Written by Jack Rosberg, Ph.D.
When I first saw her in consultation, it was obvious she was not a happy person. However, she was also in a setting where she had everything at her disposal. Everything was directed to her well being. There were no other patients. She had two therapists and a whole team of specialists plus a battalion of aides to protect her against her own impulses. She was bathed by her aides and fed by aides. She was dressed in special clothes tailored out of sail cloth. She wore a helmet to protect her when she decided to bang her head. She had convinced everyone that this was the only way she could be treated. And furthermore, she knew it. She had taught them that she had to be protected from herself and people had to be protected from her.
Once Torina was allowed to create this psychotic equilibrium, she quickly encouraged others to forget that her fear of annihilation was the sole motivating force furiously driving her to create a safe world to live in. She made them forget because they were frightened of her and of her destructive power. Thus, they also failed to remember that when she achieved her psychotic homeostasis, she would have no motivation to get better. Perhaps they did not really understand that for Torina, no price was too high to outwit the specter of death.
I believe it is truly important to explore cases such as Torina even if we only gain one small grain of wisdom from her thirty years of human tragedy.
My impression when I first saw her, was that she was thin and appeared debilitated, but not from deprivation. I felt she was literally being consumed by her own fears and that these energies were so powerful that people were afraid to test her psychosis: Everyone had intuitively retreated from her because she appeared so awesome and overwhelming.
As with most patients, emotional contact begins when the therapist responds to a transference reaction. Torina was no exception. She reacted strongly to my "deep voice". I made an immediate, strong statement of my own to interpret and reframe the transference. My purpose was to begin a chain of affective and cognitive interactions which would inescapably bind us to each other.
THE APPROACH TO TREATMENT
To understand my approach to Torina, you must first understand what I think about treatment. Treatment is a series of direct interpersonal confrontations leading to a common goal; to force the patient to choose between staying sick and getting better. This case discussion is focused on "Breaking Down Defenses and Beginning a Treatment Relationship".
First; patients deserve our help and we will do everything we can to see that they get it.
Second; there is nothing fair about schizophrenia. It doesn’t let people do what they want to do with their lives. It interferes with their humanity. It robs them of their dignity, and deprives them of their happiness.
To accept responsibility for the treatment of psychotic patients is a commitment many therapists do not understand. It is always easier to blame the patient for not getting better. Nobody likes to look inside and see their own pathology mirrored by the patient’s psychosis. Nobody likes to experience the feelings of failure and fatigue as the patient appears to win round after round. And, most importantly, nobody wants to expose the incompetence they feel when they are asked to take on the well rehearsed pathology of the veteran schizophrenic.
A CONSULTATIONBEGINNING TREATMENT WITH TORINA PART I
When I first saw Torina, she was standing up in a huge cavernous room with an aide sitting close by. Her arms and legs were in restraints and she was talking to herself. She was at the end of the room and could see what was going on from every angle. When I came into her view, she immediately became aware of me and looked at me. She was a little restless, but did not seem particularly threatened. When I went into another room with the treatment team, I had no idea where I would work with her. The team decided to take Torina out of the large room and put her to bed in five point restraints in her own bedroom. Although I was not told this, I became aware that something was happening to Torina because I could hear her talking louder and louder and with more and more anxiety as she was being led back to her bedroom.
Torina now knew who was going to see her. I had glanced through the doorway at her and she had seen me. When next I saw her, she was tied to her own bed. I looked at her and she looked at me for a long time. A feeling came over me that she knew she had someone to deal with she had not dealt with before. She began to mutter in Swedish and Italian. I said, "There’s going to be some changes made today". At this point she said fearfully, "He has too deep a voice".
I told her who I was and that I wanted to help her if I could. She quickly revealed that she was bright and clever. (She speaks and understands English, Swedish and Italian) and that she was vividly aware of her surroundings. I found she was able to identify the individuals in the treatment team by their specific traits and habits. The world and the people in it did not melt into each other but every part of her environment had special and distinct meaning for her.
BEGINNING TREATMENT WITH TORINA - PART 2
I knew from experience that Torina had probably learned that someone she did not know might be a threat to her. And that she would interact with this new person until she could discover their weaknesses. She would then destroy them or drive them away, learning all the while how better to prepare herself the next time the threat appeared. What I am saying to you is that she had seen people like me before. She had learned how to destroy them so they would no longer bother her. I cannot tell you how bitterly disappointed she was when she discovered she could not destroy me nor drive me away.
She began immediately to engage in the destructive, angry behavior that has always been so frightening to people around her. She screamed, cried, begged me to kill her, to pull her hair; she banged her head on her bed (not hard enough to hurt her, but hard enough to frighten an inexperienced therapist). She assaulted me in the only way permitted by her restraints. She spaton me until I was drenched with spittle. Then, she raged at me to leave her alone, not realizing that, in her frustration and terror, she had allowed me a pathway into her psychosis.
