resources” (Russinova, 1999). A client may say about a program where she seeks out new friends, “This program helps me take actions to recover.” The client is motivated to act to foster her recovery. She takes responsibility for the consequences of her thoughts and actions, thinking critically about her own plans, actions, and thought processes. On the other hand, hope that elicits passivity, while it may promise change, functions mainly to comfort and reassure a person (Davidson et al., 1999). This kind of hope promotes, often covertly, the holding of a wish and expectation that wholly external sources will bring about a desired change. A writer illustrates this sense of hope by saying that when he takes a plane, he hopes that the plane does not crash. This hope is passive because the writer has no ability to affect whether the plane crashes (Jensen, 2006). Acting on hope that elicits passivity, a client may say about a program, “I’m going to the program, so I hope I recover.” The client here avoids taking responsibility for her action. She hopes the program itself will create the result. She may simply show up for activities. She may participate in directive groups, groups that do not encourage interaction, initiative, or mutuality among members. Going to groups can become a kind of pleasant but rather blind routine. Such a passive agenda of hope often applies as well to the taking of medication. Hope that elicits passivity at times secretly depends on magical thinking whereby the will and expectation that something will happen somehow translates into the belief that it will happen. Hope is then no longer a positive expectation based on an imagined future, but acquires a sense of inevitability. While superficially they provide active strategies for improving one’s life, self-help books, inspirational readings, and “supportive” psychotherapy often act mainly as fuel for such passive hope (Schiff, 2004). One may therefore need to keep acquiring more and more books, or receiving more and more therapy. Hope here is almost magical. It is “almost” magical because one needs a certain measure of reality in order to avoid seeing that one’s fulfillment is based on magic.Hope that elicits passivity therefore typically mixes in some agency. This kind of hope can make one feel better, especially for short periods of time. On the whole, however, it discourages a person from pursuing active and responsible solutions. Passive hope is not

Downloaded by [New York University] at 12:41 13 August 2016 linked with specific reality based plans of action. Some peer groups thrive on sources of passive hope (Jensen, 2006). One needs instead a network of friends who encourage active hope. By “hope” we are referring to a commitment to dreams. We wish to avoid any suggestion that we are affirming the passive approach to hope. For the active and passive conceptions of hope are easily blurred together in the ordinary use of the word. Some mental health professionals and others who write about hope focus on the active sense of hope, but their reliance on the conventional use of the word unintentionally continues to communicate the passive sense (Jensen, 2006). Writers may be attracted to an unconscious 62 Social Interactions With Friends sense of comfort, warmth, and security that can be conveyed through the passive and magical sense of the word, without realizing that these qualities depend on an approach to fulfillment that contradicts what they want to communicate. The use of the word hope may not unavoidably convey such a passive approach, but if one wishes to avoid this, one needs to consciously act in order to avoid passivity. Bertram Karon, in a classic work on the psychoanalytic psychotherapy of schizophrenia, stresses the need for providing “informed optimism” (Karon & VandenBos, 1977). This may sound cautious compared to the pursuit of dreams, but Karon thinks that “if the therapist and the patient continue working as well as possible, the odds are very strong that the patient will improve and the major problems will be resolved” (1977, p. 149). Karon indicates to the patient that such therapy is hard work and describes to her specifically the kinds of activities that such work will require. In addition to its suggestions of passivity, hopefulness often lacks such specificity about the work the client must undergo in order to be successful. Hope often relies on only a general idea of what is being sought and how one intends to bring it about. Friends can amplify their ability to foster hope by creating formal structure.

Peer Support Peer support offers a powerful means of recovery from psychiatric disorders (Davidson et al., 1999). Peer support means collaborative interaction among those diagnosed with severe mental illness. Although peer support staff receive training, they generally rely more on what they have learned from experience than on specialized theoretical knowledge. Many forms of peer support have emerged in recent decades. The practice stands out as a central component in the recovery movement (Mead, Hilton, & Curtis, 2001). In fact, social policy in many countries promotes the employment of “peer support specialists.” England, for example, requires all mental health services to use and train “peer support specialists” (Slade, 2009, p. 105). Since the mental health profession is made up of hierarchies, the peer worker’s adoption of a collaborative approach can make a significant difference in the field of mental health, which is addressed below (Davidson et al., 1999).

Downloaded by [New York University] at 12:41 13 August 2016 The shared experience among peers gives peer support many advantages over regular staff. Peers provide helpful role models for those whose recovery is less developed. Peers can readily empathize with other peers. They help validate the other’s experience. Such actions facilitate client engagement (Mead et al., 2001). The concept of peer support, however, not only concerns the abilities that result from having shared experiences with the population one serves, but also provides a whole new way of viewing treatment. Bolstered by the civil rights and human rights movements, interest in peer support emerged out of client dissatisfaction with the existing mental health system. Many were disillusioned by controlling and hierarchical practices Social Interactions With Friends 63 within the system (Orwin, Briscoe, Ashton, & Burdett, 2003; Mead & Mac- Neil, 2005). Activists addressed not only physical and sexual abuse, but also institutional abuse (Mead & MacNeil, 2005). Peer support offered a way to bring about more collaborative relationships, which could counterbalance the relatively hierarchical ones prevailing in the mental health system. Mary, a member of NAMI’s Peer-to-Peer support group, comments about the helpfulness of connecting with others:

It meant so much to me to know that I was not alone with schizophrenia. Other people had gone through the same experience—the isolation and pain of the experience of losing it. Just to know that I was not alone made such a big difference. I realized I had other people who cared.

Peer support challenges “us versus them” thinking. It creates a sense of mutuality between supporter and supportee. This improves the quality of their connection. At the least, according to one study, the approach speeds up the process of engagement (Davidson, Shahar, et al., 2006). The supporter/supportee distinction at times becomes erased. Peer support con- siders each participant potentially capable of acting as either supporter or supportee (Davidson, Shahar, et al., 2006). The perspective of the person helping loses rigidity. She can be more readily able to empathize with and identify with the supporter/supportee. She becomes more capable of experiencing and reflecting on her own psychological vulnerabilities. By acting both as a helper and as a supportee, the person being helped cultivates initiative, responsibility, and self-esteem. An alternative model has been put into practice: a mental health worker does not “treat” the client, but rather, the two collaborate to solve problems (Solomon, 2004). Peer support helps clients think of themselves as equals in society rather than as members of an inferior class. Mead and McNeil (2005) say, “Being a ‘mental patient’ can become a full time job and once we’ve taken it on, we really are tied into the system. Our finances, housing, support and job opportunities are dependent on our job as a “mental patient” (Mead & McNeil, 2005, p. 1). Collaborative interaction with peers helps people feel more capable of taking on new roles, not confining themselves to the roles of someone with “a mental illness.”

Downloaded by [New York University] at 12:41 13 August 2016 Peer support’s collaborative basis shows up in many ways (Davidson et al., 1999). It rejects the use of coercion. It fosters clients’ empowerment. It stresses mutuality and cultivates a sense of community. And when possible, the consumers themselves direct the support (Solomon, 2004). In Personal Recovery and Mental Illness: A Guide for Mental Health Professionals (2009), Mike Slade describes three levels of peer support: mutual self-help groups, peer support specialists, and consumer-operated services. Mutual support groups, he notes, emerged outside of traditional mental health services. They tend to be non-hierarchical. They emphasize lived experience and use interaction structures designed to encourage 64 Social Interactions With Friends each member’s participation. The atmosphere of such groups encourages non-pathologizing attitudes towards “mental illness.” These groups often support social and political aims. Slade (2009) refers to four central components of mutual help groups: 1) they form narrative communities, where members tell personal stories promoting recovery; 2) leaders act as inspirational role models for the others; 3) by design, these communities encourage all members both to help others and to receive help; and 4) the groups foster a sense of community. Alcoholics Anonymous (AA) meetings exemplify a widely influential form of self-help groups (Humphreys & Moos, 2001). Often, members take turns telling stories of how alcohol abuse ruined their lives and how AA has helped them to recover. Thus, everyone both gives and receives help. Recovering alcoholics facilitate the groups and act as role models. These widely shared life patterns of the members contribute to a strong sense of community. “Peer support specialists” comprise the second level of peer support outlined by Slade (2009, p. 104). These peer support specialists have explicit experience of psychiatric disorders. Peer support specialists, as indicated above, have the backing of social policy in many countries (Mead & Cope- land, 2000; Patel, Flisher, Hetrick, & McGorry, 2007). They have been described as “recovery coaches,” who may, for example, act as role models, advocates, and “truth-tellers” (Slade, 2009, p. 108). The peer support specialist has a paid job that turns the experience of “mental illness” into a valued resource. The workers receive an opportunity to help others, to build self-esteem, and to acquire job skills (Schwartz & Sendor, 1999). Peer support specialists have many advantages over non-peer mental health workers. They can often more easily understand the client’s experience, empathize with it, and validate it. This helps their ability to bond with clients. Peer support works against the “isolation, despair, and demoraliza- tion many experience as a result of their contact with conventional mental health services” (with their detached practitioners) (Davidson, Shahar, et al., 2006, p. 8). This collaborative form of interaction helps workers engage with clients. Peers act as role models, providing living hope that clients can recover. They often appreciate the importance of “giving back” what they themselves have been offered. And, importantly, peers are much less likely to secretly (or

Downloaded by [New York University] at 12:41 13 August 2016 overtly) pathologize and stigmatize client behavior (Davidson et al., 1999). Despite the many advantages of academic training, peer support specialists ironically can benefit from the fact that they have not undergone this training (Slade, 2009). Non-peer workers often mistakenly believe, as they are implicitly taught, that effective mental health practice requires a consistent, unquestioned detachment from their clients (Davidson et al., 1999). Of course, detachment is useful and important at times, but this attitude toward detachment creates distance and prevents authenticity. In peer support, the client sees the worker as a whole person, not as a kind of projection. This aids the connection between them, which to some degree Social Interactions With Friends 65 approximates friendship. Non-peer workers—mental health professionals and others who do not identify as having a mental illness—often unquestioningly uphold boundaries that prevent flexibility in providing help (Rep- per & Carter, 2011). Moreover, mental health professionals often feel that they “know better” than clients—or at least that they need to appear as if they do. In feeling superior, however, they may deny the parts of themselves that resonate with the client’s experience—this undermines workers’ ability to access key emotional resources. A sense of superiority inhibits a worker’s ability to question her own views (for example, in response to a client’s disagreement). It interferes with their ability to bond with clients. Finally, approaches adopted in academic training can lead workers to develop a “doing to” attitude toward practice with the client, rather than a “doing with” attitude (Slade, 2009, p. 114). Relying on a “doing to” attitude, a professional treats clients (or uses interventions) rather than collaborating with them. Thus, a hierarchy is established, which keeps clients at a distance (Engel, 1977; Taylor, 1979). The employment of peer support specialists has advantages for the staff members they work with (Slade, 2009, p. 104). The presence of peer support workers, given their alternative perspectives, can help regular staff members to become more aware of their own values and beliefs (Mowbray, Moxley, & Collins, 1998). This challenges the “us versus them” view of staff and clients. Workers come to experience new points of view. They may come to question assumptions that they have taken for granted. The use of peer support specialists can affect a whole agency—and, in turn, the mental health system—by exposing it to a recovery perspective of psychiatric issues (Mowbray et al., 1998). Slade’s third level of peer support consists of peer-run programs. These programs provide one of the most effective ways of promoting personal recovery. (Personal recovery can be understood as a unique process of recovery that is fulfilling and makes a contribution to society.) He points out in particular that when a staff has a majority of workers who are peers with clients, stigmatizing beliefs about clients may be difficult to uphold. Staff members view the experience of “mental illness” as a strength rather than an indication of weakness. Mark Salzer and his co-authors (2002) present some of the ideas under-

Downloaded by [New York University] at 12:41 13 August 2016 lying services delivered by consumers in Consumer-Delivered Services as a Best Practice in Mental Health Care Delivery and the Development of Practice Guidelines: Mental Health Association of Southeastern Pennsylva- nia Best Practices Treatment Team. These ideas include: 1) Peers can help normalize the embarrassing situations faced by other peers. They can give these peers perspective on what is taking place. 2) Peers have credibility as role models. They model self-efficacy. 3) Peers can offer the varied kinds of support that the others require. 4) Peers offer knowledge that is based on experience. 5. Peers benefit by helping other peers. The peers who help others, for example, become more knowledgeable and more confident. 66 Social Interactions With Friends A good deal of evidence points to the effectiveness of peer support. A review of this evidence is presented in SAMHSA’s publication “Consumer-Operated Services: the Evidence” (U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Admin- istration, 2011). This article supports the conclusion that peer support contributes to the mental health system as a whole. A significant result of peer support is its focus not only on individuals but on the building of relationships (Mead & MacNeil, 2005). Peer support, however, affects larger groups (Solomon, 2004). It can bring about learning communities. Such learning communities act as systems that, according to Littlejohn and Domenici (2007), involve “webs of influence where ripples can fan out in a number of interesting directions” (p. 3). Peer support in this way produces a form of social change. Nonetheless, peer support workers face some difficult problems (Slade, 2009; Wells, 1999). They receive low pay (Wells, 1999). They run into problems based on their differences from “regular” staff members (Wells, 1999). Other workers may experience the perspectives of peer workers as threatening and at times may disrespect them (Wells, 1999). Peer workers’ emphasis on experience as a basis of knowledge can sometimes lead them to uncritically believe in their own experiences as evidence of absolute truth. They may develop misleading generalizations based on the seeming uni- versality of their own experience. Peer workers need to understand their “personal” experience as socially constructed (Eisenberg, 1988). Peer workers may live a life surrounded by their peers. They need to beware of the phenomenon of the “mental health ghetto”—wherein one becomes locked into a pattern of work and interaction involving only one’s mental health peers and co-workers. Finally, peer self-help groups can become frustrated at the difficulty of working to change the mental health system since they exist outside of its normal boundaries.

Creating Mutuality in Relationships One-sided relationships—with helpers playing the dominant role—are central in the lives of psychiatric clients (Miller, 2008). This unfortunately occurs despite the fact that 1) mutuality is crucial to recovery and 2) there

Downloaded by [New York University] at 12:41 13 August 2016 is a widespread literature showing the importance of mutuality in helping relationships (Finfgeld, 2004; Miller, 2008). Non-mutual relationships, even when they provide much help, can be harmful to psychiatric clients in various ways (Miller, 2008). Note, however, that mutual relationships can at times lead to harmful prejudice against authoritative ideas and practices. Nurullah (2012), as we indicated earlier, reflects on the negative dimension of help in an article reviewing available studies on the effectiveness of providing social support. Shockingly, Nurullah (2012) says that researchers have been unable to demonstrate that social support creates desired effects. Social Interactions With Friends 67 He says that “many studies have reported that specific supportive behaviors either have no positive effect on well-being . . . or may even be detrimental to the recipient” (Nurullah, 2012, p. 174). Examined closely, these results in part seem to reflect a lack of mutuality in the helping relationships studied. Recipients feel demeaned, indebted, or guilty as a consequence of receiving help. The help may be experienced as invasive, demanding, or imposed. He suggests the need for mutuality in social support, for example among family members. Mutuality in relationships is extremely important for psychological growth (Jordan, 1986) Yet the relationships that people diagnosed with severe mental illness have both with their providers and with their families tend to be one-sided (Jordan, 1986). By default, friendship is often the only place where mutual relationships develop for these individuals, though there is often much imbalance here as well. Mutual relationships help people because they respect and value the unique subjectivity of each person involved. Each person sees the other in her wholeness (Jordan, 1986; Miller, 1986). This differs from relationships in which people become seen in terms of their status as a patient or doctor—or simply as the bearer of a mental illness. In mutual relationships, no framework or label is projected onto the other party. Each person is receptive to the other’s subjective world and open to change. Empathy therefore plays a major role in these relationships. Mutuality implies that each person reveals her inner world. Each party is also seen as an initiator, not as a passive recipient of the other’s services. Miller and Stiver (1998) view mutuality as “a shared activity in which each (or all) of the people involved are participating as fully as possible” (p. 43). One-sided relationships can restrict individuals’ potential for growth. Such relationships may facilitate hierarchy, control, and predictability (Miller, 2008). Hierarchical relationships can seduce us because they may avoid the messiness, vulnerability, and unpredictability inherent in mutual growth. Our society conceives of help in the form of hierarchical relationships (Miller, 2008). This fits the society’s tendency toward individualistic and hierarchical orientation. Experts treat people diagnosed with severe mental illness. The list of what is needed for treatment—medication, therapy, rehabilitation, and so

Downloaded by [New York University] at 12:41 13 August 2016 on—tends to focus on things that are done to the client, not by the client (Amundson, Stewart, & Valentine, 1993). But getting better by effectively dealing with a changing environment is linked with taking initiative. Tullio Scrimali’s (2008) extensive work with schizophrenia suggests that recovery depends greatly on clients playing a positive role in society. This may be why people with schizophrenia in developing countries—which are often less socially fragmented than developed ones—have a better prognosis than those in industrialized countries with extensive mental health systems (Scrimali, 2008; Sartorius et al., 1986). In some countries, people with 68 Social Interactions With Friends schizophrenia perform dignified work on a farm. In the U.S. they usually play the ignoble role of “mental patient”—not an actor, but a recipient of services. Patrica Deegan (1996) states that:

We are here to witness that people who have been diagnosed with mental illness are not things, are not objects to be acted upon, are not animals or subhuman life forms. We share in the certainty that people labeled with mental illness are first and above all, human beings (p. 2).

Skolnick (1997) says that meaningful group work requires a person with schizophrenia to “rejoin the group as an emotionally alive contributing person rather than an objectified thing” (p.1). Those with psychiatric diagnoses require mutual relationships with society. It appears that “treating” them in one-sided relationships often causes more harm than good (Stuart, 2006). Non-mutual relationships have many negative effects on people diagnosed with severe mental illness (Jordan, 1986). These relationships may encourage compliance rather than autonomy. This can contribute to people’s helplessness, passivity, and stagnation. It can discourage creativity and risk-taking (Breggin, 1994). Compliance leads to the development of a false self. This closes off the expression of a person’s authentic opinions, feelings, and needs. Non-mutual helping relationships can also contribute to low self-esteem. As we have noted, they can make individuals feel guilty, indebted, or demeaned. They can also make people feel unneeded, weak, incapable, and inferior. Finally, they can breed resentment—resentment on account of the diagnosed person feeling alienated, depersonalized, and objectified by another—which can cause the diagnosed person to do this to others (Thor- nicroft, Rose, & Kassam, 2007). Non-mutual relationships tend to distance the helper from the person being helped (Rogers & Pilgrim, 2010). This can make it difficult to develop trust. It can limit the joy, energy, and love that might otherwise result from the activities shared together. Distance and hierarchy in a helping relationship can make the person being helped feel vulnerable and afraid of being criticized (Rogers & Pilgrim, 2010). This can elicit defensiveness rather than receptivity and responsiveness.

Downloaded by [New York University] at 12:41 13 August 2016 Mutual relationships, on the other hand, encourage agency. They support initiative and self-efficacy. They foster collaboration. The parties involved need each other. Both develop the ability to be changed by their experience. These qualities build strong and vital connections between people. This connection not only helps people to achieve goals, but is a valuable end in itself (Mueser, et al., 2002). People diagnosed with severe mental illness do not need professionals, or groups, to develop mutual relationships like Alcoholics Anonymous. Mutual relationships do, however, often develop out of self-help groups (Mead & MacNeil, 2005, 2006). Moreover, therapists, peer support workers, and Social Interactions With Friends 69 various kinds of groups contribute to the development of mutual relationships. Directive and leader-centered groups, at least during sessions, may not contribute much to the development of mutuality (Yalom & Leszcz, 2005). Non-directive groups that create a holding environment, however, offer a good opportunity for individuals with psychiatric issues to open up to each other and develop mutual relationships. The modified Tavistock group discussed in chapter 12 provides a good example of such a group (Semmelhack, Ende, Hazell, 2013). Tavistock Groups, Open Dialogue, and Therapeutic Communities all include at least some element of hierarchy (Hoffman, 2003; Seikkula & Olson, 2003). The idea of “flattening the hierarchy” refers to a reduction of hierarchy, not its obliteration. The kind and degree of hierarchy, vary a great deal. Hierarchical relationships can elicit unquestioned belief (Hoffman, 2003), yet at times the benefits provided by this belief outweigh the damage that may be caused through the suspension of critical thinking. We need to question what hierarchy does and where, rather than embracing the naïve idea that we can suddenly just do without it. We do not wish to simply deny the usefulness of hierarchical relationships (Hoffman, 2003). With the notion of hierarchical relationships in mind, we would like professionals to become mindful of the impact of this type of interaction dynamic on individuals, groups, and society as a whole.

Supporting One’s Desired Identity Stigma spoils the identities of people with psychological disabilities (Goff- man, 1961). Friendship can help people with psychiatric disabilities to create social contexts in support of their desired identities. Why is this so important? “The ideal or hoped-for self,” says Slade, “is a key motivator for action and change” (Slade, 2009, p. 87). Having a desired identity, supported by oneself and by others, creates an enthusiasm for living. One is therefore motivated to provide support for this desired identity. Social institutions tend to strip patients of their identities, replacing them with the identity of a mental patient (Estroff, 1989; Goffman, 1961). With- out undergoing the long and difficult process of developing and cultivating a desired identity, a person who has had a psychological breakdown is in danger of being kept down by the forces that would define her merely as

Downloaded by [New York University] at 12:41 13 August 2016 someone with a severe mental illness (a “crazy person”). At times, in fact, a mental health professional will outright push onto a patient the label of a “disease,” telling her, “You are a schizophrenic” (Caplan, 1996). Helping people to forge a new identity, friendship enables one to “rede- fine themselves [sic] as a person,” not a patient (Schön et al., 2009, p. 345). One study of recovery found that “at the heart of the recovery process was the transformation from an illness-dominated identity to an identity of agency [and] competence” (Mancini, 2007, p. 50). Interactions with friends can help people cultivate a social framework in which others support their desired identity. The client can help to bring 70 Social Interactions With Friends about a social context where others encourage, expect, and help her to live in accordance with the identity she desires. Such a social context can effectively “treat” “schizophrenia,” addressing, for example, such problems as poor motivation, absence of pleasure, or being “schizoid.” It can also help organize the ego. Here is an example of the creation of such a social context. Joe has been hospitalized and now is beginning his recovery from a breakdown. He is numb and has low self-esteem and little motivation. After some months pass, Joe meets Mike at a day program. Both like music, and gradually they form a friendship. Mike plays guitar; Joe also played guitar at one time and shows a little bit of interest in playing again. Mike encourages Joe to play again, and after a while Joe begins to pick up the instrument every now and then. Mike treats Joe not as a mental patient but as a musician. This raises Joe’s self-esteem as a guitar player. They go out to hear live music. Mike lends Joe books about music. Joe becomes interested in jazz and begins to play jazz on the guitar. He and Mike teach each other songs. Joe and Mike play guitar together. Joe starts to remember how to play songs he played many years ago. As Mike’s friend, Joe meets other musicians and sometimes plays the guitar with them. After a year or two passes, Joe and a couple of friends decide to form a band. Two groups have become important in Joe’s life—the band and a small, informal group of musicians who hang out together. Joe’s relationship with Mike, as well as with these groups, plays a major role in reviving Joe’s identity as a musician. Joe’s friendships and his passion for music do not solve all his emotional problems, but in addition to reducing his symptoms, they help bring about a sense of well-being. They help him to restructure how he thinks about his life. Mike transforms Joe—Joe’s concepts of himself and others (his internal objects). His trust in others improves. “Relationships lie at the heart of identity. One develops a positive identity by establishing or re-establishing identity-enhancing relationships” (Slade, 2009, p. 84). Like psychotherapy, Joe’s friendships act as a holding environment that helps him to explore new aspects of his identity. He experiments with new roles. Psychotherapy facilitates a “free” exploration of psychic depths, but friendship has other advantages. Friendship helps to create an environment in which others provide a more sustained and authentic appreciation of

Downloaded by [New York University] at 12:41 13 August 2016 one’s identity. Joe chooses his friends. They share his passion for music. Unlike a therapist, they are not paid to respond to him. It is not their job to focus on sensitively responding to his needs (for, say, an hour per week). Rather, this is an environment in which Joe must respond to the demands and possibilities of reality. He can deepen his relationships because he can spend lots of time with his friends, and they are free to determine the time, place, and context of their interaction. Joe’s friends help him to develop a fullness of life, a sense of belonging, and a sense of self-esteem that therapy could not. His friendships truly are a “treatment.” Social Interactions With Friends 71 Friendship has more flexibility of structure than psychotherapy, social institutions, groups, or the family (Allen, 2008). In friendship, a person has a greater ability to create her life in accordance with her own needs, characteristics, opinions and environments. One chooses what to do, how to do it, and most importantly, who to do it with. One chooses objects and environments to make use of. This flexibility is essential for a person to create a life that she finds worth living. The needed social context is notavailable . It cannot be provided or prescribed. Rather, one must create it. Perhaps because they have less control over friendship than over other aspects of clients’ lives, professionals leave out the key element of friendship when describing what constitutes treatment. Friendship can help reframe one’s identity in many ways. For one who is transforming her identity, friendship can provide encouragement, appreciation, inspiration, the expectation that one will live up to one’s standards, and connection with others who share the same passion. Friendship can create a context in which one is needed. It can be a place where people find someone who believes in them. “One crucial reason people with serious mental illnesses recover,” according to Elizabeth Baxter, a psychiatrist who has had severe mental illness, “is because they find someone who believes in them and their recovery” (Kupersanin, 2002, p. 1). This can be a professional, but it can also be a friend. A friend’s prizing of an individual with a psychiatric disability can help to change that person’s internal object relations and in turn contribute to a change in identity. Alongside therapy and medication, friendship plays a key role in recovery.

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NOTE: For works cited from the World Wide Web, the links were accurate at the time of publication. With time, however, they may have changed and might not be accessible in the same way as referenced here. This page intentionally left blank Downloaded by [New York University] at 12:41 13 August 2016 Introduction to the Cases

We now present eight cases in which we discuss the role of social interaction in clients’ mental health. These cases stand on their own regarding the concepts presented in the first three chapters and can be used individu- ally for teaching purposes. We examine the interaction structures presented in Chapters 1 through 3, as well as other interaction dynamics. Words in the text related to important interaction structures will be italicized. Not all of the italicized interaction structures are listed in the Synthesis Chap- ter 13. Only the more major structures are listed there. Although these cases together suggest a rather negative profile of the mental health system, we wish to point out that they also show hopeful interactions that take place on many levels of these institutions. Downloaded by [New York University] at 12:41 13 August 2016 This page intentionally left blank Downloaded by [New York University] at 12:41 13 August 2016 4 The Depersonalized Musician

Dr. Jean is a trained art therapist working part-time at Sunrise Place, a nursing home. She describes her experience of working with Tim.

Working as an art therapist in a poorly run nursing home, I noticed on a daily basis an old man in the hallway who was described to me as a “schizophrenic.” He sat silently, barely moved, and seemed totally disen- gaged from the world around him. He seemed completely withdrawn, incapable of interaction with others. Suddenly one day he looked me in the eyes and shouted, “Metamorphosis, metamorphosis . . . metamorphosis!” I was quite taken aback and asked the man what he meant. It became clear that he was referring to Kafka’s story, “Metamorphosis,” in which a man wakes up one morning to discover that he has been transformed into a giant, repul- sive insect. Tim wanted me to bring him the story. After I gave it to him, he returned it and said that he could not read the story “Because it is my story.” He felt that the institution, including everyone around him, made him feel like he was a disgusting object, like a huge insect. Through this surprising interchange, Tim and I had made a connection. We began having short conversations about literature in the hallway during which Tim began to reveal his story. I came to realize that Tim was not merely a “chronic schizophrenic.” He had attended two years of college and studied music. He had a beautiful voice and had played the violin. I also discovered that this bright and articulate person had never had any psychotherapy, due to his lack of health insurance and possibly the stigma held by many mental health professionals that schizophrenia is untreatable. Fol- Downloaded by [New York University] at 12:41 13 August 2016 lowing his first breakdown in his early twenties, Tim reported that he had been largely overlooked by an underpaid and overworked psychiatric staff at each hospital to which he had been admitted. Tim was left alone in a mental health system where he had been either invisible or intermittently visible to mental health professionals whom he felt treated him like he was less than human—“like an insect.” His parents and one older brother were deceased. He reported having a close relationship with his parents, who had died over two decades ago. His older brother died of cancer when he was a teenager. He had first cousins, but had lost touch with them over the years. Tim was all alone. 82 The Depersonalized Musician Although Tim’s psychosis was overtly evident, he was still able to function appropriately in the nursing home community when given the opportunity. He acknowledged auditory hallucinations and delusions of persecution. Specifically, he had transient episodes of hearing the voice of the devil and had the periodic belief that he would be kidnapped and tortured by aliens. Still, Tim was far more than a diagnosis of schizophrenia. Soon after our first interaction I invited Tim to attend a Monday morning art therapy group. The nursing home administration initially did not want to implement this group, viewing it as a waste of time and resources. But my persistence in advocating for it led to a ten-week trial of the program. This group provided Tim with a holding environment, an environment where this sensitive man could feel safe, enveloped by care, and, gradually, able to express emotions, connect with the other residents, and embrace his true self. This holding environment characterized by empathy and unconditional positive regard proved to be an antidote to the depersonalizing and alienating environment epitomized by the nursing home as a whole. Tim’s extreme social withdrawal had led the busy staff to believe that he was not interested in or capable of interacting with others. His withdrawal, however, had been a defense, helping him to avoid facing the painful struggle of dealing with the depersonalizing nursing home environment. While the art therapy program was short-lived, Tim thrived in it. Although overburdened with a caseload of 75 residents, I was the only source of psychotherapy in the facility and managed to provide Tim with psychotherapy every two weeks and as needed. I came to realize that Tim had been greatly emotionally impacted by the depersonalizing effects of the stigma of mental illness. Kayser-Jones (1990) defines depersonalization in her book Old, Alone, and Neglected:

Depersonalization is the loss of personality, individuality and a sense of identity; it is what follows when people are treated with indifference, as if they have no value and are of no significance. All events that bind one to the social system are “personalizing”; conversely, everything that detaches one can be called “depersonalizing” (p. 41).

Downloaded by [New York University] at 12:41 13 August 2016 For most of the time Tim had spent in institutions he was detached from the larger social system. People failed to communicate with him, respond to his needs, or even know his name—he was identified simply as a “schizophrenic.” Tim came to perceive himself as nothing but an “insect.” The art group and our interactions reconnected him to a social system, thus to some extent defusing his experience of depersonalization. My experience with Tim led me to pay more attention to the depersonalizing interactions taking place in the facility, interactions whose effects could be amplified due to the great emotional sensitivity of the residents. I recall one particular interaction between Tim and a member of the nursing staff that appalled me and was not just depersonalizing, but extremely The Depersonalized Musician 83 dehumanizing. This growth-stifling interaction spoke to the kind of treatment Tim had at times endured over the years. Tim had just taken a swal- lowing test to assess his capacity to consume solid foods. With the results of the test having been obtained, the nurse on duty—known to be harsh with clients—delivered the results in the following interaction, which was observed by the art therapist. “Tim,” Nurse Z said, “Tim, your swallow test results are back, and guess what, you will never drink water or eat solid food again. Tim, do you understand this? You will never be able to drink water or eat solid food again. I guess you are less likely to have an accident if you drink less water.” Tim’s face went blank. He loved food and a cold glass of ice water. These were some of the few pleasures in his life. The delivery of the results occurred in a public hallway with other residents within hearing distance. The callous way in which the results were delivered contributed to Tim experiencing an emotional meltdown. Tears ran down his cheeks. Nurse Z had been irritated with Tim since he urinated in his pants earlier in the day. He couldn’t get to the bathroom on time. She blamed this accident on his laziness rather than taking into consideration his poor mobility. This interaction between Nurse Z and Tim exemplified the interaction dynamic staff revenge. Staff revenge occurs when staff members take out on the client their negative feelings in response to the therapy. Observing the exchange, I quickly intervened and took Tim into my office to process the news. Upon further examination, it became apparent that the results of the test were not definitive and that the test needed to be given again in six weeks. Tim described himself as feeling devastated by losing his ability to swallow whole food and unthickened liquid. The harsh way in which this news was delivered only contributed to his feeling alienated and depersonalized. Fortunately, Tim’s involvement in psychotherapy served as a buffer to help him process the news. In art group, Tim shared how the news had been delivered. Other members shared their experiences of un-empathic interactions with the nurse in question. Tim was relieved at not being singled out by the nurse. He received peer support (Repper & Carter, 2011). The group, in the spirit of a culture of enquiry, reflected on the possible

Downloaded by [New York University] at 12:41 13 August 2016 reasons for the Nurse Z’s style of delivery. One member suggested that she was burned out and should retire. Another member suggested that being harsh and emotionally distant was a way for Nurse Z to protect herself psychologically from the extremely painful dynamics of working in the nursing home. Still another member suggested that this was a “trickle-down” effect. Nurse Z was treated in a toxic way by her superiors and merely reenacted this same style of treatment with residents on the unit. Additional dialogue during the session helped members—including Tim—to relate the interactions with Nurse Z to other interactions with authority figures, including parents and caregivers in early childhood, when they had experienced being treated as if their feelings just did not matter (Miller, 1980). 84 The Depersonalized Musician Another interaction contributing to Tim feeling depersonalized and alienated involved the staff’s failure to investigate the physical pain he’d been experiencing. The stomach pain and a sensation that he was being “pushed forward” by the force of the pain were attributed to his paranoid schizophrenia. One certified nursing assistant (CNA) suggested that his complaints were “all in his head” and that he was trying to “manipulate staff” into giving him more attention. Verbal punishment was common, with staff telling him to “shut up” and then threatening to put him to bed in his room if he did not quiet down. After one week of making consistently the same physical complaints, Tim was unable to get out of bed, and nursing staff hospitalized him for medical reasons. This hospitalization proved life-saving because the medical staff at the hospital discovered that he had an infected gall bladder that needed to be operated on immediately. His physical complaints were real but discounted at the nursing home largely due to his psychiatric diagnosis: a form of amputating containment. The process of treating only part of someone—in this case Tim’s diagnosis of paranoid schizophrenia—as if it represented his whole personhood can be identified as metonymy, which can be a form of depersonalization. Metonymy is common in psychiatric institutions in which individuals become their diagnoses (e.g., the “schizophrenics”) rather than being viewed as people who have been diagnosed with a psychiatric illness. In direct response to this incident, the Director of Nursing (DON) put explicit procedures in place mandating staff to take all medical complaints made by residents seriously, regardless of their psychiatric diagnoses. The DON stated that to ignore physical symptoms in any resident could lead to lethal consequences. Tim’s experience was empowering for him because he felt as if he had been a catalyst leading to institution-wide changes benefiting all residents. Validation of the role he took in instituting beneficial changes occurred in Tim’s individual therapy. Tim’s participation in therapy led him to reflect on his childhood. He was shocked by what he recalled. He remembered that he had been labeled “crazy” by a school nurse at the age of seven. This hurt him deeply. The label gradually became engrained in Tim’s very sense of who he was. With- out realizing it, Tim had some unusual behaviors (e.g., mumbling to himself, a twitch in his face, cracking his knuckles and sometimes staring off into

Downloaded by [New York University] at 12:41 13 August 2016 space for periods of time), which led some neighbors and classmates to call him “crazy.” Tim was bullied and treated like an outcast. He internalized this stigma and came to view himself as “crazy.” When Tim graduated from high school, he began to disappear from society. Tim was saved by his music, playing violin and singing, which became the central part of his life. Tim’s isolating situation continued for nearly 15 years. When his father and mother died, six months apart, Tim suffered an emotional collapse. His apartment soon became filled with trash and old newspapers. He could barely get out of bed in the morning. Then he began to hear voices cursing at him. The internalized view of himself originating The Depersonalized Musician 85 in childhood manifested itself. He saw himself as being entirely “crazy” and wished that he could die. When a relative happened to stop by his apartment, she saw Tim’s condition and that of the apartment. She managed to convince him to go to the hospital for an evaluation. The hospital staff diagnosed Tim as having schizophrenia. The treatment team determined he was not capable of caring for himself and arranged to have him sent to a nursing home. Tim also believed he was not able to care for himself, so he went along with the plan. Tim was transferred from the hospital to Sunrise Place, where he met me and, as indicated earlier, engaged in brief individual therapy and an art therapy group. While the right dosages of psychotropic medication were important to Tim’s stabilization, he needed more than just medication management. Tim’s psychotherapy led him to understand how he had come to internalize the label of “crazy.” While Tim’s therapy was valuable to him, I helped him come to the conclusion that he could further his development by transferring to another nursing home with a more humane and interactive environment. This new nursing home, Hillside Manor, had a much more home-like environment and offered more opportunities for individual and group therapies as well as activities that promoted peer interaction. The institution also strongly emphasized Tavistock group work, discussed in chapter 12 of this book. Also, staff members had undergone provider training through the National Alliance on Mental Illness (NAMI) (Mohr, Lafuze, & Mohr, 2000). This training is designed to help mental health professionals gain insight into their own prejudices, thus reducing stigmatization of severely mental ill clients and improving treatment. Additionally, the owners of Hill- side Manor had family members with severe mental illness and thus had lived the experience of dealing with these devastating diseases. The owners’ lived experience contributed to their strong advocacy for residents’ rights. Humane, highly interactive treatment was a trademark of this nursing home, which was ranked one of the best in the state. Psychiatrists, psychologists, social workers, and other mental health workers worked together as a team with the goal of helping patients to get better. Besides being in excellent physical condition, Hillside Manor offered

Downloaded by [New York University] at 12:41 13 August 2016 multiple opportunities for positive interactive experiences. Residents had a gym available to them and exercising was encouraged. There was also a theater group made up of residents who regularly put on shows. The staff treated the residents with respect and care. These factors, along with com- passionate and talented individual and group therapy staff, seemed to have a significant impact on the residents as a whole. The residents were often cheerful, forming close bonds with each other. Some residents dated and one couple had gotten married at the facility. The development of friendships with other residents fostered a sense of hope, which was central to Tim’s recovery (Schön, Denhav, Troper, 2009). In this nursing home, Tim made 86 The Depersonalized Musician important gains. His internalization of the milieu helped to improve his mood, strengthened his sense of self, and provided him with the trust that others could be good “objects” for him. This “internalization of a good object,” the milieu, helped Tim to distance himself from the introjections of the label “crazy” (introjections of a bad object are linked to projection and projective identification), which had begun in his childhood (Fairbairn, 1952; Klein, 1946). Introjection is a form of internalization that does not fully integrate into the self what is taken in from the external world. The introjection of a “bad” object can take a number of forms. For example, it can be an attempt to control the object by taking it inside, or an attempt to secure a “bad” object because one believes it is the only kind available (Fairbairn, 1952; Klein, 1946). Tim introjected the label “crazy” at an early age. It was thrust upon him by society, his peers, and adult authority figures. Perhaps he introjected the label because he believed it was the only way to procure a badly desired relationship with his peers. He might have done so because he felt that the pressure to conform was just too great. Or, it appears that he might have behaved in this way out of vengeance—if the others call him “crazy,” he was going to be crazy. The introjection of a “bad” object can be much more powerful when it triggers emotions linked with the same interaction pattern early in childhood. Tim was badly misunderstood in his early childhood years by others such as teachers, school nurses, and counselors. His introjection of early negatively charged interactions with adult caregivers greatly impeded his ability to see himself as a worthwhile person in adulthood (Klein, 1946). This appeared to amplify the label “crazy” later on. When he received effective help, Tim managed to counteract the damage caused by introjecting a “bad” object by internalizing “good” objects. Through his relationships with therapists, residents, staff, and a girlfriend he met in the nursing home, Tim was apparently able to internalize attitudes that helped him to significantly improve his self-esteem, his mood, and his relationships with others. The interaction dynamic of internalizing “positive objects” seems to be present in all cases of successful treatment (Ogden, 1979). Tim’s family members also became new objects for him in a way. During his years of isolation in his apartment and in nursing homes he had lost

Downloaded by [New York University] at 12:41 13 August 2016 touch with his family, now consisting solely of first cousins. He thought his relationships with them were gone forever. However, as Tim developed more confidence through his treatment, he decided to contact family members again. He began with a cousin named Alfred. He and Alfred had had an argument over whether Tim needed treatment after his parents died. Tim became very upset, and that argument was the last time he had spoken with Alfred, many years ago. He remained emotionally cut-off from Alfred many years later. Tim revisited his earlier relationship with Alfred in therapy and decided that Alfred had only been trying to help him. His therapist helped Tim think through the situation. Then Tim managed to locate Alfred’s number and called him. The Depersonalized Musician 87 Tim reestablished a relationship with Alfred and went on an outing with him. Then Tim managed to reconnect with two other relatives as well. Since Tim was no longer dominated by the feeling that he was “crazy,” he was able to relate to his relatives on a more mutual basis. This enhanced Tim’s self-concept. Long fractured interpersonal relationships with family members became restored. Tim’s cousin Alfred and two other first cousins started visiting him on a regular basis. Approximately four years into treatment Tim noted that he had broken out of his “cocoon” and was “a bit more in the world.” This remark followed his participation in a talent show at the nursing home during which he played Amazing Grace on the violin. The show was videotaped and included live performances as well as interviews with the performers and clinical staff—showing the value of the arts in facilitating psychiatric treatment. Tim, who had taken second place in the competition, was interviewed. He highlighted how empowering his experience of performing had been. He stated that playing the violin as well as being interviewed for the DVD had made him feel “a little more human . . . like I’m a part of the outside world again.” The performance helped Tim to develop his desired identity as an artist. Tim developed a relationship with a woman at the facility who later became his girlfriend. They offered each other emotional support and validation. Tim identified his girlfriend, Cindy, as playing a central role in his recovery. In group and individual therapy, he identified her as being the beacon of hope for him and the impetus for him to reclaim his identity as musician and artist. Cindy, with the assistance of Tim’s cousin, Albert, helped plan a family reunion at the nursing home. Ten extended family members attended and stayed for over two hours. The family reunion served as an intervention in which members embraced a healthy Tim. Family members met his girlfriend Cindy, shared pictures and memories of positive times from the past, and heard Tim play his violin. They exchanged addresses and made plans for future family gatherings. Food was shared, pictures were taken, and love was expressed between them. Tim recalled this reunion fondly long after the event. Tim died of a heart attack earlier this year at the age of 73. This remarkable person, who endured many years of suffering in institutional settings,

Downloaded by [New York University] at 12:41 13 August 2016 died surrounded by his cousin Alfred, family members, and auxiliary family including residents, staff, and his long-time girlfriend. At the time of his death, he was very familiar with the term self-actualization and believed that this was a process he was actively engaged in during the last few years of his life. Although Tim never lived in the outside community once he entered Hill- side Manor, or held a full time job, or married and had a family, he lived a full life in his own right. Shortly before his death he stated that he felt he had lived a “life worth living,” one in which he had “grown as a person.” He acknowledged that he had accepted his life, “the good, the bad, and the ugly.” Interaction structures played key roles in Tim’s mental health. These included the first nursing home, where he experienced depersonalization at 88 The Depersonalized Musician the hands of Sunrise Place’s staff; his introjections of the label of “crazy” in his youth; his linking up with me, the art therapist; the dynamics of the art therapy group he joined; his transfer to Hillside Manor—a facility with a strong mental health treatment focus, readily providing group and individual therapies; his relationship with his girlfriend, Cindy; and his reconnection with his cousin, Alfred. His positive interactions with mental health professionals supported and mirrored him, and these interactions facilitated a positive sense of self (Kohut, 1977). We wish to emphasize two interaction dynamics especially of note: 1) The mental health system’s long-standing depersonalization of Tim, which contributed to his remaining in an extreme state of social withdrawal that suppressed the potential and vitality that existed within him, and 2) Tim’s internalization (with the help of therapy) of many growth-promoting interactions and relationships at the second nursing home, which counteracted Tim’s introjections of being “crazy” and helped him to live a happy and satisfying life.

REFERENCES

Fairbairn, W. R. D. (1952). Psychoanalytic studies of the personality. New York: Routledge. Kayser-Jones, J. S. (1990). Old, alone, and neglected: Care of the aged in the United States and Scotland (Vol. 4). Oakland, CA: University of California Press. Klein, M. (1946). Notes on some schizoid mechanisms. The International Journal of Psychoanalysis, 27, 99–110. Kohut, H. (1977). The restoration of the self. Chicago: University of Chicago Press. Miller, A. (1980). The drama of the gifted child: The search for the true self. New York: Harper Collins. Mohr, W. K., Lafuze, J. E., & Mohr, B. D. (2000). Opening caregiver minds: National Alliance for the Mentally Ill’s (NAMI) Provider education program. Archives of Psychiatric Nursing, 14(5), 235–243. Ogden, T. H. (1979). On projective identification. International Journal of Psycho- analysis, 60(2), 357–373. Repper, J., & Carter, T. (2011). A review of the literature on peer support in mental health services. Journal of Mental Health, 20(4), 392–411. doi:10.3109/09638237. 2011.583947 Schön, U. K., Denhav, A., & Troper, A. (2009). Social relationships as a decisive factor in recovery from severe mental illness. International Journal of Social Psy- chiatry, 55(4), 336–347. Downloaded by [New York University] at 12:41 13 August 2016

Dr. Zan is a psychodynamic psychotherapist who has treated severely mentally ill clients in long-term care for over 20 years. Dr. Zan discusses the case of Anna.

