Client Directed
Recovery
The Designed Change Institute presents:
Client Directed Recovery
Self Directed Recovery from Schizophrenia
by Thomas O. Sargent, M.Div., M.Ed.
© Copyright Thomas O. Sargent and DCI 1978
Virginia City, Montana
The CDR process has its beginnings over twenty years ago in observations which I made while working on the wards of a state mental hospital. Commonly, ward attendants and other workers would be confronted with a patient having a psychotic experience which was disruptive to the ward. Many of us found that "talking the patient down" was easier than using a straight jacket or, later, drugs. Some of us even found this process more humane.
Being a curious person and a tinkerer, I began to catalogue those things that seemed to work best, like responding warmly and being safe for the patient; talking about things that the patient would focus on with interest; confronting the patient with visual images of less stressful things like the ten thousand foot mountain that rose immediately behind the hospital. It soon became obvious, as it has to many workers on many hospital wards, that to focus away from the distress and away from the source of the distress, which were associated with the psychosis, reduced its intensity, or abated it altogether.
Then the tinkerer in me, being yet unsatisfied, worked to teach the whole process to the patient. In many cases this worked well, and I suspect that many others have done the same, although I know of none. One further advantage became apparent: the patient that was able to use this process was no longer dependent upon me or the hospital staff. In some instances the patient was able to remain in situations which previously produced a psychotic reaction simply by shifting the focus of attention to non distressing subjects - and back to the psychosis producing situation still holding the calming images.
I found that this approach met with varying degrees of success, so I tinkered some more. I found that talking with a patient about a psychotic episode would often reinstate it, sometimes partially and occasionally completely. I found that short trips close to or into the psychosis, followed by the already demonstrated ways out and into calm and self esteem, taught the patient two important things:
1. The Individual can develop the skills to enter and then abate psychosis.
2. Psychosis is not such a scary experience.
The development of such an easy method to train a psychotic patient to have charge over the "mysteries" of schizophrenia further extended its usefulness. Patients could reinforce themselves with this sense of self determination to move to non psychotic behavior.
To help reduce the fear of psychosis I often referred to the then widespread use of LSD to produce psychosis, and that the patient could get it legally and free of cost, except that the cost to the patient was her very life. Developing an understanding of these facts helped to motivate the patient away from psychosis and into self recovery.
Patients that found schizophrenia no longer scary had less trouble with this process and reduced recurrence of the psychotic episodes. This led me to the suspicion that feelings states determined the presence or absence of psychosis, and I began to pay more attention to training patients to be aware of their feelings states and how they can alter them with ease. A basic method we use is to focus attention upon whatever will produce the feelings state which might be desired at the moment, the same process as "talking down the patient". Identifying the central role of feelings states gave me more tools to share with my patients. At present in the CDR Program we teach innumerable methods for altering feelings states, and clients select those with which they are most comfortable. We also have learned to develop in the group a climate that says loud and clear that there are several special things about those of us who are able to become psychotic. We have a surprising number of inventive and creative faculties and are allied with the many artists and creators in this world.
It is my experience that fear is the feelings state that produces the psychotic experience. Always. Even when the emotional state is outwardly something like depression or anger. Patients who develop these skills usually identify how fear is concealed by the more obvious feelings they notice in themselves or that are seen by observers. Thus, reducing the fear of psychosis has reduced the incidence of psychosis. The implication is, of course, that fear of psychosis is a major cause of psychosis. Most mental health workers have observed that anxiety about becoming psychotic precipitates psychosis. Further, during psychosis the experience itself may be so frightening that it intensifies itself exactly like the feedback when a microphone is exposed to a nearby loud speaker.
The two elements, training in altering feelings states and the development of a climate in which psychosis is a mark of being special, are central to the CDR groups. However, an experience with a group of chronic schizophrenic outpatients produced another element which we use, which seems to integrate the whole process.