It is essential that we are aware of the importance of understanding the character armor of the therapist and using the therapist’s feelings as a vehicle for imposing reality on the patient. I bring this up now, because I want you to understand that I was angry, more than angry. I was furious that this bright, creative human being was being controlled by murderous impulses which made her nothing more than an animal. At one point, I raged at her that she was a dictator and a miserable beast. She responded by screaming at me to kill her. I told her that it was against the law to kill her, but that if the law permitted me to do it I would be happy to do so. We must understand that this was not an expression of countertransference, but of reality. In the ondition I found her, this patient was a dangerous, murderous human being who would stop at nothing to kill, maim and destroy anything which she felt threatened the integrity of her psychosis. For any therapist to pretend that this kind of patient does not generate genuine and appropriate feelings of outrage, fury or even hatred is patently absurd. That the patient never hears about these feelings is part of the inadequacy and incompetence of psychotherapy as we know it today.
The charade that is passed off as therapy denies the patient the opportunity to develop in areas where growth has been prevented.
BEGINNING TREATMENT WITH TORINA - PART 3
Throughout this period, Torina continued to spit at me and try to kick me. I continued to ask her why she was so crazy and why she wouldn’t let me help her. I also reminded her, again and again, that she could do nothing to drive me away. In this one respect she was absolutely helpless. I feel strongly that my desire to outlast her no matter how she tried to drive me away finally convinced her to listen to me and to pay attention to this crazy man who might really be more powerful than she was.
In a last ditch effort at defeating me, but one which revealed only too clearly the power and control I was beginning to wield over her, Torina began talking to me entirely in English. "Kill me, kill me. Do it today". At this point, she was trying to pull for one of two things. First, she really may have felt like dying rather than continue to try to protect herself from the fear of annihilation. She is a terrified person with very little in life other than her psychosis. And, what little she had was certainly being significantly upset by me. Secondly, she was asking me again to violate her. This long standing tactic was one she could depend on. It had worked, again and again. Just make the other person angry enough and they will violate you. It was dependable; a sure thing. She could not afford to believe it would work with me. She knew from long experience, that if she could get me to do that, then she would have defeated me. If she could change the position of power, she could make me ineffective as a therapist and reduce the threat to her system of survival.
With these thoughts in mind, I began yelling at her, "You crazy woman, you don’t have to be this way. Who the hell do you think you are, God? How dare you do this to all these people. You may think you have the whole world at your side (referring to the staff providing her with treatment), but you are not going to control my LIFE!!!"
BEGINNING TREATMENT WITH TORINA - PART 4
Again, she broke out in a renewed burst of spitting and kicking, trying all the while to get me to act in a violent way towards her. I began to realize and to literally feel how she had experienced this kind of violence before. I said to her, over and over again, " No, No, No, No, No, No". Had I responded to her provocations; had I even touched her in the slightest way, or even suggested to her that I might, she would have seized it as an assault on her. For this reason, I even stopped trying to put a barrier between her spitting at me and my face. It was important that I was able to be that close to her and not respond to her provocations in a revengeful way. She certainly made me angry. I felt anger and I expressed it in a verbal way and at the same time expressed, on a repeated basis, that I wasn’t going to let her drive me away from her. She was spitting at me out of her rage and frustration with me. I couldn’t stop her and I recognized that if I had tried to do so, it would have ended any opportunity I had to reach her.
It is important to understand, that I was not acting permissively. That is, I was not encouraging her to express herself by spitting at me. And I was not telling her that I was willing to tolerate her gratifying whatever impulse she happened to feel by spitting at me. I told her I didn’t like it. I told her to stop doing it. And I also told her that even if she continued, she could not push me out of her life.
This is the essence of this kind of Direct Confrontation Therapy. I was now in her life and she didn’t want me there and she couldn’t do anything about it. As time went on, however, she became increasingly eager to yield to my demands so that I would go away and she could feel more secure.
One must remember that therapy always affords opportunities for negotiation. Not everything is life threatening or crucial to the immediate well being of the patient. One must always consider the patient’s best interests and try to help each patient reach new areas of understanding or behavioral change. This requires compromise. Compromise only works, however, if there is a relationship between the patient and therapist. Once the relationship exists, the patient and therapist can understand whose needs are being met. When this happens, psychotherapy, like politics, can afford to yield to the art of compromise.
CONCLUDING THOUGHTS ON THE CASE OF TORINA
In Direct Confrontation Therapy, language carves out the road both the patient and therapist must travel. The emotion of the therapist becomes the fuel to ignite the patient to action. If however, the therapist’s unconscious contains materials which are too frightening or if the therapist has not yet developed the freedom to express in words or feelings the intuitions which arise from these unconscious forces, the patient will be lost to treatment and another brick will be added to the delusional wall which separates the patient from health.
What was important to Torina, was that I consistently demonstrated to her that I was not afraid of her violence; that I was not afraid of her psychosis; and that I was prepared to continue waging battle with her in a way which would not violate her and which would be consistent with her getting better. I had held out hope to her and she had responded. I believe for the first time in her life, someone had not be afraid of her fear, and if we had continued working together, that this would have become the basis for a genuine therapeutic alliance. I had been able to influence Torina to change her behavior to accommodate me. When she permitted me to do that, it became possible for me to change my behavior to accommodate her.
In summary, Torina was not allowed to escape into her primary process. My therapeutic encounter with her forced her to deal with the perceptual reality we all share; the reality of language connected to appropriate emotion. When done successfully and consistently, these encounters foster the interjection of realistic values and beliefs. These, in turn, make the patient feel a sense of safety as the therapist takes on more and more of the burden of the patient’s illness. It is at this point that the process of change truly begins.