Anna was a resident in a long-term care facility where I worked as a psychodynamic therapist. (Some of the object relations theorists I relied upon included Fairbairn, 1952; Guntrip, 1992; Klein, 1975; Miller, 1980). I knew most of the residents at this facility, but had never noticed Anna, nor had she been brought to my attention by the social services department. When she first approached me, I perceived Anna to be an overweight woman, very shy and unassuming, in her early forties. She sat quietly in the hallway watching other patients or viewing TV in the lounge. She appeared to have very few friends and was frequently tearful and anxious. Upon further inquiry, I discovered she was articulate, had received a high school education, and had attended a community college. She had even obtained certification as a nursing assistant and worked in a hospital for over a year. We first met in the small dining room of the facility. She approached me speaking in a barely audible voice, asking if I might chat with her about “the situation.” “You see,” she said, “I have been experiencing heart problems and would like someone to talk to about them.” When I asked her about the nature of her condition, she stated that she had experienced an extremely elevated heart rate during a physical examination and was going in for further cardiac testing. Anna asked me if she could set up a session to talk about her medical situation. She stated that she had heard from residents Downloaded by [New York University] at 12:41 13 August 2016 that I could be trusted. When I asked her specifically about what she wanted out of our meeting she stated, “Someone to listen to me.” We decided on an appointment date and time. A quick examination of Anna’s chart prior to our first appointment showed that she had been given a diagnosis of schizophrenia at age 25, with a history of auditory and visual hallucinations. There was also evidence for paranoia and other delusional symptoms. She also experienced intense anxiety in response to these psychotic-like symptoms. This diagnosis contributed to numerous hospitalizations and protracted stays in long-term care facilities. These facilities—nursing homes as previously discussed—were 90 The Woman Who Couldn’t Get Her Abuser Out of Her Head traditionally designed for the care of elderly individuals, but given the limited housing options for adults diagnosed with severe mental illness where she lived, they had, in some cases, become a primary housing option for many mentally ill individuals, an option for housing that was only exceeded by jails (Lang, 2009). Anna arrived for our first meeting nervous and initially very quiet. She talked about how she was concerned about having a heart condition and expressed a fear of dying. I inquired about her history. My inquiry into her background invited a long silence on Anna’s part. She stated that her family was large and not close to each other. She said, “I am basically on my own.” Anna openly talked about her diagnosis. Based on the DSM IV-TR (Ameri- can Psychiatric Association, 2000), her description of symptoms confirmed a diagnosis of schizophrenia. Anna said that she heard voices and sometimes experienced visual hallucinations with bouts of intense paranoia starting in her late teens. Her description matched the information in her chart. When I inquired about the nature of the voices, Anna abruptly changed the subject and refocused the conversation back to the stress test and MRI she would be receiving to explore the possibility of a heart condition. We discussed basic relaxation techniques for coping with the medical tests and arranged a second therapy appointment. It was clear from our first session that Anna was fully oriented and had good insight into her psychological condition. She had personal strengths—communication, insight, empathy, and creativity—that were often overlooked following her initial diagnosis of schizophrenia. During my second session with Anna, she arrived very tearful. She had undergone an MRI and experienced a panic attack midway through the procedure. Her elevated heart rate and blood pressure resulted in the medical team terminating the procedure. She was embarrassed and worried the hospital staff thought negatively about her following the panic attack. Anna stated, “I just couldn’t make it through those procedures. I am fearful that the doctors and nurses think that I wasted their time. I just couldn’t go through with it. I felt so frightened.” I provided her with unconditional positive regard, empathy, and congruence. First and foremost, I listened and witnessed her sadness and deep despair

Downloaded by [New York University] at 12:41 13 August 2016 over what had occurred. Anna responded positively to this holding environment, with her painful affect de-escalating. This holding environment was an interaction structure that was central to facilitating a positive transference with Anna. When Anna calmed down I asked her if she had ever before felt panicked in small spaces. After a long silence she stated that, yes, she had felt frightened in small spaces since childhood. I explained that fears experienced in adulthood were frequently linked to early childhood anxiety pro- voking experiences. I asked her to recall these experiences from her history. After a long silence, she became tearful. I empathized with her sadness and The Woman Who Couldn’t Get Her Abuser Out of Her Head 91 re-emphasized that frightening or anxiety-producing childhood experiences could be linked with a sense of despair that can follow one throughout the life cycle. I explained that what frequently helps to improve people’s emotional state is to put disturbing experiences into a narrative form (van der Hart, Steele, & Brown, 1993). Again after a long pause she proceeded to tell me that I would not believe her and that she had never been believed. She abruptly stated, “I want these memories to go away . . . can you please make them go away.” I gently inquired about what had happened to her and assured her that if she did not want to share more it was OK. Again, Anna stated that she wanted to tell me but worried that I would not believe her. She said, “You see, no one has ever believed me—the minister, my mother, the psychiatrists, and what if you don’t believe me, then what?” I reinforced the fact that anything she said to me would be accepted and explored within the context of the therapy, unconditionally. Still, Anna revealed nothing other than that she feared I would not believe her. While this interaction made me curious about Anna’s background, I interpreted her reluctance to share as linked with the need to develop more in our therapeutic relationship. Furthermore, I questioned whether some psychotic-like paranoid ideation might have been triggered in response to the medical issues she was experiencing. I found myself gravitating toward the traditional medication model, contemplating the possibility of an increase in medication. In terms of countertransference, my own anxiety about dealing with Anna’s painful history caused me to contemplate containment of her affect—amputating containment. It was during the third session that Anna revealed a long-held secret to me. As was often the case, Anna was very quiet at first. We chatted about activities in the facility, her fears over health problems, and simple roommate issues. Then she abruptly shifted the subject. Anna stated, “I have decided to tell you. I hope that you will believe me.” She stopped talking and tears ran down her cheeks. I suggested that whatever it was must be very sad. Shockingly, Anna stopped crying, looked me straight in the eyes and stated, “I was raped countless times. I was raped by him!” Stunned by her remarks, I inquired about the rapes—believing it necessary to rule out that they were a part of a delusional system or had perhaps occurred within the facility.

Downloaded by [New York University] at 12:41 13 August 2016 Anna responded, “No . . . no, it was throughout my childhood.” I was taken aback. She was sobbing as she gave me the basic outline of her story. She stated:

ANNA: “My mother divorced my father when I was five. She remarried Gregory. My twin brother and I went to live with them. The rest of the children stayed with my father.” DR. ZAN: “So you went to live with your mother and stepfather, not your birth father.” 92 The Woman Who Couldn’t Get Her Abuser Out of Her Head ANNA: “He [birth father] didn’t want me. He said that I was retarded and useless.” DR. ZAN: “Retarded?” ANNA: “Well, you see, I had this hearing problem, and it never got diagnosed until I was eight. I had very poor hearing which made me seem to be retarded.” DR. ZAN: “So you were stigmatized as retarded and rejected by your father. That must have been very painful.” ANNA: “Yes, it was,” she said, crying. I began to believe that I was retarded and worthless and unwanted. Finally, we moved in with my mother and Gregory, my stepfather. My mother worked third shift. That’s when it started. Every night he would come into my room. It started with fon- dling and then became more and more intense. He started raping me regularly. I did not know what was happening to me. I was six years old. I just took it. I was terrified to tell anyone. He left my brother alone. It was me whom he targeted. I lived in terror. He threatened to kill me if I told anyone . . . kill me and my brother and mother. My mother just worked nights and was drunk during the day. She was aware of the nightly abuse that went on between my stepfather and me for years or at least was in denial. I was in a prison with nowhere to go for my entire childhood.”

Gradually, over six months, Anna and I pieced together a narrative that portrayed one of the worst sexual abuse histories I have ever encountered in my career as a psychologist. Anna had grown up in a dysfunctional house- hold, riddled with abuse and neglect—interactions characteristic of childhood discord. The family was void of a holding environment characterized of loving caregivers. From early childhood onward, she had been subjected to negative projections that she had internalized—being retarded, stupid, a worthless person, etc. Negative projections continued as she was given the diagnosis of schizophrenia and was further depersonalized and dehumanized by a mental health system that labeled her as “crazy.”

Downloaded by [New York University] at 12:41 13 August 2016 Anna’s stepfather had systematically abused her from the age of six to age 15—physically, emotionally, and sexually. The rapes stopped after Anna’s miscarriage of her stepfather’s child as a sophomore in high school. She described the incident in a session:

ANNA: “I had cramping and I went to the ladies’ room at the high school. Blood came out and a fetus was there . . . in the toilet. Oh my God. I flushed it away. I flushed it down the toilet (quietly crying).” DR. ZAN: “Anna you were in a difficult place. You had no support. It’s not just the fetus that got flushed away but your The Woman Who Couldn’t Get Her Abuser Out of Her Head 93 childhood as well. That fetus may represent a childhood flushed away by a social system that failed to provide you with any emotional support, any place to go to tell your story and get help and protection.” ANNA: “Even today when I go by playgrounds I cry when I see the children playing. I never played. I had no childhood (quietly crying).” DR. ZAN: “You are very likely mourning the loss of your childhood and the loss of your innocence.”

Anna’s story brought to mind Alice Miller’s work (1980) The Drama of the Gifted Child. Miller suggests that children terrified of abandonment by caregivers become conditioned to please them, i.e., they become conditioned to a culture of obedience. The children are molded by these caregivers, who threaten them with abandonment or worse if they fail to meet the caregiver’s emotional needs while forsaking their own. In the extreme form, meeting these emotional needs may take the form of sexual abuse. This dynamic leads to the loss of an authentic, spontaneous sense of self in the developing child and eventually in the adult. Years later the adult child, in therapy, can come face-to-face with the loss of childhood and the loss of themselves that occurred as a result of a traumatic upbringing. Through therapy the adult can mourn the loss of the childhood, ideally resulting in the birth of an authentic self in adulthood. For Anna, the abusive voices and visual hallucinations were very likely flashbacks of a childhood stolen at the hands of an abuser. Flashbacks are recurrent and abnormally vivid recollections of a traumatic experience, such as sexual or physical abuse in childhood, sometimes accompanied by auditory, visual, tactile or other types of hallucinations (Briere, 2004; Muser et al., 1998). Anna’s stepfather, however, was not the only one who betrayed her. Anna had also been betrayed and neglected by her mother, who acted as if the abuse was not occurring. She was also betrayed by her birth father, who labeled her a “retard” and literally abandoned her. At the age of 17, Anna went to her minister and told him that her stepfather had repeatedly raped her throughout her childhood. The minister, however, suggested that she

Downloaded by [New York University] at 12:41 13 August 2016 was responsible for the abuse and that she had in fact seduced her stepfather. This fundamentalist Christian minister had equated her with Eve in the Garden of Eden seducing Adam to eat the apple from the Tree of the Knowledge of Good and Evil. Even teachers ignored the tell-tale signs of abuse—bruises, cuts, poor hygiene, etc. Anna’s severe hearing deficit, left untreated up until the age of eight, left many teachers believing she was mentally retarded, a determination which further depersonalized her, dis- crediting any attempts she made to communicate that something was not right with her family. As a 25-year-old, Anna sought the help of the mental health system, which attributed her “ravings” about the abuse to delusional ideation due 94 The Woman Who Couldn’t Get Her Abuser Out of Her Head to schizophrenia. She stated, “I told him, the psychiatrist, I was raped . . . I was raped . . . believe me . . . I hear voices, angry voices that raped me . . . I see him.” Anna’s experience of abuse was obscured by her diagnosis. She became simply a schizophrenic. Her personal history leading up to the diagnosis was dismissed by the mental health system. No one in the mental health profession, including this psychiatrist, asked her about whether she could identify the voice or who the “he” who raped her was. Individuals in the mental health system treated her experience as if it was simply a symptom of her psychopathology. No one asked what the voices said to her or if the voices could be linked to a specific person. Post-traumatic stress disorder is a much more accurate diagnosis for Anna given her history. According to Briere (2004), PTSD is a condition in which symptoms typically include flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about a traumatizing event. If a traumatic past is not revealed by the client, the symptoms of PTSD can frequently lead to a misdiagnosis of a psychotic disorder (Read & Ross, 2003). Perhaps if one mental health professional (MPH) had taken the time to listen to Anna about the nature of her voices she would have told her story and been treated for post-traumatic stress disorder (PTSD) decades earlier. If an accurate diagnosis had been made years earlier, decades of institutionalizations could have been avoided. Anna could have been making a positive contribution to society rather than languishing in psychiatric wards. Judith Herman (1997) elaborates on PTSD, suggesting that the ordinary diagnosis of PTSD in some individuals should be upgraded to be a complex post-traumatic stress disorder, CPTSD, also known as multiple interrelated post-traumatic stress disorder. This is a psychological injury that results from long-term exposure to social and/or interpersonal trauma in the context of captivity, which results in the loss of control and helplessness leading to deformations of identity and sense of self. A vast majority of individuals diagnosed with a severe mental illness who are institutionalized have trauma histories (Briere, 2004). In many cases these histories are severe. Yet few individuals, once obtaining a diagnosis of a psychotic disorder, are reevalu- ated and correctly diagnosed with PTSD; therefore, they remain untreated. The various people in Anna’s life—her mother, stepfather, father, teachers, minister, and mental health professionals—unintentionally or, in some

Downloaded by [New York University] at 12:41 13 August 2016 cases, intentionally (the stepfather) engaged in an unintentional conspiracy to scapegoat the “stigmatized” person, Anna, who lacked power over them. In the mental health system this interaction structure (which leads to scapegoating) can be identified as the unintentional conspiracy of those in power. This unintentional conspiracy works because: 1) People in power, including Mental Health Professionals (MHPs), tend to align with one another, accepting at least in a general way the diagnoses of other MHPs, as opposed to the views of the stigmatized person who is not in power. The mother is stuck in alliance with the stepfather, who knows the minister and teachers, etc. 2) The traumatized person, as part of the trauma, develops a “repetition compulsion,” a repetition that seeks to master the original trauma. The Woman Who Couldn’t Get Her Abuser Out of Her Head 95 The concept of the repetition compulsion ignores the social basis of the repetition of the trauma. 3) The mental health system tends to stigmatize and blame people with “mental illness,” which is partly why being traumatized can be described as “schizophrenia.” The system officially relies on its conventional language, which obscures the social dynamics related to people’s problems. Anna’s trauma narrative became lost. There is amputated containment, and her diagnosis obscures the entire social dynamics of the patient. 4) The person blamed, i.e., the designated patient, Anna, is intimi- dated and persuaded by people in power into accepting their beliefs about who she is, a “schizophrenic.” She internalizes the stigma. She is fearful of challenging those in power. There is a culture of obedience reminiscent of the work of Milgram (1963, 1974) and Haney, Banks, and Zimbardo (1973). After spending decades not being believed, at the age of 43 Anna revealed her story to me. I listened to her and believed her. She stated that she felt lost in the mental health system, where she was overmedicated, stigmatized, and disbelieved concerning her abuse. She had internalized the stigma and believed she was crazy. She was constantly re-traumatized by living under these stressful conditions. Staff members who objectified anddepersonalized Anna by treating her as simply a crazy person caused her to relive the original trauma, facilitating a culture of fear that diminished Anna’s capacity to cope psychologically with her history. One could say that Anna was punished by the system supposedly designed to treat her (Mueser et al., 1998). Shortly after revealing her story Anna stated, “Being believed by you gives me hope. You actually listened to my story and believed me. I felt validated for the first time in my life.” Anna remained ostracized from family and friends who did not want to believe her story. Anna’s story suggests a severely pathological family that designated her as the patient, and projected psychopathology onto her, likely as an unconscious strategy to keep the sexual abuse a secret. Following her revelation Anna engaged in five years of intense therapy focused largely on the trauma. This therapy helped her to regain a sense of self and eventually to reclaim a life worth living. We wish to present five interaction dynamics that characterized these years of therapy. Downloaded by [New York University] at 12:41 13 August 2016 1. HELPING THE CLIENT TO TELL HER STORY

Anna appeared to thrive on therapy. The therapy took place three times per week and also as needed. It was grounded in a positive holding environment characterized by unconditional positive regard, empathy, and congruence. Anna was listened to and validated as a person. Her story was unconditionally believed and because of this she felt empowered to tell it. The function of the interactions was to empower rather than to disempower her, and reciprocity was a goal of each therapeutic encounter (Jordan, 1986; Miller & Stiver, 1998). Herman (1997) identifies the positive interaction 96 The Woman Who Couldn’t Get Her Abuser Out of Her Head between therapist and client as being critical to recovery in trauma. She quotes a survivor’s perceptions about what good therapy is: “Good therapists were those who really validated my experience and helped me to control my behavior rather than trying to control me.” A good therapist needs to meet the client where she is at the moment rather than imposing on the client what the therapist believes to be good for the client. The telling of Anna’s story led to a re-examination of her diagnosis and ultimately the disowning of negative projections. Her diagnostic formaliza- tion of schizophrenia had depersonalized her and left her feeling alienated from society. Her history of abuse was denied, lost, and ignored, i.e., amputated. She was seen by staff, family, and others as a “crazy” person. Worst of all, she saw herself as “crazy.” She internalized a stigma. Herman’s (1997) perspective stands in stark contrast with the Western medical model, which establishes power over the patient by the medical professional. In traditional Western medicine, a diagnosis is given to the client based on her presentation—psychological and behavioral—and medication is prescribed to “contain” the symptoms. The client’s history of trauma, deaths, and other losses are typically ignored by the professional. Social interaction between psychiatrist and client is kept to a minimum—typically in 10–15 minute sessions—and emphasis is on whether the medication is working. RD Laing (1960), a psychiatrist but a long- time critic of psychiatry, believed that psychiatrists and psychoanalysts will never succeed in understanding such phenomena as mental illness—particularly psychosis—as long as they (psychiatrists and psychoanalysts) persist in looking at people from an alienating, and alienated, point of view. He believed that this was the way that psychiatrists and psychoanalysts typically looked at a patient. Logically, a 10–15 minute session does not allow a psychiatrist or any other type of diagnostician to see the client/patient as a multi-dimensional person (with a life, a family, an education, and possibly a career) and therefore could be misinformed in the diagnostic labeling of the individual under such time-constrained circumstances. Anna described herself as being “talked at” by her psychiatrist rather than being engaged in a social interaction with him characterized by reciprocity. She said, “He seemed to overlook that I was more than “a compi- lation of symptoms but that I was a person, a daughter, a friend, a human

Downloaded by [New York University] at 12:41 13 August 2016 being rather than simply a diagnosis.” Perhaps mental health professionals practice amputating containment as a way of avoiding the intense pain associated with witnessing and processing extremely traumatic memories of abuse with a client. This tendency on the part of the MHP may be a form of countertransference (projective identification) that goes unanalyzed in a culture of psychotherapy in which unconscious processes are denied in favor of more concrete cognitive behavioral ways of dealing with behavior. The therapist becomes the container for the resistance and ambivalence the client has about facing the painful feelings associated with her memories. The The Woman Who Couldn’t Get Her Abuser Out of Her Head 97 traditional Western or medical model approach to people diagnosed with severe mental illness is disempowering to patients, including, frequently, those with PTSD who need to tell their stories. In Anna’s treatment, an important mechanism for client empowerment was psycho-education. Psycho-education about PTSD and its symptoms clearly empowered Anna. For the first time, she was introduced to the possibility that she suffered from post-traumatic stress disorder rather than schizophrenia. As her psychologist, I explained the origins of PTSD as residing in trauma and explained that she had been subjected to longstanding abuse of an intimate nature by individuals who were expected to play the roles of nurturer, protector, and provider rather than tormentor. I explained that flashbacks, triggers, and seasonal and anniversary effects, during which time she relived the abuse, were symptoms of PTSD. An open flow of communication between Anna and me provided for a didactic understanding of behaviors in the Here and Now. Over time, Anna began to tell her story in a new way:

All those years they called me schizophrenic. I simply stated that I had audio and visual hallucinations and that at times I felt scared, anxious and paranoid . . . within 15 minutes a psychiatrist gave me the diagnosis of paranoid schizophrenia. From then on, I was simply a schizophrenic doomed to a life of medication and institutionalizations. And to tell you the truth no one in the mental health profession except one counselor when I was 35 years old ever asked me if I had been abused. I hesitated to tell her out of fear that I would not be believed. When I finally broke down and had to go to the hospital it was almost a relief to be diagnosed with schizophrenia. It gave me an excuse for my unforgiveable actions. I was simply crazy. I started to believe that I never was abused. That everything I believed happened to me really had not happened because I was a schizophrenic who was only hallucinating. I don’t believe this anymore. I am a survivor of an abusive childhood. It makes me feel strong to understand what happened to me.

For years Anna’s voices had been deemed as hallucinations, a phenomenon not linked to anything but a “chemical” imbalance in her brain.

Downloaded by [New York University] at 12:41 13 August 2016 Psycho-education had led to a new understanding of these “hallucinations.” They now became flashbacks of earlier traumas. Her newly acquired psychological vocabulary helped to hold and reframe her traumatic experiences (Briere, 2004). For example, an understanding of her experiences as flashbacks took the mystery out of the symptoms, allowing her to psychologically process the meaning of the flashbacks. Her capacity to link the flashbacks to historic events allowed for the development of a narrative and the capacity to process in language the intense affect attached to these memories. 98 The Woman Who Couldn’t Get Her Abuser Out of Her Head 2. RELINQUISHING INTERNALIZED PROJECTIONS

A critical component to Anna’s treatment after identifying the problem as PTSD was reassigning blame where it belonged. In a sense, Anna had introjected the guilt and shame belonging to the perpetrator (Fairbairn, 1952). What follows is a poignant therapeutic interaction taking place several months into the treatment that assigns the blame to whom it belongs—the perpetrator:

ANNA: “I am so ashamed at what I have done. I hate myself for my thoughts. I feel like I am to blame. I am filth.” DR. ZAN: “My sense is along the way a lot of people who are to blame have put all of the blame into you. And I sense some of the anger you have expressed towards yourself belongs elsewhere.” ANNA: “Yeah, I think you are right.” DR. ZAN: “Well to tell you the truth right Here and Now I’d like you to name just who deserves the blame so you can get it out of you and put it where it deserves to go.” ANNA: “OK, Gregory—my stepfather, my mother, the minister, teachers . . . I wish I could kill them all. Isn’t that horrible?” DR. ZAN: “Well, actually, it’s not horrible. I mean, it seems perfectly logical that you would want to kill the person or people who abused you. In fact, having this kind of anger is pretty normal . . . acting on it is another story and I would do everything in my power to stop you from hurting them or yourself. However, I believe the murderous rage (Klein, 1975) you are directing towards the people you have named as your abusers is more constructively aimed at them rather than at yourself. Anna, the reality is your abusers are guilty of a serious crime, a felony which would put them in jail for many years.” ANNA: “It really feels good to blame them. I mean to name them

Downloaded by [New York University] at 12:41 13 August 2016 as the ones who hurt me.” DR. ZAN: “Anna, what they did to you is criminal; it’s as simple as that and they should have been prosecuted.”

An important outcome of this session was Anna’s decision to engage in a mock trial of the abusers. It was very important to bring justice, even in a symbolic way to the abusers. This theatrical reenactment of what should have taken place in the social justice system validated for Anna the degree of criminal activity that she had been subjected to and had survived. This reenactment also allowed Anna to shed the projections of “perpetrator,” “crazy person” and “seductress” and allowed her to claim the identity of The Woman Who Couldn’t Get Her Abuser Out of Her Head 99 a “survivor.” As part of the therapeutic process, Anna researched the sen- tencing rules her stepfather would have been subject to had he been prosecuted for his crimes against her. In the reenactment, Anna made a personal statement to her abuser, and he was sentenced to 90 years in prison. Anna commented on how the mock trial helped to reduce the blame and guilt she had harbored towards herself for decades. The guilt was placed where it belonged—on the abuser(s). Anna was also able to show empathy for the abusers’ situations, people who in some cases were likely the products of sexual abuse themselves. However, Anna’s movement towards recovery was checkered with some setbacks. Following the mock trial there was an increase in flashbacks of otherwise forgotten experiences of abuse. The increase in flashbacks was characterized by an increase in somatic symptoms (McFarlane, Atchison, Rafalowicz, & Papay, 1994). I likened the process of working through years of abuse and the shedding of projections to peeling back layers of an onion. With each layer that was peeled back, a new layer appeared. Each new layer involved new memories. Likewise, the somatization of affect at times preceded the emergence of a new memory. It was as if the somatic symptoms (stomach aches, constipation, and incontinence) were the body’s first line of defense against the emergence of a new memory. The memories were initially too painful to put into narrative form. Therefore, the somatization may have been a defensive effort to avert the memories from coming into consciousness at all. In Anna’s case, the therapeutic process was utilized to gradually put words to the psychological meaning of the somatic symptom or the felt sense of the memory (Gendlin, 1982), ultimately creating a narrative memory. The elaboration of the memories in narrative form—within a safe therapeutic holding environment—reduced the intensity of negative affect attached to the flashbacks. Anna gradually shed the projections of seductress, crazy person, sinner, etc., and began to own the identity of abuse survivor. In a sense, the process of therapy was like deactivating nuclear waste material—her highly negatively charged memories. Anna’s telling of the narrative was accompanied by a reduction in both psychological and somatic symptoms. For example, Anna lost 50 pounds and no longer experienced enuresis. It appeared that her ability to translate her physical and psychological experience into lan-

Downloaded by [New York University] at 12:41 13 August 2016 guage served as a source of empowerment for Anna. Working through the painful feelings associated with Anna’s traumatic memories led to a strong countertransference reaction on my part and the use of projective identification as a communication tool in the therapy (Racker, 2012). Communication of my own countertransference reactions also helped Anna to relinquish negative internalized projections and process painful affect. For example, I had an intense countertransference reaction to Anna’s memory of the minister blaming her for the sexual abuse. I felt anger contemplating how delusional he was to believe that a little girl could seduce a 47-year old man. I communicated this reaction to Anna, thus utilizing my countertransference reaction as a therapeutic tool to help 100 The Woman Who Couldn’t Get Her Abuser Out of Her Head my client understand her experience. After I shared my feelings about the minister with her, Anna stated that she too was angry about how she had been treated. She acknowledged how voicing this anger helped her to feel empowered rather than feel like a helpless victim. At times, I found myself—like Anna—questioning whether the abuse had really ever happened. It is likely that these feelings may have emerged in response to the client’s fear of addressing the trauma through projective identification. Anna evoked in me her own ambivalence and fear about exploring her traumatic history. Additionally, a part of me may have acqui- esced to the traditional mental health system’s perspective on maintenance and stabilization of the client through amputating containment. I feared that delving into a traumatic history might lead to psychological destabiliza- tion and that Anna might not be able to handle disintegration in response to painful affect linked with the abuse. For a short time, I found myself thinking that perhaps we should leave well enough alone. Ultimately though, Anna and I chose to address the trauma head-on (Read & Ross, 2003). R. D. Laing (2013) addressed the importance of the mental health provider, in his case, the psychiatrist, being fully present with the client and his or her experience and the tendency of mental health professionals to avoid direct interpersonal contact with the “mentally ill” person. The tendency for mental health professionals to treat the symptoms and avoid the pain linked with trauma brings up the ethical consideration that in avoiding trauma we could be harming versus helping the client, there may be a tendency in mental health, as a whole, to avoid containing and processing feelings linked with severe traumatic histories. Training of young professionals should include supervision with an understanding of the tremendous therapeutic value of projective identification and appropriate containment of affect.

3. HAVING CORRECTIVE INTERACTION EXPERIENCES

The restoration of two relationships fractured by conflict proved to be therapeutic for Anna. The first involved a disagreement with her psychiatrist and was ultimately positively resolved. The second involved forming a more

Downloaded by [New York University] at 12:41 13 August 2016 positive bond with her mother. With respect to her psychiatrist, Anna had an intense regression following the death of a beloved uncle, which led her psychiatrist to hospitalize her for suicidal ideation. During her hospitalization, he took it upon himself to terminate individual therapy without notify- ing me about the termination. I received a memorandum stating that Anna’s psychotherapy had been terminated. In a sense, the discontinuation of therapy without Anna’s consent, or therapist notification, served as a form of punishment in response to Anna’s suicidal ideation. Upon learning about the termination, I immediately paged the psychiatrist and questioned his order. I stated that Anna had a severe abuse history and was making great progress towards recovery. The psychiatrist said he was unaware of the abuse history The Woman Who Couldn’t Get Her Abuser Out of Her Head 101 but believed Anna did not have the cognitive capacity to process the abuse and she needed simply medication management, i.e., amputating containment. He felt that exploring historical issues was not therapeutically war- ranted. His belief that Anna could not handle processing painful memories of abuse could have been a projection of his own inhibitions about dealing with painful affect associated with her memories of abuse. When I questioned the psychiatrist about the uncle’s death that triggered the current hospitalization, he was unaware of the death and had concluded that Anna had experienced a spontaneous regression, characteristic of her “chronic state of schizophrenia.” Once again I noted the psychiatrist’s tendency to obscure Anna’s lived experience by emphasizing the diagnosis. When speaking with the psychiatrist, I reinforced the fact that Anna was a high school graduate, with some college education, and that she was her own guardian. She also had a work history as a certified nursing assistant and, in my professional opinion, was cognitively equipped to deal with painful abuse issues in a positive therapeutic holding environment. My comments fell on deaf ears. Upon discharge from the hospital I had to notify Anna that her therapy had been terminated by the psychiatrist. She was furious and to my surprise, made the insightful interpretation that the doctor was acting like other male authority figures in her life by silencing the telling of her story. I told her that I would support her decision to address with the psychiatrist her desire for therapy. However, I suggested that it might be emotionally strengthening for her to address the issue with her doctor on her own terms rather than to involve me. At her next appointment with the psychiatrist, Anna angrily demanded to have her psychotherapy reinstated and sought an explanation for its sudden termination. To the psychiatrist’s credit, he recognized his error in failing to explore termination with her. He discussed with Anna her progress in psychotherapy. He then reinstated therapy and apologized to Anna. This event proved to be extremely therapeutic for her because she was able to confront a male authority figure, as she had not done in the past, and not to be silenced with respect to her abuse history. Concurrently, unlike other male authority figures in her life, the psychiatrist made retribution through his apology and his reinstatement of therapy. His actions facilitated a corrective experience. In a session, Anna stated, “I have gained a voice . . . I really told that guy off.”

Downloaded by [New York University] at 12:41 13 August 2016 I suggested that, symbolically, the assertion of her needs for psychotherapy to her psychiatrist and her expression of anger toward him for discard- ing this need without consultation with her depersonalized her. Her anger toward her psychiatrist reflected anger toward other authority figures who had abused her in her life, including family members, her stepfather, the minister, and other mental health professionals who had similarly ignored her needs. I suggested that this experience in which she asserted what she needed (psychotherapy) was indeed a corrective one. Anna agreed, stating that she felt empowered. Furthermore, the interaction with her psychiatrist triggered a reeval- uation of the diagnosis of schizophrenia. The treatment team seriously 102 The Woman Who Couldn’t Get Her Abuser Out of Her Head discussed her condition and eventually changed her diagnosis to PTSD. The change in diagnosis from paranoid schizophrenia to PTSD symbolized the mental health’s establishment legitimization of Anna’s history and served as an important validation of who she was as a human being. In one session, we reflected on how the diagnosis of schizophrenia, combined with the failure of members of the mental health systems to explore the abuse, had negatively impacted her recovery for decades. This fact was interpreted as another reenactment of how she had been silenced throughout childhood and adolescence about her sexual abuse history. Furthermore, Anna acknowledged that her embracing of the diagnosis of schizophrenia allowed her to remain in a state of denial. She was able to temporarily convince herself that the abuse did not happen and that the terrifying flashbacks were merely hallucinations that were symptomatic of her psychosis. Another corrective interaction experience occurred between Anna and her mother. Anna’s childhood interactions with her mother were characterized by hostility, criticalness, and emotional over-involvement—Expressed Emotions. Even into her thirties, while geographically distanced from her mother, Anna would receive hostile and critical phone calls. These telephone calls would trigger intensely painful affect in Anna. After four years of therapy, Anna came to see her mother as a victim of a broken mental health system that had failed to provide her too with support. She had concluded that it was very likely her mother had an untreated mental illness, possibly bipolar disorder. She described childhood memories of her mother being deeply depressed and self-medicating on drugs and alcohol. She also believed that her stepfather had physically abused her mother. After over ten years of being emotionally cut off from her mother, Anna made a phone call to her. The call was very emotional. Anna described what had happened to her as a child. To her surprise her mother, who had remarried and been in therapy herself, apologized to Anna for everything that had occurred. While it took many months, gradually Anna and her mother developed a more positive and supportive relationship. This more supportive relationship with her mother further helped to facilitate Anna’s recovery.

4. SHARING POWER Downloaded by [New York University] at 12:41 13 August 2016 Anna also participated in a Tavistock-style therapy group (see chapter 13). The facility where Anna received treatment viewed psychotherapy as important and therefore allowed for the implantation of this group. The Tavistock group addressed a host of issues, including trauma. The collaborative support among peers in this group created another venue for Anna’s recovery. Anna brought about a poignant moment of healing when she shared the fact that she had a miscarriage at the age of 15 and flushed it down the toilet at her high school. She revealed that she’d been impregnated by her stepfather. Anna cried and expressed tremendous guilt about the incident. The group consultant interpreted this experience to be traumatic for Anna, but also The Woman Who Couldn’t Get Her Abuser Out of Her Head 103 perhaps representative of miscarried opportunities in the group-as-a-whole. This interpretation initiated great validation and caring for Anna by fellow group members. Concurrently, group members pooled their many dehumanizing experiences of having miscarried childhoods, marriages, educations, careers, etc., as a result of their own severe abuse histories and decades of mental illness. Their mental illnesses, many of which had been misdiagnosed as anything but PTSD, had generally been left untreated. Medications were adminis- tered and memories had been ignored. The narratives of these abused men and women remained silenced. The group spontaneously held hands and in a moment of intense emotion, one of the members who happened to be African-American, sang out “We shall overcome . . .” The group cried, laughed, and hugged each other in a celebration of the healing capacity within Anna, every other member of the group, and the group-as-a-whole. Here the Tavistock-style group parallels a therapeutic community. The Tav- istock group’s communal structure facilitated a sharing of power among its members. All participants appeared to feel empowered. Research (Semmelhack, et al., 2008, Semmelhack, et al., 2013) strongly suggests that Tavistock-style processing groups with individuals diagnosed with severe mental illness foster group cohesion. Group cohesion contributes to improved self-esteem, self-efficacy, and a decrease in anxiety and depression. A cohesive group can enhance members’ feelings of empowerment. The resulting increased degree of cohesion in the group allowed for an environment of enquiry. Group members felt free to share with each other how they had felt demeaned and put down at times by specific staff members in the institution. Identifying staff members’ behaviors as being unacceptable within the institution diminished the power that demeaning remarks had on any one given client, including Anna. For example, Anna spoke about a nurse calling her a manipulator:

I had a flashback of my stepfather raping me. I started screaming out for help. I told the nurse what happened and asked for a PRN. She looked smugly at me and suggested that I was trying to manipulate staff and was seeking attention and medication. I didn’t get any medication to help me relax that night but instead got written up for my behavior.

Downloaded by [New York University] at 12:41 13 August 2016 I could not help it. I was so scared. All I wanted was for someone to listen to me. The nurse made me feel so humiliated.

Group members empowered by their strong interpersonal bonds refuted the nurses’ punitive remarks, identifying them as insensitive and inappropriate. The group validated Anna’s feelings. The response to Anna’s story reduced the power projected onto the nurse as all knowing and powerful by residents, allowing group members to reclaim their own sense of power as human beings. Friendship and peer support can serve as a mitigating factor that helps neutralize the power differential between individuals, and the implicit rules of the institution and those who ensure their adherence. 104 The Woman Who Couldn’t Get Her Abuser Out of Her Head 5. USING INSTITUTIONAL STRUCTURE AS TREATMENT: CREATING A CULTURE OF ENQUIRY

An important characteristic of many institutional settings is the inflexi- bility in scheduling and the use of space and the inability to change the nature of the living space. In general, treatment is equated with structure, and structure is equated with the importance of regimentation in the delivery of services. Interaction is often left out of the treatment equation with med-pass, bingo, and basic living skills groups viewed as the sole treatments for mental illness (Lieberman & Mueser, 1994). The room furnishings are also regimented. The philosophy behind this appears to be that the mentally ill person adapts poorly to change and that structure facilitates recovery (Lieberman & Mueser, 1994). In essence, this dynamic may more frequently be a projection of the staff’s need for structure than any treatment need indicated by the clients. Generally, the individual’s needs, talents, and general uniqueness are ignored. With Anna, the rigidity of the environment and her schedule needed to be addressed with staff. Fortunately, the administrator of her facility was willing to adapt to Anna’s unique needs in order to facilitate treatment. This administrator’s flexibility is unique in nursing home settings (Grabowski, Aschbrenner, Rome, & Bartels, 2010). An important institutional rule was that living spaces could not be altered in the institution. In other words, walls were painted a specific color (white), beds chairs remained in a specific formation, etc. The clients’ relationship with their environment was not taken into consideration with respect to their diagnoses. For Anna, her bed directly faced a closet. Her interactions with the closet had negative consequences with respect to her recovery. In the course of therapy, it was uncovered that her stepfather had frequently raped her on her bed and then locked her in her closet for hours at a time. Consequently, her room’s con- figuration served as a trigger for negative emotions, including flashbacks related to past trauma. The closet was a powerful trigger. Anna was given permission to rearrange her room, including painting and the design of the closet. The room was painted in a color Anna found comforting. The ability to reshape her space proved to be very empowering for Anna. The closet now became a safe holding space. It was decorated

Downloaded by [New York University] at 12:41 13 August 2016 with panda bears and pictures of a beloved maternal grandfather, whom she believed, if he had survived, would have protected her from the abuse. The identification of her grandfather as a “good object” further solidified her internal world as one emphasizing positive versus negative internalized objects (Mahler, Pine, & Bergman, 1975). As therapy progressed, there were many signs of improvements in the quality of Anna’s interactions with staff and peers. For example, there were no further hospitalizations, Anna was elected resident counsel president, her capacity to assert her needs and set boundaries with others increased, and she made plans for discharge. Furthermore, Anna’s experience with the The Woman Who Couldn’t Get Her Abuser Out of Her Head 105 psychiatrist and other interactions on her unit demonstrated an increased insight into how interactions in the Here-and-Now can act as reenactments of the past, thus triggering intense emotions (Lindy, Green, & Grace, 1992). The recognition of a Here-and-Now interaction as a reenactment offered Anna an opportunity to work through archaic emotional experiences. Her increased capacity to talk about emotions connected with reenactments in therapy helped deactivate affect attached to memories and allowed her to disavow negative internalized projections. This process led to the emergence of hope, new possibilities, and ultimately new positive memories. A particularly powerful interaction involved a dream Anna had near the end of one phase of her therapy. She had had a very difficult day. It was a snowy, depressing winter day near her birthday, a particularly charged anniversary event. During the day, she kept asking God why so many terrible things happened to her. She begged God to allow her to put all of the bad experiences behind her. She reported this dream:

It was simply a replaying of my life . . . It was like a movie . . . Every- thing in my miserable life came to the forefront . . . and the damn thing kept replaying itself over and over. I saw the house where I grew up . . . where the rapes happened. The room was quiet . . . I was only six years old and Gregory, my stepfather, came into the room. I was watching him, the bastard, get down on his knees. He took my clothes off and raped me again and again and again. I felt like ten tons were on top of me. That was the first part of the dream. Next, I am eight years old and in the living room. My mother and brother are not there. Gregory forces his penis into my mouth. I did not know what was going on . . . He kept threatening to kill me and my mom.

Anna proceeded to go through her life and describe scene after scene of abuse until Anna divorced her abusive husband at the age of 35. After reading her description of the dream out loud during a therapy session, Anna stated that her abuse history, at that moment in time, was not causing her as much distress as it had the day before she had the dream. In fact, the dream was like a movie. It felt like the story had all come together. Now she had the story, a story she could tell, and a story that was uniquely hers. After the

Downloaded by [New York University] at 12:41 13 August 2016 dream, Anna had a remission of enuresis, a decreased number of flashbacks, and an improved sense of self-esteem. Anna ultimately made it out of the nursing home and into the community. She now lives in a supportive living setting, also referred to as a group home, with five other adults. She has a part-time job and a boyfriend. Shestill suffers from periodic flashbacks and has some anxiety related to her history of abuse. But she is living a life worth living. She describes herself as being a survivor and having grown greatly as a person through her therapeutic exploration of what happened to her growing up. She states that medication management alone could not have helped her get better. She says, 106 The Woman Who Couldn’t Get Her Abuser Out of Her Head It was a combination of things, a supportive therapeutic environment, an ability to be heard in group and individual therapy, supportive social service workers and most importantly having people there who believed me, responded to me, and ultimately understood who I was. I felt such relief to know that my experience was horrible but real. I was not paranoid schizophrenic. I was a person subjected to unheard of abuse who survived it.

Anna has been able to embrace what she calls “the healthy parts of myself.” At the time of this writing Anna stated that she now perceives herself to be a contributing member of the community. She has a part-time volunteer job at a hospital and healthy peer relationships. She describes herself as “enjoying life.” Anna is a part of a matrix of positive interpersonal relationships outside of the therapeutic milieu. Being a part of this matrix provides her with support and serves a pseudo-therapeutic function. It also allows her to support others who have not progressed as far as she has in her journey towards recovery. I wish to emphasize the facility deserves much credit for Anna’s progress. Anna has transformed her life with the help of an empathic administrator who allowed her to rearrange her room, a Tavistock group the facility provided, and a therapist employed by the facility.

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Dr. Singer is a client-centered counselor in private practice. Early in his career he worked at Fountain Nursing Home, where he met Martin. This is the case of Martin.

When I first met Martin he was sitting in the hallway of a long-term care center by the first floor nurses’ station. I had been assigned to do therapy with him by the Social Services Department. It was his seventieth birthday, and he had been transferred from his apartment to the facility. While at home he had been falling daily. Unable to get up on his own, he kept calling 911 for assistance. Finally, after weeks of emergency calls, doctors recommended that he not live alone. They believed his falling and inability to elevate himself without assistance made him a danger to himself. With no close family or friends to assist him with housing, doctors recommended that he be transferred to Fountain Nursing Home. Martin sat looking depressed and grimacing in pain, with his walker placed in front of him. This was no ordinary walker; it was a large contraption with huge arm supports heavily padded to uphold his severely arthritic arms. I wished him a happy birthday. His response was, “Some happy birthday . . . my birthday present is getting locked up in here.” When I asked him how he was feeling, he responded, “Not so good. I’m in pain . . . always in pain . . . it hurts me to do anything.” When I asked him how long he had been in pain, he paused and stated, “Since I can remember . . . forever it seems.” Martin had severe osteoarthritis that impacted every joint in his body.

