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At the beginning of my clinical internship, when I "didn't know any better," I had the opportunity to work with a patient who had just the sort of history and personality
that leads most professionals to avoid them. At the time, Tom age 40 (1982), had at least a 22 year history of schizophrenia. For the majority of those years Tom lived in
psychiatric hospitals, and occasionally in board and care homes.
Prior to the time of his admission to the Anne Sippi Clinic, Tom was hospitalized at least 20 times, with his stay in those hospitals lasting typically from two to twelve months,
including one ten year period at Atascadero State Mental Institution; these hospitalizations were often followed by a 2 month period of non-treatment in a board and care setting followed
by another hospitalization.
In his medical records it stated that Tom's first break occurred in his late teens (a common time for the first signs of schizophrenia) triggered perhaps by family and academic
pressures in his last years of high school. Tom's childhood was marred by abuse and domestic violence. When asked about this he stated that "my parents drove me insane and then my
father deserted me because of my insanity." Tom had not heard from his father for ten years prior to his admission, and his mother had died of complications caused by a lifetime of
chronic alcoholism. This family description is not meant to blame his or any family for the illness schizophrenia, but rather, to give adequate background to the social and familial
issues surrounding this person's manifestation of this illness.
In July 1982 Tom was referred to the Anne Sippi Clinic after one of his many hospitalizations, this time at Patton State Hospital in Southern California. It should be noted however
that although Tom has a history of paranoid schizophrenia the most consistent reason for his many long psychiatric hospitalizations had been violent acting out and delusional fits of
rage. Tom reported that this most recent hospitalization resulted from a flair up between himself and one of the residents at a board and care home where he was residing. He elaborated on
this by stating that he "was being made to look crazy by people who were controlling his mind." Although at other times he admitted his hospitalization was as a function
of uncontrollable anger.
Tom is a very large man, approximately 6' 7" tall. At the time of his admission, Tom's physical appearance was very disheveled, he seemed angry and withdrawn, and indicated that
he felt any problems he might be having would be caused by others. After a short period of adjustment he began expressing loud angry thoughts seemingly unaware of others, often
slamming the door and yelling at the sky statements such as "I hate God," and " I am going to the lake of fire." Tom was actively psychotic, he was verbally hostile
with patients and staff, and had almost daily fits of rage where he would throw pool balls, chairs and almost anything in reach. His sleep was fitful and he appeared agitated in the hall.
He frequently expressed paranoid thoughts, and in the course of therapy was physically confrontive and regressed. In all, Tom seemed an extremely angry, delusional, disorganized
man, who withdrew into his own thoughts in response to internal cues.
Clinically speaking, Tom's mental status at admission revealed loose associations with occasional lapses into blocked thought processes. He admitted to paranoid delusions, perhaps
best described as a feeling of alienation and an amorphous sense of peril. His affect was at times appropriate, and at times loud and angry. His intellectual abilities seemed above
average with intact long and short term memory, and he was able to offer insight into his own behavior, though lacked the ability to integrate this insight when feeling pressured or
angry. So here was Tom, with all the symptoms of severe schizophrenia and the character flaws that come from a hard life and many years in hospitals where because of his size and
angry demeanor he was avoided, isolated, and punished for his psychological problems. So there I was a new therapist, who was full of the expectation that it was up to me to help
Tom, believing that Tom was not a failure, but that his previous treatment's had failed. Perhaps it's the new therapists who know what seasoned therapists must constantly re- learn, it is up to
us to provide care and hopeful treatment to our patients, even if it is difficult!
Of course, with the kind of history Tom had, treatment started with much objection. In order to spend the necessary time with Tom (and this was considerable), I was forced to pursue
him not necessarily in the office, but in the hall, the recreation room, his room, and all around the grounds. I realized quickly that for treatment to be effective with this isolated
person it was vital that I form a relationship with him, a relationship which would serve to create a buffer when those internal cues intruded and Tom was acting out. Over the next
several months, I began spending more and more time with Tom often responding to his anger, and meeting his aggression head on. This proved to be one of the most impactful aspects
of working with this difficult patient. It seemed that Tom had, in other setting's, been placed in isolation when he became angry. There, punishment had replaced human interaction, now it
was up to me to reverse that pattern.
Unfortunately, Tom had developed a strong delusional system. Not only did he blame others for his problems, but Tom felt that psychotherapists in particular were "working with
the devil," to undermine his happiness. This was a difficult aspect of his psychosis involving trust. Tom had been let down by many of his previous therapists,and Tom was not about
to readily trust another. In my effort to overcome this difficult resistance I was tested many times. There were many late night sessions, much acting out behavior, and the time
commitment was tremendous. As a new therapist with much to learn, I was forced to rely on determination, and if I could help it, I was not going to fail with one of my first clinical
cases.
Determination is a powerful thing and gradually, with many steps forward and steps back, it began to result in some behavioral improvement. Tom's rage began to dissolve, and he
became a more cooperative patient.
As treatment continued Tom was seen in individual psychotherapy five days per week, group therapy daily, movement therapy, exercise, and when his impulse control had improved, daily
outings to mountains, museums, movies, and most importantly the library. Tom was a very avid reader. As time passed he made progress in many spheres including psychotic symptom
reduction, interpersonal relations, personal hygiene, and most importantly rage reduction. Tom's therapeutic relationships, had dramatically, been replaced with productive healthy
relationships. As a result of a strong positive transference between himself and his therapist, Tom began a gradual re-integration of social skills and self awareness.
Treatment with Tom continued for several years, there were intermittent psychotic episodes, but with less of the ferocity of his previous years. Tom was reeducated in social skills
and eventually moved to a board and care home in the community where he lives today. For him a lifetime of recurrent psychiatric hospitalizations was halted. He has not seen the
inside of a psychiatric hospital since.
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