What I discovered with these patients is that their behavior is largely devoted to two things: 1. Ritualistic behavior which is designed to keep the patient from psychosis-producing feelings states and situations. 2. The interpersonal use of psychotic episodes which have identifiable interpersonal meaning. In a very rigid way, these patients were doing exactly what I had been training other patients to do in a more flexible and life affirming way. Also, these patients were using these skills in ways which were interfering with their lives. Since they were already skilled in going in and out of psychosis as they seemed to find the need, I decided to see whether I could help them discover how they were using psychosis, which was so obvious to those around them. For this I used one simple concept, and built the whole history of the group around it - the interpersonal meaning of the psychotic episode.
We began with the interpersonal meaning of almost all behavior (one resident of a church nursing home said, "It's like when I pour tea for the ladies at my table"), and the further thought that much (or most?) behavior occurs because of its interpersonal meaning. In twelve sessions with ten patients there were two dramatic shifts by individual group members to other behavior than psychosis to produce the same interpersonal effect. Some years later, when I read the work of Thomas Szasz, I had a stronger sense of what I had put together. The fact is that I wasn't teaching the patient with psychotic experience anything new. I suspect that all but a few "psychotics" have learned to precipitate their psychotic experiences for their own particular interpersonal purposes.
At this point it is vital to point out that the skills which I was for several years helping patients to develop was already well developed, especially in chronic schizophrenics. All I was doing was making it aware behavior which then could become CHOSEN behavior, and other behavior could equally well be chosen.
Our Client Directed Recovery Program works well with some, not with all schizophrenics. We are not researchers, so our results are colored by what we think we see. There is no question that we are producing results, some startlingly extensive, and some in unanticipated directions. I think it is the mark of a true humanistic and client directed approach, that when Ralph became fully aware of these elements of his thirty years of schizophrenia, and that his alternative was to leave his mother's safe but annoying side and go "out there", he elected to remain schizophrenic. I am sure that he is convinced that you have to be crazy to go "out there" and struggle for the things that are already provided for Ralph. In contrast with most evaluators, I would say that CDR worked well with Ralph. He made a clear choice to continue awarely what he had been doing unawarely for thirty years.
We did consider doing research, but it is sad to note that when we went to a funding organization to develop a scientific study of Client Directed Recovery, the psychiatrist we were referred to said, "If you are having the results you claim, your patients have been misdiagnosed". Since we were in the business of helping clients, we decided not to attempt to beat down this obviously defensive wall of the medical establishment, even though we had patients recovering who were diagnosed by many different psychiatrists.
Finally, a happy story with a sad ending. I worked with a chronic schizophrenic who had been hospitalized over a dozen times. She came a long way for help, so we worked with just one approach. There was a tree close to the door in front of her house and in session she could recall how the rough bark could dig into her fingers when she hugged the tree hard. She learned to associate with that tree her own roughness, her solidity, her persistence and her aliveness. She agreed to repeat this simple exercise both at the tree and away from it at least three times a day.
The result of this simple exercise (which she faithfully repeated every day and in every session), was a new relationship with her self and with her husband and freedom from psychosis. This went on for well over a year, when she died of a sudden heart attack. Her husband came and spent over an hour with me both to deal with his loss and with his questions about why the hospital failed to help her and how it was that I could give them a bit over a year of happiness after so many years of unpleasant schizophrenia. He permitted me to tape the session.
Personally, I believe that her self-induced change in feelings states either caused or contributed to her heart attack, which is a whole other area of antagonism with the medical field. The parental doctors just do not want their patients to manage their own illnesses by altering their feelings without chemicals prescribed by them. We have a full program "Wellness" which individuals use in order to alter feelings to support recovery from physical illness and to integrate wellness into their lives. Of course, there are some humanists who are antagonistic to the idea of simply altering feelings states. It's a hard life, ain't it.
Schizophrenia is not Hopeless
you can take it into your own hands
Designed Change Institute, Inc., P.O. Box 771, Farmington CT 06034 (860) 674-1635, and
P.O. Box 134, Virginia City MT 59755 (406) 843-5503