Downloaded by [New York University] at 12:41 13 August 2016 Knee replacement surgery was out of the question due to his diagnosis of brittle diabetes, which made healing difficult at best. Compounding these physical problems was his deteriorating eyesight due to glaucoma and mac- ular degeneration, as well as a hearing impairment. The loss of his sight was particularly difficult for Martin, since he loved to read. Martin’s physical pain appeared to be exponentially increased by the somatization of intense psychological pain due to his many losses (Mon- son & Monson, 2000). These included his independence, his physical health, his cat, his apartment, and above all his parents, whom he had never thoroughly mourned. The Depressed Man in Chronic Pain 109 When asked about his emotional state, Martin described himself as being a “bit” depressed. It later became evident that he was greatly underesti- mating the amount of sadness he was experiencing at the time of this initial encounter. His chart indicated that he had a longstanding diagnosis of Major Depressive Disorder and had been hospitalized many times. His first hospitalization followed the death of his mother 15 years ago. His father had died several years earlier. His mother’s death prompted a near fatal suicide attempt. Martin was treated with electroconvulsive shock treatment (ECT), combined with medication (Fink, 2001). He recalled receiving no psychotherapy or grief counseling during this hospitalization. His symptoms were treated, but the underlying reasons for his melancholia—a profound sense of loss—were amputated by the system and ignored. Martin described his childhood as being very lonely because he was an only child. His parents provided for his basic needs, but showed no outward expression of love. They were strict parents placing numerous conditions of worth on young Martin. For example, Martin could only play with certain children approved of by his parents, he had to dress a certain way as determined by his mother, and he was not allowed to learn to ride a bike because his parents believed he would fall and hurt himself. Martin stated that he had to be a good little boy or punishment was quick to follow. Martin was also bullied by students throughout grade school and high school. He was ridiculed for being overweight and having to go to special classes due to learning disabilities. The children he grew up with did more to spoil Martin’s emerging identity than help it to thrive (Dineen Wagner, 2012; Erickson, 1993). In early adolescence, one starts forming a sense of identity (Erickson, 1993). In optimal circumstances (characterized by a supportive holding environment) one is able to actualize a fledgling sense of who one is in the world. However, if circumstances are not optimal and one is bullied, ridiculed, and degraded by others, this authentic sense of self may not flourish (Juvonen, Graham, & Schuster, 2003). The ridicule that Martin faced during this critical period contributed to his early identification as being a loner. These factors contributed to his being set up as an outsider and ultimately the class scapegoat. Many times he ran home to avoid being heckled at or beaten up by neighborhood boys. Martin’s ability to be intimate with others suffered during what Sullivan (2013) identifies as the pre-adolescent

Downloaded by [New York University] at 12:41 13 August 2016 period in which the seeds for close interpersonal relationships are planted through one’s “chum” (Dineen Wagner, 2012). Martin’s lack of self-confidence, his depression, and his overly protective parents contributed to his tendency to isolate himself as a young man. Most of his adult life was spent caring for his aging parents. These factors contributed to his limited life experience. His only job was working as a stocker at a grocery store for about a year. Never having had a romantic relationship, something he clearly regretted, and given his lack of a career, he lamented that he never had really done anything with his life. In fact, he said, “I have spent most of my life alone taking care of others [parents].” 110 The Depressed Man in Chronic Pain Initially, I was very perplexed about how to proceed therapeutically with Martin. While there was strong evidence for the efficacy of cognitive behavioral and other treatment modalities for depression, I took Martin’s lead in selecting a therapeutic orientation, which suggested that he needed to be validated using the client-centered facilitating conditions of unconditional positive regard, empathy, and congruence (Feller & Cottone, 2003; Kirschenbaum & Jourdan, 2005; Rogers, 1957; Rogers, 1961; Rogers, 1980). Martin had overtly indicated what he wanted in an initial interaction with me: “I want someone to listen to me.” Unconditional positive regard is the state in which the therapist accepts the client for who he is. It means that there are no conditions of acceptance, no feeling of “I like you only if you act this way.” Empathy involves the therapist’s accurate understanding of the client’s awareness of his own experience. It involves sensing the client’s experiential world “as if” it was your own. Congruence suggests the involvement of the therapist in the relationship with the client in a genuine and integrated way. Contrary to the client’s incongruence—anxiety, depression, agitation—the therapist presents himself as an integrated and whole being, a pillar of trustworthiness to the client. Typically, in client-centered therapy the therapist engages in active listening, which requires the accurate understanding and reformulation of what the client has said by the therapist (Rogers, 1957). Our hypothesis is that, unlike in psychodynamic therapy, there is no attempt to interpret the latent meaning of the client’s comments, although sometimes the difference between interpretation and intuitive understanding is minimal. The rationale behind this client-centered intervention was to create a supportive environment in which Martin could be himself, to think and say what he really was experiencing. A client-centered approach appeared to be the best antidote to the multiple conditions of worth he was plagued with throughout much of his life. In Carl Rogers’ (1957) approach, long-internalized, archaic beliefs about being unwanted and unloved, linked to conditions of worth, gradually start to shift within the therapeutic space. In other words, the adult who believed as a child that he would only be loved if he met his caregivers needs is able to gain confidence within this therapeutic environment. He acquires the capacity to assert what he needs from the world without fear of rejection. Carl Rogers (1959) suggests that these archaic beliefs

Downloaded by [New York University] at 12:41 13 August 2016 contribute to a state of incongruence or unhappiness, i.e., psychopathology, and infringe upon a person’s ability to express who he really is. Conditions of worth facilitate a state of incongruence in a person, which ultimately leads to the thwarting of the actualizing process—the process of becoming a fully functioning person. Gradually, within a client-centered environment, the client is able to cope with his situation and there is an initiation of a desire to move forward with his life ultimately towards self-actualization (Maslow, 1943). The following section contains a description of interaction structures in the institution that impeded the actualizing process in Martin. These The Depressed Man in Chronic Pain 111 non-growth-promoting interactions ran counter to Carl Rogers’s theoretical approach, contributing to withdrawal, suppressed self-expression, somatization of affect, and amputated feelings such as sadness and anger that therapeutically needed to be expressed. These interactions exacerbated Martin’s depressed state. They also served as a recapitulation of his treatment in childhood and adolescence as a bullied and demeaned individual. Next are excerpts from a predominantly client-centered session that appeared to show psychological growth in Martin. Here, Martin began to express his true feelings and appeared to move towards the expression of a more authentic sense of self. The description of interactions is meant to suggest that Rogers’s client-centered therapy provided a type of antidote to the more growth-impeding interactions characteristic of the institution as a whole. Then the rationale for my judicious use of interpretation within the principally client-centered session is discussed. Finally, the importance of group work in creating a sense of social support with peers that can counteract non-growth-promoting interactions is reviewed.

NON-GROWTH-PROMOTING INTERACTIONS IN THE INSTITUTION

Martin’s depression appears to have been sustained by a psychiatric nurse and two certified nursing assistants who consistently created interaction structures that perpetuated his depressed state and his experience of himself as not being wanted. Depersonalization appears to have played a role in their interactions with Martin. These staff members treated Martin like an object to be moved about like furniture rather than as a human being who they should engage in conversation (Fink & Tasman, 1992). Depersonaliza- tion occurred when the nurse referred to Martin as a “Lazy Manipulator” as he slowly, due to his arthritis, walked down the hall for medication pass. It also occurred when the nurse mumbled “retard” under her breath when referring to Martin, which reinforced his internal sense of worthlessness. Martin’s lack of family support and weakened physical state made him vulnerable to being a target for these staff members. With no caring family member available to advocate for Martin, he became particularly vulnerable

Downloaded by [New York University] at 12:41 13 August 2016 to being depersonalized and punished by staff, who may have felt unmoni- tored in their treatment of him. Staff projections also frequently inhibited Martin’s psychological growth. Martin’s weakened state due to his physical and psychological infirmities set him up to be an object of the staff’s projections. Martin was typically labeled as being lazy. The reality was that Martin’s severe osteoarthritis made movement very difficult for him; hence, he was at times late for medication pass. In fact, it may have been the staff’s laziness in not wanting to assist him in walking to the nurses’ station that commandeered the situations. The staff’s laziness may have been projected onto Martin. 112 The Depressed Man in Chronic Pain Punishment was frequently employed when staff dealt with Martin. The psychiatric nurse frequently demeaned Martin by writing him up for behaviors that were largely out of his control due to his poor mobility, such as not getting to med pass on time, dropping a glass of water on the floor, or failing to make it to the bathroom on time. Accidents could have been avoided in many cases if CNAs acted swiftly and got Martin to the toilet in a timely fashion. Their slowness to respond to a client’s needs in such instances was suspect (Menzies-Lylth, 1960). Sometimes staff punished Martin by withholding a cup of coffee or a cigarette. At other times he was restricted to sitting at the nurses’ station even though he wanted to be resting in his room. Public humiliation as a form of punishment for Martin was also evident. This occurred when Martin’s incontinence was announced in front of all the clients sitting at the nursing station. Martin commented on how these interactions made him feel humiliated. He frequently stated, “I am so . . . so alone and nobody wants me. I am useless and stupid.” Another misuse of power was made possible by an unknown mental health professional who incorrectly labeled Martin as mildly mentally retarded (MR) and officially listed this diagnosis in his chart. There was no written substantiation for the diagnosis, such as a psychological battery. A nurse and two CNAs used this diagnosis to stigmatize Martin as not only emotionally and physically impaired, but cognitively compromised as well. The nurse in question frequently used a harsh voice and made derogatory comments, calling Martin “stupid” when ordering him to come forward for a medication pass. She would often humiliate him publicly for not immediately responding to a command—mumbling “idiot” under her breath. Martin’s inability to respond in a timely fashion was largely due to his chronic pain and difficulty in mobilizing himself. His hearing impairment also required staff to speak loudly when giving him a direction or he could not hear them. Some staff, not aware of this hearing deficit, concluded that Martin’s failure to respond in a timely fashion suggested that he was non-compliant. Martin disputed his MR diagnosis when he found it in his chart during a routine review with a social service worker. He immediately requested diagnostic testing to override the diagnosis. This testing, ordered by his psychiatrist, proved that Martin was in the low intelligence range but clearly not

Downloaded by [New York University] at 12:41 13 August 2016 mentally retarded. The recognition of a misdiagnosis of MR greatly boosted Martin’s spirits and increased his self-esteem. Later he acknowledged having internalized the stigma of being MR, viewing himself as stupid and useless. The corrected diagnosis helped to diffuse this internalized stigma.

EXCERPTS FROM THE THERAPY SESSION

These excerpts are from a session to elucidate a series of interactions that appear to have contributed to Martin’s psychological growth. The session demonstrates how unconditional positive regard, empathy, and congruence The Depressed Man in Chronic Pain 113 can counteract growth-inhibiting institutional interactions. A Rogerian (1957) approach to therapy is emphasized in the dialogue highlighted in the excerpt from the session. The need for empathy in therapy and psychiatry is also highlighted in the work of RD Laing (2013). Martin appeared to start the session with deeply somaticized feelings related to losses, neglect, and other painful experiences in his life that have been repressed possibly due to conditions of worth. Gradually, he shifted from the pure somatization of pain to the verbal artic- ulation of emotional pain. Near the end he expressed a desire to jumpstart the actualizing process and to keep moving forward by not giving up. I met weekly with Martin for 45-minute individual sessions for three years. This is a portion of his 48th session: It opened with Martin talking about his extreme physical pain due to osteoarthritis. An effort was made to facilitate a therapeutic holding environment characterized by Rogers’s therapeutic conditions within which Martin was willing to speak openly about his thoughts, feelings, and fantasies:

MARTIN: I’m not feeling that good these days, Doctor; a lot of pain and everything. DR. SINGER: Yes. MARTIN: And they’re doing what they can for me (physical therapists). I know what they can do for me but I’m not that patient sometimes—I’m not. DR. SINGER: Okay. MARTIN: To do it, and I’m trying but I don’t know if the pain will ever stop. I’m really in a lot of pain. This is affecting my mood too. I feel so down. DR. SINGER: So when you say “pain,” can you help me understand what kind of pain? MARTIN: Arthritic pain. My joints; every part; my knees; my hands, my whole body, intense pain . . . horrible undescribable pain. DR. SINGER: Just in every part of your body you’re feeling pain? MARTIN: Right. Right. That’s a horrible feeling. The only

Downloaded by [New York University] at 12:41 13 August 2016 time I don’t feel it is when I’m sound asleep.

In the next part of the session, Martin stated he missed his mother and indicated that without her there was a hole. An interpretation on my part triggered the shift from the expression of physiological pain to one of intense emotional pain. In the facility, the open expression of sadness would likely be attenuated by medication or punishment. The hole left by the absence of Mar- tin’s mother was extremely painful. He was able to express feelings related to this loss within the therapeutic relationship. His ability to express his emotion in the therapeutic relationship amplified the use of amputation of emotion within the facility. 114 The Depressed Man in Chronic Pain DR. SINGER: And I wonder if, besides the physical pain that you’re feeling, that underlying that there is some emotional pain as well. MARTIN: There is. There is. And today is a little bad for me. My mother is gone there is a hole. It is a deep lonely hole (cries softly). I am so very sad . . . and empty. DR. SINGER: So the losses, one being Mom are contributing to the pain. MARTIN: I miss my mom so much. And my physical health. I feel so sad sometimes and down on myself. Some- times I think I can’t make it. I’ll just end up a vegetable and give up. DR. SINGER: You feel so bad . . . it hurts so much you . . . it might be easier to throw in the towel.

Martin responded to this validation of his feelings by expressing a more cohesive and goal-directed sense of himself. Validation of Martin’s coping skills and determination to move forward was important in his facilitating psychological healing and in reinforcing strengths. Wallerstein (1986) states:

A first principle for techniques of strengthening defense is to encourage, praise, or in general, to give narcissistic support for those ego activities in which defense is combined with adaptive gratifications . . . (p. 389)

Here Martin shifts from being overwhelmed by his pain to an expression of his desire to cope with his situation:

MARTIN: But I am trying to cope. I love to read. Reading makes me forget everything. DR. SINGER: Yeah. Right, you are in pain. But you have a way to cope with it. Reading helps you focus on something other than the pain. MARTIN: Then I’ve got a nice roommate, too, although he sleeps a lot. He don’t bother anybody. He talks to

Downloaded by [New York University] at 12:41 13 August 2016 me. We get along really nice. DR. SINGER: I notice a shift in your tone of voice when you talk about those two things, reading and your roommate. MARTIN: Yeah. I love to read and my roommate is good. DR. SINGER: So those are the ways that you can get out of the pain. MARTIN: Yeah . . . right . . . I can forget about the pain then for a short time. I go to rehab five days a week working with them, I feel I’ve got to do it so I won’t get in really bad shape. I don’t want to be bedridden. And The Depressed Man in Chronic Pain 115 talking about the pain to you or your students helps. It helps to be listened to by someone who cares.

Martin’s enhanced state of congruence was evidenced by a more determined tone of voice, a more positive mood, and his ability to describe the strategies used to cope with his painful situation. Still later, Martin affirmed the importance of being listened to and understood.

MARTIN: I like to talk about things. DR. SINGER: Yeah. MARTIN: Right. It feels good to talk and to be listened to. Yeah, and you listen well. DR. SINGER: So it’s talking and being listened to. MARTIN: Yeah, it makes me feel good to be listened to and you do well and your students help me. Yes, and I keep going. DR. SINGER: You keep going. MARTIN: Right. I won’t give up. If I need something I’ll get it from you or your student or somebody. DR. SINGER: You go to a resource. MARTIN: Yeah. I’ll go to who I need. But I’m—so far making it—I’m here still here. DR. SINGER: You’re here. MARTIN: Yep. I’m glad for it . . . being here. I’m a tree like in the play . . . a redwood tree and I’m not going anywhere. DR. SINGER: Just like a tree in the redwood forest. Solid . . . stead- fast and not going anywhere like in the play. Red- wood trees live long lives and are one of the largest species on earth. Perhaps you are uniquely strong and long living like the Redwood. MARTIN: I never thought about it that way . . . but it could be so.

The metaphor of being a redwood suggested an enhanced sense of congru-

Downloaded by [New York University] at 12:41 13 August 2016 ence, of integration, and a sense of being grounded, like a well-rooted redwood tree. Martin had played a redwood tree in a recent play put on at the institution. He loved playing the tree and reported that he evoked pleasant memories from his performance as a means of soothing himself when he felt bad. Appreciating Martin’s increase in self-expression in therapy requires discussing another negative interaction dynamic that he faced. Amputat- ing containment is indicated in the institutional need to remove disruptive affect. This interaction dynamic is suggested in the next segment of the session when Martin talked about not feeling understood by staff and the need to avoid expressing feelings. The open expression of painful feelings was 116 The Depressed Man in Chronic Pain typically contained by medication instead of through an interaction with a staff with the goal of understanding why the feeling state is emerging.

MARTIN: I don’t want no conflict, so I do what I’m supposed to do, everything. They [staff] don’t understand that I can’t move fast for myself, and then they lose their temper. . . DR. SINGER: But the experience of dealing with people who don’t understand must be difficult. You simply can’t move that fast and for staff to not understand that must be frustrating. MARTIN: Right. DR. SINGER: Perhaps dealing with those kinds of misunderstanding people hurts a little bit? Makes you feel alone and unwanted. MARTIN: Yes it hurts. It does. Sometimes I feel like crying but I don’t. I keep it all inside. It’s safer that way. DR. SINGER: Safer? MARTIN: I don’t get given a shot or told to shut up. Here, with you it is OK to talk to you; you understand. In groups too I can talk and not get hurt.

While in the milieu, Martin held feelings in to protect himself; in therapy, he felt free to express himself. He talked about the positive therapeutic effects of expressing these feelings later in the session. It appeared that within the session, the feeling of not being judged allowed for the development of a culture of enquiry:

MARTIN: It’s safer to keep it inside out there [referring to the milieu]. But then I let it all out when I talk to a person like you. You’re easy to talk to, good to talk to. And it is good to let it out. DR. SINGER: Do you feel there is anything you are holding in, here with me? MARTIN: No . . . I can talk about it, pain. The pain. That’s

Downloaded by [New York University] at 12:41 13 August 2016 so bad. Oh, it’s hard walking, moving. Anything is hard to do. But it helps to say this to you. . . . I hold it in too long, and so then I have to tell. It helps then. DR. SINGER: It helps to talk about it . . . to get the magnitude of the pain out in the open. MARTIN: Yeah. I feel better then. DR. SINGER: You feel better when you talk about it. MARTIN: It makes me feel like I can make it. The Depressed Man in Chronic Pain 117 The free expression and validation of Martin’s pain appeared to strengthen his inner resolve to “make it.” It appeared to activate his coping skills, as indicated in the session where Martin communicated much pride in his ability to keep going:

MARTIN: I try not [to give up] Go, go, go. Regardless of the pain. I fight it . . . keep on going . . . going . . . I’m going to make it. I know I can. I got to just keep going. DR. SINGER: You want to keep on going. MARTIN: You are darn right. I can’t let myself be a vegetable. I can’t.

At the end of the session Martin demonstrated his capacity to counteract the negative perceptions of the self, the environment, and the future by evoking good memories from the past—including his participation in the spring play:

MARTIN: I didn’t think I could do it, the play I mean. But I did it. I sat for 30 minutes like a tree. I have good memories from that play. DR. SINGER: Good memories? MARTIN: It was a nice play. I was proud for that, believe me. It made me feel good [performing]. Yes, I have a lot of good memories like the play, of my mother and father, of family, the students and you too. DR. SINGER: These memories help you. They are like fuel. MARTIN: Yes. I have got the good memories, my roommate, books I’ve read, my parents. But still I want to know that there are some people proud of me that I can keep going. And I know there are people that are proud of me. Like you and some of the other residents. I want to keep going . . . going . . . go . . . go . . . go . . . fight it! DR. SINGER: You need people to validate that you can make it. You can make it. Downloaded by [New York University] at 12:41 13 August 2016

THE JUDICIOUS USE OF INTERPRETATION

Although this was primarily a client-centered session, I used interpretation at times with the goal of helping Martin to make unconscious thoughts and feelings conscious. Institutional settings are notorious for neutralizing or suppressing intense feelings, including those connected with the grieving process (Whitaker, 2010). Holding in affect related to grief can contribute to 118 The Depressed Man in Chronic Pain a host of somatic issues (Sack, Lahmann, Jaeger, & Henningsen, 2007). At least a percentage of Martin’s physical pain was somaticized affect related to depression and unresolved mourning (Gort, 1984). The rationale for the use of interpretation was to help him identify unconscious feelings, thoughts, and beliefs whose repression might be contributing to physical pain. The goal in making the unconscious conscious was to give these otherwise unconscious experiences meaning, thereby enabling Martin to integrate them into his sense of self. Martin appeared to respond positively to this technique. An example occurred early in the session, when I suggested that perhaps some of the physical pain was emotional.

DR. SINGER: And I wonder if, besides the physical pain that you’re feeling, that underlying the physical there is some emotional pain as well.

Martin immediately responded with a comment confirming the validity of this interpretative suggestion.

MARTIN: There is. There is. And today is a little bad for me. My mother is gone there is a hole. It is a deep lonely hole (cries softly). I am so very sad . . . and empty. I loved her.

My simple interpretive suggestion that some of the pain could be emotional led Martin to release painful affect linked with the loss of his mother. His ability to emote painful affect linked with this loss suggested that the mourning process was activated in the session. The authentic expression of emotional pain may lesson his physical pain.

GROUP THERAPY

Finally, group therapy helped to facilitate the development of a holding environment (Winnicott, 1965), a “reflective space” within which

Downloaded by [New York University] at 12:41 13 August 2016 individuals—including Martin—can express thoughts, feelings, and fantasies in front of supportive peers that they might otherwise have felt they needed to repress. Specifically, group therapy contributed to a culture of enquiry in which toxic interactions by staff, such as those described above, could be safely explored by residents. Martin felt validation when the group labeled the nurse’s interactions with him, described earlier, as inappropriate. Furthermore, interactions with his peers contributed to his feeling less alone in the experience of being demeaned because other group members confided that they too had been treated in a similar manner by the same staff members. The group’s verbal critique of staff behavior empowered the group The Depressed Man in Chronic Pain 119 members. They recognized that, while group members may have psychological diagnoses, staff members too can act in inappropriate or even pathological ways. Positive interactions with peers, including validation and support, can counteract negative interactions with staff—a form of peer support. The reminiscing in group therapy of growth-promoting activities—such as the spring play—are equally positive sources of soothing material to be evoked in times of stress. Another important outgrowth of group therapy for Martin was the formation of a friendship with Fred, another member of the group. Fred and Martin loved board games and began to play them on a regular basis. Other members of the community also took notice and joined in. Soon there was an ongoing game of Monopoly at the facility with four other residents playing the game with Fred and Martin. A subgroup of the therapy group had been formed, which served as another source of peer support (Hazell, 2005). Opportunities for play with other residents provided more avenues for building positive memories with others (Forrester-Jones, et al., 2012).

CONCLUSION

Martin’s exposure to validating events that allowed for the free expression of emotion in a nonjudgmental environment (Rogers, 1957) proved to be at least a partial antidote to those staff and institutional interactions that were demeaning, depersonalizing, and alienating and perpetuated depression, pain, and self-doubt. The combination of groups, individual therapy, and peer support offered Martin the necessary and sufficient conditions for therapeutic change and proved to counterbalance the negativity of institutional life. Martin’s shift from a sense of hopelessness in the excerpts from the session to a feeling of hope at the end is indicative of the story “The Lit- tle Engine That Could” (Piper, 1930). A brief synopsis of the story follows:

A little railroad engine was employed about a station yard for such work as it was built for, pulling a few cars on and off the switches. One morning it was waiting for the next call when a long train of freight-cars

Downloaded by [New York University] at 12:41 13 August 2016 asked a large engine in the roundhouse to take it over the hill. “I can’t; that is too much a pull for me,” said the great engine built for hard work. Then the train asked another engine, and another, only to hear excuses and be refused. In desperation, the train asked the little switch engine to draw it up the grade and down on the other side. “I think I can,” puffed the little locomotive, and put itself in front of the great heavy train. As it went on the little engine kept bravely puffing faster and faster, “I think I can, I think I can, I think I can.” As it neared the top of the grade, which had so discouraged the larger engines, it went more slowly. However, it still kept saying, 120 The Depressed Man in Chronic Pain “I—think—I—can, I—think—I—can.” It reached the top by drawing on bravery and then went on down the grade, congratulating itself by saying, “I thought I could, I thought I could” (http://en.wikipedia.org/ siki/The_Little_Engine_That_Could).

Martin is like the little engine that could. He shifted from believing he could not make it, an internalized belief stemming from negative interactions in childhood combined with non-growth-promoting interactions with the mental health system, to the belief that, despite the pain, he would make it. In the end Martin had hope. It was particularly important for Martin to express his feelings in a client-centered environment given his situation: 1) he had no living relatives and few friends to listen to him, and 2) he resided in a nursing home, which is an environment where one can feel judged by staff and at times depersonalized and even dehumanized (Jervis, 2002). There were many “conditions of worth” (Rogers, 1957, 1961) evident in this institutional setting that appeared to discourage the expression of authentic emotions. Furthermore, individuals who overtly cried or expressed anger were written up by staff for acting inappropriately. While he never left the nursing home, he cultivated friends and engaged in activities that were productive to him in the facility. Five years into therapy, while Martin still had bouts of depression and was in extreme pain from the arthritis, his mantra was, “I think I can—I think I can . . . ” And from time to time, when he accomplished something like acting in a play, his mantra changed to, “I thought I could—I thought I could—I know I could—I did!” It was sincerely rewarding working with Martin as he progressed on the road to becoming a more fully functioning person.

REFERENCES

Dineen Wagner, K. (2012, November 2). The importance of friends. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/child-adolescent-psychiatry/ importance-friends Erikson, E. H. (1993). Childhood and society. New York: W.W. Norton & Company. Feller, C., & Cottone, R. (2003). The importance of empathy in the therapeutic

Downloaded by [New York University] at 12:41 13 August 2016 alliance. Journal of Humanistic Counseling, Education and Development, 42(1), 53–61. Fink, M. (2001). Convulsive therapy: A review of the first 55 years. Journal of Affec- tive Disorders, 63(1), 1–15. Fink, P. J., & Tasman, A. (Eds.). (1992). Stigma and mental illness. Arlington, VA: American Psychiatric Publishing. Forrester-Jones, R., Carpenter, J., Coolen-Schrijner, P., Cambridge, P., Tate, A., Hallam, A., . . . Wooff, D. (2012). Good friends are hard to find? The social networks of people with mental illness 12 years after deinstitutionalisation. Journal of Mental Health, 21(1), 4–14. Gort, G. (1984). Pathological grief: Causes, recognition, and treatment. Canadian Family Physician, 30, 914–924. The Depressed Man in Chronic Pain 121 Hazell, C. (2005). Imaginary groups. Bloomington, IN: Authorhouse. Jervis, L. (2002). An imperfect refuge: Life in an “old folk’s home” for younger residents with psychiatric disorders. Social Science & Medicine, 54(1), 79–91. Juvonen, J., Graham, S., & Schuster, M. A. (2003). Bullying among young adolescents: The strong, the weak, and the troubled. Pediatrics, 112(6), 1231–1237. Kirschenbaum, H., & Jourdan, A. (2005). The current status of Carl Rogers and the person-centered approach. Psychotherapy: Theory, Research, Practice, Training, 42, 37–51. Laing, R. D. (2013). Selected works RD Laing: Self & other (Vol. 2). New York: Routledge. Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370. Menzies-Lyth, I. (1960). A case in the functioning of social systems as a defense against anxiety: A report on a study of nursing service of a general hospital. Human Relations, 13, 95–121. Monsen, K., & Monsen, J. (2000). Chronic pain and psychodynamic therapy: A controlled outcome study. Psychotherapy: Theory, Research, Practice, Train- ing, 37(3), 257–269. Piper, W. (1930). The little engine that could. New York: Platt & Munk. Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic change. Journal of Counseling Psychology, 21(2), 95–103. Rogers, C. R. (1959). A theory of therapy, personality, and interpersonal relationships: As developed in the client-centered framework. New York: McGraw Hill. Rogers, C. R. (1961). On becoming a person. Boston, MA: Houghton Mifflin, Co. Rogers, C. R. (1980). A way of being. Boston, MA: Houghton Mifflin, Co. Sack, M., Lahmann, C., Jaeger, B., & Henningsen, P. (2007). Trauma prevalence and somatoform symptoms: Are there specific somatoform symptoms related to traumatic experiences? The Journal of Nervous and Mental Disease, 195(11), 928–933. Sullivan, H. S. (Ed.). (2013). The interpersonal theory of psychiatry. New York: Routledge. Wallerstein, R. (1986). Forty-two lives in treatment: A study of pychoanalysis and psychotherapy. New York: The Guildford Press. Whitaker, R. (2010). Mad in America: Bad science, bad medicine, and the enduring mistreatment of the mentally ill. New York: Basic Books. Winnicott, D. W. (1965). The maturational processes and the facilitating environment: Studies in a theory of emotional development. New York: IUP.

Dr. Brown has a Ph.D. in psychology and has been in private practice for 22 years. She has studied at the Focusing Institute and is well-versed in trauma therapy. Several of her clients reside in nursing homes. Dr. Brown discusses the case of Sandra.

Sandra was a 64-year-old Jewish woman who had been living at Fallor Place Nursing Home for 17 years. She was known in the facility for her bright red wig and outspoken personality. She was wheelchair-bound due to osteoarthritis in her knees and was afraid to undergo knee replacement surgery, which would likely enable her to walk. Other medical conditions such as obesity and Crohn’s Disease complicated her condition. Sandra had virtually no family. During an initial intake with me, she was quick to share important information about herself in a very direct manner. She had a cousin in New York City with whom she had lost contact decades ago. Also, she admitted to having a son she gave up for adoption at birth because she said, “I didn’t want him to go through what I went through.” When asked about what she went through, she fell silent for a moment. Then she changed the subject. In discussing her history in such a matter of fact way including the adoption, her nonchalant manner regarding her son and her quick shift in topic may have been a defense against painful affect. “It was a closed adoption,” she said, “I knew nothing of his whereabouts.” But otherwise Sandra had no other known living relatives. She told

Downloaded by [New York University] at 12:41 13 August 2016 the administrator that she wanted psychotherapy and was eager to work with a female psychologist. She was open to self-exploration. Our therapeutic relationship spanned eight years. Sandra had been diagnosed with major depression and borderline tendencies 20 years earlier by a psychiatrist at a state mental hospital. How- ever, she described her depression as starting much earlier, at age seven. At the time we began working together she had experienced over 20 hospitalizations and 16 suicide attempts. Sandra had been on disability since the age of 41. She described herself as having multiple therapists and The Last Train Out of Berlin 123 psychiatrists over the last 20 years, never making much progress towards recovery. When asked about her multiple attempts to find a therapist, she paused and said:

I just kept looking for someone who would understand me and I didn’t find the right person. Oh, some were good, don’t get me wrong, others I simply fired. I guess I would give up on them or they would give up on me. But I’d inevitably reengage in treatment and try to get better.

Her reluctance to give up on the therapeutic process suggests that she found value in positive interaction dynamics with the right therapist. She intuitively may have felt that she needed the right person to understand her. Before becoming disabled by her mental illness, Sandra worked as a sec- retary at a major corporation for eight years. During this time, she lived with her mother. Her father had been deceased since her late teens. San- dra became deeply depressed and attempted suicide following her mother’s death. After being hospitalized for four months, she was forced to leave her job and obtained disability for depression. Her treatment team at the hospital determined that Sandra could no longer care for herself, and she was transferred to Fallor Place, where I met her. Sandra was given little say in where she was to live. She was so overcome by her depression, the suicide attempt, and the death of her mother that she agreed to the transfer which speaks to the implicit power of obedience built into institutional settings. Curiously, her chart indicated very little of her family history, which was likely a factor contributing to her psychopathology. The lack of any personal information in her chart suggested that mental health professionals had inadvertently eliminated her family experience from the records—a form of amputating containment. The chart emphasized her symptoms and her history of hospitalizations, but appeared to ignore the context in which Sandra’s personality was formed. From a Bowe- nian (1978) perspective, the person is a product of the system within which she was raised and continues to be intrinsically a part of this system even if members are deceased. Therefore, the treatment of the individual cannot be separated from the family context in which the individual personality was formed. As treatment progressed, it became apparent that it was important

Downloaded by [New York University] at 12:41 13 August 2016 to understand this family context. Sandra was a first generation American and the only daughter of German Jewish immigrants who had escaped from Nazi Germany when she was only three months old. Sandra tells the story of her family’s escape from Germany:

We were on the last train out of Berlin trying to get to the U.S. At some point during our journey, Nazi officers ordered, “All Jews off of the train.” My terrified parents followed the orders and, with me inmy 124 The Last Train Out of Berlin mother’s arms, exited the train. It was at this point that a Nazi officer noticed my beautiful curly red hair. “Oh, what a beautiful child,” he said, and then he calmly ordered my parents to get back on the train, which eventually took them to safety. From then onward my family believed that my beautiful curly red locks saved our lives that day in Berlin.

The horrors of Nazi Germany and the many familial losses that Sandra and her parents experienced—the vast majority of their family died at the hands of the Nazis—became the backdrop for her life in U.S. and it was simple: persecution, loss, and fear. Sandra’s parents distanced themselves from their religious roots upon arriving in America. They spoke little of their experiences in Nazi Germany. It’s as if the family amputated a tremendously traumatic experience that was too emotionally charged to process. Sandra appeared to become the psychological container for much of the unspoken painful affect that existed in the family, through projective identification. She was a victim of an intergenerational transmission process, a common interaction dynamic in families (Bowen, 1993). The bright red wig of curly hair Sandra wore in the facility became imbued with the psychological meaning of her family’s escape from Berlin. The omnipresence of her red wig suggested that unconsciously she did not want the threat of being taken by the Nazis again. The interactive process of projective identification between mother and daughter operated as follows (Ogden, 1979; Sandler, 1988). Sandra’s mother had experienced unspeakable traumatic pain as a result of the Holocaust. Her mother was unable to articulate—or to feel—this pain and repressed it in her own psyche while evoking it in her daughter. Her mother acted toward her daughter, Sandra, in such a way—abusively, neglectfully, etc.— that the painful affect related to her mother’s traumatic experience were evoked in Sandra through projective identification. Sandra might fail to bring the emotional pain related to the Holocaust into consciousness during her life time and instead transmit it in a similar manner as her mother did into her child (Rowland-Klein & Dunlop, 1998). Sandra acknowledged that she purposefully gave her son up for adoption because she feared she would mother him the way she had been mothered and pass the painful affect related to the family’s history to him. In this way, unprocessed psychologi-

Downloaded by [New York University] at 12:41 13 August 2016 cal trauma is transmitted through generations (Rowland-Klein & Dunlop, 1998). This differs from projective identification that may occur between therapist and client in that the transmission of affect and/or experience is intergenerational—between family members (Bowen, 1978). As her story unfolded, Sandra described her childhood as resembling life in a concentration camp. There was an abundance of childhood discord, punishment, and criticism. The only child of two Holocaust survivors, San- dra described herself as isolated and alone. The family remained emotionally cut off from their history—talk of “The WAR” was forbidden. Her mother, clearly traumatized by World War II—although never diagnosed The Last Train Out of Berlin 125 with post-traumatic stress disorder or any other psychological illness—was emotionally and physically abusive to Sandra. Sandra described her early interactions with her mother as characterized by constant criticism and demeaning remarks. She was punished frequently with “the belt.” Sandra had difficulty identifying why she was being punished. She described punishment as occurring frequently and unexpectedly. Sandra described her mother as “acting like a Nazi guard.” She was told that she was “stupid,” “ugly,” and a “worthless” child. In response to this ridicule, she did everything in her power to please her mother to no avail; Nothing could please her. At one point in therapy, she said that she wished the Nazis had taken her and that enduring the ridicule of her mother was akin to living in a concentration camp. Therapeutically, it seemed appropriate to introduce bibliotherapy into the treatment. I suggested that Sandra read the book The Drama of the Gifted Child, by Alice Miller (1980). This book discusses the narcissistic parent who molds the child to meet her own unmet narcissistic needs. The parent finds in the child’s false self a substitute for their own missing internal sense of identity. Fearing loss of the parent, the child gratifies the parent’s unconscious needs at the cost of her own self-realization. The child’s repression of her own needs and emotions in favor of meeting those of the parent leads to the creation of a “false self” (Winnicott, 1956). According to Miller (1980), difficulty in experiencing and ultimately developing one’s own emotions leads to a bond of permanence with the per- secuting parent, which prevents individuation—or becoming a “true self.” Sandra molded herself to meet her mother’s needs to avoid punishment and above all abandonment. Sandra stated, “I never knew myself . . . there was no spontaneity, joy or play. I was a robot who just knew what to do to please her and somehow the real Sandra got lost in all of that.” Long after the abusive parent has died, the introjected parental imago lives on in the psyche of the client, producing demeaning and self-deprecating ideations perpetuating the “false self” (Kohut, 1982; Miller, 1980). What is described as depression and often experienced as emptiness, futility, and loneliness can be recognized as the tragedy of the loss of one’s “true self” or alienation from the self (Miller, 1980). One is constantly in a negative, persecutory interaction with one’s self. For example, Sandra constantly

Downloaded by [New York University] at 12:41 13 August 2016 dialogued with herself citing her lack of intelligence, ugliness, and lack of accomplishment as rationales for her suicidal tendencies. Sandra embraced the book The Drama of the Gifted Child, forming a positively charged therapeutic-like relationship with its contents. She was like the “gifted child” described in the book. She stated, “That book is my story. My mother was like a monster. Anything I did was demeaned and labeled no good. I was constantly punished for no rational reason by my mother. I could not be myself. I tried so hard to please her. I wanted her to love me. I lived in fear of abandonment. I was terrified . . . the way she would look at me as if she wanted me to die.” 126 The Last Train Out of Berlin After reading the book, Sandra no longer felt as alone because her mother’s treatment of her was also experienced by others. While her understanding of the book was in no way a panacea for her condition, it provided some form of intellectual scaffolding, which allowed her to move forward with growth-promoting therapeutic interactions that enhanced her treatment. The book contributed to the development of a therapeutic holding environment. An understanding of the contents of the book, combined with a safe empathically charged therapeutic environment, allowed for the cultivation of a culture of enquiry. Metaphorically, the book became a transitional object (Winnicott, 1965) that contributed to the development of trust in the therapeutic relationship. A transitional object, according to Winnicott (1953), is an object (stuffed animal, blanket, or some other object) which is imbued with the scent of the mother and is used by the child to self-sooth when the child is not in the presence of her mother. Concurrently, Sandra came to understand that a kind of transfer of emotion had occurred between her and her mother—technically, projective identification. I suggested that her mother (a product of World War II) had been terrified and traumatized by the possibility of annihilation in a concentration camp. Unable to talk about this experience in narrative form, Sandra’s mother treated her daughter in such a way that her terror (Sandra’s mother’s terror) got evoked in Sandra. This interpretation of the mother-daughter interaction provided Sandra with an intellectual scaffolding for understanding and processing the interaction dynamic that occurred between the two—mother and daughter. In terms of the transference with Sandra, I could metaphorically be perceived as the “good mother” to her. In my absence, she could use the book as an object to soothe herself when painful feeling got evoked in response to a fantasy of being abandoned by me. Sandra confided to me that, between sessions, reading the book helped evoke the calming feeling she frequently experienced in therapy when in my presence. In this safe therapeutic space the client was, over time, given the permission to mourn her childhood—a lost childhood—and to gradually come into contact with her own true sense of self. The true self is the spontaneous essence of a person and involves the ability to express one’s self authentically without any fear of rejection (Kohut, 1982; Miller, 1980). According to Alice Miller (1980), access to

Downloaded by [New York University] at 12:41 13 August 2016 the “true self” is possible only when one is no longer afraid of the intense psychotic-like world of one’s early childhood. The ultimate process of mourning the lost childhood means facing the pain of never really having a childhood at all and ideally leads to an increase in vitality and creativity in the client. For Sandra, this process was complicated by the austerity and harshness of her living environment in the nursing home, which appeared to be a recapitulation of the abusive and neglectful atmosphere prevalent in her childhood. Fallor Manor had a poor rating as a long-term care facility, but still met minimal standards to remain licensed. Symbolically, the institution was a The Last Train Out of Berlin 127 poor mother who was largely incapable of empathy and routinely punished, depersonalized, and dehumanized the residents, including Sandra. The maintenance of clients as “stable” (symptom-free) was preferred over progress towards recovery—characterized by authenticity, spontaneity, creativity, and eventual discharge. The stabilization of residents was largely induced by the use of medication and can be identified as a form ofamputating containment. The staff had little interaction with the residents. It is important to note that the Fallor Manor housed over 300 residents and was understaffed by mental health professionals, employing only two full-time social workers and a minimal number of psychiatrists and psychologists as outside contractors. In this austere environment, clients’ progress through therapy was de-emphasized. Residents were viewed as being chronically mentally ill—hopeless cases des- tined to live out their lives in the institution (Minkoff, 1987). Fallor Manor, like Sandra’s mother, could be viewed metaphorically as a “bad mother”—a cold, unloving entity that at times could be abusive and neglectful. The physical environment was characterized by the smell of urine, walls that needed to be repainted, old furniture sometimes needing repair, and only a few windows that offering limited sunlight. The austerity of the environment and lack of staff interaction was not conducive to the development of a culture of enquiry. Most staff members were oblivious to any client’s history, including Sandra’s. One therapeutic group session was held per week, led by a contracted psychologist. Only residents assertive enough to ask to participate took part in the group; approximately ten residents out of 300. Many of those who attempted to assert for treatment were deemed to be manipulating and pathologized by staff (Potter, 2012). For the most part, residents sat around in the halls in wheelchairs staring at the walls or congregated in the dining room, sitting on mismatched chairs placed around old, broken tables. What was particularly curious was that no music was played in the facility. The background noise became the occasional screams of residents in need of help, the conversations of staff—sometimes including derogatory remarks about residents—and at times just silence. In some respects, the environment may have mirrored Sandra’s early interactions with her parents; particularly her mother (Goffman, 1961). The environment lacked positive sensory stimulation. The smoking room, a small area designated for smoking cigarettes, was one of the few places where any

Downloaded by [New York University] at 12:41 13 August 2016 resident socialization took place. Sandra sometimes smoked, not for the nicotine, but for social contact. Sandra had been objectified by the facility and the mental health system throughout most of her life. She viewed herself largely as a depressed person with borderline tendencies. “Borderline tendencies” appeared to be the label given to Sandra’s ability to assert her needs with staff or to criticize poor treatment, for instance by filing a complaint with social services. Rather than viewing these actions as a healthy sign of being able to assert herself, the staff labeled these “non-obedient” behaviors as symptoms of her psychopathology (Potter, 2012). This capacity to assert herself stood in stark 128 The Last Train Out of Berlin contrast to most others, frequently over-medicated residents who simply complied with the status quo. An administrator once stated to several staff members that he wished the “borderline” Sandra would shut up because, “It would save me a lot of time and aggravation.” Like her mother, staff spoke to Sandra in demeaning ways and would withhold privileges such as smoking to punish her when she failed to agree with institutional requirements, such as showering at a specific time or failing to comply with medication management. The open expression of affect, such as sadness and anger, was subdued by medicating patients. The need to have dialogue with Sandra and to identify the meaning of her feeling states was ignored by staff. The staff’s propensity to ignore feeling states facilitated the depersonalization of Sandra and others in the institution, serving as a form of amputating containment (Haley, 1959; Langsley, Pittman, Machotka, & Flomenhaft, 1968). While Sandra asserted her need for individual therapy, most of the other residents in the facility did not receive any kind of treatment other than medication management. This lack of therapy may have been driven by the widespread belief held by residents that asking for more than what was given by the system would result in negative consequences such as punishment or, worst of all, abandonment to the point of homelessness or imprisonment. Therefore, Sandra’s ability to assert herself more than the average patient, and thus the staff’s view of her as having “borderline tendencies,” could be perceived as a positive prognostic sign with respect to her recovery. Fur- thermore, the labeling of Sandra’s assertive behavior as “borderline” was a projection of the institution’s own pathological tendencies onto her, which undermined her attempt at independence and, ultimately, recovery. Through projective identification, staff constantly put their frustration, sadness, anxiety, and rage into the residents—much as her mother had transmitted the trauma of the Nazi Holocaust to Sandra. This process can also be viewed as a form of the intergenerational transmission process (Danieli, 1988). An important aspect of Sandra’s treatment involved making interpretative links between the present and events in her history. This was done to create awareness of Sandra’s propensity to recreate her oppressive past in the present with the hope that, in the present, things would work out better, a manifestation of what Freud (1914) might define as repetition com-

Downloaded by [New York University] at 12:41 13 August 2016 pulsion. For example, Sandra formed a relationship with a much younger 35-year-old male resident named Fred. He acted as if he wanted a romantic relationship with her. The one caveat with respect to his remaining in the relationship was that she needed to do whatever he wanted her to do or he would leave her. Over the course of a three-month time period he became increasingly verbally abusive, demanding cigarettes, money, and sexual favors. When she failed to comply, he threatened her with rejection. In therapy, Sandra expressed great sadness about the possible loss of this relationship. An interpretive connection was made between Fred and Sandra’s mother, whom she also sought to please in order to avoid The Last Train Out of Berlin 129 abandonment. She responded at first angrily to this interpretation, stating, “Why do you bring up my mother all of the time? She is long dead. I want to forget her.” It was suggested that, while her mother was physically dead, she was not dead in Sandra’s head. Sandra’s tendency to recreate past relationships in the present as abusive as the one with her mother was likely done with the unconscious hope that this time things would be better—she would be loved rather than rejected. After a long pause, Sandra responded to my interpretation, “It scares me, what happened with Fred. Why do I continue this pattern of repeated self-abuse? It is frightening.” Another example of a reenactment occurred with respect to Sandra’s psychiatrist, who failed to respond to a phone message in which she indicated she was suicidal. She stated that he did not respond for two days, and then only his assistant called back. Sandra was tempted to call the licensing board and report him for negligence but hesitated to do so out of fear of retribution by him. I suggested that her doctor’s failure to respond—while unethical—mirrored her mother’s failure to respond to her needs in childhood. Her desire to report the psychiatrist to the licensing board might resonate with an unconscious desire to have reported her mother to the Department of Children and Family Services (DCFS) for neglect and abuse. While Sandra was resistant to embracing this interpretation overtly, over time she began to understand the parallels between her present interactions with others and her history. The therapeutic process of creating a safe holding environment in which Sandra and I could reflect on how actions in the present could be linked to the past helped to facilitate insight into the origins of her behavior. This insight allowed Sandra to become less enslaved by her history and the oppressiveness of her current environment, ultimately making her more self-aware and thus giving her an increased sense of agency. The therapeutic process enhanced Sandra’s capacity for more effective interpersonal communication and promoted a culture of enquiry. This culture, facilitated and maintained by the therapeutic relationship, led Sandra to assert the need to write her life story. Sandra wanted to create a narrative of her life. A friendship with another woman with an abuse history and who suffered from depression provided Sandra with peer support. Sandra’s friend, Cindy, encouraged her to write her life story. This relationship supported a culture of enquiry and provided an oasis from the dehumanizing interactions that

Downloaded by [New York University] at 12:41 13 August 2016 frequently occurred between Sandra and staff. During one therapy session, Sandra commented about the friendship, “Cindy helps me to feel like a person. We talk about everything together. You know, I never had a friend like her. I have always been alone.” The interpersonal psychologist Sulli- van (1974) talks about how having a friend or “buddy” in childhood is an important developmental step in developing other positive and supportive relationships throughout the life cycle. The importance of friendship in the developmental process is also highlighted by Eric Erikson (1963), who identifies the important stage of development in early adulthood characterized by the dialectic of intimacy versus isolation. Erikson believed it important 130 The Last Train Out of Berlin that people develop close interpersonal relationships with others in order to facilitate a sense of well-being. Many individuals experiencing mental illness early in life, like Sandra, have compromised relationships with others due to the debilitating effects of their disease and the failure of society to provide outlets for helping this population to form healthy relationships with others (Forrester-Jones et al., 2012). Cindy provided an important therapeutic function for Sandra. By encouraging her to write her autobiography, Cindy helped Sandra to create a social context to support her desired identity. During the fourth year of treatment, Sandra began the process of writing her autobiography. The piece constituted a growth-enhancing interaction with herself. At times, we would use parts of individual sessions for writing or to review parts of her narrative written outside of therapy. The process of writing allowed Sandra to link aspects of her tragic history together into a coherent whole. By writing her life story, Sandra was better able to clearly acknowledge what was lost—much of her childhood—and to deepen the mourning process. The linking of painful memories together facilitated a better understanding and insight into why she suffered from depression. The process of reflecting on her story allowed her to gain insight into positive memories that included reminiscing about good experiences with her father, whom she believed really loved her, and interactions with her mother that were at times nurturing. By writing her story, Sandra reflected on her mother’s own untreated psychopathology and mourned the possibility that her mother could have been much more nurturing had she obtained treatment and support. Sandra was able to reflect on and express anger in response to how the mental health system had failed both her and her mother. Furthermore, Sandra discussed the difficulty she had leaving home. She recalled trying to move out of her childhood home three times in adulthood. Each of her attempts at separation-individuation led to intense feelings of loneliness and depression, which ultimately resulted in her moving back home to her mother. Failure to complete the process of leaving home without intensely painful feelings suggested compromised emotional object constancy (Mahler, Pine, & Bergman, 1975). Emotional object constancy (Mahler et al., 1975) refers to the establishment of a relatively stable, benign, and positive representation of the mother in the child’s psyche and eventually a representation of others that “holds”

Downloaded by [New York University] at 12:41 13 August 2016 even in the face of absence, disappointment, or anger. A lack of consistency or absence in mothering and few positive or satisfying experiences in childhood, combined with trauma and neglect—as with Sandra—can contribute to compromised object constancy and, ultimately, severe psychopathology. The individual’s capacity to evoke a positive and soothing internalized self-object allows for the process of individuation and, ultimately, autonomy as a self in the world. Emotional object constancy allows an individual in adulthood to maintain a healthy sense of self, separate from one’s mother, and to flourish independently as a contributing member of society. The Last Train Out of Berlin 131 In psychotherapy, the manifestation of a positive relationship between therapist and client that is characterized by empathy, congruence, and unconditional positive regard (Rogers, 1957) can contribute to the reparation of compromised object constancy. Ideally, I, the therapist, becomes introjected as a good object in the psyche of Sandra, the client. Sandra could evoke this intra-psychic representation of me during times of stress, contributing to an increased capacity for independence and autonomy. One outcome of Sandra’s completion of her personal narrative was her decision to get knee replacement surgery. This somewhat shocking announcement during therapy in her fifth year of treatment suggested a desire to start the separation-individuation process once again (Mahler et al., 1975). Sandra stated that she wanted her independence (Erikson, 1993). Also, the decision implied the possibility that therapy had contributed to improved object constancy and, ultimately, to Sandra’s becoming a more fully functioning person. Within months of her initial decision and as the date of the surgery came closer, she became ambivalent about going through with it. This ambivalence is reminiscent of the rapprochement stage in the path towards emotional object constancy (Mahler et al., 1975). In the rapprochement stage, the toddler desires independence, but is terrified of it. The toddler is faced with two intense fears: engulfment by the mother and abandonment by her. Factors that contribute to a positive resolution of the rapprochement crisis include a parent’s continued emotional availability combined with a willingness to encourage the child’s independence. The parent tolerates the child’s ambivalence while remaining present as a secure base where the toddler can emotionally “refuel” with a hug from the mother before again asserting independence and darting away into the environment as an independent being. Metaphorically speaking, the nursing home milieu was not a “mother” conducive to supporting independence. Nor did it provide a secure base where support and affirmation of Sandra’s independence was the norm; dependency was the norm. The nursing home promoted the dehumanization and depersonalization of Sandra. Therefore, outside of affirmation within the therapy relationship and the peer support from her friend Cindy, Sandra had limited encouragement within the nursing home. Her orthopedic sur- geon, however, provided much support. In fact, on at least one occasion a

Downloaded by [New York University] at 12:41 13 August 2016 staff member of the nursing home discouraged surgery, warning Sandra that she did not have the strength—mentally or physically—to successfully complete rehabilitation. Ultimately, Sandra did move forward with the surgery. This was a tremendous step for Sandra toward separation-individuation and, ultimately, the reclaiming of her sense of self. After knee replacement surgery, Sandra returned to the nursing home. Rehabilitation was difficult, with periodic setbacks due to medical compli- cations, but ultimately Sandra was able to walk independently with the help of a walker. 132 The Last Train Out of Berlin The successful completion of the surgery heralded in a new dynamic to the therapy, with Sandra’s desire to “start over.” This desire to “start over” was preceded by an emergency phone call in which she complained to me of being in great pain in the rectal area. During the phone call she stated that no staff in the nursing home would listen to her but that she felt like something had to come out of her rectum and that it was blocked. While I stated that I would immediately alert medical staff to explore the nature of her pain, I also encouraged her to free associate with respect to what word, thought, or feeling she might link with the pain. I explained that, while the physical dimension of the pain could not be ignored, the psychological dimension also needed to be addressed. The mind could engage in a form of amputating containment by somatizing affect that might be too frightening to bring into consciousness and verbally express. I suggested the rectal pain might be indicative of some preverbal idea, thought, or fantasy beginning to emerge. The free association process facilitated an interaction process with the body or “felt sense” (Gendlin, 1982). The goal of this therapeutic intervention was to allow for the meaning of the felt sense to emerge in therapy. The next day, Sandra reported that she’d had a massive bowel movement following our conversation and felt better. She stated that the word “ostracized” was what she had associated with the pain. She described how all her life she had felt ostracized and that every time she started to bloom she would get emotionally cut off by her mother, mental health professionals, etc. Sandra felt like she was starting to bloom again but feared getting cut off. We discussed how she risked the possibility of sabotaging herself by failing to allow herself to bloom. She had internalized the stigma of being inadequate and risked “getting cut off at the bud” once again. Sandra then asked me to advocate for her by writing a letter to the reality show Starting Over. I suggested that the issue was not about me writing the letter but about the need to have someone advocate for her. I also suggested that she needed to advocate for herself. She acknowledged that for years she had been alone with no one there for her. She felt angry and frustrated by the lack of support in almost every aspect of her life. Six weeks later Sandra, with the help of her friend Cindy, wrote the letter to the reality show Starting Over—a letter she never sent but read to me in therapy. The letter indicated that she wanted an apartment, a romantic

Downloaded by [New York University] at 12:41 13 August 2016 relationship, and a job. She wanted the opportunity for a new start, including a makeover. I suggested that while the letter was important, her actions suggested that she had already begun the process of starting over. The letter symbolized that the psychological process of making a new beginning was already underway. In fact, on her own initiative she started the process of finding another nursing home—one more suitable to her needs. Sandra wanted a nursing home that offered more opportunities for group and individual therapy, as well as activities offering opportunities for interaction with other residents, including field trips. She also desired to renew her spiritual connection with Judaism. The Last Train Out of Berlin 133 With little assistance from Social Services at Fallor Manor, which actually exhibited resistance, she was able to find a nursing home that supported her with more psychological services to help in facilitating her recovery. While Sandra continued to suffer from depression, its intensity had diminished. She was able to move forward. During an initial transition period to the new nursing home, however, she experienced some feelings of ambivalence. She missed Cindy and some staff, but she quickly adapted well to her new environment. Sandra had progressed in her journey towards recovery. She had resisted the former nursing home’s staff norm of viewing stabilization in clients as the goal and had grown as a person by moving on intra-psychically—individuating—as well physically—separating by moving to a new facility. She had bloomed. She joked in therapy that she was a “late bloomer.” Sandra continued the process of mourning her lost childhood, the absence of a psychologically healthy mother, and the experience of the Holocaust in which she lost most of her family. Additionally, she felt rage towards the mental health system she felt had let her down by objectifying and dehumanizing her. While Sandra’s recovery was not characterized by going back to college, living in an apartment by herself, or getting a job, it was nonetheless one suggestive of great progress in her growth as a person. Sandra formed many positive relationships after moving to the new nursing home, which served as a strong source of peer support. She renewed her spiritual connection to Judaism and with the help of social services made contact with a long-lost surviving cousin in New York from whom she had been emotionally cut off. While they were unable to reconnect in person, their relationship developed through regular telephone calls and letters. Through the interactions with her cousin she gained a greater understanding of her mother’s history and the details of the war that contributed to her mother’s psychopathology. Sandra’s redefining of her mother as a Holocaust survivor provided her with a broader understanding of why her mother may have acted abusively toward her. Sandra was able to forgive her mother. By forgiving her mother, she was gradually able to neutralize the extremely negative introject of this primary caregiver, which had dominated her childhood and much of her adulthood. Her ability to see her mother in a more neutral manner led Sandra to view herself less negatively as well. Sandra’s regained

Downloaded by [New York University] at 12:41 13 August 2016 mental health was the result of a combination of medication, therapy, peer relationships, greater self-understanding, and eventual reconnection with an emotionally cut off family member, which allowed for growth-promoting interactions—all of which contributed to her recovery.

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Bowen, M. (1978). Family therapy in clinical practice. New York: Jason Aronson. Bowen, M. (1993). Family therapy in clinical practice. New York: Jason Aronson. 134 The Last Train Out of Berlin Danieli, Y. (1988). Treating survivors and children of survivors of the Nazi Holo- caust. In F. Ochberg (Ed.), Post-traumatic therapy and victims of violence (pp. 278–294). New York: Brunnel/Mazel. Erikson, E. H. (Ed.). (1963). Youth: Change and challenge. New York: Basic Books. Erikson E. H. (1993). Childhood and society. New York: W. W. Norton and Company. Forrester-Jones, R., Carpenter, J., Coolen-Schrijner, P., Cambridge, P., Tate, A., Hallam, A., . . . Wooff, D. (2012). Good friends are hard to find? The social networks of people with mental illness 12 years after deinstitutionalisation. Journal of Mental Health, 21(1), 4–14. Freud, S. (1914). Papers on technique. In Remembering, repeating and working through (Standard Edition, Vol. 14, pp. 145–157). New York: W.W. Norton & Company, Inc. Gendlin, E. (1982a). Focusing. New York: Bantam Books. Goffman, E. (1961b). Asylums: Essays on the social situation of mental patients and other inmates. New York: Anchor Books/Doubleday. Haley, J. (1959). The family of the schizophrenic: A model system. The Journal of Nervous and Mental Disease, 129(4), 357–374. Kohut, H. (1982). Introspection, empathy and the semicircle of mental health. Inter- national Journal of Psych-Analysis, 63(4), 395–407. Langsley, D. G., Pittman, F. S., Machotka, P., & Flomenhaft, K. (1968). Family crisis therapy—results and implications. Family Process, 7(2), 145–158. Mahler, M. S., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant: Symbiosis and individuation. New York: Basic Books. Miller, A. (1980). The drama of the gifted child: The search for the true self. New York: Harper Collins. Minkoff, K. (1987). Resistance of mental health professionals to working with the chronic mentally ill. New Directions for Mental Health Services, 33, 3–20. doi:10.1002/yd.23319873303 Ogden, T. H. (1979). On projective identification. International Journal of Psycho- analysis, 60(2), 357–373. Potter, N. N. (2012). Mad, bad, or virtuous? The moral, cultural, and pathologizing features of defiance.Theory & Psychology, 22(1), 23–45. Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic change. Journal of Counseling Psychology, 21(2), 95–103. Rowland-Klein, D., & Dunlop, R. (1998). The transmission of trauma across generations: Identification with parental trauma in children of Holocaust survivors. Australian and New Zealand Journal of Psychiatry, 32(3), 358–369. Sandler, J. (Ed.). (1988). Projection, identification, projective identification. New York: Karnac Books. Sullivan, H. S. (1974). Schizophrenia as a human process. New York: W.W. Norton. Winnicott, D. W. (1953). Transitional objects and transitional phenomena—a study of the first not-me possession. International Journal of Psycho-Analysis, 34, Downloaded by [New York University] at 12:41 13 August 2016 89–97. Winnicott, D. W. (1956). On transference. The International Journal of Psychoanal- ysis, 37, 386–388. Winnicott, D. W. (1965). The maturational processes and the facilitating environment: Studies in a theory of emotional development. New York: IUP.

Dr. Jones, Ed.D., is a licensed clinical psychologist and professor of psychology specializing in the treatment of severe mental illness. Her clinical orientation is psychodynamic, with a special interest in the work of Melanie Klein. She talks about Shirley, a resident of the nursing home Green Garden, a person Dr. Jones treated early in her career.

Staff viewed Shirley as a difficult patient. She would scream obscenities at staff and chant unintelligible sounds for long periods of time, relentlessly, with no apparent triggers. Her outbursts could be heard from one side of the building to the other. Although bedridden and unable to walk, Shir- ley had strong upper body strength—she would throw objects across her room, once hurling a small television onto the floor. Additionally, she was known to experience catatonic posturing for periods of time, most likely due to a seizure disorder. The unusual nature of her postures disturbed some non-clinical staff, who viewed them as “otherworldly.” Shirley led a lonely existence. She spent her days lying in bed with little human contact for hours at a time, mumbling to herself, sleeping, and hallucinating. Many of her delusions were persecutory in nature. She felt as if she were under attack by others. After years of being institutionalized, Shirley had good reason to see the environment as a dangerous place. Shirley’s unusual behavior quickly resulted in many mental health professionals and lay staff joking that “the best treatment for Shirley would be an exorcism.” The staff joked that she was possessed. That is, using the Downloaded by [New York University] at 12:41 13 August 2016 interaction structures of scapegoating and projective identification, they saw Shirley as being demonically possessed. This was far from humorous since it was charged with negative fantasies that further objectified and dehumanized her. This notion allowed those treating her to distance themselves from experiencing the agonizing affect expressed through her actions by dismissing it. Shirley’s “demonic” behavior led most CNAs, nurses, and other medical staff to ignore her rather than meet her basic needs, which were most likely related to a need for emotional contact. The use of amputating containment and punishment was evident in the staff’s treatment of Shirley. They managed Shirley’s “acting out” behaviors 136 The Woman Who Believed She had No Heart by drugging her, hospitalizing her, placing her in isolation, or punishing her by depriving her of commissary food, such as chips or candy bars. She was diagnosed as a “chronic” paranoid schizophrenic, and based on the psychiatric standards at the facility there was no hope for any form of recovery other than symptom management. Treatment consisted of psychotropic medications and intermittent electroconvulsive therapy (ECT). Shirley’s morbid obesity made mobility very difficult. Time out of her room consisted of sitting in the hallway in a geriatric chair alone in a corner talking to herself—at times screaming obscenities. After forming a relationship with Shirley, I was able to see that beneath her disturbing acting out behavior was a profound sense of emptiness. She stated that she felt like an “empty pill box with a broken heart” and later communicated the delusion that she had literally no heart at all. She described herself as being physically “gutted” or disemboweled by doctors who “put her away in places that stripped me of my insides.” She stated that she was virtually an empty shell and said, “I am dead inside . . . I am dead.” Although Shirley’s beliefs about herself suggested delusional ideation with respect to her physical state, on a metaphorical level they communicated a sense of isolation, emptiness, and aloneness—suggested by her living situation, a long history of institutionalizations. The lack of empathy, unconditional positive regard, and congruence in her life had left her with a broken heart and, finally, no heart at all. When this interpretation was made in therapy Shirley acknowledged having a deep sense of emptiness and being very sad about spending many years alone, profoundly disconnected from others in institutional settings. Shirley’s emptiness stemmed from being institutionalized as a toddler. At her current age of 72, this meant that Shirley had spent 69 years of her life locked up in mental health facilities or jail for petty crimes. She had spent virtually her entire childhood, adolescence, and adult life in institutions. For ten years she was hospitalized in a notorious asylum for the insane on the East Coast. Shirley revealed that she had been abandoned by unknown parents at a hospital for crippled children in upstate New York at 12 months old. From Shirley’s account, she never knew her parents or any other family members. At the age of 12, she asked a well-liked nurse about her family and was told her mother had been unfit and had abandoned her at the doors of

Downloaded by [New York University] at 12:41 13 August 2016 the hospital as a baby. In therapy she said, “All I knew as a parent was the institution” [the crippled children’s hospital]. Based on her recollections, the institution was not a very good parent. She described the environment as toxic. She described herself as trying to run away from the hospital several times. Each time she was apprehended, beaten, and placed in isolation for her actions. Later there were a few nurses at the institution who showed her some loving care. Her fragmented memories of her early childhood were put together into a more cohesive narrative over several years of therapy as Shirley told her story. These memories suggested that she was physically, sexually, and The Woman Who Believed She had No Heart 137 emotionally abused within these institutions. As an abandoned child in a rural area in upstate New York with no adult to advocate for her, there were few societal protective mechanisms to help her. She quickly became objectified and identified as merely another “crippled child”—regardless of the fact she had no physical disability in childhood. The historical context in which Shirley had been initially institutionalized in the early 1950s provided her with very limited opportunities for growth in terms of her education, socialization, and, most importantly, the experience of being loved. No alternative housing was sought for Shirley, who was raised within the walls of the hospital for crippled children for the first fifteen years of her life. Late adolescence and most of her early and mid-adulthood was characterized by years of institutionalization in mental hospitals, homeless shelters, and jail until she was placed by a social worker at Green Garden. At the age of 72, with no known family and few friends at Green Garden, she was depressed and paranoid. She viewed the few staff members at Green Garden who legitimately paid attention to her as her auxiliary “mamas.” Her labeling of those who cared for her as “mamas” suggested a deep unmet need to be mothered. As a young, idealistic provider when I began treating Shirley, I had the naïve belief that high quality care was the standard in the U.S. and readily available to all individuals diagnosed with severe mental illness. These idealistic views of institutional care in America were quickly squelched. Green Garden did not live up to its name, which suggested a beautiful garden setting characterized by excellent accommodations and quality medical and psychiatric care. Paradoxically, Green Garden was virtually desert-like, with stark interior design of old un-matching furniture, dusty plastic plants, poorly cleaned linoleum floors, unpainted walls, and inadequately trained, poorly paid staff showing little attention to the residents’ needs. It had the stench of urine—the likely result of the failure of staff to promptly change adult diapers, provide residents with regular showers, and change linens and underclothing on a consistent basis. The sanitation in the facility met the minimum standard of care to maintain licensure as a long-term care facility. Most residents did not receive individual or group psychotherapy. Treatment consisted of one 20-minute visit by a psychiatrist and a medical doctor once a month, which was sometimes irregular. One resident reported

Downloaded by [New York University] at 12:41 13 August 2016 not seeing her psychiatrist for three months. Staff members were apathetic to the needs of the residents. One certified nursing assistant (CNA) commented, “Putting in my eight hours here is my only goal. This is all about making a living and a meager one at that. These residents are manipulating trouble makers.” Many interactions between staff and patients at the nursing home could be characterized as depersonalizing and invalidating. For Shirley, the quality of communication with staff was likely experienced as a reenactment of the type of interactions she experienced during years of institutionalizations in dehumanizing treatment settings. 138 The Woman Who Believed She had No Heart A number of factors contributed to the destructive interaction dynamics that occurred at Green Garden, including the fact that staff members were underpaid and overworked and the facility was understaffed. The residents were often seen as manipulating troublemakers—an attitude that trickled down from the chief operating officer of the facility, Mr. Georg, though this attitude was most likely a projection. As the chief administrator, Mr. Georg was responsible for running all the departments at Garden Green, including housekeeping, dietary services, nursing care, psychiatry, medicine, and social services. Mr. Georg was described as “tyrannical” by employees and residents. Aside from a few select confidants in the front office, he treated those who worked for him with great disrespect. He was known to fire employees quickly and for unsubstantiated reasons. He spoke in a condescending and demeaning way, void of eye contact and with no indication of any sense of humanitarianism. He was described as simply desiring to maintain residents at the minimal cost possible to reap the greatest possible profits for his health company. Some years after leaving Green Garden, I was told that it was viewed by many reputable nursing home providers in the area as “The Dead Gardens.” One interaction I had with Mr. Georg served as a strong indicator of how he objectified staff and patients. It occurred when I entered the main office to make a copy of a document for a therapy session. This interaction serves as an example of a form of projective identification (Rychlak, 1981). Mr. Georg looked at me and in a harsh and demeaning voice ordered me out of the office. His voice elevated to the point of almost yelling at me to, “Get out of here and do your job.” He promptly slammed the door on me. I was shocked and dismayed by the interaction. I immediately experienced feelings of anger, but I also felt insulted, depersonalized, and devalued as a professional, a doctor of psychology. It quickly became apparent to me how others who were trapped in the institution due to their mental health condition or their need to make a livelihood might be made to feel by a tyrannical leader. After all, I was a contracted employee who could leave at any time. It also became apparent to me how this interaction style, originating in the leader, could infest the organization. Green Garden at times seemed to function like it was a “psychotic” institution. The idea that institutions become psychotic is based on the

Downloaded by [New York University] at 12:41 13 August 2016 work of Wilfred Bion (1961) and Menzies-Lylth (1960, 1988). The notion of psychotic-like institutions is grounded in the group-as-a-whole approach—practiced extensively at the Tavistock Institute in London. This perspective suggests that staff members are acting in oppressive ways not only on behalf of their own inner prejudices but also on behalf of the institution as a whole. Indeed, Green Garden as a facility exhibited many symptoms characteristic of a psychotic person, including chronic splitting on the part of staff (e.g., the patients are bad people who are manipula- tors, while the staff are all good benevolent care givers). There was also massive denial of the inhumanity frequently displayed by the institution The Woman Who Believed She had No Heart 139 towards residents and staff who were at times objectified by management as part-objects rather than being treated as human beings. An example of a part-object relationship at Green Garden nursing home was evident when a Nurse simply referred to the person in bed “A” as “paranoid” with one leg rather than identifying her as Mrs. Smith, a person with a daughter, grandchildren, a career, an education, etc. Projection was rampant among the institution’s staff members, including the tyrannical leader. Mr. Georg attributed unwanted parts of himself to the residents, who were for the most part helpless to thwart these projections. Through projection the residents were labeled as lazy, useless, chronic, and always manipulative of staff. Concurrently, like in psychotic individuals, a strong sense of paranoid anxiety flourished at Green Garden, with staff members and residents fearing that at any point the tyrannical leader—Mr. Georg—would kill off an employee by firing her or dispose of an unwanted resident by putting her into exile through hospitalization or arbitrarily transferring her down state to another unknown and perhaps worse facility—located far from family. Particularly Bion’s (1961) ideas concerning groups and institutions, based on the work of Melanie Klein (1946), a psychoanalyst and object relations theorist, will be elaborated on in chapter 12 of this book. In this psychotic-like institutional setting, I committed myself to working with Shirley for over a four-year time period. I will discuss five sessions that occurred in succession during the fourth year of treatment, which I believe led to a breakthrough for Shirley. In conceptualizing my therapeutic approach, I embraced Carl Rogers’s (1957) facilitative conditions for a therapeutic relationship, including empathy, unconditional positive regard, and congruence. This approach led to the evolution of a positive therapeutic alliance. I also used the work of Melanie Klein (1946). A description of the theoretical perspective of Klein follows. Melanie Klein (1946) conceptualized the human psyche as consisting of these two developmental positions: The paranoid-schizoid and the depressive positions. These two positions, based on mother-infant interactions, represent different ways of processing information, and they are both diachronic and synchronic. The term “positions” suggest that Klein (1946) was not describing a phase or stage to be passed through, negotiated, and

Downloaded by [New York University] at 12:41 13 August 2016 resolved, but rather internal states, or ways of perceiving the world, that will be experienced throughout one’s lifetime. In this sense, the notion that the positions are synchronic indicates that they exist simultaneously throughout a lifetime. By diachronic, Klein suggested that one stage of development comes immediately before the other in development. The paranoid-schizoid position—occurring from 0–6 months of age—precedes the depressive position, which emerges around the time of object constancy (Piaget, 1969) or at approximately eight months of age. The paranoid-schizoid position is characterized by psychotic ideation: splitting, projective identification, primary process thinking, and a lack of differentiation of ego functioning. 140 The Woman Who Believed She had No Heart From Klein’s point of view, the infant’s mind is characterized by the psychotic process. On the other hand, the depressive position is represented by secondary process thinking, ego integration, an ability to tolerate ambigu- ity, higher-level defenses such as repression, and improved reality testing. This starts at eight months of age—at the beginning of object constancy in the infant—and in the psychologically healthy person continues throughout one’s life cycle. In terms of Klein’s theory, a relatively healthy individual has passed through childhood with a preponderance of “good enough” interactions with mother and therefore turns out in adulthood to be firmly grounded in the depressive position characterized by healthy psychological thinking—grounded in good reality testing. In contrast, an individual with an abusive and neglectful childhood (characterized by childhood discord) can result in being grounded in a predominantly negative internal object worldview characteristic of the paranoid-schizoid position. This individual is frequently psychologically compromised and later diagnosed with a severe mental illness such as schizophrenia or schizoaffective disorder. Under the right stressors, even someone who appears to be grounded in the depressive position can experience psychological symptoms indicative of the fact she is slipping into a more paranoid-schizoid way of viewing the world. From a Kleinian (1952) perspective, when someone experiences a breakdown she shifts into the paranoid-schizoid position. Reintegration is made possible therapeutically through interpretations and other kinds of therapeutic interactions—characterized by empathy, congruence and unconditional positive regard—that provide an opportunity for psychological holding and ultimately the restoration of an integrated sense of self characteristic of the depressive position. The capacity for the client to put painful paranoid and angry affective states into a narrative allows the person to reintegrate into a more non-psychotic state of being in the world (Wigren, 1994). For Shirley, a series of therapeutic interactions demonstrated the process of disintegration to a paranoid-schizoid position followed by a reintegration into a more stable depressive state. Klein’s theory of positions acts as a framework for observing the interactions and interpreting them. The quality of interactions during the following five sessions provided the client with a corrective experience—one unlike the experiences of childhood

Downloaded by [New York University] at 12:41 13 August 2016 that were characterized by neglect and abuse. The five sessions took place over a week-long period during the fourth year of treatment. My ability to hold painful affect contained in Shirley through the process of projective identification and the subsequent interpretations of this affect in the therapy appears to have helped facilitate a positive reintegration. Furthermore, these interactions jumpstarted the piecing together of a personal narrative of trauma and neglect that allowed for the processing of painful affect long somaticized, denied, and/or projected onto the environment, including onto those around her. Inter-psychic work leading up to these significant interactions likely contributed to the solidification of a sense of self capable of accessing and ultimately processing painful experiences. This intra-psychic The Woman Who Believed She had No Heart 141 work, though largely based on psychodynamic thinking, was framed in Rogers’s (1957) conditions for therapeutic change as discussed earlier. The first of the five breakthrough sessions took place one week before Shirley’s 76th birthday. After approximately four years of treatment, she announced in therapy that she had been raped 76 times in her life. I suggested experiences in her life were so painful that it was as if she had been raped every day of her life. She proceeded to say she was getting her memory back. During the remainder of her session she described in a fragmented way memories involving abuse by doctors, betrayals by other residents, miscarriages, and traumatic hospitalizations. The fluid way in which she communicated these memories had not been evidenced in any of our earlier sessions. In fact, prior to this session it was if she had no history other than what was documented in her chart, which was minimal at best. One day later, during the second session, she continued to describe memories of physical, sexual, and emotional abuse during numerous hospitalizations. She described the doctors, “as taking out my heart” and reiterated feeling like an empty shell of a person. I interpreted her heartless state as having been treated in inhumane and perhaps “heartless” ways by many mental health professionals. She lamented at having been institutionalized for almost her entire life, and thus not having any real life. She also reported having no memories prior to the age of 12, when she was told by a nurse that she had been abandoned at the Crippled Children’s Hospital by a mother unable to care for her. During the third session, held two days later, the client began recovering memories prior to age 12. Shirley cried as she remembered the experience of living her childhood in the hospital for “deformed babies.” She stated, “I was all alone at the facility for years. The institution was the only parent I ever knew. The only relationship I had was with that hospital. I remember trying to run away; they found me and put me in a cement room. I had no underwear on. Staff came into the room. I was raped. I soiled myself.” She cried softly, mumbling to herself, “My mother . . . my mother . . . oh, who was my mother?” During this session, she appeared grounded in the depressive position. While tearful at times, she was able to link her memories together (Bion, 1959) well and appeared to be emotionally and cognitively integrated at the end of the session. She seemed to be able to process painful

Downloaded by [New York University] at 12:41 13 August 2016 affect through the telling of her narrative. One day after the session, I received an emergency phone call. The nurse, Emma, stated that Shirley was calling out for me and was in great turmoil. She was enraged at me, though at the time the reason why was not clear. Emma had taken on the role of auxiliary “mama” to Shirley and showed great empathy towards her. Her connection with Shirley helped to facilitate treatment. Emma stated that she needed me to get to the facility as soon as possible to assess Shirley. Upon seeing Shirley for the fourth time that week, it was apparent to me she that had shifted from the depressive position experienced in the earlier session to the paranoid-schizoid position. This could have been triggered by the emergence of painful memories during the 142 The Woman Who Believed She had No Heart earlier session, combined with the anniversary effect of her birthday. She screamed out that she hated me and that I was a “bitch.” I was split off as solely a bad object, a bad “mother” (Klein, 1946, 1952). She wished me dead or paralyzed in a car accident. She demanded that I discharge her from the facility to go out east to New York. Shirley continued to demean me for 45 minutes. During this time, I realized that I was filling up with feelings of anger, betrayal, sadness, and shame. These feelings were most likely put into me by Shirley via projective identification. I felt paralyzed for a moment, not knowing how to respond to her. Rychlak (1981) talks about concordant countertransference as a form of projective identification in which the client evokes in the therapist feelings she experienced in response to demeaning remarks made toward her by parents or other significant caregivers in her life. The therapist is able to feel firsthand what it was like to be the abused client. The nursing staff suggested that I write up Shirley in response to her outburst toward me. Instead, I attempted to empathize with Shirley’s emotional state. Being written up for the expression of strong emotions, as stated earlier, is standard procedure in many institutional settings. Being written up is a form of punishment that aborts rather than facilitates the therapeutic process, which in Shirley’s case involved retrieving memories and telling her story. I suggested to Shirley that her emotional state might be triggered by an anniversary effect linked to her birthday and the painful memories she had recovered during the recent session. She had been abandoned by her mother and was angry, but also mourning this loss. I suggested that she really wanted to “discharge” painful feelings toward those who in the past had hurt her—her mother, mental health professionals, and others—rather than be “discharged” from the facility. I highlighted that during our last session, she had acted toward me in such a way that she evoked in me painful feelings that she was likely experiencing. Or perhaps she wanted me to be “paralyzed” with painful emotions—“the way you were when you were put down and abused by others in your life.” I suggested that the feelings of hurt, shame, anger, and so on that she evoked in me were feelings she had experienced when people in authority put her down at different times during her life. The session ended with Shirley calming down slightly but

Downloaded by [New York University] at 12:41 13 August 2016 still experiencing some anger toward me. Two days later, I had the fifth session with Shirley. Not knowing what to expect, I approached her room with some hesitation. Remarkably, Shirley was like a different person, calm, logical, and goal-directed. I interpreted this change in her demeanor—silently to myself—to indicate a shift from the paranoid-schizoid to the depressive position. I was surprised when I received an apology from Shirley.

SHIRLEY: “I didn’t want to hurt you. I was just so angry. I was afraid that you would never come back after what I said The Woman Who Believed She had No Heart 143 to you. I believed that you would abandon me and that you would hate me for how I acted towards you.”

It was quite remarkable that Shirley showed great insight into her behavior toward me during the last session and made a sincere attempt at reparation. Reparation, from the perspective of Melanie Klein, gives strong evidence that the child or adult has entered into the depressive position and is attempting to heal the emotional rift that occurred during the paranoid-schizoid phase of experience when the client felt murderous rage and engaged in defensive maneuvers, including splitting and projective identification. I utilized this session to reiterate some of the interpretations made during the prior session. I suggested that what had happened during the last session was indicative of Shirley’s need to express painful feelings linked with her longstanding history of abuse. I suggested that the rage she expressed toward me during that next session was an indication of the anger that had been expressed toward her by her abusers—including her absent mother, mental health workers, doctors, and others. The feelings I felt in response to Shirley’s demeaning remarks—shame, anger, sadness—were a reflection of her feelings in response to the abuse and neglect she had experienced during countless institutionalizations starting in early childhood, an example of projective identification. She had evoked in me her feelings—feelings that were too painful for her to express verbally. Shirley’s response towards my interpretations was surprising.

SHIRLEY: “You know I am a trauma survivor. Do you think you could get me a psychologist to help me with these issues? They really hurt me. You are correct.”

For four years Shirley had denied my role as her psychologist. Now she was asking for a psychologist to help her work through her trauma history. Speaking interpretively, she was now ready to engage in treatment with the psychology part of myself. I responded with the following interpretation:

DR. JONES: “Perhaps you are now ready to utilize the psychologist

Downloaded by [New York University] at 12:41 13 August 2016 part of me. Shirley, we have been working together for four years and all along I have been your psychologist.”

She laughingly responded with the following remark:

SHIRLEY: “Really, well that’s a good thing because I like you and perhaps you can help me get a handle on everything.”

After these breakthrough sessions, Shirley showed a reduction in paranoid ideation and a decrease in depression. She formed more positive 144 The Woman Who Believed She had No Heart relationships with some of the staff members, including Nurse Mahoney and Abbey, her neighbor. Abbey began to stop by Shirley’s room frequently to visit. Shirley also showed an increased capacity for self-reflection. Approximately two months after the breakthrough sessions described previously, Shirley reinforced that I was her psychologist and engaged in the following interaction:

SHIRLEY: “Well, you are my shrink, and I’m a bit out of my nut shell. You helped me to get out. I almost died, but you and Mary, the nurse, kept me alive. I almost died you know.” DR. JONES: “I think that you are referring to a psychological death perhaps rather than a physical one.” SHIRLEY: “Well yeah. Staying in the nut shell and not coming out ever is like being dead. I talk about things now and don’t hold them in as much. I am more aware of my surroundings.”

At this point, I suggested to Shirley that she was more aware of herself and she agreed. Klein’s (1946, 1952) concepts of the paranoid-schizoid and the depressive positions helped me to organize and respond to the confusing interactions with this client. I terminated with Shirley about two months later. During the termination process Shirley expressed sadness and anger toward me for leaving her but came to understand why I had to leave and learned to accept it. Unlike other endings in her life, which were typically abrupt and unsuspecting, ours was characterized by mutual respect for each other and an amicable parting of ways rather than a sudden abandonment. A new therapist was assigned to her case, whom Shirley cautiously embraced. Given the toxicity of Green Garden it was hard to predict the long- term prognosis for Shirley. However, in the four years I spent working with her, it appears that growth-promoting interactions with a caring professional—me—and other providers later in her treatment contributed to a positive reintegration on the part of the client (Dabrowski, 1964). After terminating with Shirley, I made several telephone inquiries about her prog-

Downloaded by [New York University] at 12:41 13 August 2016 ress with the Director of Nursing (DON). The DON suggested that while Shirley had suffered several regressions after my departure, with the help of a new caring therapist she was able to reintegrate following each episode. Even when these reintegrated states were short-lived, time spent in the depressive position provided Shirley with the opportunity to freely express her feelings, form more meaningful relationships in Green Garden, and at least begin the process of mourning the loss of her mother as well as lost opportunities in her life. Shirley is likely the byproduct of a mental health system in the U.S. that allows individuals like her to “slip through the cracks” and virtually The Woman Who Believed She had No Heart 145 disappear into a quagmire of institutional settings that are merely storage units for vulnerable mentally ill individuals. These individuals could perhaps be contributing members of society if given therapeutic opportunities that promote rather than diminish psychological growth. In Shirley’s case, from an existential perspective, her ability to have psychotic-free moments when she could embrace the healthy parts of herself and be expressive toward others in meaningful ways suggests progress in her growth as a human being. Recently it was reported that Green Garden was closed following an inspection by state surveyors, who stated that it was not meeting the necessary standards of care to remain licensed. Shirley was transferred to an available bed somewhere else in the state. Shirley’s location is currently unknown, as is her current state of mind.

REFERENCES

Bion, W. R. (1959). Attacks on linking 1. Journal of Psycho-Analysis, 40, 308–315. Bion, W. R. (1961). Experiences in groups. London: Tavistock. Dabrowski, K. (1964). Positive disintegration. New York: Little Brown. Klein, M. (1946). Notes on some schizoid mechanisms. The International Journal of Psychoanalysis, 27, 99–110 Klein, M. (1952). Some theoretical conclusions regarding the emotional life of the infant. The Writings of Melanie Klein, 3, 61–93. Menzies-Lyth, I. (1960). A case in the functioning of social systems as a defense against anxiety: A report on a study of nursing service of a general hospital. Human Relations, 13, 95–121. Menzies-Lyth, I. (1988). Containing anxiety in institutions: Selected essays (Vol. 1). London: Free Association Books. Piaget, J. (1969). The psychology of the child (2nd ed.). New York: Basic Books. Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic change. Journal of Counseling Psychology, 21(2), 95–103. Rychlak, J. F. (1981). Introduction to personality and psychotherapy: A theory-construction approach (2nd ed.). Boston, MA: Houghton Mifflin, Co. Wigren, J. (1994). Narrative completion in the treatment of trauma. Psychotherapy: Theory, Research, Practice, Training, 31(3), 415–423.

NOTE: For works cited from the World Wide Web, the links were accurate at the time of publication. With time, however, they may have changed Downloaded by [New York University] at 12:41 13 August 2016 and might not be accessible in the same way as referenced here. 9 Monster Woman

Dr. Samson has a Ph.D. in social work and is a licensed clinical social worker working at a state hospital. She has a special interest in dialectical behavior therapy (DBT). She tells the story of her work with Frances.

I was assigned to a patient in a state mental hospital with the comment, “Good luck with that one, Dr. Samson, she’s a monster.” Frances was known by mental health professionals in the institution as “the chronic borderline.” This state Hospital had two factions of mental health professionals. One faction, newly trained in dialectical behavior therapy (DBT), believed that a biopsychosocial approach stressing interpersonal interactions was the treatment of choice for individuals diagnosed with borderline personality disorder (BPD)—people with BPD could get better (Linehan, 1993b; Linehan et al., 2006). The second faction believed BPD to be a chronic condition, with symptom management through medications as the only option for these patients who were not going to improve. This faction was prone to stigmatize Frances as a result of her diagnosis, deeming her to be a manipulator who was prone to violence. The DBT therapeutic model is largely based on interaction structures with group, family, and individual components (to be elaborated on later in this case) (Linehan et al., 2006). This program was new to the institution and controversial among the second faction of mental health providers who held stereotypes about people diagnosed with BPD. The literature suggests that borderline personality disorder is a diagnosis Downloaded by [New York University] at 12:41 13 August 2016 notorious for being stigmatized by mental health professionals. According to Clement (2013):

There is evidence which suggests that clinicians regard clients with BPD less favorably than clients with other diagnoses and consider them manipulative, in control of their symptoms and behaviors, not really ill, and resistant to therapy. These prejudices can lead to emotional distancing on the part of the therapist and contribute to poor clinical outcomes. Individuals with BPD are especially sensitive to rejection and Monster Woman 147 may perceive this emotional distancing as abandonment and respond negatively by engaging in self-harm or withdrawing from treatment (p. 1).

Nicknamed “The Monster Woman” by some staff members, Frances was known to shove, push, and even bite staff members when emotionally esca- lated. Most of the incidents of violence were exhibited by Frances when she was forcibly restrained by staff. This short interaction between Frances and staff exemplifies the consequences of implicit and explicit rules being broken within an institution. It also speaks of the intensity of the punishing response by those in power and their inability to compromise or negotiate. The stigmatization and dehumanization of Frances is apparent in the label “monster.” Oxford Dictionary defines a monster as “an imaginary creature that is typically large, ugly, and frightening.” This definition does not appear to be a good psychological platform upon which to start therapy (Oxford Online Dictionary, 2015). The psychologists, social workers, and psychiatrists who were members of the faction who believed BPD could not be treated, grinned sarcastically when they heard that Frances, “The Monster Woman” had been readmit- ted. I overheard one staff member say, “Here we go again.” Frances endured many projections on the unit by mental health professionals and other staff members who perceived BPD to be untreatable. For example, besides being designated “The Monster Woman,” I overheard staff members describe her as “dangerous, manipulative, chronic, hopeless, untreatable, lazy, impulse ridden” and at all costs “to be avoided.” It was evident no one wanted her on their caseload. Even mental health professionals who practiced DBT (already overloaded with cases) could not take on Frances. Snide remarks were frequently made about Frances, frequently within her earshot, and treatment of any kind was deemed to be futile. One nurse was overheard saying that they should “stick her [Frances] in the chronic unit; that’s where somebody that chronic belongs . . . she’s never getting out of here.” As a new social worker hired at the institution, trained in cognitive behavioral approaches with a strong humanistic background, I was quickly assigned to Frances by the unit psychiatrist. I naively accepted Frances, unaware of the

Downloaded by [New York University] at 12:41 13 August 2016 institutional baggage projected onto her by staff. Shortly after starting therapy with her, a colleague overheard a psychiatrist describe the assignment to me as a “patient dump.” I was briefed on Frances by the psychologist who had worked with her during her last hospitalization. The psychologist stated, “The best you can do with Frances is maintenance. By that I mean keep her from hurting herself or anyone else. She’s really one of those “lifers” in terms of being institutionalized. There’s really little future for her. I can tell you she really pulls you for anger, depression, you name it; she manipulates the heck out of you. And she really can be dangerous. She is simply extremely difficult to work with.” 148 Monster Woman The psychologist presented an objectified view of Frances as a “borderline,” not as a person. When I asked him to describe her psychosocial history he could remember little of it. He stated, “I’m not a psychodynamic therapist. I didn’t really focus on how her past influenced who she is in the Here and Now. She’s a borderline. That’s the long and the short of it. Behavioral therapy was the best I could do just to get her to take her meds.” The psychologist reviewed with me concrete and impersonal medical records that indicated that Frances had borderline personality disorder. Medical records indicated:

Frances is a 31-year-old female diagnosed with borderline personality disorder. She was non-voluntarily hospitalized at this mental institution on February 20, 1999 following a suicide attempt. The patient attempted to overdose and was found by a friend who called 911. She has consistently exhibited affective instability, recurrent depression, intermittent bulimic behaviors, unstable interpersonal relationships and impaired impulse control. Her history includes frequent self-injurious/ self-mutilating behavior, 18 suicide attempts, compulsive spending and a history of substance abuse. Frances had over 21 hospitalizations at this State Mental Hospital over the last ten years following suicide attempts. She was first hospitalized at the age of 18. She has endured periods of homelessness. At the time of this hospitalization she has exhausted all city and community resources. Treatment team members believe that there is limited hope of residential placement due to her long history of self-injurious behavior. Family members are unavailable to offer emotional or financial support.

This very objective and ahistorical picture of Frances is indicative of amputating containment, revealed little of her early life experiences, which were characterized by a number of devastating traumatic events. Frances’s traumatic history likely played a major role in shaping her psychological and emotional being and contributed to her current diagnosis. After a brief interview, I obtained historical information that gave me a greater understanding of who Frances was as a person. Frances was adopted into a sibship of five. She knew nothing of her bio-

Downloaded by [New York University] at 12:41 13 August 2016 logical parents since it was a closed adoption. She perceived herself to have been abandoned by her birth parents. She endured severe abuse by her adoptive father, who raped her, beat her, and sodomized her on a regular basis, as well as by a verbally abusive adoptive mother who treated her like “the crazy one that we never should have adopted.” She remembered her father entering the room on a nightly basis. She said, “I thought he was the devil coming into my room to punish me. I believed I deserved to be punished. It wasn’t until I reached 14 when I began to realize I was sexually abused. I simply didn’t know any better. But by then it was too late. I was really depressed, anxious and felt out-of-control.” She was also targeted by two of her older male siblings, who bullied her, calling her “fat,” “ugly,” and Monster Woman 149 “stupid” and at times becoming physically aggressive towards her. Within her family system she was the designated patient (Selvini, Boscolo, Cec- chin, & Prata, 1980). She described herself as feeling “alone” for most of her life. She also stated, “No one ever talked about the abuse. No one ever asked me about it. I felt like I had nowhere to go.” Through grade school and high school she was a loner. Yet she received above average grades, wrote poetry, and learned to play the piano. Judith Herman, in her book Trauma and Recovery: The Aftermath of Violence—From Domestic Abuse to Political Terror (1997), suggests that borderline personality disorder is a form of severe post-traumatic-stress-disorder, but is rarely treated as such (Driessen et al., 2002). In most cases, the stigma associated with the disorder inhibits therapists from treating the trauma. The patient is simply written off as a “chronic borderline.” This viewpoint leaves the patient virtually untreated other than receiving medication management—amputating containment. In many respects, such patients are alone in the world of mental health, paralleling their early histories when they were alone in abusive families. During a debriefing with the last psychologist who worked with Frances, I was warned not to meet alone in a room with her because she was dangerous. When I asked my colleague whether Frances had acted in a violent or hostile way toward him, he simply stated that she was “highly manipulative” and had been verbally aggressive towards him—calling him an “asshole.” He reiterated that she was capable of pushing, hitting, and biting staff, although this had never occurred during his relationship with her. She was frequently put into restraints and given shots to regulate affect. Curi- ously, the last psychologist was unable to identify any strength in Frances as a person. He was unaware of her ability to write poetry or play the piano. He appeared to be nearly oblivious to her abuse history and to the fact that she was adopted. My first encounter with Frances was on the unit. It involved a humorous interaction that in retrospect set the tone for a positive therapeutic relationship. Frances approached me as I stood behind the Nurses’ Station writing notes. She said, “So I heard you are going to be working with me. Are you looking forward to it? By the way, I plan on starving myself this weekend.” Using a communication style known in the dialectical behavior therapy

Downloaded by [New York University] at 12:41 13 August 2016 world as “irreverence,” (Linehan, 1993b; Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006), I said I looked forward to working with her and that a couple of days of not eating would not hurt her. She could stand to lose a few pounds. My intervention caught Frances by surprise. She got a huge grin on her face and asked in an eager tone of voice, “When are we meeting on Monday?” I replied, “Does 9:30 a.m. work for you?” She stated an affirmative, Yes.” “ This began a two-year treatment relationship that proved to be fascinating, rewarding, and at times exhausting. Irreverence from the perspective of DBT is not meant to be invalidating. It is an interaction technique used to get the client’s attention—catch her off guard—shift her emotional response, and ultimately get her to see 150 Monster Woman the situation from a completely different point of view (Miller, Rathus, & Linehan, 2006). Irreverent interventions and reciprocal communication, which is more empathic, are the earmarks of DBT. Dialectical means that two opposites are true at the same time. Thus in DBT there is a need for a balance between irreverent interventions, designed to catch the client off guard—as with Frances—and more reciprocal interventions grounded in validation and acceptance (Robins, Ivanoff, & Linehan, 2001). While the institution continued many interaction dynamics that diminished Frances’s ability to psychologically heal, including a culture of obedience, an environment characterized by the use of projections, and the employment of amputating containment, the DBT program offered an oasis from invalidation. The dialectical behavior therapy (DBT) program had been introduced since Frances’s last hospitalization. Fortunately, I was not only trained in cognitive behavioral and humanistic psychology, but also certified in DBT. I was well aware of the stereotypes many mental health professionals harbor toward individuals diagnosed with borderline, as mentioned earlier, and how these unflattering beliefs frequently sabotage treatment. I was also very aware of Marsha Linehan’s (1993a) and Dominic Markham’s (2003) belief that if you do not believe someone can get better, then do not treat the person. One week into Frances’s hospitalization, I, in collaboration with the kind and insightful psychiatrist, recommended that she enroll in the dialectical behavior therapy program. Treatment goals included improving distress tolerance and emotional regulation skills (Robins et al., 2001). I supported DBT with client-centered techniques. The DBT program offered Frances an environment that was empathic, validating, and humanistic. Highly interaction-based, DBT focuses on interaction dynamics between client and therapist, peers and client, and client, therapist, and family. The program fostered a culture of enquiry, hope, empowerment, and peer support. In essence, DBT was an oasis within the institution, which was largely an empathic desert with respect to the treatment of borderline personality disorder. Frances and I attended DBT group twice per week and engaged in individual therapy three to four times per week. Almost immediately, Frances

Downloaded by [New York University] at 12:41 13 August 2016 appeared to enjoy the peer interaction and intellectual stimulation provided by the DBT group experience. She attended the group regularly and actively participated in all DBT activities. While in the group, she openly shared her thoughts and feelings and showed compassion toward other group members. Besides completing the homework assigned by the group leader, Fran- ces would complete additional DBT homework assignments. Group leaders quickly perceived her to be one of the “stars of the group” and “one of the most motivated group members.” She became friends with several group members and even organized a pizza party for the group. Frances commented on how valuable it was to interact with peers with similar life experiences to hers. She was very engaged in individual therapy as well. Monster Woman 151 Frances stated that she found other therapeutic modalities to be highly judgmental. She responded well to DBT because of the accepting atmosphere, concrete tools, camaraderie, hopeful environment, and emphasis on emotional regulation and distress tolerance (Robins & Rosenthal, 2011). Dialectical behavior therapy was introduced to the hospital by the state’s Director of Mental Health, who was influenced by the research supporting DBT’s effectiveness in the treatment of borderline personality disorder (Linehan, 1993a; Robins & Rosenthal, 2011). The director, who was an advocate for individuals diagnosed with severe mental illness and a member of the National Alliance on Mental Illness (NAMI), believed in a more biopsychosocial model of treatment than was typically embraced by most state institutions. According to Dimeff and Linehan (2001), dialectical behavior therapy is a cognitive behavioral treatment model for difficult-to-treat mental disorders including borderline personality disorder. DBT involves individual, group, and family therapy components and is strongly grounded in interaction interventions. While framed in cognitive-behavior therapy, it also has humanistic elements reflected in such components as mindfulness, unconditional positive regard, and the importance of empathizing with the client. Emphasis is given to four dimensions of treatment: mindfulness, emotional regulation, distress tolerance, and interpersonal relationship building. The individual diagnosed with BPD has not learned how to label emotional arousal, how to tolerate distress, or when to trust his own emotional responses as reflections of valid interpretations of events in the environment. Self-destructive behaviors such as burning and cutting oneself have an affect-regulating quality. They are effective in eliciting helping behaviors from an environment that otherwise ignores efforts to ameliorate intense emotional pain (Klonsky, 2007; Suyemoto, 1998). A central premise of the DBT model is that the individual diagnosed with borderline personality disorder is typically the product of an environment characterized by invalidating interactions. According to Marsha Linehan (1993b):

A defining characteristic of an invalidating environment is the tendency to respond erratically and inappropriately to private experience (e.g., beliefs, thoughts, feelings and sensations), and in particular to be insen-

Downloaded by [New York University] at 12:41 13 August 2016 sitive to private experience that does not have public accompaniments. Invalidating environments also tend to respond in an extreme fashion (i.e., to overreact or under-react to private experience that does not have public accompaniments” (p. 3).

From this perspective, hospital environments frequently contribute to borderline behavioral patterns by invalidating clients (Fruzzetti, Shenk, & Hoffman, 2005; Linehan & Heard, 1992). In one particular case, my ability to “talk Frances down” from an emotionally heightened state following a depersonalizing interaction with a nurse was sabotaged by the invalidating hospital system. The incident started when Frances told a nurse that she did 152 Monster Woman not feel well and was starting to experience overwhelming feelings of loneliness. Frances was seeking the nurse’s attention. She started crying and then sobbing. The nurse responded to the emotional escalation by telling Frances to “shut up” and go to “her room.” Frances responded to the nurse’s invalidating remark by calling her a “bitch” and throwing a glass of water onto the floor. The nurse then threatened to put her in restraints and give her a shot if she did not comply and go to her room. This invalidating response by the nurse led to an even more intense emotional outburst from Frances—she screamed and swore, becoming even more agitated. In accordance with the DBT model, I observed the incident and took Frances into a quiet room to help her emotionally regulate by talking with her about what triggered the outburst. Frances was tearful, angry, and felt demeaned by the nurse, but was gradually emotionally regulating. She put words to her feelings, saying, “The way she [the nurse] looked at me, like I was an animal. She didn’t listen to me. She just threatened me with restraints.” I calmly encouraged her to continue to put words to her feelings and engaged her in a breathing exercise to further help her to regulate. She was calming down. She stopped crying and was processing her feelings (Greenberg, 2004). However, in accordance with institutional procedures, the psychiatric nurse had already activated the “restraint team,” who surrounded us like a posse in the quiet room. Two of the four uniformed security officers present ordered Frances to “Get on the stretcher now!” Frances was terrified and started to run. She was thrown onto the stretcher, put in full leather restraints, and immediately given a shot. One of the officers commented, “That woman is a wild one, really out of control.” The officer, like the institution, was oblivious to her role in perpetuating the borderline behavior pattern demonstrated here (Liggins & Hatcher, 2005). The hospital staff had succeeded in producing a reenactment of how Frances must have felt when she was cornered by an abusive adoptive father who physically raped and abused her numerous times. Rather than allowing her to self-regulate, which she was well on her way to doing during our one-on-one session, the institution hijacked the therapeutic interaction and imposed power over Frances in a toxic way, thwarting the possibility of using the situation as a growth-promoting interaction.

Downloaded by [New York University] at 12:41 13 August 2016 The DBT community was not understood by many of the professional staff. An us versus them dynamic developed. The “us” designation was attributed to the hospital staff who “knew” the “truth” about borderline personality disorder but understood little about DBT, which at the time was a relatively new therapeutic modality. Borderline personality disorder was labeled as untreatable at this institution and the patients were labeled as highly manipulative and not trustworthy. The DBT supporters, of whom I was one (designated “us”), believed that people with borderline personality disorder could be treated and could have a life worth living (Linehan, Goodstein, Nielsen, & Chiles, 1983). The Monster Woman 153 “them” group believed that individuals with borderline personality were a “chronic and dangerous” group of patients who were manipulative and untreatable. The progress that Frances and other patients made in Dialecti- cal Behavior Therapy was pathologized by some psychiatrists (in the “them” group) as a symptom of borderline personality disorder—patients’ manipulation of the DBT therapy team members to better get their needs met. One psychiatrist commented on Frances’s increased capacity to “charm” her therapist into believing that she was improving when she was really capable of becoming a “monster” at any time. This same psychiatrist viewed any positive interpersonal behavior by Frances as manipulation. Yet, despite resistance to the program, dialectical behavior therapy has been statistically proven to work. In controlled treatment trials, DBT has reduced anger, suicide attempts, para-suicidal acts, and the number of days spent in psychiatric hospitals (Stanley, Brodsky, Nelson, & Dulit, 2007). Overall treatment improved social adjustment, treatment compliance, and dropout rate among those individuals participating in the studies (Linehan, et al., 1991; Linehan, 1993b). DBT helped Frances, as well as numerous other clients in the institution. Even with exposure to toxic interactions as described above, Frances made therapeutic progress. In several ways the Dialectical Therapy Program (DBT) within the state hospital where she was being treated mirrored a therapeutic community similar to the Open Dialogues Program (Seikkula & Olson, 2003). The DBT program allowed for the exploration of interpersonal dynamics and their psychological impact. DBT involved the 24-hour availability of individual therapists trained in DBT, regular group work, and intense individual therapy. Additionally, members of the dialectical behavior therapy team met as a group to reflect on group work, individual therapy, and personal interactions toward their therapy with clients and family members. This approach to treatment greatly contrasted with the larger hospital treatment dynamic (Palmer, 2002). DBT group and individual therapy helped Frances to improve her ability to reflect on and regulate her behavior. Moreover, she regularly consulted with me on how to apply DBT skills to cope more effectively with a given situation. For example, after getting into an intense argument with another patient over what Frances viewed as an invasion of her private

Downloaded by [New York University] at 12:41 13 August 2016 space—Frances perceived the other patient to be standing “too close” to her in the medication line—Frances completed a behavior analysis that reviewed all of the events leading up to the outburst, which was reviewed in individual therapy. She reported gaining insight into her actions and greater mastery of the application of DBT interpersonal and emotional regulation skills through this analysis. Over the span of 12 months of group and individual therapy utilizing the model, Frances markedly improved in her ability to use the DBT core skills of mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance. In fact, DBT skills helped her to negotiate a discharge 154 Monster Woman out of the institution to a friend’s house. Prior to discharge, Frances showed improved interpersonal organizational skills as evidenced in her ability to independently coordinate important aspects of her discharge plan, including obtaining the aforementioned housing option. When faced with potentially conflictual interactions with patients or staff members on the unit, Frances was now able to avoid destructive emotional outbursts by meditating, listening to music, or taking time outs. Frances was also more capable of delaying gratification and satisfying her needs through compromise solutions. For example, Frances agreed to take a medication she had previously rejected for a three-week trial period. Also, she showed a willingness to wait to meet with her social worker rather than demanding immediate attention. Frances, a woman who before treatment had been chronically tired and poorly groomed, who expressed hopelessness about the future and a lack of direction, improved. I saw her lose weight, improve her hygiene, and demonstrate an increased capacity to act on her own behalf. Her sense of hopelessness about the future was replaced with personal goals, including a desire to be discharged, form an intimate relationship, and go back to school. The increased strength in her tone of voice, the clarity of her thoughts, and an emergence of a sense of humor suggested an enhanced sense of self-integration and less fragmentation (Kohut & Wolf, 1978). Eight days after her self-negotiated discharge, she showed insight into her psychological state when she sought voluntary readmission to the hospital to avoid self-harming. This readmission stands in stark contrast to other hospital stays that were precipitated by suicide attempts or suicidal gestures and were not voluntary. Frances credited the interaction skills she had learned in DBT individual and group therapy with helping her avoid harming herself or someone else when faced with emotionally difficult situations—family conflict and the loss of a close friend—while out of the hospital. In individual therapy, Frances was able to reflect on the faults in her self-designed discharge plan. She had shown the capacity to compromise and an awareness of her limitations through her willingness to accept a structured group home rather than an independent living situation. Moreover, she communicated a continued commitment to perfecting her DBT skills through group and individual therapy (Swenson, Sanderson, Dulit, & Linehan, 2001). Within

Downloaded by [New York University] at 12:41 13 August 2016 six months, Frances was discharged to a group home. Years after being out of contact with Frances, I think about my interactions with her. Despite the struggle for DBT to gain support with the institution, Frances did well. I saw her as a remarkable person who was able to survive within an often unforgiving mental health system and in spite of an early history of intense abuse. Frances ultimately did gain discharge into the larger community. My hope is that she is living a life worth living. In terms of countertransference, I recognize that my advocacy and belief in recovery could inadvertently lead me to overlook real client weaknesses that were the result of severe psychopathology. This tendency to under-pathologize a patient—if not attended to in peer supervision—can Monster Woman 155 lead to grave consequences for the client and/or the community. Peer supervision is important (Coster & Schwebel, 1997). A balance must be achieved to treat clients like Frances effectively—this balance involves the recognition that psychopathology does exist in the person, but the person is not the psychopathology (Overton & Medina, 2008). Growth-promoting interactions that validate the person and seek to build skills and ultimately diminish the psychopathology are critical if mental health is to be established. Too often, therapists and mental health institutions split off their own psychopathological parts and place them in individuals who are designated by the system to be “borderlines” or “psychotics.” The underlying pattern of psychopathology contained in the individual is maintained by a pattern of invalidating interactions with the designated patient. Insight into these patterns of interaction by mental health professionals and institutions is needed to facilitate positive therapeutic change. I am reminded of Mary Shelley’s Frankenstein (1818). In this brilliant novel, Dr. Victor Frankenstein creates his own monster and maintains the monster’s horrific acts towards himself largely by way of his invalidating interactions toward the monster. The monster—initially a pure soul—develops a terrifying behavior pattern largely in response to an environment that depersonalizes and invalidates him. All the monster really wants is unconditional positive regard—love. Perhaps, as mental health professionals, revisiting this novel from time to time might remind us to think about how our own actions impact on those whom we treat. Are we interacting in ways that promote psychological health or in ways that make patients into monsters? C.G. Jung (1959) highlights the notion of the shadow. The shadow can be perceived as those dark parts of the self that we push into the unconscious or deny—greed, murderous rage, hatred, selfishness, sickness, psychosis, etc. Mental health professionals, who are in positions of power (Hopcke, 1992) over vulnerable populations (like severely mentally ill individuals), risk projecting shadow aspects of themselves onto their patients. We then perceive ourselves to be the “healthy ones,” while those who we project onto become the “mentally ill.”

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Clement, T. (2013, May 13). Stigma in a clinical setting for clients with borderline personality disorder. Retrieved from http://www.scattergoodfoundation.org/ activity/general/stigma-clinical-setting-clients-borderline-personality-disorder#. VHJcJGTF_DI Coster, J. S., & Schwebel, M. (1997). Well-functioning in professional psychologists. Professional Psychology: Research and Practice, 28(1), 5–13. Dimeff, L., & Linehan, M. M. (2001). Dialectical behavior therapy in a nutshell. The California Psychologist, 34, 10–13. Driessen, M., Beblo, T., Reddemann, L., Rau, H., Lange, W., Silva, A., & Ratzka, S. (2002). Is the borderline personality disorder a complex post-traumatic stress disorder? The state of research. Der Nervenarzt, 73(9), 820–829. 156 Monster Woman Fruzzetti, A. E., Shenk, C., & Hoffman, P. D. (2005). Family interaction and the development of borderline personality disorder: A transactional model. Develop- ment and Psychopathology, 17(04), 1007–1030. Greenberg, L. S. (2004). Emotion–focused therapy. Clinical Psychology & Psycho- therapy, 11(1), 3–16. Herman, J. (1997). Trauma and recovery: The aftermath of violence—from domestic abuse to political terror. New York: Basic Books. Hopcke, R. (1992). A guided tour of the collected works of C. G. Jung. Boston, MA: Shambhala Publication. Jung, C. G. (1959). The principal archetypes. In D. Richter (Ed.), The critical tra- dition: Classic texts and contemporary trends (pp. 666–676). Boston: Beford/ St. Martins. Klonsky, E. D. (2007). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology Review, 27(2), 226–239. Kohut, H., & Wolf, E. S. (1978). The disorders of the self and their treatment: An outline. International Journal of Psychoanalysis, 59(4), 413–425. Liggins, J., & Hatcher, S. (2005). Stigma toward the mentally ill in the general hospital: A qualitative study. General Hospital Psychiatry, 27(5), 359–364. Linehan, M. M. (1993a). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. Linehan, M. M. (1993b). Skills training manual for borderline personality disorder. New York: Guilford Press. Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive behavioral treatment of chronically parasucidal borderline patients. Archives of general psychiatry, 48(12), 160–164. Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., & Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63(7), 757–766. Linehan, M. M., Goodstein, J. L., Nielsen, S. L., & Chiles, J. A. (1983). Reasons for staying alive when you are thinking of killing yourself: The reasons for living inventory. Journal of Consulting and Clinical Psychology, 51(2), 276–286. Linehan, M. M., & Heard, H. L. (1992). Dialectical behavior therapy for borderline personality disorder. In J. F. Clarkin, E. Marziali, & H. Munroe-Blum (Eds.), Bor- derline personality disorder: Clinical and empirical perspectives (pp. 248–267). New York: Guilford Press. Lynch, T. R., Chapman, A. L., Rosenthal, M. Z., Kuo, J. R., & Linehan, M. M. (2006). Mechanisms of change in dialectical behavior therapy: Theoretical and empirical observations. Journal of Clinical Psychology, 62(4), 459–480. Markham, D. (2003). Attitudes towards patients with a diagnosis of borderline personality disorder: social rejection and dangerousness. Journal of Mental Health, 12(6), 595–612. Downloaded by [New York University] at 12:41 13 August 2016 Miller, A. L., Rathus, J. H., & Linehan, M. M. (2006). Dialectical behavior therapy with suicidal adolescents. New York: Guilford Press. Monster. (2015). In Oxford’s online dictionary. 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Dr. York is a Board Certified Clinical Psychologist specializing in the geriatric population and end of life care. He presents the case of Rose.

Rose was a powerful woman whose grief and transformation in her final years was a moving event for the community in a nursing home. When I first met Rose, I was stunned by her appearance. She was an 89-year-old woman whose hair and makeup were perfect. She wore an ele- gant hat, large crystal earrings, and a form-fitting gold lamé print pantsuit. Her southern accent accentuated her perception of herself as a Southern belle. Originally from Georgia, Rose considered herself to be perfectly cast for Gone with the Wind in the role of Scarlett O’Hara. In her younger years, she was a photographer and a model. She also sang professionally and did impersonations of Marilyn Monroe. Her husband was a World War II hero who swept Rose off her feet at the young age of 16. Rose describes meeting Willy as love at first sight. She stated:

The moment I saw that man, I knew I was going to marry him. I looked back after walking by him in front of that grocery store, paused for a moment and then walked towards him. I looked straight into those gorgeous dark eyes and said, “Honey . . . I’m going to be your wife.” The rest, my dear [she said to me] is history.

Downloaded by [New York University] at 12:41 13 August 2016 Rose was, in fact, a self-proclaimed diva who sang with gusto. She was a great presence on and off the stage. She liked to think of herself as a professional performer, having won first place in the facility’s talent show at the age of 88 for her rendition of Marilyn Monroe’s “Happy Birthday Mr. Presi- dent.” Other residents supported her desired identity by showing admiration for her fortitude and talent, contributing to the self-confidence she radiated. She seemed to thrive on mirroring and idealization from peers and others, a need possibly unmet in childhood (Kohut & Wolf, 1978). There was also a narcissistic quality to Rose’s personality. However, Rose was reluctant to talk about the quality of her childhood and little was recorded in the chart. The Woman Who Never Mourned 159 While narcissism is a healthy developmental trait in individuals, the intensity of Rose’s self-absorption suggests that she may have been depleted of mirroring and idealizing experiences in childhood. Such individual’s may develop psychological defenses aimed at reducing negative self-related feelings by creating an exhibitionistic and unstable facade of grandiosity and success. Such people become preoccupied with fantasies of perfection and power and tend to exaggerate their achievements and talents. They work to avoid situations and people who challenge their defenses and threaten to shatter their sense of pseudo-grandiosity (Kohut, 1971). When you were with Rose, it was as if the world revolved around her. Her life was a stage and Rose was a one-woman show. I was struck by the fact that, while in terms of physical age Rose was 89, she presented through her mannerisms, dress and language as if she were much younger. Tobin (1999) describes the phenomenon of the extremely old individual seeing herself as a relatively young person as a part of healthy aging in many elderly adults. Tamara McClintock Greenberg (2009) in her book Psychodynamic Per- spectives on Aging and Illness talks about functional narcissism in the aging person. For example, in the case of Rose, for years she relied on her external appearance for the attention and privilege that it allowed. Her natural beauty drew the attention of men and the envy of women. From this perspective, focusing on her looks, as an octogenarian, allowed her to avoid dealing with an inner sense of emptiness and the painful feelings (sadness and loneliness) associated with deterioration and loss. Rose was placed at the facility after a fall that precipitated a hip injury. She could no longer live without assistance and required 24-hour care. As the psychologist, I was assigned by the Social Services Department to work with a person who appeared to be very engaging. In an initial intake interview, Rose was articulate and goal-directed. She demonstrated good long-term and short-term memory. While her gross motor movement was compromised and she needed the use of a walker due to her hip injury, she got around well enough and demonstrated adequate fine motor movement. Psychological testing showed that she had average intelligence. Rose described herself as being a good student and a high school graduate who later went to photography school. Rose and her husband ran a successful photography business for 40 years. She added that her eye for detail

Downloaded by [New York University] at 12:41 13 August 2016 “got my Willy [her husband] the jobs.” She denied any history of suicidal or homicidal ideation, but acknowledged a history of depression with psychotic symptoms. Asked to elaborate on this history, she simply said, “I got over things.” When questioned about the psychotic symptoms she said, “I ignored the voice and got over it too.” At the time of the initial interview, she stated that she was “happy to be alive.” She had had a successful career, three beautiful children, and “the man of my dreams.” She spoke fondly of all three of her children, one of whom—her youngest daughter, Maria—lived in town and visited her frequently. Sam, her younger son, was out of town but had regular telephone contact with her. 160 The Woman Who Never Mourned During the interview I asked Rose about Eddie, her oldest son. I said, “What happened to Eddie?” “Eddie,” she paused and whispered, “disappeared.” Her expression instantly changed from gaiety to despair. Her voice shifted from expressive to monotone. Her eyes teared up and there was nothing but a pregnant silence in the room. I was left speechless, and profoundly sad. Later, I interpreted my speechless, sad state to be a manifestation of projective identification. I was containing for Rose unspeakable feelings, most likely related to what happened to her oldest son. These feelings included anxiety, intense sadness, and hopelessness (Racker, 2012; Sun- derland, 2001). When pressed more, she indicated that she did not want to talk about her son and that everything was in the past. She reported that, “Life is good and that I feel great.” I was struck by the sudden shift in her affective state to from sadness to joy. In retrospect, Rose’s perspective of seeing the world as good was a reaction formation most likely in response to the deeply repressed painful emotional states she harbored. A reaction formation occurs when an individual suppresses a painful emotional state and in its place expresses the opposite state—in this case sadness is replaced by joy (Freud, 1957). She quickly shifted the discussion to what activities she could engage in at the facility that day. Yet, it soon became apparent that behind Rose’s impressive self-presentation, Eddie’s disappearance played a significant role in her psychological and physical well-being. While the effect of his disappearance on Rose’s psyche was dismissed in the 1960s by the mental health system, the impact of this event was acknowledged in psychotherapy in 2005 and ultimately played a significant role in Rose’s sense of integrity and fulfillment in the last year of her life (Tobin, 1999). Rose exhibited two characteristics identified by Tobin (1999) as functions of healthy aging in extreme old age: functional aggressiveness and functional paranoia. Aggressiveness is a function of attempting to gain a sense of control over one’s environment when faced with change such as relocation to a nursing home and/or the loss of functioning due to limited mobility and increased reliance on others. Tobin (1999) found that those who were “more aggressive, even nasty, were more likely to survive intact after relocation” (p. 13).

Downloaded by [New York University] at 12:41 13 August 2016 Concurrently, functional paranoia is evidenced by “distrust, suspicious- ness, and blaming others” in one’s environment (Tobin, 1999, p. 14). This paranoia in the elderly person is functional, reducing the elderly person’s sense of vulnerability. Tobin states, “It is better to blame others than oneself and become depressed” (1999, p. 14). It is not uncommon for an older person living in an institution to blame staff or another resident for taking an object he may have in fact misplaced, as a way of avoiding acknowledging memory loss or other infirmities. Rose could be demanding and at times blamed others for stealing objects she found missing. Staff members did not perceive these tendencies as being functional, as suggested by Tobin (1999). They interpreted her demands—her The Woman Who Never Mourned 161 incessant need for assistance when toileting and her daily desire to have her hair and makeup done—as a sign of “borderline tendencies” (Lester, 2013). It is interesting to note that this behavior that would be perceived as a sign of good hygiene outside of the institutional setting was interpreted as evidence for psychopathology in the institution. Also, staff used Rose’s overt expression of justifiable anger when her needs were not met in a timely fashion to further substantiate their view of her as a “borderline-like” person. In one instance, Rose confronted a nurse whom she believed had given her the wrong dos- age of medication. Rather than investigating the claim and acknowledging the mistake—if it had in fact occurred—the nurse went into a rage, depersonalizing Rose by calling her a “crazy woman” and mumbling “bitch” under her breath. Lester (2013) posits an interesting position on borderline personality disorder/traits that may be applicable to Rose. She points out that BPD is largely diagnosed in women. While typically the traits of BPD (demanding- ness, mood swings, splitting, rage, etc.) are pathologized, from a different vantage point she suggests that they could “indicate enormous resilience, adaptation, creativity, and a struggle to survive environments that have been invalidating, abusive or erasing” (p. 72). Given that many women deal with demeaning situations characterized by abuse, neglect, poverty, sexism, age- ism, etc., her hypothesis seems plausible. In Rose’s case, institutionalization and the aging process itself could be viewed as invaliding, and certainly staff’s treatment of her in some cases exemplifies this. Her display of “borderline traits” may have been her only way to adapt to an otherwise emotionally destructive and intolerable environment. Another behavior exhibited by Rose that was annoying to staff was her tendency to blame others, such as staff and residents, for objects missing in her room. The accused person, usually a staff member, would become highly defensive towards Rose in response to the accusations. Rather than looking at these behaviors from a functional point of view, given Rose’s advanced age (Greenberg, 2009; Tobin, 1999), staff would fail to empathize with her and ultimately pathologize her more. Rose became the object of many negative projections and was seen as a “liar, instigator and overall obnoxious patient” by staff. These projections contributed to the depersonalization and dehumanization of her. The emphasis on the so-called “acting out behaviors” in the Here and Now

Downloaded by [New York University] at 12:41 13 August 2016 inhibited the development of a culture of enquiry, further distancing the staff and Rose from her history of traumatic loss. Maintaining Rose as a compliant and quiet resident, rather than dealing with her feelings and behaviors, seemed to be the staff’s way of managing her. Another way to facilitate this more passive demeanor in an otherwise outspoken and assertive individual was through amputating containment—increasing sedative medications or keeping Rose isolated in her room. Furthermore, staff often threatened to hospitalize Rose or relo- cate her to another facility, both forms of punishment, for blaming others for stealing objects or otherwise acting out inappropriately. This was an ever-present threat (Haney, Banks, & Zimbardo, 1973; Rosenhan, 1973). 162 The Woman Who Never Mourned While a few staff members tolerated Rose’s personality, most did not. One nurse, whom we shall call Nurse A, in particular exhibited an extremely toxic reaction towards Rose, treating her disrespectfully and frequently dehumanizing and humiliating her. This nurse labeled her as a “bitch” and a “borderline” and described her as being “too mean to die.” She was overheard telling a staff member, “God didn’t want her . . . and neither did the devil . . . that’s why she won’t die.” One interpretation of the remarks made by Nurse A towards Rose is that they were a projection of the nurse’s own insecurities onto the resident [Rose]. It was the nurse, not Rose, who might have felt like a “bitch,” “borderline,” and “too mean to die.” Perhaps by projecting these thoughts, feelings, and fantasies onto Rose, Nurse A was able to rid herself of painful self-perceptions and feelings of low self-esteem that she may have harbored about herself. Additionally, the process of projecting negative ideation onto Rose further facilitated the process of depersonalizing her. Additionally, the nurse’s tendency to negate the aging Rose may have been a way of avoiding dealing with issues of her own mortality. Robert Kastenbaum (2000), in his book The Psychology of Death, briefly talks about the difficulty many mental health professionals have had dealing with the topic of death. Another toxic interaction between Nurse A and Rose occurred one day during afternoon medication pass. Rose was in the line to receive her medication and unexpectedly received a phone call from her daughter. She asked Nurse A if she could take her medications before speaking with her daughter. Nurse A erupted with rage, stating that getting medications out of queue was unacceptable and she would have to wait like everyone else. Nurse A mumbled negative comments about Rose under her breath, at one time mumbling, “I can’t stand that woman . . . she’s an idiot.” The small group of residents who witnessed this event and overheard her remarks went silent. The incident could have easily vicariously traumatized any one of the other residents and most certainly was counter-therapeutic. Rose missed the phone call from her daughter. Nurse A withheld a positive experience from Rose, thus punishing her. Though management addressed this incident with Nurse A, she remained employed by the nursing home because of her “overall efficiency.” Nurse A also made negative facial expressions during medication pass towards Rose and others. The contempt exemplified by Nurse A in these

Downloaded by [New York University] at 12:41 13 August 2016 behaviors further facilitated the process of dehumanization in Rose and others. Nurse A’s failure to empathize with Rose did not help facilitate a sense of dignity in her and greatly diminished the possibility for the creation of a culture of enquiry (Kastenbaum, 2000). During these interactions one might imagine Nurse A thinking:

I don’t need to deal with her feelings. She needs to sit down, shut up, and follow the program. You know what? I think I’ll just have her put to bed. That way I won’t have to deal with her complaining or need- iness. I just don’t need to deal with her manipulative behavior on my The Woman Who Never Mourned 163 shift. I need to get rid of her. I will just have the CNA [certified nursing assistant] put her to bed and be done with the bitch.

In this hypothetical internal interaction dynamic, Nurse A depersonalizes and alienates Rose and then acts in a way that attempts to amputate Rose’s emotional state. There is no consideration that Rose just needs Nurse A to listen to her for a few minutes. There is a complete absence of empathy towards Rose, which might validate her humanness. Being “put to bed” is symbolically a way of amputating her feeling state, amputating containment, and generally resulted in a magnification of painful emotions rather than a reduction in them. After being “put to bed,” Rose could be heard screaming for help from her room rather than in front of the nurses’ station, with the underlying reason for her distress being ignored. Later interactions with Rose revealed that she had had similar toxic interactions with staff members at different long-term care settings. It seems that her assertiveness and portrayal of a strong personality were deemed problematic. Staff in long-term care facilities may face demanding clients like Rose, whose behavior can be defiant and at times very difficult to manage. But frequently the adaptive nature of these behaviors gets overlooked. Assertive or even defiant behaviors in elderly adults may be a defensive response to the harsh reality of being institutionalization, loss of functioning, and acceptance of their own mortality (Greenberg, 2009; Tobin, 1999). Many staff members working at long-term care settings prefer to treat compliant, quiet patients, rather than individuals who show assertiveness and self-determination. In some extreme instances, those clients deemed as problematic can be over-medicated to control behavior. Several CNAs also treated Rose with disrespect. As an assertive 89-year- old, Rose was set up to endure many negative projections on the part of staff members, including the CNAs. Rather than identifying her as a unique individual, with assertive tendencies and some healthy aggressiveness, several CNAs identified Rose as a demanding older resident whose sense of individuality needed to be curbed. This perception of Rose was promoted and reinforced by Nurse A’s treatment of her. Rose’s depersonalization relates to Goffman’s (1961) notion of how orga- nizations can systematically strip a person of her identity. The institutional

Downloaded by [New York University] at 12:41 13 August 2016 framework cannot tolerate a person being a subject rather than an object, and punishes the person while trying to strip away the “excess” part of her personality—such as her heart—that extends beyond the role assigned to the person by the institution. “Excess personhood,” being beyond one’s institutional role or being too much like a person, cannot be tolerated. Curbing Rose’s individuality and independent spirit was facilitated through degrading interactions with staff, including greatly delaying her requests for assistance in bathing or toileting. At times, Rose appeared to be punished for expressing her needs openly. On one occasion, Rose asked a CNA to purchase a Cherry Coke for her and provided the staff member with 164 The Woman Who Never Mourned the money to make the purchase. This request was delayed for hours for no overt reason. They caused much discomfort for Rose, who felt abandoned. Few staff members, including social workers or psychiatrists, took the time to understand the unique and painful history of a woman who was still psychologically growing as she approached her nineties despite a profound loss—a loss that for decades had remained unspoken: the loss of her son, Eddie. There was, however, another important antidote to the toxic interactions with the staff—Rose’s membership in the larger therapeutic community. A valuable component of this community—including a caring social service worker, psychology graduate students, and the psychologist—was her membership in a Tavistock group. This larger community served as a safe holding environment in which Rose could feel free to express herself. The Tavistock group, which met twice weekly, was an important component of the holding environment and is described earlier in Chapter One and elaborated on in Chapter 12. It allowed residents to voice their thoughts, feelings, and fantasies in an environment characterized by empathy, congruence, and unconditional positive regard. Participants in this group embraced Rose’s personality and life experiences and served to jump-start the mourning of her deceased son, which had been in a state of suspended animation for over 50 years. In the group, Rose received peer support and hope. Through this group, other residents became friends with Rose and validated her for her wisdom, holding her in high esteem as a “wise elder.” This identity of the “wise elder” was one that Rose found particularly beneficial, serving to reinforce a desired identity. She appeared to benefit from the group’s tendency to treat her as an idealized object, and the members seemed to benefit from having her to idealize. Perhaps this observation of group behavior is reflective of some early self-object deficit in her and other group members’ histories unknown to this writer (Kohut & Wolf, 1978). A great deal of Rose’s psychological healing appeared to be the result of therapeutic interactions that took place between her and other residents. Many of the healing relationships with peers were formed through their participation in the group. Rose developed close friendships to help counteract the toxicity present in many of her interactions with staff. Through these relationships and the members’ openness to hear each other’s stories in a nonjudgmental way, Rose was able to commence the grieving process

Downloaded by [New York University] at 12:41 13 August 2016 and tell the painful story of the loss of her beloved son, Eddie. The group, in a sense, provided Rose with the emotional scaffolding for her to mourn in a safe environment—one which prevented her from emotionally imploding— emotionally collapsing as a result of her grief. The Tavistock group was focused on building self-esteem and relationships and had been ongoing in the facility for many years. The utility of the group in building self-esteem and reducing depression and anxiety, as well as increasing self-efficacy and group cohesion, is documented in Group Therapy for Adults with Severe Mental Illness: Adapting the Tavistock Method (Semmelhack, Ende, & Hazell, 2013). Rose was a member of this Tavistock group from when she was first admitted to the facility. The Woman Who Never Mourned 165 Group members, including graduate student observers in their mid to late twenties, showed admiration and respect for a woman who appeared to have lived a fairy-tale existence into her late eighties However, shortly into treatment, during a Tavistock-style processing group, Rose opened up about part of her life that was a nightmare rather than a fairy tale. As she told the story, the persona of the perception of a perfect life dis- solved. Instead, a life marred by tragedy, depression, and stigmatization quickly surfaced. It was during a group focused on loss that the tragedy was revealed. Members of the group were sharing experiences of lost childhoods, parents and siblings who had passed away, and losses due to disease and mental illness, when suddenly and unexpectedly, Rose spoke. It was like the group flashbacked five decades. She slowly and deliberately spoke of her oldest son, Eddie. Group members—including me—knew that he was deceased; however, the circumstances of his death remained elusive. Then, in a period of 20 minutes, during which time stood still, Rose told the story. She began:

We were vacationing in Minnesota and camping in the North Woods not far from Lake Superior. Maria and Sam were three and seven. Eddie was just one day away from turning 13. We had been camping and everyone was having so much fun. The next day we planned to cele- brate Eddie’s birthday and then drive back to Atlanta. It was the end of the summer and school was starting in one week. That day before he turned 13, Eddie begged to go on a canoe trip with a local guide. He wanted to do something independent. After all, he was going to be a teenager. I felt very reluctant to allow him to go, but after a family discussion with Willy [her husband] I gave in. We set certain parameters: the guide was to stay near the shoreline of the lake, and the tour was to last only an hour, so Eddie would be back for lunch. Eddie was so excited to go. He was elated as the guide arrived at our campsite to pick him up. We waved good-bye and went on with our regular morning campsite routine. Around 12:30 p.m., it struck Willy and me that Eddie wasn’t back yet. We waited another half hour, and still another hour. I started to feel panicked. This was well before the

Downloaded by [New York University] at 12:41 13 August 2016 age of computers or cell phones. We drove to the nearest ranger station and explained the situation. A search team promptly left to find my Eddie. Three hours passed with no word. Then a ranger on horseback approached our camp. I immediately experienced a feeling of dread and felt myself almost leave my body as I heard the words from the mouth of the park ranger: “Mr. and Mrs. Carpo, we believe your son drowned in a canoeing accident. The guide and your son appear to have hit a squall in the lake which capsized the boat catching both the guide and my son in the undertow. All we have found so far is an overturned canoe and two life jackets. There is simply no sign of your son or the guide. Of course, we will continue to search but this is an extremely deep lake, and it is 166 The Woman Who Never Mourned our belief that your son may have drowned.” I screamed, cried, I was out of control. I couldn’t believe my baby Eddie was gone. A day and a half later there was no sign of Eddie. The Rangers told my husband to “Take your wife home. There is not anything else that can be done.” It was 1962; there simply wasn’t the technology we have today. From that day forward my life was never the same. I never recovered from the loss of Eddie. I blamed myself for letting him go and was overwhelmed by grief and guilt.

Rose cried softly at the end of her story. Other group members tried to comfort her and they cried too. It was as if we were back in 1962 and this traumatic event had reoccurred during group therapy. The group, along with Rose, was grieving the loss. During this session it became apparent that beneath the perfect makeup, hair, nails, and gold lamé pantsuit was a woman with a broken heart. Her angry outbursts and demanding personality masked a deep wound that had never really been addressed. Rose’s health had been deteriorating in the weeks prior to this session. The jolt of a medical diagnosis may have prompted her to turn inward and to relate to others in a very genuine way by telling her story (Greenberg, 2009). Later, the content of individual therapy sessions confirmed that Rose had become profoundly depressed and psychotic after the disappearance of Eddie. Electroconvulsive therapy (ECT) treatments and repeated hospitalizations could not take away a “pain that was so deep it could not be described. It stabbed me in the heart . . . I was lost.” Psychiatrists in the 1960s told her to move on and to forget about Eddie. She was merely told to amputate a traumatic experience that should not have been ignored. Even today, psychiatry appears to have pathologized what might be considered normal grief in the DSM 5 (Frances, 2012; Rando et al., 2012). As time went on, Rose’s depression became split off from the tragedy, and she was treated simply as a woman with severe depression, with periodic psychotic symptoms. Further enquiry into the nature of the psychotic symptoms revealed that she would at times hear Eddie’s voice calling out to her. Mental health professionals in the 1960s and later in her psychiatric treatment had failed to enquire about the nature of the voice or her loss. The

Downloaded by [New York University] at 12:41 13 August 2016 grieving process, as described by Kubler-Ross, Kessler, & Shriver (2014), was aborted. But like a soldier whose leg is amputated in battle, Rose continued to experience “phantom pains” in the amputated limb because the unfinished business of mourning her son Eddie had been blocked (Brown & Stoudemire, 1983). For years Rose suffered in silence, developing a host of somatic symptoms—ulcers, gastric problems, etc.—that are reflective of unresolved grief (Parkes, 1964). She hid her agony behind her glamorous persona. She stated, “I had no support, Eddie was gone, I just repressed everything.” Rose went on to say the only thing that kept her living was her need to mother her two remaining children. However, after the loss of Eddie, “I was The Woman Who Never Mourned 167 a greatly compromised person. I was constantly told to get over it. But how do you get over losing a part of yourself and never seeing the body of your son again?” It became clear that Rose, from a Freudian perspective (1917), was melancholic. Her mourning process had been stunted and she was locked in a state of despair. She compensated for the loss with the “diva” appearance, but underneath the persona was severe pain. The amputated mourning process was at least partly due to a mental health system ill equipped to facilitate her healing. The psychiatrists, social workers, and other mental health professionals had simply told Rose to get over it and “take a pill,” or they tried to shock the feelings away with ECT. “She had other children to mother,” was a statement made by a psychiatrist shortly after Eddie’s disappearance that contributed to her profound guilt as she felt ill equipped to mother due to her broken heart. In individual therapy sessions, Rose revealed that this secret had remained in suspended animation. But in the current environment characterized by empathy, unconditional positive regard, and congruence she felt safe to talk about the tragedy again. Rose trusted me and felt safe to share her story. Rose told the story of Eddie’s disappearance many times in group therapy sessions and in individual therapy. Each time, new details emerged. Fellow residents consoled her and many spoke of similar losses; gradually, Rose appeared to improve. More than 50 years after Eddie’s loss, she appeared able to grieve the loss and move on to what Kubler-Ross, Kessler, & Shriver (2014) deemed to be the acceptance stage. Evidence for improvement included her capacity to openly acknowledge the devastating impact Eddie’s loss had on her life. She was able to talk openly and express her feelings about its catastrophic impact. Her feelings were validated by friends, students, and some mental health professionals. Rose acknowledged at one point having made peace with Eddie’s loss (Kubler-Ross, Kessler, & Shriver, 2014). Especially validating to Rose was her ability to communicate the impact of the loss of a child to peers, others who had also lost a child (Klass, 1988). Rose acknowledged not feeling alone, and this eased her pain. Additionally, her daughter Maria, who was three at the time of the Eddie’s death, engaged in a family intervention with her mother in which the impact of the loss on the family system was acknowledged. Maria, who

Downloaded by [New York University] at 12:41 13 August 2016 was to o young to completely understand what had happened at the time of Eddie’s disappearance, cried and acknowledged how much she missed never having really known her older brother. Rose told her daughter the story of what happened on the day of the disappearance and subsequent days following the incident. Maria had longed to know these details for many years, but a code of silence had kept this information secret which is a common occurrence in families. (Bowen, 1978; Hinshaw, 2005; Karpel, 1980). She embraced her mother, now better understanding the trigger for her mother’s struggle with depression. Later, her son Sam came to town and participated in several family sessions along with his sister. He too was able to acknowledge the sadness he experienced in response to the sudden 168 The Woman Who Never Mourned disappearance of his older brother. The family intervention proved helpful in providing a holding environment in which family members could provide each other with love and support. The family acknowledged that they had not had the support at the time of Eddie’s disappearance to adequately deal with his loss. They also acknowledged that Eddie’s death had impacted negatively on the family dynamic, contributing to Rose’s psychopathology and leaving her less able to adequately mother her children into adulthood. The most shocking aspect of the case is that for years Rose had merely been treated for a depression with psychotic features. There was no docu- mentation of this loss or any other—including the loss of her husband—in her chart. The mental health system had obscured Rose’s experience of devastating loss and amputated any knowledge of the trauma from her medical records. While the depression was evident, the profound impact of the loss of her oldest son on her worldview, as well as on her family, was ignored. Loss and the need to mourn are frequently ignored in the psychiatric world, where medication management is the panacea and therefore amputating containment takes precedence over verbally processing experience. Also, the importance of family intervention and peer support in dealing with mental illness and loss frequently gets ignored or even gets seen as an impediment to symptom management (Bowen, 1978). Rose died in the institution at the age of 91. The demeaning interactions with staff were counterbalanced by a peer support network that fostered a sense of love and acceptance. Peer support combined with a therapeutic holding environment ultimately cultivated a culture of enquiry that facilitated Rose’s psychological growth. The admiration and validation she received from her friends proved to be a powerful antidote to the stigmatization, alienation, and depersonalization she had experienced in a mental health system that quite frankly had ignored her experience for years. Rose was allowed to share previously repressed material, which was now heard by others and accepted. She was given the opportunity to tell her story to others, who listened and understood her. In the process of sharing her story and feeling understood, Rose was able to reframe her experience from one of unspeakable loss to one that allowed for an increased self-awareness and appreciation for what she still had in life. Much like her son, who drowned in Lake Superior never to be found again, Rose’s profound pain

Downloaded by [New York University] at 12:41 13 August 2016 for years was drowned by a mental health system not capable of treating her mourning. According to Tobin (1999), reminiscing can “serve to reinforce a core self when current everyday life does not provide evidence for the self-concept” (p. 15). Rose’s story was heard by the greater community, which appeared to counteract at times the demeaning interactions towards her by staff members. In retrospect, Eddie was brought to life in the many group and individual sessions when Rose shared her story. Not only did this resurrection of repressed memories facilitate her healing, but it also facilitated an intergenerational healing process for her children, Maria and Sam. In the last months of her life, Rose expressed to me that she felt loved and could more openly express love. The Woman Who Never Mourned 169 REFERENCES

Bowen, M. (1978). Family therapy in clinical practice. New York: Jason Aronson. Brown, J. T., & Stoudemire, G. A. (1983). Normal and pathological grief. JAMA, 250(3), 378–382. Frances, A. J. (2012). DSM 5 is guide not bible—ignore its ten worst changes. APA approval of DSM-5 is a sad day for psychiatry. Psychology Today: DSM5 in Distress. Retrieved from https://www.psychologytoday.com/blog/ dsm5-in-distress/201212/dsm-5-is-guide-not-bible-ignore-its-ten-worst-changes Freud, S. (1917). Mourning and melancholia. The standard edition of the complete psychological works of Sigmund Freud, Volume XIV (1914–1916). On the history of the psychoanalytic movement, papers on metapsychology and other works (pp. 237–258). London: The Hogarth Press and the Institute of Psycho-analysis. Freud, S. (1957). The origins of psychoanalysis. New York: Doubleday. Goffman, E. (1961). Asylums: Essays on the social situation of mental patients and other inmates. New York: Anchor Books/Doubleday. Greenberg, T. M. (2009). Psychodynamic perspectives on aging and illness. London: Springer. Haney, C., Banks, W. C., & Zimbardo, P. G. (1973). Study of prisoners and guards in a simulated prison. Naval Research Reviews, 9, 1–17. Hinshaw, S. P. (2005). The stigmatization of mental illness in children and parents: Developmental issues, family concerns, and research needs. Journal of Child Psy- chology and Psychiatry, 46(7), 714–734. Karpel, M. A. (1980). Family secrets. Family Process, 19(3), 295–306. Kastenbaum, R. (2000). The psychology of death. New York: Springer Publishing Company. Klass, D. (1988). Parental grief: Solace and resolution. New York: Springer Publish- ing Company. Kohut, H., & Wolf, E. S. (1978). The disorders of the self and their treatment: An outline. International Journal of Psychoanalysis, 59(4), 413–425. Kubler-Ross, E., Kessler, D., & Shriver, M. (2014). On grief and grieving: Finding the meaning of grief through the five stages of loss (2nd ed.). New York: Scribner Publishing. Lester, R. J. (2013). Lessons from the borderline: Anthropology, psychiatry, and the risks of being human. Feminism & Psychology, 23(1), 70–77. Parkes, C. M. (1964). Effects of bereavement on physical and mental health—a study of the medical records of widows. British Medical Journal, 2(5404), 274–279. Racker, H. (2012). Transference and countertransference. New York: Karnac Books. Rando, T. A., Doka, K. J., Fleming, S., Franco, M. H., Lobb, E. A., Parkes, C. M., & Steele, R. (2012). A call to the field: Complicated grief in the DSM-5. OMEGA—Journal of Death and Dying, 65(4), 251–255. Rosenhan, D. L. (1973). On being sane in insane places. Science, 179(4070), 250–258.

Downloaded by [New York University] at 12:41 13 August 2016 Semmelhack, D., Ende, L., & Hazell, C. (2013). Group psychotherapy with severely mentally ill adults: Adapting the Tavistock method. London: Routledge. Sunderland, C. (2001). Containing anxiety: a resident therapist’s experience. In J. H. Berke, M. Fagan, G. Mak-Pearce, & S. Pierides-Muller (Eds.), Beyond madness: Psychosocial interventions in psychosis (pp. 120–134). London, UK: Jessica Kingsley Publishing. Tobin, S. S. (1999). Preservation of the self in the oldest years: With implications for practice. New York: Springer Publishing Company.

Dr. Stern is a doctoral-level social worker whose background is in psychodynamic object relations therapy. He also has extensive training in cognitive behavioral therapy. He has worked in state mental institutions for the past 15 years. Dr. Stern describes the case of Barry, an African-American man who had been homeless for many years.

Barry was a homeless man who endured many hospitalizations over 20 years, mostly in state mental institutions, starting at the age of 18. He experienced many depersonalizing interactions with mental health professionals, which did little to foster his psychological growth. These negative interactions reenacted Barry’s childhood experiences with his mother, who neglected and abused him (to be discussed later in this chapter). In contrast to these depersonalizing growth-inhibiting interactions, Barry’s story shows how a relationship with a therapist in a hospital setting can provide an oasis where growth-promoting interactions can occur. As the therapist, I employed an object relations approach. Examples drawn from a transcript of a session are used to illustrate interactions within the therapeutic relationship that led Barry to insights into how early family interactions impacted on his sense of self in the Here and Now. In addition, interaction dynamics that facilitated growth between peers in the community—the dumpster people—and a friend (Bob) are also discussed (Sullivan, 2013). Barry, a 45-year-old African-American man, came to a state mental hos-

Downloaded by [New York University] at 12:41 13 August 2016 pital after five previous institutionalizations during a 15-month period. He was suicidal. Upon entering the hospital in the spring, Barry said, “I was homeless and living in a trash dumpster.” The dumpster was a special one located in an exclusive area of a major city in the Midwest. According to Barry, “It was not an ordinary garbage can. I was proud of my “residence” because it was located in a wealthy neighborhood.” He described himself as being, “one of the dumpster people.” Barry said dumpster people were a team of nomads who bonded in their homelessness and disconnectedness from “normal” society. There was a feeling of mutuality among these individuals. The Man Who Lived in a Dumpster 171 This current hospitalization followed the tragic death of a friend after which Barry became suicidal. He told the story of his friend’s shocking demise during the intake interview. In a monotone voice, Barry described the day that his friend, Bob, who slept in the dumpster next to his, was brutally crushed to death and literally “shredded” by a garbage truck. The monotone nature of Barry’s description of the event suggests that he was in a state of shock and in the denial stage in his grieving process (Kubler-Ross, Kessler, & Shriver, 2014). Concurrently, his monotone voice spoke to the unprocessed trauma of witnessing his only friend’s death. Bob was apparently drunk and unable to react quickly enough to what was happening. According to Barry, there was, “No obituary, no wake . . . nothing. He was just gone. Nobody cared about the guy except me and a couple of the other dumpster folk. We kind of looked out for each other and then he was gone.” Barry said he had talked with Bob every day. Bob was a touchstone for Barry.

On some days I’d go all day without talking to anyone but at the end of the day there was Bob. We’d share a few laughs, maybe a swig of whiskey, talk with a few other dumpster people and then call it a day. It really hurt me when Bob died. I felt lost without my friend. I became very sad and finally suicidal. I did not see what meaning my life had without my dear friend Bob.

Barry’s relationship to Bob and the other dumpster people highlights the value of friendship in maintaining a sense of humanness and ultimately psychological health in individuals living in extreme circumstances. Bob served as a peer support for Barry, validating his purpose as a human being (Ogden, 2014; Sullivan, 2013). Barry described his years of homelessness as a brutal experience (Ogden, 2014). Homelessness is not uncommon for individuals with severe mental illness (Foster, Gable, & Buckley, 2012). Living in a northern state, he experienced sub-zero temperatures during one harsh winter after another. He would try to shield himself from the elements by living in abandoned cars and buildings. Barry emphasized the dangerous weather conditions for homeless people. He said, “One time during the winter I nearly froze to

Downloaded by [New York University] at 12:41 13 August 2016 death. I couldn’t find a place to sleep. So, I opted for a park bench. It was 40 below zero that night. I lost three fingers to frost bite.” Homelessness had taken on toll on Barry’s health in that he suffered from diabetes, COPD, migraines and a weakened immune system. Upon his admission to the hospital, Barry had no address, no personal identification, and was unaware of ever having had a social security number. The lack of any official identification could symbolize his position as an “outsider” with respect to society as a whole. He looked exhausted and depressed. He was admitted to the hospital and examined by a psychiatrist, who diagnosed him with schizophrenia and prescribed the typical 172 The Man Who Lived in a Dumpster medications used to treat this disorder (e.g., Risperdal, Zyprexa, etc.). Upon examination of Barry’s chart, I noticed that during previous hospitalizations he had been diagnosed with schizoaffective disorder, depression with psychotic symptoms, and psychosis not otherwise specified. The plethora of diagnoses and the absence of relevant personal information about Bar- ry’s history suggested that the mental health system may have inadvertently used psychiatric labels to obscure his personal experiences. It is indicative of amputating containment. The added factor of being an African-American male may have contributed to what might be perceived as Barry’s being over-diagnosed. Hewlick (2012) quotes Dr. William B. Lawson, MD, Ph.D., and a professor at Howard University on this phenomenon: “Black people are over-diagnosed . . . frequently misunderstood by their psychiatrists, and largely disenfranchised. . . . Blacks are disproportionately more likely to be homeless, incarcerated, and uninsured” (p. 1). These personal experiences of disenfranchisement from society most likely contributed to feelings of anger and depression in Barry. Societal oppression paralleled earlier familial experiences characterized by neglect and abuse in his early childhood. Barry’s five most recent psychiatric hospitalizations had taken an emotional toll on him. He described his experience of being institutionalized as depersonalizing, invalidating, and demoralizing. He felt that the mental health system had reduced him to his diagnosis. He stated that at times, “I feel like an animal in a holding pen.” Barry said that his hospitalizations, “Gave me three hots and a cot . . . nothing else, no treatment that I know of other than pills, pills and more pills! No one seemed to care about me.” He indicated that he had received no psychotherapy other than psycho-educational groups focused on medication management and personal hygiene. This may reflect the fact that, in many parts of the U.S., there is little money to support treatment of those diagnosed with mental illness (Lehman, 1998). Limited funding, combined with short staffing and the many demands of inpatient practice, leaves no time for psychotherapy. Treatment utilizing only psychotropic medications becomes expedient (Hertzman, 1992). While medication eliminates many of the symptoms of severe mental illness, so-called “chronic” patients remain severely impaired and socially limited after years of psychotropic treatment. The importance

Downloaded by [New York University] at 12:41 13 August 2016 of social interaction in treatment is in most cases ignored. Barry’s description of being “maintained” in these institutional settings solely via medication management suggests the propensity to create an atmosphere of amputating containment. The staff medicates in part to avoid experiencing the painful disruptive affect associated with serious emotional problems and, many times, the historical traumatic experiences that accompany them. The psychiatric hospital where Barry was admitted housed over 500 patients. The hospital was understaffed, holding true to the medical model insisting that medication was the treatment of choice over psychotherapy (Double, 2014; The Man Who Lived in a Dumpster 173 Leifere, 2001). Staff placed “patients,” as they were called, in locked units because they were believed to be a danger to themselves and others. This hospital had several units. One was the infamous “Godzilla Unit”— Unit B. The presence of this unit epitomized the culture of obedience in this hospital. The ultimate punishment for anyone in any other unit, including Unit A, where Barry was housed, was transfer to Unit B, a place where patients were sent when psychiatrists believed that they would never get out of the institutional setting (Goffman, 1961a). Depersonalization flourished among staff members on this unit. The very nature of the unit’s philosophy that the patients were “chronically” mentally ill hindered treatment. Staff appeared to treat clients in ways that perpetuated mental illness, rather than facilitating healing (Jennings, 1994, 2013). Residents constantly feared being transferred to Unit B. Few staff wanted to work on Unit B. It was seen as dangerous and filled with “borderlines” and “anti-socials” who were not treatable. Staff frequently punished the residents, e.g., by denying anxious patients PRNs (as needed medications) or restraining them on a stretcher for acting out. It seemed as if aggressive staff impulses were projected onto the patients, who were helpless to ward off these projections. Barry was lucky to be placed on Unit A, where discharge was possible. However, all patients perceived the threat that they might be transferred to the “Godzilla Unit” should they fail to improve or if they “acted out.” This omnipresent threat kept patients’ behaviors in check (Gadit, 2008; Goffman, 1961a; Rosenhan, 1973). Therefore, the interaction dynamic of punishment predominated in Unit A. The most violent behaviors would likely lead to transfer. However, even less egregious behaviors, such as throwing food, failing to shower, failure to take medication, or swearing at staff, could lead to transfer, depending on the patient. I say depending on the patient because the psychiatric staff picked favorites among patients whose acting out behaviors might be seen as less serious than those of others. Barry told me that patients who complained openly about conditions on the unit—e.g., about food or treatment—were viewed less favorably and treated less humanely (a form of staff revenge). Those patients who maintained a code of silence and were compliant got better treatment. The adherence to the code of silence and the perception amongst the patients of better treatment when they obey

Downloaded by [New York University] at 12:41 13 August 2016 speaks to the power of the implicit rules within an institution. Administrative staff set boundaries around visiting hours that often deprived patients of meaningful interactions with loved ones. Visiting hours were highly restricted throughout the hospital—between 6:00–7:30 p.m. daily, including on weekends—with few options for friends and family members unable to conform to this schedule. At times, work and other obliga- tions prevented friends and family from visiting and engaging in positive, meaningful interactions with their relatives on the unit. No cell phones were allowed. A single pay phone for some patients provided their only link to the outside world. This policy stands in stark contrast to most medical hospitals, 174 The Man Who Lived in a Dumpster where the seriously ill patient being treated for cancer or kidney failure is given practically open access to family members, friends, and others whom doctors believe can have a positive impact on patient well-being (Weinberg, 1952). Psychiatric hospitals, for the most part, have rigid visiting hours with limited privacy (Rosenhan, 1973). Yet, frequency of visits from friends and family can positively impact on outcomes (Jan, 1977). Peer interactions were largely limited to a community meeting held for 30 minutes every morning from 10:00–10:30 a.m. on the unit. Community meetings were originally conceived of as mechanisms to empower residents, but this was not the case here. This potentially therapeutic event became anti-therapeutic when staff failed to exhibit unconditional positive regard, empathy, and congruence towards participants. Attendance by patients was mandatory. Those who failed to attend for any reason would be written up. Far from an open dialogue, the community meeting consisted of a psychiatric social worker talking at the residents, rather than to them. First the staff reviewed the Unit’s rules. A rigid hierarchy promoted a culture of obedience while hindering the development of a culture of enquiry (Dreu & Nijstad, 2008). Staff then asked members to share their concerns “openly” during the remainder of the meeting. However, Barry described these meetings as information-gathering sessions by staff. They would attempt to extract from patients information about “acting out” behaviors on the unit. It was common knowledge among patients that they had to be highly cautious about what they said during these meetings. Barry said that there was a code of silence among patients who attended the community meetings. The norm was for participants to present a “rainbow-like” perception of what was occurring. Barry also commented on how the meetings promoted an “us versus them” dynamic differentiating between the royalty—psychiatrists, psychologists, psychiatric social workers, and nurses, in that order—and the “peasants,” the patients. These meetings appeared to be set up, perhaps unconsciously, to reinforce the hierarchy within the institution and not to foster a therapeutic dialogue. This hierarchy, with psychiatrists at the top of the pecking order, was mirrored among the patient population. I observed that those patients with a family, job, and/or established “life” outside the institution were given more credibility among patients and staff members. Those who were homeless, without significant family members—sometimes

Downloaded by [New York University] at 12:41 13 August 2016 referred to as the “dregs of society” and likewise the “dregs of the institution”—were often neglected by staff (Kayser-Jones, 1990; Price, 2009). Not having a family member to watch over his treatment, Barry was set up to deal with the whims of staff members. Barry suggested that if he was pushed or abused by a staff member he had no voice; there was no one to back him up. Staff members, Barry believed, would just say that Barry’s allegations were a hallucination, a function of his psychosis. Barry noted that he had seen abuse on the unit several times that did not get addressed by the hospital’s administration. The code of silence was reinforced by the fear of punishment—mistreatment on the unit, or transfer to the Godzilla Unit (Goffman, 1961a). The Man Who Lived in a Dumpster 175 On Unit A, Barry protected himself by acting like a tough guy. He often criticized hospital staff, referring to them as useless and just out for the money. At one point he labeled me as an “incompetent junior psychologist” who was worthless—indicative of a negative transference reaction (Winn- icott, 1956). Being labeled “worthless” and “incompetent” by Barry con- jured up intense feelings in me—anger, sadness, and anxiety. The intensity of these feelings suggested something other than my own issues emerging. I hypothesized that Barry was putting into me, via projective identification, his own feelings of low self-esteem, loss, and rejection. This was validated as the therapy proceeded. Barry spoke in an expressionless way, but his tone of voice was pregnant with anger. His tough guy image suggested he did not want any closeness. Yet there was something about his demeanor, his glance, suggesting that he wanted a friend. The blank expression and deep cavernous eyes he exhibited when he described his experience suggested a lost self (Kohut & Wolf, 1978). Every so often when he spoke there would be a twinkle in his eye, an aliveness in his voice that suggested that his authentic self was present, but perhaps somewhere far away in his unconscious hiding from the emotional pain he had experienced as a result of traumatic experiences linked to his childhood. Barry was referred for individual therapy by his psychiatric social worker during a care-planning meeting. I was assigned the case by the psychiatrist after Barry had been hospitalized for over two weeks. This timing suggests that Barry had 14 days of institutionalization with no psychotherapy except for participation in the community meetings. This failure to provide some form of psychotherapy to a patient with suicidal ideation reflects the institution’s propensity to devalue the importance of interpersonal interaction in recovery. It suggests that the institution unconsciously devalued the emotional life of the patient by, in essence, denying treatment. The failure to prescribe psychotherapy for a suicidal patient might be compared to the failure of a medical doctor to prescribe an antibiotic for someone with pneumonia. I worked with Barry for two years, meeting with him three times per week for 50-minute periods. Although my primary approach to treatment was grounded in object relations theory, I utilized a variety of interventions, including cognitive behavioral therapy, client-centered therapy, and

Downloaded by [New York University] at 12:41 13 August 2016 psycho-educational approaches. Gradually over a period of months, the consistency of therapy (Freedman, Hoffenberg, Vorus, & Frosch, 1999), my expression of empathy, unconditional positive regard, and congruence (Rogers, 1957), and Barry’s perceived desire to participate in the therapeutic process contributed to the development of trust and ultimately positive therapeutic change in him. Object relations theory, my primary theoretical approach, highlighted in the sections of the transcript presented here, stresses Barry’s inner object world. Object relations therapy focuses on interpersonal and intrapersonal interactions in the treatment. The therapist works with the client to create a narrative of his earlier life experiences through interpretation of how these 176 The Man Who Lived in a Dumpster past events become reenacted in the Here and Now. The client interacts with the self, introducing new ways of perceiving archaic experiences, ultimately contemporizing this old material with information obtained through the therapeutic process. Developmentally, the absence of optimal conditions for growth and/ or a preponderance of negative interactions with the primary caregiver in childhood can lead to distorted internalized objects and inadequately integrated personality structures (Klein, 1946). The individual may become locked in an archaic drama in which internal object representations from the past grossly distort current reality testing. A person’s internal representations of object relational experiences in the past dominate her inner world to such a degree as to render life painful and confusing by distorting present relationships. The unconscious nature of the archaic drama contributes to its recapitulation in the Here and Now (Fairbairn, 1952). Once early negative childhood experiences that are fueling reenactments are made conscious and put into a narrative—through therapy—the person is liberated to act in new ways that promote a healthy sense of self (Miller, 1980; Wigren, 1994). Barry’s childhood was steeped in abuse and neglect; this represents the interaction dynamic of childhood discord. His mother mistreated and neglected him. His father abandoned him. His dreams of a successful life were crushed by a mother who failed to validate his abilities. These early life experiences were internalized and contributed to his distorted views of himself and the environment—a false self (Miller, 1980; Winnicott, 1965, 1971). Through a relationship with an empathic and caring clinician, the client replaces unsatisfactory object experiences with satisfactory ones (Mallinck- rodt, Porter, & Kivlighan. 2005). Through such interactions Barry built new memories founded on positive experiences, including new object experiences in the world. In therapy, the interpretation of transference and countertransference reactions creates insight into how archaic object relationships may be distorting contemporary ones (Cashdan, 1988). Interpretations emphasize “the dynamics of continuance, repetition, and attempted mastery of internal dramas derived from history . . . and carried inside” (Pine, 1990, p. 49). The interpretive process of linking events in the Here and Now perceived

Downloaded by [New York University] at 12:41 13 August 2016 as hostile or abusive with Barry’s early childhood experience helped in his treatment. This process of linking the Here and Now with the There and Then helped to illuminate for Barry how he might be contributing to reenactments of his abusive childhood. Ultimately, these reenactments in the Here and Now contributed to his psychopathology. Later we will present examples of this interpretive process. My goal was to help Barry gradually reintegrate split-off parts of the personality into the ego. These parts—thoughts, feelings, and fantasies—are split off into the unconscious as a defense against the painful affect that might emerge should they be made conscious. The open expression of these The Man Who Lived in a Dumpster 177 split-off parts of the self in childhood could have resulted in abandonment by the caregiver (Clarkin, Yeomans, Kernberg, & Kernberg, 1992; Miller, 1980). In Barry’s case, his split-off rage and sadness were related to a mother who failed to support and validate him and his dreams. The emergence of this awareness allowed Barry to relinquish those aspects of the past that were hindering him from moving forward with his life. While the memories of abuse and neglect were not forgotten, the expression of painful affect associated with them (within an empathic therapeutic holding environment) reduced the influence they had on his life in the Here and Now (Greenberg, 2004). As suggested earlier, Barry’s shift from a defensive stance in the therapy to a more trusting one appeared to be strongly related to the consistency in which empathy, unconditional positive regard, and congruence were expressed in therapy (Rogers, 1957). The therapeutic relationship became a safe holding space away from the negative, growth-inhibiting interaction dynamics frequently exhibited on the unit (Winnicott, 1965). Until the session discussed here, Barry had been emotionally distant. At times he was verbally aggressive, joking that he didn’t even want to know my name and did not really like me. He also appeared reluctant to share any information about his early childhood other than to say that things had been “Okay.” During the session being discussed, it became apparent that Barry valued our relationship more than he had portrayed in earlier sessions. A positive therapeutic alliance emerged. This positive alliance may have been growing and was being covertly communicated through regular therapy attendance and an openness to carry on a conversation for 50 minutes, even if it was at times hostile, three times per week (Kordy, von Rad, & Senf, 1988). The session highlighted here is the first session during the six- teenth month of treatment. During this session, Barry opened up about his view of staff on the unit and his difficulty trusting them. Furthermore, he demonstrated verbal evidence of the positive therapeutic relationship. He states:

BARRY: “Nothing but lies roll off their lips. [staff] They are not to be trusted. [The staff’s judgmental way of treating the client may have been a reenactment of how

Downloaded by [New York University] at 12:41 13 August 2016 Barry had been treated by his mother growing up, a mother that could not be trusted.] I say they’d lied . . . cheated their way through their whole lives . . . I did nothing like that . . . just tried to survive. I don’t get a straight answer even if I ask them.” DR. STERN: “So maybe you are seeing me that way too because I’m staff—that I can’t be trusted. And when you are talking to me, I’m sensing a bit of sadness that I’m one of those people whom you feel you cannot connect with or trust.” 178 The Man Who Lived in a Dumpster BARRY: “It’s not that way cause I connect with you.”[The client’s remarks suggest that within the therapy relationship there is the possibility for a corrective experience (Bascal, 1990; Stern, 1994). Unlike in the relationship he had with his mother, he can connect with me.] “It’s like cold and there is no place to stay, no warmth. You listen to me. It’s better that way. Not like the twilight zone.” His relationship with his mother may have been cold and strange—in the “twilight zone.” The quality of interactions with his mother is addressed in more detail later.

This interaction suggested that the emotional warmth of simply listening provided a sense of cohesion for Barry. Another human being listening to and understanding him allowed him to feel out of the “twilight zone.” This positive therapeutic alliance allowed for a safe environment that contributed to the evolution of a culture of enquiry within which his past could more safely be explored. The positive quality of the relationship provided a corrective experience, in stark contrast to negative experiences Barry had with his mother. This culture of enquiry allowed for the reflective and therapeutic dialogue to emerge later in this session. Barry opened up about how and why he felt like garbage, his negative relationship with his mother, and how the negative experiences of childhood contributed to the derail- ment of his dreams. The recapitulation of the toxic mother is evident in the numerous punitive, hostile, and dangerous places he found himself in, including mental hospitals, homeless shelters, and the streets (Van der Kolk, 1989). In other words, as a child Barry felt emotionally homeless without an identity—scapegoated in his own family. As an adult he reenacted this earlier childhood situation by putting himself in situations symbolizing how it was for him as a child—homeless and without an identity in the family (Fitzgibbons, 1986; Herman, 1997). Freud (1912) discusses the concept of a repetition compulsion, whereby the person reenacts the past with the hope that the reenactment will turn out better and, unlike in childhood, he will be loved, recognized, and find a home or metaphorically find himself. On a systemic level, institutions, including society and the mental health

Downloaded by [New York University] at 12:41 13 August 2016 system, symbolically cast Barry out, like his mother. The mental health system (per his account) branded him a hopeless, homeless schizophrenic. The session continued and further highlighted how early childhood experiences as well interactions within the United States mental health system emotionally damaged Barry.

BARRY: “Well, you see, it’s dangerous out there . . . putting yourself out there when its 30–50 degrees below zero. Wandering around out there, it’s spooky . . . the garbage man (laughs). Oh yeah . . . the garbage man . . . one of my friends got shredded by a trash compactor.” The Man Who Lived in a Dumpster 179 DR. STERN: “He got shredded?” BARRY: “Yeah. You know when they push the button. They had a closed casket.” DR. STERN: “Just shredded like garbage. Did you ever feel that way?” BARRY: “Mm . . . mm . . . I felt like left over garbage that nobody wanted to empty. She never wanted me . . . my mother. Never . . . never.” DR. STERN: “So this sense of being like garbage that nobody wanted, what’s coming up for me is this image of you in this large family that perhaps ignored you. Not acknowledged by anyone for your accomplishments. It’s like your feelings got shredded and you felt worthless . . . you wanted to be loved and cared for by a mother who treated you like garbage.”

In my interpretation, I attempted to link Barry’s experience of living in a garbage can and having his friend “shredded” to his childhood experience of having been treated like garbage by an unavailable and uncaring mother (Brenner, 1973; Rosenfeld, 1985). This interpretation appeared to hit a nerve in Barry, who went on to validate it with his response, which was filled with painful affect.

BARRY: “I never much thought about that . . . but you know the way she’d look at me.” DR. STERN: “She?” BARRY: “My mother . . . she’d never say nothin . . . cause we never really talked other than simple things. Do this for me or can you get me this? There wasn’t any talk about the future or how are you doing in school. Just none of that . . . she didn’t care. She never loved me.” DR. STERN: “As you are saying that though . . . I’m sensing that for you there was the hope that there might have been a better way to communicate, perhaps akin to how we are talking now . . .” Downloaded by [New York University] at 12:41 13 August 2016 Interpretively, I attempted to link the past with the present, suggesting that in the “Here and Now” in the therapy, he had the quality of communication he wished for with his mother. Barry acknowledged the accuracy of my response.

BARRY: “Yeah . . .” DR. STERN: “Perhaps you felt discarded and ignored by her.” In the following section, Barry acknowledged that she treated him like garbage. In essence, his choice of living in a garbage can as an adult was a 180 The Man Who Lived in a Dumpster reenactment of how he felt as a child, thrown away like garbage. BARRY: “Yeah. I felt like she couldn’t deal with everyone, but I just ignored it. There were seven more kids here, ain’t got enough time for me. So I took it. She didn’t want me. She didn’t know what she had and she threw it away.” DR. STERN: “Like garbage?” BARRY: “Yeah . . . like that . . .” DR. STERN: “She didn’t realize what she was missing out on in not paying attention to you.” BARRY: “But what I wanted to do in the community . . . have like the little grocery store . . . and a car wash next to it . . . a little playground with a launder mat . . . but I didn’t have it, no backbone; no backing . . . all gone.”

Barry’s remarks suggest that he had no one to emotionally hold him—no holding environment. Neither his mother nor his father were available to support his efforts. There was no love in his early childhood. He most likely felt abandoned, abused, and neglected. Barry recreated this state as an adult by being homeless, alone, and living in garbage cans.

DR. STERN: “Hopes and goals were put in the garbage . . . ended up in the dumpster by your mother . . .” BARRY: “Yeah, right in the garbage.” DR. STERN: “I’m sensing sadness in your voice.” BARRY: “Always . . . always . . . never had a chance to be a computer programmer or to learn calculus. No . . . just about everything I ever learned I never got to apply . . . so it’s dim now, very dim. She never noticed me. She was blinded to me. I just disappeared.” DR. STERN: “Like the shredded friend?” BARRY: “Got hospitalized . . . homeless. Ain’t nobody cares anyway.”

Downloaded by [New York University] at 12:41 13 August 2016 DR. STERN: “Feeling like nobody cares about you or ever has, perhaps feeling like I don’t care either.” [This interpretation of a possible transference gets refuted in Barry’s response to my remark.] BARRY: “No, no, it’s not like that, it’s just that, I’m a shadow of who I was.” (He starts to cry.) [There is one minute of silence.] DR. STERN: “I sense you are mourning who you could have been. Mourning a past that could have been different had The Man Who Lived in a Dumpster 181 your mother been there for you, had others been there for you.” BARRY: “It’s just that I had big ideas . . . I wanted to be somebody . . . do something . . . but I needed a backbone, just wandering around looking for something.” DR. STERN: “Well, perhaps that’s why you ended up at this hospital, to find a backbone.” [This interpretation suggests that the hospitalization and the therapy provided during his stay served as a corrective experience. It suggests he gained some internal strength through this experience.] BARRY: “I needed help . . . I was homeless . . . so I called Chris [case worker at the homeless shelter] and got the ball rolling.”

In the next section of the session, Barry gets in touch with a tremendous sense of loss. He begins to mourn a self that he was unable to actualize (Miller, 1980). He shifts from a state of melancholia/depression to mourning (Freud, 1917). Barry comes to name what he had lost, to acknowledge the hole—caused by abuse and neglect—rather than to deny it. By putting words to painful feelings associated with the losses, Barry processes feelings and can move on to cathect new objects, goals, and fantasies (Freud, 1917). The corrective interaction dynamic lies in the presence of an empathic therapist who, unlike his mother, can listen, acknowledge, and validate the client’s suffering. This process of recognizing the emptiness, futility, and impoverishment of nurturing enables a move toward a renewed sense of self-discovery (Kohut & Wolf, 1978; Miller, 1980). Per Alice Miller (1980), Barry can re-embrace the self that had been taken hostage by his mother. He begins to rebuild a fledging sense of self through the therapeutic relationship that allows him to embrace feelings, thoughts, and fantasies that in childhood had to be repressed in order to please his mother. Later in the session, Barry identifies the importance of being heard, responded to, and understood. This process of feeling understood and validated, versus stigmatized or scapegoated, helps link Barry back into an open

Downloaded by [New York University] at 12:41 13 August 2016 dialogue with society. This open dialogue with others in the community as a whole is necessary in order to facilitate the healing process and reengage him in the process of self-development. New positive experiences in the world facilitate the manifestation of an inner world made up of memories that are more positive. Powerful symbolism emerged in Barry’s description of the shredded human being who was his friend. Barry felt shredded by a mental health system that left him feeling worthless. Also, the shredding of Barry’s friend may have been linked with early childhood experiences. Barry may have 182 The Man Who Lived in a Dumpster felt emotionally damaged by an abusive and neglectful mother who left him feeling abandoned. The session continued:

BARRY: “I got placed here and that’s when I started seeing different staff members, psychiatrists . . . stuff like that . . . But out of all of them . . . You’re the only one I really be waiting to see . . . The rest I don’t care if I see them or not . . . That’s probably a dumb thing to say . . . But it’s true.” DR. STERN: “What is it about our dialogue that makes you feel that way?” BARRY: “I mean it. It’s straightforward. It’s open . . . It’s . . . you know . . . get it off your chest . . . whatever it is . . . ah . . . We may not be able to do it in one session . . . Ten sessions . . . a hundred sessions . . . but at least you know somebody lends you an ear.”

Then Barry further revealed how emotionally distant he was from his mother. He felt that his mother and his family used him for financial support.

BARRY: “When I turned 16 they told me to get out of the house and to work . . . I worked for minimum wage . . . I gave her money . . . All I wanted was her love.” DR. STERN: “So you felt used by her somehow.” BARRY: “Always . . . always . . . I became nothing to her but a paycheck.” DR. STERN: “Perhaps that is what you believe that I think you to be . . . a paycheck.” BARRY: “No, that’s not so, not with you.”

Barry refuted my interpretation of the transference. He said that he viewed our connection differently. He saw the connection as authentic and positive. Near the end of the next session—following the analyzed part here—Barry presented me with a gift: the certificate he had obtained for completing “The

Downloaded by [New York University] at 12:41 13 August 2016 Facts of Life” group. This discharge-planning group taught the necessary skills for Barry’s reentry into society—balancing a checkbook, completing a resume, getting housing, and so on. I interpreted this gesture, the giving of the gift, to symbolize our growing alliance and his desire for me to support his desired identity. I suggested that Barry was hoping that I, unlike his mother, would acknowledge his accomplishments—in a corrective therapeutic experience and facilitate his growing sense of being a person in his own right. The certificate could be interpreted as symbolizing Barry’s liberation from the unconscious archaic drama fueled by a history of abuse and neglect. By entrusting me symbolically with his “self,” symbolized in the The Man Who Lived in a Dumpster 183 certificate, he could symbolically merge with a nurturing auxiliary mother figure, the therapist, who could care for his “infant” self by taking care of the certificate. This experience of being emotionally held and cared for contrasts sharply with the negative experience he had growing up. I agreed to keep the certificate until Barry was discharged. I wanted to show my willingness to hold his damaged self as he worked through painful issues related to early childhood within the therapeutic relationship. Giving me this certificate was a turning point in Barry’s treatment. After- wards, he spoke much more freely about the trauma of having grown up in a home where he was abused and neglected. He processed his traumatic experiences by putting them into a narrative and gained insight into how his past influenced his actions in the present (Wigren, 1994). Near the termination of the therapy he acknowledged that, while his mother was physically dead, “She was not dead in my head. It’s like she was living there in my head and I just kept beating up on myself just the way that she beat up on me when I was a kid—sabotaging myself over and over again” (Rothschild, 2000). While object relations theory has been highlighted in the analysis of this session, a client-centered approach was also pivotal in the interaction dynamics that facilitated his recovery. Barry thrived in an emotional holding environment characterized by empathy, unconditional positive regard, and congruence. In time, Barry experienced a reduction in his medication. On the Unit his capacity to self- regulate his affect, engage in interpersonal relationships, and show positive affect increased. He showed self-efficacy in helping facilitate his discharge from the institution into the community, by finding housing with the assistance of a caring social worker. Following two years of therapy, the facility placed Barry in a group home. His wrap-around plan included occupational training and individual and group therapy, as well as medication management. Barry resided successfully in the group home for over five years. He took great satisfaction in having a home with “a real address.” He eventually obtained a part-time job and made some friends. He started dating. Recent cutbacks in the state’s budget have negatively impacted on mental health benefits (Dunn, 2013; McGovern, 2014). Barry’s group home had to close down. Residents were placed in nursing homes or left to find their

Downloaded by [New York University] at 12:41 13 August 2016 own housing. Barry’s whereabouts are unknown. It is hoped that the United States mental healthcare system did not return him to the experience of another cycle of homelessness reminiscent of a childhood history characterized by abandonment. While the authors recognize that ethnicity and race are significant factors in the the client’s biopsychosocial identity, the decision was made to focus the case on the interaction dynamics outlined in earlier chapters. When a future revision of this manuscript occurs, an additional section of analysis of this case could be devoted to the interaction dynamics of race and ethnicity in diagnosis and treatment. 184 The Man Who Lived in a Dumpster REFERENCES

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We now move from the analysis of social interaction in case studies of individuals to the analysis of social interaction in the case study of a group. Our book Group Therapy for Adults With Severe Mental Illness: Adapting the Tavistock Method (2013) presents a quasi-experimental study which demonstrated that Tavistock groups, a form of group interaction, promote growth for psychiatric clients. The Tavistock method offers a powerful context for learning about interpersonal dynamics (Bion, 1961, 1962). Although a number of professionals believe that this method is not appropriate for clients diagnosed with severe mental illness, our book challenges these beliefs using statistically based studies. These studies examine how Tavistock groups affect clients’ anxiety, depression, group cohesion, and self-efficacy. The results of this work contributed to our interest in study- ing social interaction and mental illness. In fact, it is interesting to note that Tavistock groups played a central role in the treatment of four out of the eight individual cases discussed earlier. Participation in the Tavistock groups could have played an important role in these clients’ psychological improvement. The Tavistock method grew out of the same source as the therapeutic community, Bion’s experiment with groups at the Northfield hospital during World War II (Bion, 2013; Harrison & Clark, 1992). Although Tavistock shares some basic characteristics with therapeutic communities, the Tav- istock method is less intensive than Open Dialogue (Seikkula & Olson, 2003) or the Therapeutic Community (Hinshelwood, 2001; Main, 1977).

Downloaded by [New York University] at 12:41 13 August 2016 The Tavistock method can be implemented more easily than these other programs and in a more cost effective manner. Before introducing the present study, which provides and explores an example of a Tavistock group, we will briefly discuss the interaction structures that underlie the Tavistock practice. The Tavistock group structure views: participants group activity from the perspective of the group-as-a-whole. A “consultant” interprets group dynamics on the level of the group-as-a-whole. The consultant’s interpretations point at interaction dynamics in the Here and Now that the group appears to be unaware of at the moment. The person making the 188 The Tavistock Method interpretations “consults” to the group, rather than leading it. It is up to the group, then, to respond to these interpretations and attempt to integrate them with their experience of the group. The interpretations help the group to pursue its task: examining its own interaction dynamics in the Here and Now (Banet & Hayden, 1977; Bion, 1961; Rice, 1965). For example, a group is discussing a difficult argument between two members. The group notices that it has not left much time for planning an upcoming picnic. The subject shifts to the question of how much time is needed to plan the picnic. The consultant then interprets: “This group fears that the discussion of the argument will reveal the members’ conflicting positions on this touchy issue. The discussion of the picnic is being used as a way of avoiding the question of where the group stands in the argument between the two members.” The consultant’s interpretation calls attention to the group’s dynamics in the Here and Now. The group’s dynamics can be interpreted using many different frameworks including the unconsciously experienced “good mother”, “bad invasive mother”, or the “good-enough” mother (Malcus, 1995, pp. 55–63). The group’s behavior can be interpreted in terms of defenses used to avoid anxiety. Bion (1961) emphasizes the interpretation of group defenses in terms of dependency on the consultant through flight or fight interactions or pairings between members. A task of the consultant is to alert members to the interactions which interfere with their task oriented behaviors and the goals of the group-as-a-whole (Bion, 1961). Inevitably, group members project unwanted aspects of themselves into the group-as-a-whole. The group can unconsciously designate a certain member as a scapegoat. The consultant’s interpretations provides members insight which allows them to take responsibility for their projections onto others and to examine them. As a result, the group is a safe place for sharing sensitive or frightening thoughts, feelings, and/or fantasies. The group’s safety also results from the focus on interpretations that responded to the group-as-a-whole—rather than to individual members. The group’s ability to process its psychic material develops over time (Bion, 1962; Semmelhack, et al., 2013). It is important to note that the Tavistock group we studied included modifications to the traditional Tavistock model (Semmelhack et al., 2013). For

Downloaded by [New York University] at 12:41 13 August 2016 example, we included a 10-minute tension reduction period after the group, where the consultant directly answered members’ questions about the session. Also, consultants more eye contact with the group members than in a traditional Tavistock group. When a member spoke about traumatic material, such as sexual abuse, the consultant would first acknowledge the pain of the person sharing the memory before making a group-as-a-whole interpretation. These modifications allowed us to address the intense anxiety and other disturbing affects that at times can result from the application of the Tavistock method. We believe that work with clients diagnosed with severe mental illness requires these modifications. These modifications resulted in The Tavistock Method 189 a less stressful, less confusing, and more empathic environment than that of a traditional Tavistock group. See our book for a full description of the modifications (Semmelhack et al., 2013). This remainder of this chapter examines a group that we demonstrated to be effective in our empirical studies (Semmelhack, Hazell, & Hoffman, 2008), but this time we take an in-depth look at the interaction processes that evolved in the group. The interaction structures underlying this successful group are discussed, and we make comments that may be helpful to those who wish to pursue a similar practice. In addition, we used the Hill Interaction Matrix to help show the value of the group-as-a-whole interaction (Hill 1971, Hill 1977). The material on the Matrix is rather complex and the reader who wishes to focus on the dynamics of the Tavistock group may not want to spend too much time on this material. Although it is a unique practice, the Tavistock method has much in common with other forms of interaction that tend to foster growth for people with severe mental illness. The method, for example, can be seen as including the dynamics of a culture of enquiry, power sharing, multi-voiced conversation, containment, and holding environment, as discussed in Chapter 1. The dataset for this analysis included process notes recorded by the group consultant after each session (during a 30-minute time segment). Approximately three pages of process notes were recorded for each group. While notes were taken for 30 group sessions, we focus on the first ten groups for several reasons: The groups were contracted with members in ten-week modules, and this initial period is crucial in setting the boundaries and tasks for the group corresponding to Yalom’s stages of group development (Yalom & Leszcz, 2005). Also, strong and significant findings emerged regarding anxiety, depression, group cohesion, and self-efficacy even from the initial ten week set of sessions (Semmelhack et al., 2013). There are four types of sessions in a Tavistock group (Banet, Hayden, & Jones, 1994). There is the Introductory Group, which explains the Tavis- tock group framework. Group sessions two through five and seven through nine consist of Here and Now Groups, in which the group examines its own process in the Here and Now. A Discussion Group—session 6—discusses

Downloaded by [New York University] at 12:41 13 August 2016 the dynamics taking place in the Here and Now Groups, Group ten is an Application Group, in which members apply what they have learned in the group to contexts in the world outside of the group (Hazell, 2005; Semmel- hack et al., 2013).

THE TEN-WEEK TAVISTOCK GROUP MODULE

Dr. Clive Hazell presents his analysis of a ten-week Tavistock Group Mod- ule. The group met one time per week for 60 minutes. The Hill’s Interaction 190 The Tavistock Method Matrix tracked the discussion of consultant/member interactions throughout the analysis. According to Hill, 1971 (Hill, 1977), the matrix is designed as a “systematic set of categories developed for use in understanding and classifying interaction in small groups, especially therapy groups. It has, however, been used not only on T-groups, encounter groups, discussion groups, but also on individual and dyadic counseling sessions.” According to Dr. Clive Hazell:

The Hill Interaction Matrix (Figure 12.1, p. 191) is a unique and powerful tool for ranking the effectiveness of therapeutic interactions created by W. Fawcott Hill (1971, 1977).

A brief description of how to analyze interactions using the Matrix follows. The horizontal axis of the matrix tracks what the group is discussing: Topics, the group itself, personal issues, or relationships. The vertical axis, the “work/style” axis, tracks the manner in which the discussion is carried out: “Responsive” (where the therapist or leader asks questions and the members respond); “Conventional” (which involves ordinary chit-chat); “Assertive” (where a member makes comments aimed at differentiating themselves or the group in some way); “Speculative” (which is rather like the general public’s view of what “psychotherapy” looks like; for example, a client asking questions about how to solve her emotional problems and receiving direct answers to these questions); and “Confrontive” (which involves authentic sharing of oneself with others). These characterizations are woefully brief and the reader is strongly encouraged to consult Hill’s early works for a more detailed and subtle rendition. Only the last two of the “Work/Style” categories are actually considered to be of much therapeutic value, and Hill cites research to bolster this viewpoint (Lee & Bednar, 1977; Seligman & Sterne, 1969). This dovetails with much psychotherapy research insofar as there have been consistent findings regarding the utility of authenticity and psychotherapy-like behaviors (Chessick, 1995; Miller, et al., 2004; Schmid, 2001). The passivity involved in the “Responsive” row led Hill (1971, 1977) to hypothesize that it is of no therapeutic value whatsoever. This again makes sense, since in this area of the matrix, clients are basically being treated as, and are often encouraged

Downloaded by [New York University] at 12:41 13 August 2016 to act as if they are, the proverbial “bumps on a log” (Hazell, 2005). Such passivity is unlikely to have consistent therapeutic benefit. Hill (1971, 1977) arranges the types of group discourse into a hierarchy of therapeutic effectiveness where, for example, cell 1B is ranked the lowest. It is important to note that the “Responsive” row is unranked because its items are considered to have no therapeutic value. In cell 1B we have the intersection of conventional talk about a topic. This is a common occurrence in groups: talking about the weather, grades, décor, politics, and so on in a very uncontroversial and unprovocative way. At the other end of the hierarchy, at the bottom right hand corner of the matrix, in cell IVE, The Tavistock Method 191 one finds the highest-ranked discourse. Here we have the intersection of “Confrontive” and “Relationship.” In this cell, there would probably be an exchange between two or more persons in which they share in risk-taking ways their ideas, thoughts, and feelings and their experience of the relationship they have with each other in the Here and Now. The traditional Tavistock group, which involves confrontive statements aimed at the whole group, would be found in cell IIE, at the intersection of the “Confrontive” row and the “Group” column. We see that Hill has given this a ranking of only moderate therapeutic value, an 8 on a 1–16 scale (see figure 12.1). Studies presented by Semmelhack et al. (2013) provide supportive findings for the idea that Tavistock style group work can be of therapeutic benefit to patients with serious diagnoses, which would seem to call this Downloaded by [New York University] at 12:41 13 August 2016

Figure 12.1 Hill Interaction Matrix was designed for making qualitative evaluations of group therapy interactions. 192 The Tavistock Method rating into question. These empirical findings are buttressed by years of experience with Tavistock groups where clear and potent therapeutic gain has been evident even though personal therapy was not the express aim of the groups. For example, Semmelhack et al. (2013) describes several studies showing significant decreases in anxiety (Beck’s Anxiety Inventory—BAI) and depression (Beck’s Depression Inventory—BDI) along with improvements in group cohesiveness (Group Attitude Scale—GAS) and self-efficacy (General Self-Efficacy Scale—GSES) in several groups conducted over multiple years in different contexts, including long-term care and group home settings. The results from our studies challenge earlier beliefs that the Tavistock model would not be therapeutic with psychiatric populations (Yalom & Leszcs, 2005). Concurrently, these results would seem to challenge the lower ranking given to group-as-a-whole type discussions that have found in Hill’s Matrix ranking—quadrant IIE (8)—a group/confrontive style of intervention. The remainder of this chapter will generate ideas as to the mechanisms that might explain the therapeutic impact of group-as-a-whole work. In addition, we will suggest that Hill’s matrix (modified so as to give a higher ranking to cell IIE) provides an excellent map for group workers of all denominations and even for psychotherapists, counselors, and educators working with families, couples, and individuals.

The Composition of the Group The group consisted of 11 members. Member Axis I diagnoses included two persons with paranoid schizophrenia, one with major depression, four with schizoaffective disorder, and four with bipolar I disorder. None had an Axis II diagnosis. All participants experienced childhood trauma including sexual, emotional, or physical abuse or neglect. All members had attempted suicide at least one time in their lives. The membership ranged in age from 30 to 70, and members were of average intelligence. Administration of the Kaufman Brief Intelligence Test (K-BIT) determined this fact at admittance into the facility (Kaufman & Kaufman, 1990). Note: The sessions are direct excerpts from transcripts constructed immediately after the session by the group leader. Hence, the flow of the

Downloaded by [New York University] at 12:41 13 August 2016 language (to some extent reflects) the nonlinear flow of the dialogue in the group-as-a-whole and the nature in which the data was recorded.

THE FIRST SESSION

This session was devoted to managerial functions and the purpose of the group, namely the examination of self-esteem in group relations. The general workings of the group were explained (see page one of this chapter) through several handouts and a brief didactic element which covered some of the basic concepts including group mentality, projective identification, The Tavistock Method 193 becoming a repository, and scapegoating. This session ended with a brief question-and-answer period.

THE SECOND SESSION

This session was reminiscent of almost every initial “Here and Now” group-as-a-whole session we have worked in. The chief concerns of the group were coping with a sense of having no directions and the attendant anxiety. There was a brief quest for a leader and then the group engaged in discussions of trust, safety, and sharing in groups. How much sharing was appropriate? Was there adequate confidentiality? At about midpoint, one of the members became loaded with anxiety and voiced that she wanted to leave the room. This was responded to with a consultation that this member was being asked to hold the anxiety for the group and take it out of the room. This consultation was responded to with some hospitality, and the group discussed further the anxiety of getting saddled with other members’ emotional baggage. After this exchange, the group shifted to norming activity in which the group attempted to set rules about listening and not putting other members down. There was little argument over these guidelines. The group ended with one member talking about an outing and another member talking about hurricanes. These were met with the consultation that this group was like an outing and there was anxiety lest a storm break out.

THE THIRD SESSION

In the second Here and Now session, the group continued to deal with issues of trust and fully joining the group. These were discussed in a derivative (metaphoric/metonymic) way and the consultations were all group-as-a-whole and consistently registered these concerns. Group members embarked on a discussion and shared of the following: “Someone stole my toothpaste; someone was rude when she bumped into me in the cafeteria; someone stole my clothes; I was betrayed by a staff member.”

Downloaded by [New York University] at 12:41 13 August 2016 The consultant responded to this discussion by stating that the group was concerned about sharing safely in this room. The group discussion following this statement focused on the good points and bad points about roommates in the facility; what made for good ones, and what made for bad ones. The consultant pointed out that the group was concerned about whether or not the current roommates, the group-mates, could be trusted. In response to this the group discussed staff members and their trustworthiness, to which the consultant responded that the group was anxious as to whether or not they could trust her, the consultant. After this consultation one member stated that she was a “tough cookie” and another responded that others were afraid of her cane. The consultant 194 The Tavistock Method pointed out that this pair was speaking for the group’s fear and consequent need for self-protection. The group then started to speak to the values of sharing and how it makes you feel better, but that they had been hurt by gossip. The consultant shared that it seemed that the group had difficulty telling the difference between sharing and gossip. This led to a discussion about the process of having to change rooms in the facility, how anxiety-producing this was and disruptive and confusing. The consultant opined that the group was talking about how this was potentially a different type of room for them, a different type of experience, and they were anxious about this change. At this point, one of the members suddenly blurted out, “Who said I am crazy?!” Other members reassured her that no one had said such a thing and that it was okay. The consultant stated that this member had spoken for the group’s anxiety at the craziness in the room. Then a member said that she needed some vodka, to which the consultant remarked that the group-as-a-whole would like to numb itself to the frightening feelings in the room. Then the discussion went to a member sharing how she had lost her father to Alzheimer’s disease. To this, the consultant responded that the group was afraid of sharing and getting close for fear of the pain of loss of something of value.

Comments This group is quite typical of many groups we have consulted with over the years. The concerns of trust, confidentiality, closeness, betrayal, and loss are very common. Somewhat less common is the sudden outburst of the fear of craziness, but anxiety of this kind is ubiquitous, perhaps just not so openly expressed. Of note is the consultant’s “steady beat” in Cell IIE” of Hill’s matrix—each and every consultation is addressed to the group-as-a-whole. They can be counted as “confrontive” insofar as they address affects, ideas, dynamics, and issues that are operating outside the group’s current awareness. The predominant technique used is that of taking the content, which on the manifest level is about something outside the room, “there and then” material, abstracting its structural properties, and applying it as a template

Downloaded by [New York University] at 12:41 13 August 2016 to the “Here and Now” situation. Essentially, the consultant is disrupting the current discourse of the group by asserting, “You think you are talking about that, but I think you might be talking about this.” Note that these hypotheses are offered as just that, hunches or guesses, interpretations that await validation or rejection by the group. Thus the consultant suggests things like, “You think you are talking about roommates, but I think you are talking about group-mates.” Of note also is the absence of explicit response by the group to the consultations. The group seems to ignore them, but this is belied by the fact that the group seems to move on and open up what might be seen as the next issue. The fact that the group moves from a position of “You cannot trust The Tavistock Method 195 people” to “I want to trust people” implies a development that can stand as a clinical validation of the consultations. In addition, we see little if any evidence in the group process of derivatives (Langs, 1977). As described by Langs the term “derivative,” indicates that the client’s talk may be taken as a commentary on the “adaptive context” in which the therapy is taking place. Langs identified different types or “orders” of derivatives. Basically, they all share the common feature that the client is making a disguised commentary on what is going on in the therapy room and its context at that very moment. For example, a client might persist in talking about a cruel and sarcastic boss who seems to insult them at every turn. While at a manifest level this can be taken as a “there and then” remark, when viewed as a “derivative” comment it may be examined as a commentary on the transference-countertransference situation operating between the therapist and client. Perhaps the client is experiencing the therapist as a critical boss or perhaps the client would like to criticize the therapist as if they are the boss. There is no solid evidence of this type of interactive dynamic taking place in the interactions that occur during this group session. We hypothesize that what we see here is called “deep listening,” but a listening to the “voice” of the group-as-a-whole, not any given individual in the group. This listening can at times appear to be a “Rogerian” listening to the group and at others times it might seem quite “Kleinian.” But it is the consistent listening to the voice of the group-as-a-whole that provides a holding environment for the creation of safety, which we anticipate will emerge in the coming sessions.

THE FOURTH SESSION

This group commenced with a discussion of alcoholism, and then the topic switched to the number of languages spoken in the group and how good people were at speaking and understanding them. At this, the consultant offered the consultation that perhaps the group was wondering what language would have to be spoken in the group in order to be understood. The group then embarked on a discussion of books and their availability in the library and the number of magazine subscriptions members possessed.

Downloaded by [New York University] at 12:41 13 August 2016 At this point, the consultant said that perhaps the group members were like ten books in fear of being opened and not being understood. Then one member stated that she needed a beer. At this point, the group started discussing different cultures at the nursing home, noting that some members were German, but they did not know about Auschwitz. The member restated that she wanted a beer. The consultant suggested that perhaps the group was anxious and uncertain as to whether the group was to be an “Oktoberfest” or Auschwitz. Members stated that the home needed to have an Oktoberfest. At this, point, a member shared that she felt that she was opinionated and that others thought she was a Nazi, but she just had strong opinions. Then another 196 The Tavistock Method member shared that her experiences when she was drunk as an alcoholic were like hell. At this, another member suggested that the group should be like an “Emotions Anonymous” group. The consultant offered that perhaps the group wanted to become an Emotions Anonymous group in order to avoid Auschwitz-type experiences that were present in the group. This consultation was followed with a discussion of the nature of sobri- ety and addictions, at which the consultant ventured that the group might be addicted to talking about addictions. The member who had been leading the discussion on addictions apologized, and the consultant suggested that perhaps this member was being used as a deflection, as a way of avoiding encountering some of the hellish experiences available to group members. Another member stated that perhaps people were covering up and pro- tecting themselves in the group. This led to a discussion of hairy legs and the shaving of them so as to look attractive or not. The consultant suggested that the group was avoiding shame around potential exposure and cover-ups. The group continued by discussing the stress and stressors they were experiencing in their lives. The consultant pointed out that, so far, one member had not spoken, and she was wondering what this member might be holding for the group. The silent member became activated by this consultation and shared that she felt like the home was a prison and that she could not get out. At this point, the other members offered advice, encouraging her to adjust, relax, try to enjoy, and seek help. The consultant responded by suggesting that perhaps the emotional part of the group was imprisoned, as if in a concentration camp, and was being told by other parts of the group to just get used to it. A discussion followed with members regarding recurrent experiences of being misdiagnosed and labeled negatively and the pain and suffering this had caused them. Then one member asked if anyone, including the consultant, had any chocolate. The consultant replied that chocolate could be sweet, but one often did not know what was in the center. The group laughed quite vigorously at this and the group ended.

Comments

Downloaded by [New York University] at 12:41 13 August 2016 Several points are nicely illustrated in this group. First the issues of a “drive” towards intimacy and sharing conflicting with issues of shame and trust are quite typical of groups at this point of development (Yalom & Leszcs, 2005). Even though the stated purpose of the group is to examine itself, pretty quickly members will decide that their aim is to get to know each other and share. The ensuing conflicts are then the material for examination. Second, we can see that the group pretty routinely migrates to the “Topic” sector of Hill’s matrix, while consultations routinely are in the “Group/ Confrontive” cell. It is always fascinating to observe how the consultant’s comments are almost routinely, blithely ignored at the manifest level while the derivative communications and the further explorations that the group The Tavistock Method 197 makes act as confirmations of the consultations when and if they are accurate. On the manifest level, there is an ignoring of the consultant but at the covert level there seems to be more collaboration. Often novice consultants have countertransference reactions to this seeming neglect of them by the group (Hazell, 2005). Third, we notice the emergence, tentative at first, of some overt collaboration between a member and the consultant. This is evidenced by a member venturing to agree with the consultant that, “Maybe we are covering things up.” It also emerges somewhat when the silent member is activated and tacitly confirms the consultations having to do with prison camps. These early ventures can be quite telling, for it often requires much courage for a group member to collaborate openly across the member/consultant boundary. In this case, she was not punished for doing so (which is a hopeful sign for the work group), but this is not always the case. Punishment in such a case might manifest itself as the group ignoring her comment or making punitive comments about her remark, such as “What are you talking about?” Any way in which the client or her remarks might get dismissed or discarded by the group-as-a-whole could be seen as a form of punishment. Fourth, we can see the consultant’s use of individual utterances as if they are confrontations of the group-as-a-whole. The silent member is clearly interpreted as “holding something for the group.” When a member apolo- gizes for leading the group in a prolonged discussion of addictions, the consultant points out that she might have been acting on behalf of the group’s wish to avoid more painful topics. Fifth, we see that the consultations are offered in a somewhat tentative voice here. This is not always the case. Consultants have different styles. We prefer to voice consultations as possibilities, hypotheses, or guesses insofar as they do not encourage the use of authoritarian defenses and stimulate a freer curiosity. Such an exercise of curiosity is directly linked to the stated task of examining covert processes in groups. If this curious nature of the group was not evident, the impingement on the work group process by negative affect would need to be reflected upon by both the consultant and the group (Bion, 2013). We also believe this approach to be in line with a more open-ended “non-foundationalist” approach more in keeping with recent developments in the use of the group-as-a-whole approach (Semmelhack et

Downloaded by [New York University] at 12:41 13 August 2016 al., 2013).

THE FIFTH SESSION

The group opened with one older male member, J, asking if the door could be left open because he was not sure that he could tolerate the intensity of the experience. The consultant offered that J might be speaking for the group’s need for relief from the pressure of being in the room. J continued to be a central person in the group, dominating much of the attention, time, and resources of the group with his sharing of his deep pain 198 The Tavistock Method and suffering. Notably, three members who were close to J seemed quite somnolent throughout. J launched into a sharing of his depression and his feelings of missing his family, particularly his brother. This took up some time, and at the end he apologized for having so dominated the group. The consultant suggested that perhaps the themes that J was touching upon were dominant for the rest of the group too. J continued sharing his profound feelings of depression and how much he missed his homeland and communications with the outside world. At this point, several members seemed to be activated and one asked J if he was married and had kids. J replied that he had neither and returned to describing his depression and his feelings of being stuck. The consultant suggested that J was holding these feelings for the group. Several members asked J about his sleep. J did not sleep well at all. Other members asked why this was so and how long this problem had been going on. J again expounded on his depression and his alienation and how he had taken up smoking again at the nursing home, even though he hated it. At this, another member shared that he was now addicted to candy bars. The consultant offered the idea that it was easier for the group to be with candy bars than with other group members. A member asked J if he prays. He replied that he was too depressed to pray. Did he have a faith? Did he go to religious services? J replied that these were no good for him. The member then asked whether J considered that any part of him might be “salvageable.” (At this point a member was called on the loudspeaker and left the group for an appointment.) The consultant suggested that perhaps the group was not feeling whole and was wondering whether it had salvageable parts. J continued by asserting that life was like a broken record, with themes repeating over and over again. At this, a member chimed in that it was bad to listen to too much nostalgic music. The consultant offered the idea that the group was having trouble listening to new music or nostalgic music in a new way. J said that he was simply feeling tormented and could not, like some people, escape through sleep. He felt lonely and the activities at the home were not distracting in a positive way. The consultant wondered aloud whether

Downloaded by [New York University] at 12:41 13 August 2016 she was being experienced as a distraction. Members replied that, no, on the contrary, they felt improvement since being in the group. J stated again that his depression was simply too deep to be relieved. Another member stated that the group is a special group and, relating back to a theme of the previous week, said, “Look, my legs are still hairy!” The consultant responded with the comment that the depression in the group was indeed very deep and the hairy legs represented anxiety and depression. The group then talked about issues of privacy. They felt exposed in the bathrooms and the showers. One member was surprised that the bathrooms The Tavistock Method 199 were co-ed. The consultant offered the idea that the group was like a co-ed bathroom. It was scary to take it all off in here. One member responded to this by saying that she felt all right about it and another said that she was terrified. The consultant stated that there was a desire to share in the group, but it was terrifying. Another member then asked whether someone had said that she should leave. This remark was responded to by a member who stated, “No, nobody said that. That was just one of your voices.” This occurred at the very end of the group, so it was not consulted.

Comments This group illustrates several interesting features. We see how J comes to occupy a central role that serves at least two functions. First, he acts as a repository for the group’s sentiments of depression and torment. Thus he acts as a “group symptom” serving at the same time as an expresser and denier of the pain in the group, a compromise formation between the wish to share these painful feelings and the wish to disavow them. As a result, the feelings of pain (in the group) end up localized in J. Why he is selected as the repository, we do not yet know. Second, we see J being treated as a patient with several well-meaning helpers in the group who attempt to diagnose, explain, and cure his malady. We see these attempts all fail. This failure acts out the belief and idea that the depression in the group is unsalvageable and can be understood as the group’s attempt to communicate this idea to the consultant. Interestingly, this sequence would perhaps be coded in Cell IIID of Hill’s matrix (that is, “Confrontive/Personal”) and would thus be ranked at 13 in therapeutic potency. In the scheme, we propose this as a defensive maneuver by the group to do “psychotherapy,” (well-meaning but ineffective attempts at mimicking popular notions of helping behaviors), that are, in our conception of reality, means of avoiding emotional pain and group dynamics. This pattern of defensiveness is quite persistent, it seems to dissipates towards the end of the group, when J mentions in a Here and Now tone of voice that he is simply tormented. At that point the “hairy legs” emerge almost as a group totem or emblem and some work resumes on the issues of sharing and the terror involved in this. Again the auditory “hallucination”

Downloaded by [New York University] at 12:41 13 August 2016 that emerges at this point is tantalizing insofar as it speaks to wishes perhaps present in the group—wishes to go away or tell other parts of the group to go away. The word “hallucination” thus belongs in quotation marks because, while on the manifest level no one said “Leave,” on the latent level, it was an accurate perception. The consistent stance of the consultant in seeing such comments from what Bion, according to Kernberg & Ahumada (2000) terms a “binocular view” (in which one sees reality from both a non-psychotic and psychotic perspective), has tremendously helpful impacts on group members as they may then feel included in the group. Our data on cohesion (Semmelhack et al., 2013) supports this contention. 200 The Tavistock Method THE SIXTH SESSION (DISCUSSION GROUP)

At the outset, the consultant announced that this session was to be a discussion group, and she read the outlines of the nature of this type of group. Namely that it was an opportunity for the group to examine in a “there and then” format the possible meanings of what had transpired in the previous “Here and Now” groups. The consultant noted that with the change in task came a change in roles and that she would be acting more in the role of a group facilitator than as a consultant. L walked in after the initial announcements and apologized for his late- ness and his absence at the last few sessions. He then went on to add that he had just seen Our Town, the play by Thornton Wilder and that he liked it. The consultant wondered whether there was a wish in the group to have it be like Our Town. The play depicts the lives of average citizens in a small town between 1900 and 1913. Perhaps the group members desired average and/or normal lives. L continued that he felt so much anxiety when being around others that he was strongly affected by the fear of rejection and whether or not he could trust others. To this, the consultant suggested that L was containing and acting on behalf of the group’s feelings of ambivalence at being in the room. Two members registered with surprise that it was already week six. They thought it was more like week two or three. Other members consulted their calendars. J interposed that he felt exhausted. He had just gotten a letter from his father, and it had disturbed him deeply. The group briefly acknowledged his distress but then dropped the topic. The consultant wondered whether perhaps the group-as-a-whole was troubled, tormented by the “sins of the father.” This intervention was acknowledged as being correct, and was followed by silence. The silence was finally broken by members speaking again to the topic of the difficulty in trusting people and the difficulty in reading people, who could be so different. The consultant said that indeed there were many differences in the room, but that perhaps one thing everyone had in common was torment. D asked the consultant directly how to deal with frustration and T asked the group for methods of raising self-esteem. The rest of the group offered suggestions—always do your best, be a good American. The conversation

Downloaded by [New York University] at 12:41 13 August 2016 then drifted to relationships with people on the outside of the institution and the difficulties encountered there. The consultation to this offered that there was extreme difficulty in finding friends, that closeness was scary, and there was a fear of being cut off again. J left the room for an outing and the consultant wondered what he may have taken with him. M shared that she had no close family left. They had all died, plus she had alienated many of them with her drinking, although she had reconciled with them before they died. K shared that she was thank- ful for her father, although she had a low opinion of her mother and her The Tavistock Method 201 two sisters. T had to leave to get a phone call. The consultant offered that perhaps all the comings and goings in the group were connected somehow to people’s mixed feelings about being in the group. In response to this, C said that she was stressed and that she did not know how to get close to members when outside the group. The consultant responded that perhaps there was difficulty in getting closer to people in this room in the Here and Now. At this, the group agreed that they had things in common. They were all depressed. They then went on to discuss addictions and smoking. There was a discussion as to whether or not smoking was a way of killing oneself. The consultant reflected that the discussion about substances revealed that they were a way of relieving the pain and anxiety over making interpersonal connections in this group in the Here and Now, and that it was as if the group had “lit up and gone outside.” This was followed by a discussion about hiding things from the group and how sometimes it was best to stay out of contact. There were so many bad things in the world—wars, terrorism, and other forms of political discord. The consultant offered that the group was anxious about closeness because maybe it would not be like Our Town; maybe it would be a war. This was followed by a ruminative silence. The silence was broken when several members recalled that this was supposed to be a Discussion Group. At this point, the consultant presented didactic material on the Johari Window—a diagram that helps distinguish between states of consciousness and unconsciousness (Luft & Ingham, 1961). This continued until the end of the group.

Comments This group shows the common phenomenon of the Discussion Group (DG) being used as a “Here and Now” group. Usually, the consultant is expected to point this out and the group typically moves into DG mode, which usually involves more cognitive, Here and Now processing. In this case, the consultant allowed the Here and Now process to continue, perhaps because the material was provocative. Certainly the comings and goings of the members were worthy of an interpretation or two, especially since it did corre-

Downloaded by [New York University] at 12:41 13 August 2016 spond so well with the continuing theme of ambivalence—the conflict in the group between the wish to connect interpersonally and the wish to remain safely isolated. One is reminded of the old joke. Question: “How do porcu- pines make love?” Answer: “Very carefully!” It is also useful and interesting to note that the group again participates in “psychotherapy,” especially in its attempts to discuss means of raising self-esteem. This, again, would occupy cell IIID or IVD of Hill’s matrix and would thus receive fairly high ratings of therapeutic potency. Given our current scheme, we would not rate it as highly therapeutic, seeing it 202 The Tavistock Method more as a social defense mechanism, almost a ritual to avoid the anxiety of being in the group with all its attendant anxieties in the Here and Now. This “pseudo-psychotherapy” is perhaps an attempt at getting close, a sort of compromise formation between the yearning for and the fear of closeness. This solution is thus a relatively ineffective one in getting at true interpersonal closeness.

THE SEVENTH SESSION (HERE AND NOW)

This group opened with the admission of a new member, Cy, who simply showed up and announced that he was seeking self-esteem. The consultant decided not to move into managerial role and allowed the new member to stay. Instead, the consultant offered that this new member in some way symbolized the group’s seeking self-esteem. J stated that the group was quite helpful to him, to which Cy responded with questions as to the role of the observer in the room, as there was a student observer seated in the corner. The group, after explaining this, entered into a discussion of difficult relationships they had outside the group. The consultant interpreted that the group was avoiding issues in the room by talking about issues outside the room. Cy mentioned that he was having problems with the religion of his roommate and asked someone in the group whether they could name her religion. Another member stated that it was not polite to ask someone his religion straight out like that. The consultant wondered whether the group was struggling with the question of how to deal with differences among members in the group. At this, a member shared that she had had a nice exchange with her daughter, who had ordered her a pizza delivery even though she was in Las Vegas. The group was surprised that this could be done, and another member stated that she left messages with her family on the answering machine. The consultant interpreted this as meaning that the group was concerned that the messages delivered in this group might be left on a machine and get no reply. Then, J stated that the consultant, in an individual session, had given him three cards that he could not understand. Would she mind explaining them

Downloaded by [New York University] at 12:41 13 August 2016 to him? He wondered if he could give them back to her now so she could read them to him. The consultant wondered aloud if the group was having trouble with her interpretations. Cy then asked the group, “How do I get self-esteem?” and the group gave several suggestions. After this Cy started talking very quickly and almost incoherently. The consultant offered that Cy was expressing the racing thoughts and feelings for the group and filling space in order to avoid dealing with something else. Cy offered up the notion to the group that God was the answer and several group members seemed to agree with this. The consultant said that it The Tavistock Method 203 was as if the group felt that God would save them from having to deal with their issues. Cy then stated that he knew someone who was getting better and might be able to move out of the home. J stated that he felt better. The consultant said that this might signify some hope in the group around having an improved capacity to deal with issues in the Here and Now. M shared that she still had a chip on her shoulder that made it difficult for her to get along with others. Cy stated that he wished he had a chip on his shoulder. It might help protect him. J said that this all made him think of wood chips. The consultant said that the group was struggling with how open to be with each other. At this point, M and D said that they had to go to the bathroom and left. This was interpreted by the consultant as expressing that the issue of how close to be is hard to deal with and that the group members have to run away from each other. Several members then stated that the group did not last long enough, and questions arose as to how many weeks there were left. The consultant stated that the group was already getting anxious about the group ending.

Comments In this group, we see the new member entering and “taking over” the group, serving a dual function, rather like any symptom, of defending against anxiety about termination while also manifesting it in symbolic form. The process shows how this is, within certain limits, still interpretable and workable, perhaps even usefully instructive. The familiar theme of closeness/fear of closeness still persists, and we notice again “pseudo-psychotherapy” with Cy, the new member, being used as its leader. Of interest in this group is the “transference derivative” interpretation regarding the comprehensibility of the consultations (whether or not they are like “pizza from Las Vegas”). There is practically no acknowledgment on the manifest level of the validity of the consultations, but the persistence of the themes in the content of the group’s discourse serves as latent validation that the consultant is on to something. Also of great interest is the acknowledgment of the end of the group, some

Downloaded by [New York University] at 12:41 13 August 2016 three weeks away. This, as any clinician knows, can be of tremendous therapeutic value (Yalom & Leszcs, 2005). In the context of a “Here and Now” group, it often has existential overtones, involving themes like the “courage to be,” time, opportunities slipping away, existential guilt, and so on.

THE EIGHTH SESSION (HERE AND NOW)

This group embarked on a discussion of their parents. There was talk of mothers and fathers who were “mean” and “absent,” of parents who took 204 The Tavistock Method them camping when they did not want to go, and one member spoke in strong terms of his mother, whom he wished to leave but could not because she “had her claws in him.” The consultant responded to this data by positing that the group might have a not so good mother in it. And that the group would like to get rid of this mother but could not because she had her claws in it. At this, one member asserted that her mother was good. This then led to a discussion of jail and how hard it was to trust others in jail. A poll was taken, and it emerged that all but one of the group had spent some time in jail. The consultant wondered aloud whether something was locked up in the group. A member responded to this consultation by wondering whether it was feelings that were locked up. J responded to this with a description of his deep depression, and he wondered whether he should go to the hospital for further treatment. The consultant proffered the idea that J was perhaps containing some feelings for the group, something they would like to send to the hospital. At this point a cat entered the room. The group was suddenly suffused with warmth. “I love cats!” exclaimed one of the members. The consultant asked what the cat had brought into the room, wondering whether it was caring and warmth, perhaps. The group seemed to agree with the consultation, but continued to discuss how trust and being open was difficult. This led to complaints about the lack of privacy in the home. J then re-embarked on how he was filled with rage and further described his depression. The consultant offered that again J was acting as a container for the group’s feelings of depression and rage. The group then talked about believing that it was going in circles with regard to trust. A feeling of hopelessness emerged in this regard, and Cy then stated that the group just needed to stay focused on the positive things. The consultant said that the group was circling some very painful feelings like anger and sadness. Then C stated directly to J that it was difficult to get to know him because he was so negative. Others agreed with this observation. The consultant intervened with the idea that the group was having difficulty getting into contact with the depressed parts of itself.

Downloaded by [New York University] at 12:41 13 August 2016 J said that he did want advice from the group, but had problems putting the advice into action. Cy stated that the consultant should stop frowning or the wrinkles would become permanent. Other members questioned Cy on this comment, “Why would he say such a thing?” The consultant responded that perhaps Cy was speaking for the group that wanted better advice from her, that they wanted a consultant who was more giving. The group vigorously asserted that they did like the consultations. Then they discussed ways to relieve oneself of raging feelings. Someone mentioned that when he was in rehab there was an anger room, padded and devoted to this purpose, where one could go and hit things with a bat. The consultant wondered whether the group felt as though it needed an anger room, but The Tavistock Method 205 was afraid of being emotionally beaten up. Perhaps it was easier to go to rehab than to have feelings. A member asked whether anyone could go to the women’s issues group. The consultant, who had noticed that the discussion thus far had been dominated by women, remarked that the women’s group seemed to be alive and well in this room. The group then discussed this fact and that there were more women than men and how the men’s agenda might not be addressed. Cy then said that she wished to raise her self-esteem, that she felt stuck in a puddle and could not raise herself up. The consultant offered that Cy was perhaps speaking for the group, that it felt stuck in a puddle, unable to move up.

Comments Again, the consultant stays solidly on task and gives group-as-a-whole comments throughout the session. Of note is the recurrence of the theme of trust and how the members continue to wrestle with it. Of interest are the following consultations: (A) The idea that there is a “bad mother” in the group, which can be interpreted that the group is struggling with a “bad object” inside of the group. This bad mother object probably has to be addressed in some way before trust can emerge. (B) The use again of the discourse of the individual as representing something that is a concern for the group. In this case, the prime example would seem to be J and his deep depression. (C) The continued use of Cy by the group as an “anti-work leader” and the par- adoxical utility this has for the consultant (Klein & Astrachan, 1971). For example, Cy criticizes the consultant’s frown, is rebuked by some members, but is interpreted as having spoken for the group’s dissatisfaction with the consultations. This would be an example of working with the group’s negative transference and, in accordance with Kleinian suggestions (1975), this negative transference would have to be worked through before trust could emerge. (D) The entrance of the cat illustrates a fairly common phenomenon of group life, namely the interruption of the group by an incursion from the surrounding context—a boundary crossing. We can see that this causes an emotional response in the group, as if something emotional had been brought into the room. The consultation seems to arouse curiosity about this.

Downloaded by [New York University] at 12:41 13 August 2016 Also of interest in this group is the direct confrontation of J by C regarding the difficulty of connecting with J because of his talk of depression. This, in Hill’s matrix, would score very highly, probably IVE “Confrontive” and would be rated as potentially having a strong therapeutic impact. It demonstrates risk taking, intimacy, and some building of trust in the group and is probably the best example of this type of interaction thus far in the group. Our understanding is that such impactful interactions occur as a matter of course in a “working group” (Bion, 1961), that is, one where group-as-a-whole interpretations are used relatively frequently. When such risks are effective, they create deep safety, especially from scapegoating (Bion, 1961). 206 The Tavistock Method THE NINTH SESSION (HERE AND NOW)

Ten members were present at this group, prior to which K asked the consultant whether it was all right to distribute a questionnaire on self-esteem. The consultant responded with the idea that she wished to give self-esteem to the group. As the group started, several members noted that the student/observer was absent. The consultant noted that she felt angry at this. K then dis- tributed the questionnaire she had brought to the group. The consultant pointed out that perhaps the group wished to share not only questionnaires but also self-esteem. Several members continued to wonder where the observer was and J again stated how very depressed he felt. P joined in, stating that he too felt depressed. Still others shared that they had found out about new medications. Others stated that nothing worked. Someone mentioned that there was a radio show doctor who sometimes offered help. Yet other members stated that they felt all right. The consultant responded by offering that perhaps it was easier to deal with hopes of magical cures and to deny the depression in the room than it was to cope with the Here and Now. K mentioned that his brother had died and that she missed him. J stated that he was so depressed that he wished he was dead. This led to a discussion of what people would like to have done with their bodies when they died. Some wanted to be cremated; others wanted to be buried. To this the consultant suggested that this was session nine. It was to be the last “Here and Now” session and the sequence of ten groups ended next week. Perhaps this current concern with death had to do with the “death” of the group. Several members responded to this consultation with wishes, hopes, and ideas of another sequence of groups to follow this one. J again commented on his depression and deep sense of isolation. C told J that she was tired of always talking about depression. J apologized, and C said that she was getting depressed listening to this talk. This was followed by a discussion of how positive thinking could improve physical health. The consultant ventured that the group seems to be thinking that it might have some curative powers. C said that the group members might indeed have the power to heal each

Downloaded by [New York University] at 12:41 13 August 2016 other. At this, J took off his hat and the group shared its astonishment at how much hair he had. The consultant offered the idea that if the group took off its metaphoric hat, it would find that it had more resources than it thought it did. F then remarked that perhaps the group was about taking off masks and revealing their true selves. Another member stated that she was hurt when people often made her feel cut off. M mentioned that there were so many inappropriate people in the home. K agreed, stating that you never knew what people might say. The consultant offered that perhaps people were in fear of being inappropriate in this room. The Tavistock Method 207 K stated that everyone was all right in this group. Then several members wondered where the observer was. Someone said that perhaps the observer did not come to the group because she did not like the members. Another one offered that perhaps the observer was not there because she was afraid of them. The consultant shared the idea that there was a lot of fear in the room and the absent observer symbolized the wish present in the group to be absent, to get away. Cy then said that he felt good. P said that you had to have hope. The group ended and several members stated that it had ended too soon.

Comments We see in this group the discussion of death, which is a common topic towards the end of a group or during phases of the group life that are experienced as milestones (Hazell, 2005; Yalom & Leszcz, 2005). Also common is the wish for more life or an afterlife and some regret over time not having been spent well. The trust issues continue, but these are linked to feelings of hope and ideas about hidden resources in the group. On the other hand, there is a deep and frightening pool of despair that threat- ens to overwhelm these resources. These ideas are all responded to at a group-as-a-whole level and the group, although it felt interrupted, seemed to want more sessions.

THE TENTH SESSION (APPLICATION GROUP)

The observer handed out sheets containing information on the next sequence of groups, and K read it to the group since some members had not brought their spectacles. Someone asked when the party was to occur and the consultant wondered if the party had already started. Several members said they wanted to continue in the next sequence of ten groups and complained that the gap before the start of the next sequence was too long. Another member asked when the next group was to start. The consultant wondered whether there was anxiety in the group about being separated from the group.

Downloaded by [New York University] at 12:41 13 August 2016 At this point T came in, very anxious at being late and explaining that she had been looking for a battery for her hearing aid. J then shared that he felt profound anxiety and depression and that if he were to die of a heart attack today he would be “satisfied.” P said that she was sad to hear J say that, but that she felt depressed too. The consultant offered the idea that perhaps the group was broken-hearted at the group coming to an end. J agreed with this consultation and further shared that he was gay and that he was very sad and angry over his sexuality. Other group members assured him that his being gay was all right with them and that they had friends, relatives, and others in their life who were gay and that it was fine. 208 The Tavistock Method The consultant offered that perhaps J was sharing parts of the group that related to the anxiety of being rejected. At this, a discussion developed around the question, “Is it normal to want to die?” The consultant offered that this discussion might be related to the impending “death” of the group. Several members then stated that they enjoyed the group. This developed into a discussion about Thanksgiving, which was approaching. M then stated that she had wanted to die when she was an alcoholic and when she was a burden to others. Now she was not drinking alcohol and did not want to die. She prayed that the Lord would take care of her. K chimed in that she was about to go to Ohio and that she was on an antidepressant that was helping her. The consultant contemplated that, on a metaphoric level, the group member was talking about how the group helped members get into different “states” of mind. Furthermore, the consultant hypothesized that a state of “union” had developed between group members over the last ten weeks that was supportive to the group-as-a-whole and there was gratitude and thanksgiving for this sense of cohesiveness. J inquired about the medication that had helped the other member’s depression and this opened up a discussion about different medications, their effectiveness, and effects. The consultant wondered whether this discussion was a covert way of talking about the medicinal effects of the group. M said that she refused to take any pain medication for fear of becoming addicted. D interposed that the topic was antidepressants, not pain pills. M replied that she knew and added that talking certainly helped. C then asked the group whether it was the voices in her head or people in the group who were telling her not to come back to the next set of groups. The rest of the group quite vigorously asserted that it was the voices in her head saying this. They for sure wanted her back in the group. C was reassured by this. The consultant stated that perhaps C was speaking for everyone’s fear that they might be rejected, that there was a desire to share with the group but also a fear of rejection. T again said that she was very sorry for being late at the start of the group. She was panicked when she could not find batteries for her hearing aid. Other members reassured T that this was all right and that they were glad she was here. The consultant offered that listening was really important

Downloaded by [New York University] at 12:41 13 August 2016 to the group, as well as belonging. J stated that he still felt very depressed and as though nothing would help. The group ended, and there was an informal reception of coffee, tea, juices, and snacks.

Comments This group was intended to be an application group where what was learned from the “Here and Now” sessions can be perhaps applied to other situations. As it turned out, this group, after a few managerial communications at the outset, was more of a Here and Now group. This often The Tavistock Method 209 happens, as the group itself seems reluctant to change tasks (Hazell, 2005). Consultations can be made regarding this behavior. In this case, no consultation was made and some interesting and perhaps useful work was done on termination. Once again all of the consultations were in cell 8 of the Hill matrix. The concerns in the group continued on the theme of death, which was interpreted by the consultant as having to do with the group ending. There was also a good deal of concern in evidence regarding ostracism, which was linked to a member sharing some previously private information. Also of interest here are the consultations built upon puns: state (of the union) versus state (of mind) and Thanksgiving (as celebration) versus thanksgiving (as gratitude). Given Klein’s ideas on the depressive position and its developmental importance (1946), the mention of feelings akin to gratitude can be taken as very significant and hopeful.

CONCLUSION

We trust we have demonstrated the manner in which a therapeutic group-as- whole interaction can take place with persons carrying diagnoses of severe mental illness. Empirical research in the book by Semmelhack et al. (2013) demonstrates that such work is of therapeutic value. We considered the interaction structures underlying this successful group and made comments that may be helpful to those who wish to pursue a similar practice. In addition, we used the Hill Interaction Matrix (Hill, 1971, 1977) to help show the value of the group-as-a-whole interaction. We believe we showed that the process in the groups was in Cell 8—IIE (characterized by confrontational and group components). We also argued that, since it had such a marked beneficial impact on the measured levels of depression, anxiety, cohesiveness, and self-efficacy, the Hill Interaction Matrix (Hill, 1971, 1977) ranked such group processes too low in therapeutic effectiveness. Exactly where it should be ranked is an entirely different problem and one too large to be adequately dealt with here. We do believe, however, that the Hill Matrix itself provides an excellent map of group interaction dynamics that is of great usefulness to practitioners. Downloaded by [New York University] at 12:41 13 August 2016

FUTURE RESEARCH

More recently, our team has extended previous research on small Tavistock process groups to include the large group structure. Large groups typically include more than 12 members. The large group model has been implemented at the same institution where small group research had been conducted in the past and is described earlier in this chapter. Five large groups have been held on a monthly basis to date. The groups have included between 15 and 20 members and are facilitated by three consultants. All large group 210 The Tavistock Method members are participants in the small Tavistock processing groups that continue to be conducted in the facility. Preliminary qualitative findings suggest that the large group has had a positive effect on the membership. These findings include comments by members taken from transcripts, highlighting the importance of community in fostering change. One member commented about how much “we really do need each other,” and how coming together as a large group highlighted this fact—specifically the need for friendship. Other comments made by group members suggested that they found the group enjoyable and looked forward to getting together on a monthly basis. Another member indicated that the large group made him feel supported and validated—support of an individual’s desired identity. Quantitative research is planned to support the large group model in decreasing anxiety and depression and fostering a sense of cohesion and self-efficacy, as already substantiated by our small group studies.

REFERENCES FOR CHAPTER 12

Banet, A. G., & Hayden, C. (1977). A Tavistock primer. In J. E. Jones & J. W. Pfeiffer (Eds.), The 1977 annual handbook for group facilitators (pp. 155–167). La Jolla, CA: University Associates. Bion, W. R. (1961). Experiences in groups. London: Tavistock. Bion, W. R. (1962). Learning from experience. London: Heinemann. Bion, W. R. (2013). Experiences in groups: And other papers. New York: Routledge. Chessick, R. D. (1995). Heidegger’s “authenticity” in the psychotherapy of adolescents. American Journal of Psychotherapy, 50(2), 208–216. Cooper, G. (1996, February 22). Schizophrenia high toll of stigma and lack of family network. Retrieved from http://www.Independent.co.uk/news/ mentally-ill-do-better-inthis Harrison, T., & Clarke, D. (1992). The Northfield experiments.The British Journal of Psychiatry, 160(5), 698–708. Hazell, C. (2005). Imaginary groups. Bloomington, IN: Authorhouse. Hill, W. F. (1971). The Hill Interaction Matrix. The Personnel and Guidance Jour- nal, 49(8), 619–622. Hill, W. F. (1977). Hill Interaction Matrix (HIM): The conceptual framework, derived rating scales, and an updated bibliography. Small Group Behavior, 8(3), 251–258. Hinshelwood, R. (2001). Thinking about institutions: Milieux and madness. Lon- don: Jessica Kingsley Publishing.

Downloaded by [New York University] at 12:41 13 August 2016 Kaufman, A. S., & Kaufman, N. L. (1990). K-BIT: Kaufman Brief Intelligence Test manual. Circle Pines, MN: American Guidance Service. Klein, E. B., & Astrachan, B. M. (1971). Learning in groups: A comparison of study groups and T groups. The Journal of Applied Behavioral Science, 7(6), 659–683. Klein, M. (1946). Notes on some schizoid mechanisms. The International Journal of Psychoanalysis, 27, 99–110. Klein, M. (1975). Envy and gratitude and other works. Madison, CT: Delacorte Press. Langs, R. (1977). The therapeutic interaction: A synthesis. New York: Jason Aronson. The Tavistock Method 211 Lee, F., & Bednar, R. L. (1977). Effects of group structure and risk-taking disposi- tion on group behavior, attitudes, and atmosphere. Journal of Counseling Psy- chology, 24(3), 191–199. Luft J., & Ingram, H. (1961). The Johari Window. Human Relations Training News, 5(1), 6–7. Main, T. (1977). The concept of the therapeutic community: Variations and vicissi- tudes. Group Analysis, 10(2), S2–S16. doi:10.1177/05331647701000212 Malcus, L. (1995). Indirect scapegoating via projective identification and the mother group. International Journal of Group Psychotherapy, 45(1), 55–69. Miller, J. B., Jordan, J. V., Stiver, I. P., Walker, M., Surrey, J. L., & Eldridge, N. S. (2004). Therapists’ authenticity. The complexity of connection, 82, 64–89. Rice, L. N. (1965). Therapist’s style of participation and case outcome. Journal of Consulting Psychology, 29(2), 155–160. Schmid, P. (2001). Authenticity: The person as his or her own author. Dialogical and ethical perspectives on therapy as an encounter relationship. And beyond. Evolution, Theory and Practice, 1, 213–228. Seikkula, J., & Olson, M. E. (2003). The open dialogue approach to acute psychosis: Its poetics and micropolitics. Family Process, 42(3), 403–418. Seligman, M., & Sterne, D. M. (1969). Verbal behavior in therapist-led, leaderless, and alternating group psychotherapy sessions. Journal of Counseling Psychology, 16(4), 325. Semmelhack, D., Ende, L., & Hazell, C. (2013). Group psychotherapy with severely mentally ill adults: Adapting the Tavistock method. London: Routledge. Semmelhack, D., Hazell, C., & Hoffman, W. (2008). The impact of group-as-a-whole work on anxiety and depression in a severely mentally ill population. The Journal for Specialists in Group Work, 33(1), 43–60. doi:10.1080/01933920701798554 Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York: Basic Books.

This chapter reflects on the major group of interaction structures described in this book. We first identify what we have referred to as the institutional structures, the family structures, and the structures of friendship.

Figure 13.1 Institutional structures that hinder and promote growth Downloaded by [New York University] at 12:41 13 August 2016

Figure 13.2 Family structures that hinder and promote growth Synthesis: Reflections on the Structures of Interaction 213

Figure 13.3 Friendship structures that hinder and promote growth

The items listed above as a whole suggest that interaction structures that stifle psychological growth confront the person with psychiatric disabilities at every turn, on all levels of society. Also suggested, however, is that forms of interaction that promote growth for people diagnosed with severe mental illness may exist on all levels of society. Our formulation of structures, those just listed, as well as those in the list of more general structures below, do not provide absolute categories but tendencies. What fosters growth in one context, for example, may prevent growth in another. These lists are by no means definitive or comprehensive. We would like the categories to encourage reflection on the role of interaction dynamics in the psychological lives of those diagnosed with severe mental illness. The structures we have formulated depend on the choices we have made in our project and how we chose to write about the project. Our experience as clinicians working with this population, however, leads Downloaded by [New York University] at 12:41 13 August 2016 us to the conclusion that these interaction structures do play critical roles in clients’ lives. Based on our analysis of the cases, we have compiled a list of general interaction structures that promote or hinder growth for those with psychiatric disabilities. These structures are not necessarily linked with institutions, families, or friends of the clients. The structures are as follows: Figure 13.4 Interaction structures that tend to promote psychological damage for clients Downloaded by [New York University] at 12:41 13 August 2016

Figure 13.5 Interaction structures that tend to promote psychological growth for clients Synthesis: Reflections on the Structures of Interaction 215 The structures listed above represent widespread patterns for clients with severe mental illness, the latter half for clients who have successful treatment. Similar to the structures that promote growth, the structures that hinder growth occur in institutions, families and within interpersonal relationships. Some conclusions we have drawn from these structures include:

1. The interaction structures cited tend to play a significant role in the client’s mental illness or recovery, and often in their lives. Social interaction, the cases show, forms a very important part of what is ordi- narily thought of as an “illness”—mental illness—and forms a central component of its treatment. Acknowledging this can open up new treatment options. 2. We have found that practically all of the structures listed above occur in all eight cases. We describe for each case specific roles that the interaction structures play in the clients’ lives. Interestingly, most of the interaction structures, in one context or another, apply to most people, including those not described or having been diagnosed as having a mental illness. 3. Describing mental illness in terms of social interactions may therefore help those without a mental illness, mental health practitioners, for example, to identify with and empathize with those who do have a mental illness. In addition, whereas framing the clients’ problems in terms of diagnoses, or as disorders based on internal structures, can make the problems seem inevitable, framing the problems as interaction dynamics shows that they are potentially avoidable, or treatable. Seeing the problems in this way can also increase empathy for the clients. 4. Interaction structures can often be “treated” more readily than other components of a mental illness because these structures highlight the relatively superficial, or surface, dimension of a psychological problem. This dimension of a problem is more conscious, more accessible, and to a significant degree more external than the deeper dimensions. For the deeper dimensions include more primitive affects and the psychological imprints of a client’s entire life history,

Downloaded by [New York University] at 12:41 13 August 2016 a history deeply rooted in its childhood origins. These two dimensions of a psychological problem relate to Mitchell’s (1988) distinction between two major dimensions of a “relational matrix” that are fundamentally intertwined—the interpersonal and the intra-psychic. Changes in the interactional dimension affect the deep dimensions of the psyche.

The most general structure of interaction that stifles growth for individuals diagnosed with severe mental illness in our society appears to be projection, including projective identification. A basic reliance on projection 216 Synthesis: Reflections on the Structures of Interaction onto those treated as crazy often begins when the future client is at a very early age and in many ways this projection is perpetuated by many people, including institutions that treat people with mental illness. In fact, projection appears to feed, if not to underlie, all of the damaging structures we have discussed. Two very widespread structures of interaction that promote growth are Rogers’ (1957) facilitating conditions for psychotherapy and the act of helping the client to develop new internal objects. Much research supports the effectiveness of Rogers’ facilitating conditions as a foundation for all forms of therapy (Cain, 2010; Kirschenbaum & Jordan, 2005). These conditions, empathy, congruence, and unconditional positive regard, are practiced by professionals and non-professionals in growth-promoting conversations. The immense impact that Rogers has had on the contemporary practice of therapy in the U.S. is not often recognized. The act of helping someone to develop a new internal object happens all of the time in friendships and between lovers. Whether or not they intend this, therapists function to help create “good” internal objects in clients who may be afflicted by their “bad objects.” Creating aholding environment, for example, evokes a positive internal object.

GROWTH IN GROUPS

Finally, we would like to emphasize the powerful effect that groups have on fostering the growth of individuals diagnosed with severe mental illness. As we have shown in the institutional dynamics chapter, the group dynamics of an institution can do much to prevent growth for their clients but they have also shown reason for hope. Tavistock groups made a significant difference in a number of the individual cases we have presented in chapters 4 through 11. In addition, friendships grew out of the Tavistock groups. As we noted in chapter 12, the ongoing presence of a Tavistock group for psychiatrically disabled clients in a nursing home appeared to make the entire facility a warmer and more caring environment. Open Dialogue, stressing multi-voiced conversations, has had tremendous success as indicated by its solid outcome studies (Seikkula, & Olson,

Downloaded by [New York University] at 12:41 13 August 2016 2003). Despite the difficult social and financial environment for supporting the existence of therapeutic communities, a number of them continue to exist, to develop, and to argue consistently for their effectiveness. The New Foundation Center is a therapeutic community based partly on the clubhouse model (Beard, Propst, & Malamud, 1982). This model emphasizes respect for the client. The presence of a warm, caring, and inviting ambi- ence in the New Foundation Center has created a kind of haven for clients diagnosed with severe mental illness. As we have shown in the institutional dynamics chapter, the group dynamics of an institution can do much to Synthesis: Reflections on the Structures of Interaction 217 prevent growth for their clients, but therapeutic groups we have described have also shown much reason for hope.

REFERENCES

Beard, J. H., Propst, R. N., & Malamud, T. J. (1982). The Fountain House model of psychiatric rehabilitation. Psychosocial Rehabilitation Journal, 5(1), 47–53. Cain, D. (2010). Person-centered psychotherapies. Washington, DC: American Psy- chological Association. Kirschenbaum, H., & Jourdan, A. (2005). The current status of Carl Rogers and the person-centered approach. Psychotherapy: Theory, Research, Practice, Training, 42, 37–51. Mitchell, S. A. (1988). Relational concepts in psychoanalysis: An integration. Cam- bridge, MA: Harvard University Press. Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic change. Journal of Counseling Psychology, 21(2), 95–103. Seikkula, J., & Olson, M. E. (2003). The open dialogue approach to acute psychosis: Its poetics and micropolitics. Family Process, 42(3), 403–418.

Severe mental illness presents a growing and costly problem in the U.S. The gravity of the problem and the cost to society warrant reflection on how to effectively treat a population that, for the most part, is deemed invisible—locked away in jails or nursing homes, homeless, or otherwise marginalized. Besides the tremendous financial burden to society (over $193 billion in lost earnings annually due to severe mental illness [Insel, 2008]), we undergo an intellectual loss as well. Many of the most innova- tive ideas that have shaped society have come from the minds of individuals considered to be severely mentally ill. Artists, writers, and thinkers such as Winston Churchill, Vincent Van Gogh, Virginia Woolf, and Abraham Lin- coln have been deemed by society to be “mentally ill” (A. Adkins, personal communication, October 22, 2014). Today we treat many talented individuals with severe mental illness as simply “sick,” “crazy,” or “insane.” Their sense of themselves as “artists,” “writers” “scientists,” etc. is lost. They are often locked away in institutions, their ability to contribute to society cut off. We need treatments to help these people regain their sense of themselves as creative individuals. In the U.S., mental health professionals treat individuals with severe mental illness primarily with medication. Professionals will recommend psychotherapy—individual or group therapy—at times as a possible secondary treatment. However, group and individual therapy are costly and therefore not accessible to many individuals who need these services but simply do not have insurance that will cover these treatments. What is more, when

Downloaded by [New York University] at 12:41 13 August 2016 we do provide these secondary treatments, professionals often see them chiefly as a way of encouraging clients to regularly take their medication (Stroup, 2014). Furthermore, in the U.S. the bar is held very low in terms of what is considered recovery—generally the abatement of the most attention getting acute symptoms, hallucinations or delusions, with outcome being very poor in many cases (Mitelman & Muchsbaum, 2007). Very little attention is paid to the quality of life of individuals with severe mental illness. Personal and emotional growth is frequently not taken into account during treatment (Levine, 2012). Conclusion 219 This book has highlighted a treatment factor perhaps as important as medication but that tends not to be recognized as such. This factor consists of the interactions that encourage the client’s growth, rather than contributing to or perpetuating psychological injury or deficits. We investigated the clients’ whole relational world, including relationships with institutions, families, friends, and others. Humans are social beings; we need other people. The quality of our interactions in our world impacts on our emotional and physical well-being, whether or not we have a mental illness, but probably even more so for those whom society labels “insane.” We conclude that social institutions that encourage growth, as opposed to those that depersonalize or dehumanize people with severe mental illness, fundamentally influence their recovery. While we touch upon the role of larger-scale social dynamics, such as institutional policy, our major focus has been on social interactions, which are interlinked with these larger-scale dynamics. Our concern, to a large degree, is with how people talk to each other. This emphasis foregrounds the role of human agency in creating environments. We have addressed the types of social interactions that encourage growth for people with severe mental illness and the types that promote or maintain psychological damage. We have tried to expand the narrow view of what a mental illness is. Rather than perceiving it to be purely a diagnosis based on DSM criteria, we attempt to view mental illness as something that is manifested within an interaction dynamic. The mental illness is maintained (in addition to within the biological realm) through a myriad of negative interaction dynamics that engulf the client. The myopic view of psychopathology that most mental health professionals maintain, focusing solely on biology, removes the disorders from the relational contexts within which they are embodied (Rosenhan, 1973). Psychopathology does not exist purely within an individual. Rather, it manifests in individuals who are part of complex webs of interactions within institutions, families, and friendships. People with mental illness are directly impacted by the quality of the interactions that transpire within their worlds; in fact, we all are. For example, the work of Seligman (1975) demonstrated the impact of experiences of helplessness on levels of mood-regulating neurohormones. Human beings are group animals who thrive on interaction and whose

Downloaded by [New York University] at 12:41 13 August 2016 very existence depends on their communication with others (Bion, 1961). Medications do alter people’s biology in ways that reduce psychopathology. However, you can’t have an interpersonal relationship with a pill. One’s personality, sense of self, and humanity are to a significant degree the product of the quality of her interactions with those around her. The quality of these interactions influences the biological functioning of these individuals’ psyches (Hammack, Cooper, & Lezak, 2012). It would limit the scope of this volume to describe the current state of interaction dynamics for the severely mentally ill in the U.S. without giving 220 Conclusion some consideration to international perceptions. To give the reader a sam- pling of international interaction dynamics, we asked mental health experts from across the globe to describe the role of interactions in severe mental illness with regard to their countries. We received personal communications from mental health professionals in Australia, Hong Kong, Italy, South Korea, Poland, Romania, and Tur- key. The countries were chosen because they follow a basic Western model, which is colored and enhanced by their particular culture.1 What we emphasize here are common trends of interaction dynamics in the aforementioned countries. Our discussion is brief. In progress is a further manuscript in which we will be repeating this model in greater detail with representatives of over 30 countries. In all of the countries surveyed, stigmatization and depersonalization of the severely mentally ill population is present to a greater or lesser degree. In countries where there is a strong biological view of severe mental illness, such as Poland, stigmatization and depersonalization of the population is greater than in those countries emphasizing more psycho-social approaches, such as Romania, Turkey, Australia, and Italy. In countries with strong biological leanings there is great emphasis on medication and much lesser consideration of psychotherapy or other interactive treatment strategies such as group therapy. In Australia, the groundwork is set for an anti-stigmatization movement with a government-wide initiative of “inclusion” in place that has not yet been actualized. Italy is one of the best examples of the countries sampled; there is a strong view that treatment involving peer, family, treatment team, and patient interaction is central to recovery. In most cases, Italian mental health providers view pills as a symptom remedy rather than a true therapy. In Italy, emphasis is given to patients’ inclusion in treatment planning. Ulti- mately, mental health experts make final decisions for patients in terms of treatment plan and medication management. The Italian perspective stands in stark contrast to most of the other countries represented, where symptom management, versus the facilitation of personal and emotional growth, is emphasized. Involvement of the family is another consideration and is also noted to be important in Australia, Italy, Poland, Romania, South Korea, and Turkey. In

Downloaded by [New York University] at 12:41 13 August 2016 many instances in these particular countries, families become the caregivers of the individual with severe mental illness. What varies greatly between countries is the degree to which mental health professionals intervene in helping the family in the treatment of the person, versus using the family as a place to hide the severe mental illness individual away from society. Turkey, Australia, and Italy have given some emphasis to education of the family in understanding the illness such that the family can be placed—to some extent—in the role of co-therapist. This trend toward family involvement and more emphasis on a bio-psycho-social perspective in treatment is in fledgling stages in all of the countries mentioned—with the exception of Conclusion 221 Italy. Poland stands out as a country strongly embracing a purely biological model. Currently in Poland, psychiatry and psychology are not well understood and given sufficient recognition and resources to meet the needs of the population. In an upcoming volume we hope to elaborate more on the quality of interactions with severe mental illness by professionals on an international basis. For now, it is safe to say that stigmatization and depersonalization are universal problems in most developed countries. Recovery rates are not what we would expect in first and second world countries. According to Cooper (1996), in a study carried out by the World Health Organization, recovery rates for schizophrenia are much higher in the third world. This high recovery rate in countries like Nigeria, Agra, and north India is attributed to strong support networks and a lack of stigma (Patel, Cohen, Thara, Gureje, 2006). Clearly, the role of interaction dynamics in the treatment of mental illness is a topic that needs greater exploration internationally. In the spirit of the recovery movement in mental health, we hope to have shown that understanding the role of interaction in recovery could lead to more effective treatment. Improvements might involve increased awareness of the effects of social interaction, greater attention to this interaction in individual and group psychotherapy, and attention to how therapeutic work can include, address, and impact clients. Also, the development of friendship through the increased use of family interventions, greater use of peer support, and more employment of therapeutic communities needs to be addressed. Additional widespread use of groups in long-term care—especially groups that cultivate open interaction among members rather than, for example, psycho-educational groups—could help clients to improve their relationships with each other. As suggested in the majority of cases in this volume, the combination of group and individual therapy, as well as family and/or peer support, provides holding environments in which the severely mentally ill person can find a reprieve from the at times harsh treatment of the mental health environment. This process takes place, for example, in the case of Rose, the woman who lost her son in a boating accident. Rose’s relationships with peers in a nursing home act as an antidote to the harsh treatment by staff. Another example is the case of Martin, the depressed

Downloaded by [New York University] at 12:41 13 August 2016 man in chronic pain, whose client-centered therapy provided a safe haven within which he could express repressed feeling somaticized in his body without any threat of retribution from staff. Mental health policy makers could benefit greatly by examining highly effective approaches to mental illness such as Open Dialogue (Seikkula & Olson, 2003) or the Tavistock Model (Semmelhack, Ende, Hazell, 2013), which emphasize the importance of interaction dynamics in recovery. Edu- cators need to focus more on the contextual nature of mental illness, seeing it less as a product of a person’s biology when teaching future providers. An understanding of the role of interaction dynamics in facilitating, versus 222 Conclusion hindering, client recovery could contribute to better outcomes for individuals diagnosed with severe mental illness. Finally, we argue that our analysis of interaction structures highlights that treatability of severe mental illness, promotes empathy for those who have such conditions, and can suggest new approaches for treatment. We would like to end by noting the need for writings and speech that support alternatives to mainstream opinion on the treatment of severe mental illness. The Internet does not easily yield such points of view. We need to support the transformative means of interaction in the treatment of mental illness and consider the possibility that mental illness as a construct is supported and maintained within an interaction matrix. Our motto is “treat the interaction.”

NOTES

1. We would like to thank our international partners who treat the severely mentally ill for their responses to our questions concerning this population in their country of origin. This was not a formal research investigation, but more a simple survey of opinions in the international field. Note: These individuals are also cited in the acknowledgements section of this document. Australia (the late A. Kidman & R. Murrihy), Hong Kong (W. Wong) Italy (T. Scrimali), South Korea (Y.H. Choi), Poland (A. Kokoszka), Romania (D. David), and Turkey (M. Sungur).

REFERENCES

Bion, W. R. (1961). Experiences in groups. London: Tavistock. Hammack, S. E., Cooper, M. A., & Lezak, K. R. (2012). Overlapping neurobiology of learned helplessness and conditioned defeat: Implications for PTSD and mood disorders. Neuropharmacology, 62(2), 565–575. Insel, T. (2008). Assessing the economic costs of serious mental illness. American Journal of Psychiatry, 165(6), 663–665. Levine, B. (2012). Anti-authoritarians and schizophrenia: Do rebels who defy treatment do better? Retrieved from http://www.madinamerica.com/2012/05/ anti-authoritarians-and-schizophrenia-do-rebels-who-defy-treatment-do-better/ Mitelman, S., & Buchsbaum, M. (2007). Very poor outcome schizophrenia: Clinical and neuroimaging aspects. International Review of Psychiatry, 19(4), 345–357. Downloaded by [New York University] at 12:41 13 August 2016 Patel, V., Cohen, A., Thara, R., & Gureje, O. (2006). Is the outcome of schizophrenia really better in developing countries? Revista Brasileira de Psiquiatria, 28(2), 149–152. http://dx.doi.org/10.1590/S1516–44462006000200014 Rosenhan, D. L. (1973). On being sane in insane places. Science, 179(4070), 250–258. Seikkula, J., & Olson, M. E. (2003). The open dialogue approach to acute psychosis: Its poetics and micropolitics. Family Process, 42(3), 403–418. Seligman, M. (1975). Helplessness: On depression, development, and death. A series of books in psychology. New York: WH Freeman/Times Books/Henry Holt & Co. Semmelhack, D., Ende, L., & Hazell, C. (2013). Group psychotherapy with severely mentally ill adults: Adapting the Tavistock method. London: Routledge. Conclusion 223 Stroup, T. S. (2014). Comparative effectiveness of adaptive pharmacotherapy strategies for schizophrenia. Retrieved from http://www.pcori.org/researchresults/2014/ comparative-effectiveness-adaptive-pharmacotherapy-strategies-schizophrenia

While I was completing this manuscript, my cousin experienced a severe psychotic break and was hospitalized. As a writer and researcher viewing the process from a distance, I had become numb to the true impact the loss of a loved one’s mind has on the person and her loved ones—Family, friends, and others who touch the person’s life. Suddenly I found myself drowning in the very interactive world I was writing about. At times, I felt alone and helpless. I looked for any interaction with a mental health professional that gave the least bit of empathy and hope. Here I was, a doctor of psychology, and I thought the mental health professionals would listen to me. Yet, in many instances my voice fell on deaf ears. Not being listened to and not being understood infuriated me. I fantasized that my relative’s mind would never come back, and that I’d lost her to a process that is—mysterious, terrifying, and very misunderstood. I felt a knife run through my heart when a doctor asked me if my brilliant relative was this low functioning at baseline. “No,” I said, “She is not. She is an architect; a highly intelligent one at that.” The doctor’s response was disheartening. She stated, “So she’s generally not like this then. Well, we may need to consider Electroconvulsive Shock Therapy (ECT). She’s been here for ten days. She’s not responding well to the meds.” “Not responding,” I thought, “What does that mean? Change the meds . . . change the meds!” I held back my anger and politely asked, “Is there some other combination of medications that might work better, rather than doing something as invasive as ECT?” My mind was racing. I was writing about this . . . about interac-

Downloaded by [New York University] at 12:41 13 August 2016 tions and severe mental illness . . . this shouldn’t really be happening to me. “ECT,” I said, “Isn’t that extreme? She has always come out of this before with the right medication, and it has been in remission for ten years. She has only been here for a little more than a week.” The doctor responded by telling me that most people are on the unit for only three to four days. My relative had already exceeded the standard stabilization period by almost twice the normal length of stay. Therefore, the psychiatrist said, “More invasive measures may be in order.” 226 Epilogue Every time I left the hospital I felt that linear time had been suspended. I had to breathe in the air and touch a tree to be sure I was real and that this was actually happening to me. As I looked back on the last few months, I realized there had been signs of a decline. I had been too busy to notice, or perhaps she didn’t want me to see the decline, or she was unaware of the insidious process that was going on—she was descending into the abyss of a psychosis. To intellectualize Klein and the characteristics of the paranoid-schizoid position and psychosis is one thing; to live it or witness it is another. My professional title meant little, for I felt helpless and experienced a profound sense of loss as my relative seemed to disappear into a world characterized by hallucinations and delusions. I asked about therapy for my relative. I was told that groups and a social worker were available but the primary treatment was medication management. It was made explicitly clear that psychotherapy didn’t happen on the unit. Because, I was told, “We don’t want to open the client up to processing any big issues, like trauma in the hospital.” Yet even in this empathic abyss, every once in a while over the course of her six-week hospitalization, a mental health professional would listen to my concerns and offer me encouragement. It was during these moments, when I was listened to and my family member was viewed as a person who could recover and return to society, that I felt a sense of hope. As she recon- stituted she knew which staff members would listen, validate her, and provide the emotional holding environment she needed to truly become herself again. Healing the mind is a long process. The length of recovery time is unique for each individual. Medication is important. The traumatic experience of having someone I love have a psychological breakdown during the course of writing this book, however, has highlighted the tremendous value that quality interactions with mental health professionals have on the client and family during the recovery process. Fortunately, this story has a happy ending. My relative fully recovered and is doing well. Her six-week stay well exceeded the average, but what is average anyway when talking about healing the human mind? Average is unique for each individual. Fortunately my relative had the insurance to cover this extended hospitalization as well as the peer and the family support to make sure her bills were paid, her apart-

Downloaded by [New York University] at 12:41 13 August 2016 ment was maintained, and her car wasn’t towed while she remained in the hospital. The outcome of this case without sufficient resources—insurance coverage along with family and peer support—would have been devastating, resulting in possible homelessness, jail, or worse. Shortly after my family member’s recovery, I experienced a serious medical scare of my own. I had excellent medical insurance which I am sure was a contributing factor to the quality of my care. However, I quickly became aware of how differently I was treated with a medical condition versus how my cousin was treated with a mental health condition. As I went from one procedure to another I was given reassurance, listened to classical music, Epilogue 227 was offered orange juice and a warm blanket by health care workers. At times I felt flooded with empathy and unconditional positive regard from nurses, doctors, and other medical staff. At times it even felt like a spa experience. While the medical outcome for me was positive, it further highlighted for me the how the system in most instances treats those with mental illness differently from those with physical conditions. It’s hard for me not to consider that the at times poor treatment of my relative as a “psych patient” was due to the stigma of mental illness. Downloaded by [New York University] at 12:41 13 August 2016 This page intentionally left blank Downloaded by [New York University] at 12:41 13 August 2016 Index

Note: Italicized entries indicate important interaction structures. Italicized page numbers followed by f indicate figures.

abandonment case studies 125, 128, Barton, R. 15 135 – 45, 170 – 86; see also early Baxter, Elizabeth 71 childhood discord Beck, Aaron 7 abuse case studies see case studies Beck’s Anxiety Inventory (BAI) 192 active hope 60 – 2 Beck’s Depression Inventory (BDI) 192 Adler, Alfred 7 behavioral rules 18 adoption case study 146 – 57 Best Practice Guidelines for Consumer- advocacy, families and 43 Delivered Services (Salzer) 65 – 6 agency 69; hope supporting 60 – 2; bibliotherapy 125 mutuality and 68 Bion, Wilfred 7, 138, 139; containment Agency for Health Care Policy and and 22, 26; sharing power and Research 46 28 – 30; Tavistock method and aggressiveness 160 27, 187 – 8 Alcoholics Anonymous (AA) 64 borderline personality disorder (BPD) alienating environment 82, 83, 168 122, 127 – 8, 146 – 57, 160 – 2, amputated mourning process 166 – 8 173; mainly diagnosed in amputating containment 21 – 5, 31, women 161; as severe form of 41, 54, 84, 91, 95, 100, 109, PTSD 149; traits of 161 111, 115, 123, 127, 128, 132, Bowen, Murray, Systemic Therapy 45 135 – 6, 148 – 50, 161, 163, 168, Briere, J. 94 172; compared to containment Brown, G.W. 13 (“Bionian containment”) 22; bullying 109, 111 defined 4, 21 – 2; dynamics of 22 – 3; examples of 23 – 4; case studies: desired identity/friendship hospitalization and 24; 70; early childhood discord/

Downloaded by [New York University] at 12:41 13 August 2016 medication and 23 – 4 abandonment/psychodynamic art therapy (group) case study 2 – 3, therapy with emphasis on 81 – 8 Melanie Klein’s work 135 – 45; attachment: families and 45; interaction early childhood discord/abuse structures that compromise by mother/trauma therapy 56 – 8 122 – 33; early childhood authenticity 43, 64 discord/depersonalization/ authentic self 40, 57, 68, 109, 111, internalization/art group therapy 126, 175 2 – 3, 81 – 8; early childhood Axelrod, Julius 7 discord/depression and chronic 230 Index pain/client-centered therapy culture of enquiry 27 – 8, 83, 103 – 6, 108 – 21; early childhood discord/ 116, 118, 126, 127, 129, 150, homelessness/object relations 161 – 2, 168, 174, 178 therapy 170 – 86; early childhood culture of obedience 12 – 18, 31, 93, 95, discord/sexual abuse/dialectical 150, 173, 174 behavior therapy (DBT) 146 – 57; early childhood discord/ Dang, Deanna 45 sexual abuse/psychodynamic Deegan, Patricia 68 psychotherapy for PTSD 89 – 107; dehumanization 83, 103, 127, 131, localities and 6; selection 135, 137 – 8, 147, 161 – 2, 219 rationale for 5 – 6; trauma of delusions 36 losing a child/mourning as depersonalization 25, 31, 43, 82, 84, a geriatric patient/Tavistock 87 – 8, 92, 93, 101, 120, 127, method (group therapy) 158 – 69 128, 131, 137 – 8, 155, 161 – 3, childhood discord see early childhood 168, 170 – 3, 219; case study discord 2 – 3, 81 – 8; defining 82; example childhood trauma 36 – 8; see also case of 25; stigmatization and 25; see studies; early childhood discord; also case studies; labeling family interactions depression case study 108 – 21, 221 chronic pain case study 108 – 21, 221 depressive position (Klein) 139 – 45 Churchill, Winston 218 deprivations, examples of 14 – 15 client-centered therapy case studies desired identity 87, 130, 158, 164, 182; 108 – 21, 150, 170 – 86, 175, 221; case example of 70; damaging see also Rogers, Carl 53 – 4; friendships and 60, clubhouse model 216 69 – 71; holding environment code of silence 174 and 70; reframing identity 71; cognitive behavioral therapy (CBT) 9, social context and 69 – 70 170, 175 detachment 64 – 5 cognitive model of trauma leading to diachronic positions 139; see also Klein, psychosis 37 Melanie collaborative model 18 Dialectical Behavior Therapy (DBT) collaborative relationships 63; see also case study 146 – 57 peer support disorganized speech 36 Community Treatment 27 distance, families and 41, 44 complex post-traumatic stress disorder The Drama of the Gifted Child (Miller) (CPTSD) 94 93, 125, 181 condescending attitudes 52 dreams, hope and 60, 61 – 2 congruence 8, 90, 95, 110, 112, 115, drive theory (libido motivation) 8; 131, 136, 139, 140, 164, 167, see also Freud, Sigmund; 174, 175 psychoanalysis connections 81 DSM 5, grief in 166 “Consumer-Operated Services: the DSM-IV-TR, schizophrenia diagnosis/ Evidence” (SAMHSA) 66 symptoms 36, 90 Downloaded by [New York University] at 12:41 13 August 2016 consumer-operated services/peer-run dyskinesia 7 programs 63, 65 – 6 containing environment 22, 26, 168 early childhood development 26 coping skills 114 – 17 early childhood discord 36 – 8, 50, 51, corrective experience 100 – 102, 178, 92, 124, 140, 175, 176; see also 182 case studies; family interactions countertransference 96, 99 – 100, 154, electroconvulsive therapy (ECT) 7, 14, 176; “Hate in the Counter- 109, 136, 166, 167, 225 Transference” (Winnicott) 44 emotional cutoffs 40 – 2, 86, 102, 124, criticism 59,124 132, 133 Index 231 empathy 8, 67, 82, 90 – 1, 95, 110, “Family to Family” (National Alliance 112, 131, 136, 139 – 42, 150, on Mental Illness) 46 164, 167, 174, 175, 222, 225, flashbacks 93, 97, 99, 104, 105;see 226, 227; Expressed Emotion also post-traumatic stress and 44; families and 43 – 5, 44; disorder (PTSD) friendships/mutual empathy Focusing Institute 122 52; holding environment/ fractured interpersonal relationships 87 containment and 26; Frankenstein (Shelley) 155 importance of in treatment Freud, Sigmund 7, 8, 128, 178; see also by professionals 5 psychoanalysis empowerment 56, 63, 97, 101, 104, friendship interactions 3, 50 – 77, 150, 174 129 – 30, 171; advantages of Ende, L. 4, 164, over professionals’ and families’ Erikson, Eric 129 50 – 3, 59; mutuality and 52; for evidence-based family therapies 45 – 6 remaking social nesting 50 – 1; Expressed Emotion 37 – 40, 44, 102; transference patterns and 51; by family, friends, and mental transformative nature of 51 health professionals 56, 58, 59; friendship interactions, structures that research/programs for reducing hinder growth 53 – 6, 213f; 46; types of 59 accepting the language of “mental illness”/labeling/stigmas false self 125, 176 53 – 4; compromising attachment family interactions 3, 6, 15 – 16, (self-absorption, withdrawal, 34 – 49, 220 – 21; author’s role-playing, expressed emotion, (Dr. Diana J. Semmelhack) scapegoating) 56 – 8; naively personal experience of a employing “social support”/ relative’s psychotic break 225 – 7; hierarchical structure 55 – 6 background 34 – 6; compared friendship interactions, structures that to friendship interactions 50 – 2, promote growth 58 – 71, 213f; 59; family interventions 45 – 7; hope 58 – 62; mutuality 66 – 9; see also family interventions; peer support 62 – 6; reciprocity mothering 56; social connection 56; family interactions, structures that supporting desired identity hinder growth 36 – 42, 212f; 69 – 71 early childhood discord 36 – 8; Fromm-Reichmann, Frieda 24 – 5, 37, emotional cutoffs 40 – 2; 38 Expressed Emotion 38 – 40, 59; functional aggressiveness 160 non-mutuality 40 functional paranoia 160 family interactions, structures that promote growth 42 – 7, 212f; General Self-Efficacy Scale (GSES) 192 family interventions 35, 45 – 7; geriatric/grieving case study 158 – 69 fostering love 42 – 5 Goffman, E. 14 family interventions 45 – 7, 167 – 8; “good and bad” behaviors/factors Downloaded by [New York University] at 12:41 13 August 2016 evidence-based family therapies 16 – 18 45 – 6; “Family to Family” Greenberg, Tamara McClintock, (National Alliance on Mental Psychodynamic Perspectives on Illness) 46; holding environment Aging and Illness 159 and 45; National Registry of grief case study 158 – 69 Evidence-Based Programs and grieving process/stages (Kubler-Ross, Practices (SAMHSA) 46; Open Kessler, & Shriver) 166 – 7, 171 Dialogue Program and 47; Group Attitude Scale (GAS) 192 studies on 46 Group Therapy for Adults with Severe family reunion 87 Mental Illness: Adapting the 232 Index Tavistock Method (Semmelhack, illness: definition/identification issues 5; Ende, & Hazell) 4, 164, 187 – 211; see also labeling see also Tavistock method “illnessization” of psychiatric group therapy/work 26, 27, 58 – 9, disturbances 36 68, 105 – 6, 118 – 19, 127; art implicit cultural value system 16 group therapy case 81 – 8; “informed optimism” (Karon) 62 Open Dialogue/multi-voiced institutional interaction structures 3, conversations and 216; see 12 – 33 also mutual self-help groups; institutional interaction structures, Open Dialogue; peer support; that hinder growth 18 – 25, Tavistock method 111 – 12, 212f; amputating growth-producing therapy (Rogers) 8 containment 21 – 5; creating a culture of obedience Haley, Jay, Strategic Therapy 45 12 – 18; depersonalization hallucinations 36, 89; vs. flashbacks 97 25; environment based on “Hate in the Counter-Transference” projections 18 – 21 (Winnicott) 44 institutional interaction structures, Hazell, C. 4, 164, 187, 189 that promote growth 25 – 31, Here-and-Now interaction 105, 179; 212f; containment 26; creating see also Tavistock method a culture of enquiry 27 – 8, Herman, Judith 95 – 6; Trauma and 103 – 6; holding environment Recovery: The Aftermath of 26; Open Dialogue/multi-voiced Violence—From Domestic conversation 30 – 1; sharing Abuse to Political Terror 149 power 28 – 30; therapeutic Hewlick or Helwick???, C. 172 community 26 – 7 hierarchical model of mental health insulin coma induction 7 treatment 13, 18, 40, 52 – 3, 56, insurance companies 9 57, 62, 174; projections and intellectual scaffolding 126 19 – 21; usefulness of 69; see interaction dynamics/structures: also non-mutuality/hierarchical conclusions/synthesis of 212 – 16; relationships defined 2; historical background Hill Interaction Matrix 189 – 92, 191f, 6 – 9; issues summarized 4 – 9; 209; see also Tavistock method psychotherapy and 8 – 9; social historical background on interaction structures that promote or harm dynamics 6 – 7 severely mentally ill patients holding environment 2 – 3, 82, 90, 99, 6; that foster psychological 101, 109, 118, 126, 129, 140, growth 214f; that promote 164, 168, 177, 180, 183, 216; psychological damage 214f; defined 26; families and 45; types of 8; see also family friendships and 69, 70 interactions; friendship homelessness case study 170 – 86 interactions; institutional honesty 44 interaction structures Hooley, J.M. 38 intergenerational healing process 168 Downloaded by [New York University] at 12:41 13 August 2016 hope 95, 105, 119 – 20, 150, 216, intergenerational transmission process 225, 226; active and passive 124, 128 60 – 2; fostering 58 – 62, 85, 87; internalization 84 – 8, 176 losing 54; mutuality and 61; internalization of a good object 86, supporting agency 60 – 2 88 hostility 59 international perceptions 220 – 1, Hughes, Langston 58 222n1 humanistic movement 1, 8, 150; see interpretations 117 – 18, 140, 143, also case studies; Rogers, Carl 176 interpretive connections 128 – 9 ice baths 7 interventions, family 45 – 7 identity see desired identity introjecting “bad” objects 86, 88 Index 233 invalidating interactions 151 over-medicated residents 127 – 8; irreverence 149 – 50; see also dialectical pervasiveness of 9; side effects 9 behavior therapy “mental health ghetto” 66 mental health professionals: advantages judgmental therapeutic modalities 151 of peer support over 62 – 6; Jung, C.G. 7, 155 compared to friendship interactions 52 – 3; see also Kafka, Franz, “Metamorphosis” 2, 81 hierarchical model of mental Karon, Bertram 24 – 5, 62 health treatment; institutional Kaufman Brief Intelligence Test (K-BIT) interaction structures 192 “mental illness”: costs of 218; language Kayser-Jones, J.S. 82 of 53 – 4 Kernberg, O.F. 27 Menzies-Lyth, I. 20, 138 Kessler, D. 166 – 7 “Metamorphosis” (Kafka) 2, 81 Klein, Melanie 3, 7, 226; depressive metonymy 84 position 139 – 45; object Miller, Alice, The Drama of the Gifted constancy 139 – 40; paranoid- Child 93, 125 – 6, 181 schizoid developmental position Minuchen, Salvador, Structural Therapy 139 – 45; synchronic and 45 diachronic positions 139; see mock trial 98 – 9 also abandonment case studies mother-infant/child interactions Kubler-Ross, E. 166 – 7 139 – 45, 170 – 86; schizophrenigenic mother labeling 5, 53 – 4, 69, 84, 86, 88, 92, 36 – 9; see also case studies; 94 – 5, 96, 111, 127, 137, 146 – 7, early childhood discord; Klein, 162, 175; see also borderline Melanie personality disorder (BPD); mourning case studies 158 – 69, 170 – 86 case studies; depersonalization; Moxon, A.M. 34 – 5 stigmatization multi-voiced conversation 30 – 1, 47, Laing, R.D. 96, 100, 113 216; see also Open Dialogue Lawson, William B. 172 Program learning communities 66 mutuality 87, 170; defining 66 – 7; Lester, R.J. 161 friendship interactions and 52, Lincoln, Abraham 218 66 – 9; group work and 68 – 9; Linehan, Marsha 150, 151 hope and 61; non-mutuality/ “The Little Engine That Could” (Piper) hierarchical relationships 66, 119 – 20 67 – 8, 69; pseudo-mutuality 58 Living-Learning Confrontation 27 mutual self-help groups 63 – 4; see also lobotomies 7 peer support locked institutions 6, 12 “The Myth of Mental Illness” (Szasz) loss of a child case study 158 – 69, 221 5, 53 love: fostering in families 42 – 5; grieving and 167 – 8 National Alliance on Mental Illness Downloaded by [New York University] at 12:41 13 August 2016 (NAMI) 151; “Family to magical thinking 61, 62; see also Family” 46; Peer-to-Peer support passive hope group 63; staff training for Main, Thomas 27 – 8, 29 institutions 85 managed care 9 National Institute of Mental Health Markham, Dominic 150 (NIMH) 46 medications 1, 34, 57, 61, 101, 111, National Registry of Evidence-Based 116, 172, 218 – 19, 225, 226; Programs and Practices amputating containment and (SAMHSA) 46 23 – 4; historical background Nazi Germany experience case study 7; obscuring the role of social 122 – 34 interaction in treatment 7, 9, 55; negative ideation 37 234 Index negative projections 92, 161 – 2 run programs 63, 65 – 6; defining network therapy 47; see also Open 62; mutual self-help groups Dialogue Program 63 – 4; peer support specialists neurotransmitters 7 62, 64 – 5; in Personal Recovery New Foundation Center 216 and Mental Illness: A Guide for non-mutuality/hierarchical relationships Mental Health Professionals 40, 66, 67 – 8, 69; see also (Slade) 63 – 5, 69, 70 hierarchical model of mental Peer-to-Peer support group (NAMI) 63 health treatment; mutuality pejorative terms, used by staff 20 non-professional relationships: persecutory interaction 125 undervaluing in recovery 4 – 5; personality disorders 9 see also family interactions; personal recovery 65 friendship interactions Personal Recovery and Mental Illness: non-verbal caring 43 A Guide for Mental Health Northfield Military Hospital 28 – 9, 187 Professionals (Slade) 63 – 5, 69, nursing homes 14 70 Nurullah, A.S. 66 – 7 physically-based treatment methods 6, 7 obedience see culture of obedience Pinel, Philippe 6 – 7 object constancy 130 – 1, 139 – 40; see Piper, W., “The Little Engine That also Klein, Melanie Could” 119 – 20 objectification 20, 135 post-traumatic-stress-disorder (PTSD) object relations theory, defining/ case studies 3, 89 – 106, 122 – 34, description 175 – 6 146 – 57; defining/symptoms of object relations therapy 8, 139 PTSD 94; see also flashbacks object relations therapy case study power sharing 28 – 30, 102 – 3 170 – 86 projections 18 – 21, 31, 64, 86, 92, 100, one-sided relationships 66 – 9; see also 105, 111, 138, 139, 150, 161 – 3; hierarchical model of mental in the context of the institution health treatment; non-mutuality 19 – 21; Expressed Emotion and Open Dialogue Program 26, 30 – 1, 35, 39; owning 44; pre-institutional 36, 60, 69, 187, 221; compared life of the subject and 19; to family therapy 47; see also relinquishing internalized multi-voiced conversation; projections 98 – 100 Tavistock method projective identification 86, 96, 124, over-involvement 59 126, 135, 140, 142, 143, 159, 175 paranoia 160 pseudo-mutuality 58 paranoid-schizoid developmental psychoanalysis: historical background position (Klein) 139 – 45 8; interpersonal 1, 8; see also passive hope 60 – 2 Freud, Sigmund peer interactions 85, 150, 174 Psychodynamic Perspectives on Aging peer support 60 – 6, 83, 106, 119, 129, and Illness (Greenberg) 159 Downloaded by [New York University] at 12:41 13 August 2016 131, 133, 150, 154 – 5, 164, psychodynamic psychotherapy 8, 110, 168, 171, 209; advantages 150; abandonment case study over regular staff 62 – 3, 64 – 5; 135 – 45; sexual abuse case study in Best Practice Guidelines for 89 – 106 Consumer-delivered Services psycho-education 46, 97, 172, 175, (Salzer) 65 – 6; challenges “us 221 versus them” thinking 63; psychotherapy 1, 218; historical “Consumer-Operated Services: background 7 – 9 The Evidence” (SAMHSA) 66; “psychotic” institutions 138 – 9 consumer-operated services/peer- psychotropic medication see medication Index 235 public humiliation 112 symptoms of 13; relapses punishment 14, 84, 95, 100, 111, 38 – 40, 46; treating without 124 – 5, 127 – 8, 135 – 6, 142, psychotherapy 24 – 5 161 – 3, 173 – 4 Schizophrenia Patient Outcomes Research Team 46 rapprochement stage 131 “schizophrenigenic mother” 36 – 9 reciprocity 56, 96, 149 – 50 self-absorption, by family, friends, recovery 65, 218; hope and 61; vs. mental health professionals “stabilization” by medication 55 56 – 7 “recovery coaches” 64; see also peer self-actualization 87, 110 – 11 support self-psychology 8 recovery movement 58, 62, 221 Semmelhack, Diana J. 4; personal reenactments 102, 104 – 5, 128 – 9, 137, account of a relative’s psychotic 152, 179 – 80 break 227 reintegrated states 144 Semmelhack, D., L. Ende, & C. Hazell, relapses 38 – 40, 46 Group Therapy for Adults with reparation 143 Severe Mental Illness: Adapting repetition compulsion 178 the Tavistock Method 4, 164, reward and punishment system 13 – 14; 187 – 211; see also Tavistock see also institutional interaction method structures, that hinder growth; separation-individuation process 130 – 1 punishment sexual abuse case studies see case Rogerian therapeutic framework 3, studies; early childhood discord 112 – 13; see also client-centered Sharfstein, S., F. Dickerson, and J. therapy case studies; Rogers, Oldham, Textbook of Hospital Carl Psychiatry 20 Rogers, Carl 7, 8, 43, 110 – 11, 119, Shelley, Mary, Frankenstein 155 120, 131, 139, 141; facilitating Shriver, M. 166 – 7 conditions 216; “The Six side effects, of psychotropic Necessary and Sufficient medications 9 Conditions for Therapeutic “The Six Necessary and Sufficient Change” 8; see also client- Conditions for Therapeutic centered therapy case studies Change” (Rogers) 8 role-playing, by family, friends, and Slade, Mike, Personal Recovery and mental health professionals 56, Mental Illness: A Guide for 57 – 8 Mental Health Professionals romantic partnerships 51, 85 63 – 5, 69, 70 Ronan, K.R. 34 – 5 social connection, vs. social support 55 – 6 safe environment 26; see also holding social nesting, remaking through environment friendship 50 safe holding space 177 social supports, vs. social connection Salzer, Mark, Best Practice Guidelines 55 – 6 Downloaded by [New York University] at 12:41 13 August 2016 for Consumer-delivered Services somatization 99, 108, 111, 113, 65 117 – 18, 132, 166 scapegoating 56, 58, 94, 109, 135, 178, split-offs 176 – 7 188 staff revenge 83, 173 schizophrenia: diagnosis by the DSM Stanford Prison Experiment (Zimbardo) IV-TR 90; misdiagnosing 3, 13 89 – 106; over-diagnosing 171 – 2; stereotypes 150 Patient Outcomes Research stigmatization 43, 53 – 4, 57, 59, 65, Team (PORT) for 46; portrayals 69, 84, 85, 92, 94, 95, 112, of/symptoms 36; producing 146 – 7, 165, 168, 227; anti- 236 Index stigmatization movement in Therapeutic Community 26 – 7, 69, Australia 220; depersonalization 105, 164, 177; Community and 25; hierarchical Treatment 27; Living-Learning relationships and 52; see also Confrontation 27; Therapeutic hierarchical model of mental Culture 27; see also case studies health treatment; labeling Therapeutic Culture 27 Strategic Therapy (Haley) 45 thorazine 7 strengths approach 58 Tobin, S.S. 160 Structural Therapy (Minuchen) 45 transference 39 – 40, 126, 174, 176, suicide attempts/ideation 39, 100, 109, 180, 182, 203; friendship 122 – 3, 129, 148, 154, 170 – 1, interactions and 51; positive 90 175, 192 transformative nature of friendships 51, Sullivan, Harry Stack 7, 8, 37, 109, 129 69, 71 synchronic positions 139; see also transitional object 126 Klein, Melanie Trauma and Recovery: The Aftermath Systemic Therapy (Bowen) 45 of Violence—From Domestic Szasz, Thomas, “The Myth of Mental Abuse to Political Terror Illness” 5, 53 (Herman) 149 trauma therapy case study 122 – 33 “talking cure”: historical background 8 – 9; practitioners 7, 8; see also unconditional positive regard 8, 82, psychoanalysis; psychotherapy 90 – 1, 95, 110, 112, 130, 136, Tavistock method/group work 4, 27, 139, 140, 155, 164, 167, 174, 31, 69, 85, 102, 106, 138, 175, 227 164 – 68, 187 – 211, 216, 221; United States Substance Abuse 1st session (Introductory Group) and Mental Health Services 192; 2nd session (Here and Administration (SAMHSA) 46; Now) 192 – 3; 3rd session (Here “Consumer-Operated Services: and Now) 193 – 5; 4th session The Evidence” 66 (Here and Now) 195 – 7; 5th us versus them dynamic 63, 152, 174 session (Here and Now) 197 – 9; 6th session (Discussion Group) validation 43, 84, 102, 103, 117, 150, 200 – 202; 7th session (Here and 171, 175, 179, 226 Now) 202 – 3; 8th session (Here Van Gogh, Vincent 218 and Now) 203 – 5; 9th session verbal effectiveness 43 (Here and Now) 206 – 7; 10th verbal punishment 84 session (Application Group) 207 – 9; for anxiety, depression, Wallerstein, R. 114 group cohesion, and self-efficacy Western medical model 96 – 7 187, 209; background of the Wing, J.K. 13 ten-week Tavistock Group Winnicott, D.W. 125, 126; containment Module 187 – 92; composition and 26; “Hate in the Counter- of the group 192; conclusion Transference” 44; holding Downloaded by [New York University] at 12:41 13 August 2016 and future research 209 – 10; environment and 26 consultation example 188; withdrawal, by family, friends, and frameworks of 188; Hill mental health professionals 56 – 7 Interaction Matrix and 189 – 92, Wood, Chelsey (illustration), vi 191f, 209; modifications of Woolf, Virginia 218 188; structure 187 – 8; tension reduction period 188; see also Yalom’s stages of group development case studies 189 Textbook of Hospital Psychiatry (Sharfstein, Dickerson, & Zimbardo, P.G., Stanford Prison Oldham) 20 Experiment 13