August 1998

Those of us who are involved in the treatment and rehabilitation of the  mentally ill are, or should be, aware of how vital the treatment alliance is to  a successful outcome. It would appear to me that to ensure an effective effort,  it is mandatory on the part of the treatment team, which is a composition of  therapists and rehabilitation specialists, to concentrate on what must be done  to accomplish the goals set forth in the planning for rehabilitation.

 The attitude in treatment regarding the patient's potential for  rehabilitation and some of the steps in the treatment process will be stated as  I go along. But first, some questions. When does treatment begin? Does it start  when two people sit down together and start a discussion? Is that mentally ill  patient ready, at that point, to engage in and commit himself to rehabilitation  process?

 Does the preparatory period include the beginning of an alliance? Or, does  it suggest that protracted periods of time are necessary to create that vital  relationship?

 It is my experience that treatment and rehabilitation can begin at first  contact. The quality of that first contact can very well determine how rapidly  the alliance will forge into a meaningful therapeutic force. There is every  reason to believe that without this alliance, no meaningful treatment will come  to exist or will any substantive gains be made or will any gains be of any  lasting nature.

 I will point out some steps that can lead to the rapid development of the  treatment relationship and alliance. These concepts can be assimilated by those  who make the necessary commitment to the treatment. This commitment often  requires a strong emotional investment which can become a powerful therapeutic  tool and also difficult for the therapist to experience at first. However, these  problems can be resolved if the therapist faces these difficult experiences with  a positive attitude.

 At this point in the history of treatment the most reliable research point  out that in the overall rehabilitation of the mentally ill, a variety of  treatment modalities that are contiguous offer that person the best chance for  recovery. Psychotherapy, medication, resocialization and a number of  rehabilitation measures may enable that person to function productively to some  degree. However, knowing this does not necessarily ensure its delivery.

 One of the major obstacles obstructing the rehabilitation of the person who  is mentally ill is the difficulty experienced in establishing a level of rapport  that will lead to a meaningful alliance. This occurs because the nature of the  illness often produces bizarre patterns of behavior that interfere with normal  communication and inhibit the expression of common social conventions typically  used to initiate and maintain human relationships. These conditions may be  beyond the experience of most mental health therapists and even fewer have had  the training in the specific treatment paradigms necessary to overcome them.  These therapists are often severely challenged when asked to treat the person  who is mentally ill. They have little or no awareness of how to work as a  participant in the life of the patient or, as Freda Fromm Reichman said, '. . .  how to meet the patient in the spirit and with the expression of simply  meaningful spontaneity and frankness.'

 Although many clinicians have recognized the need to establish a  relationship with the mentally ill person as a precursor to initiating treatment  and rehabilitation, few have been able to view this requirement as a special  skill to be developed if treatment is to be successful. Fewer still have  understood the techniques required to help patients reestablish human contact,  which is different from those techniques used in more traditional therapeutic  interactions as, for example, those leading to the development of  transference.

 A thoughtful examination of the problems encountered in the initial phase of  treatment is found in the monograph 'Psychotherapy with Schizophrenics,' edited  by Brody and Redlich. In Brody's review of the several steps necessary to  conduct individual psychotherapy with schizophrenic patients one can readily see  the leveling influence the phenomena of schizophrenia has had on the character  of psychotherapy. For example, in his description of what he calls  'establishment of contact,' Brody reflects on the variety of nontraditional  approaches that have been used. He cites the innovative work of Schwing and  Federn and credits Grotjohn as among the first to recognize the need to reach  out actively to establish contact with the psychotic patient by any means  possible.

 Many of the treatment tactics are clearly not consistent with psychoanalytic  or other psychotherapeutic points of view, but they do represent serious  attempts at trying to cope phenomenologically with the behavior presented by  patient, i.e., in doing what works! Thus, although written by professionals  whose identity with psychoanalysis is well known, a level of eclecticism and an  unspoken emphasis on an existential approach to treatment is presented that  derives from the practical recognition that the clinician must ultimately deal  with the demands the illness imposes on the patient.

 Rapid contact is a series of therapeutic strategies aimed at reaching those  patients who are considered treatment resistant. We are talking about people who  are long term mentally ill patients. These patients who have had some or many  psychotherapeutic experiences. These are patients who have become crafty in  their resistances and have come to expect that the treatment efforts they  presently face will be comparable to what they experienced in the past. Instead,  they find somebody who may be willing to use any number of therapeutic  strategies with them that might shock them into some semblance of reality. These  moments of reality can add up to a substantial sum as treatment continues. We  should consider the possibility that symptomatic changes can become significant  in that they allow for redirected energies toward healthier goals. The  phenomenon called rapid contact is aimed at persuading the person that their  experience of being mentally ill can be understood by other people and that help  is possible.

 Also, that their experience can be shared in order for them to believe that  the changes can be made. That one doesn't have to wait for what appears to the  patient to be endless periods of time before understanding and reassurance can  take place and to reassure the patient that they are understood and there is  somebody capable of helping them. This as contrasted with the slow methods that  are typically used with excessive care and concern that only seems to suggest to  the patient that the persons employing these methods do not know what they are  doing and the patient is once again faced with failure. I must emphasize the  patient does not fail in the treatment effort, we, the professionals fail. They  are sick and do not know how to recover, we must point out the direction in a  flexible and spontaneous way that gives rise to greater hope.

 In the early stages of treatment either in the initial session and/or  sessions, we are preparing the patient for change, from apathy to interest and  some measure of productivity. If therapy is to end properly, it must begin  properly. Of course readiness for treatment varies with each individual. We must  understand that we are treating individual human beings, not diagnosis. However,  I believe that the question of when a patient is ready for treatment is more a  function of the therapist's needs and abilities than the patient's capacities to  respond in a positive manner. To reach these difficult treatment cases, the  therapist needs to be free enough to use newer or older established methods  depending on the needs expressed by the patient. This requires a therapist with  an eclectic mentality. Treatment of any kind is an influence process that should  begin as rapidly as possible given the resistance to change that is part of both  patients and the therapist in the therapeutic interaction.

 Understanding what mental illness comes to represent to the patient  recommends the therapist's forceful intrusion into the patient's world. Being  forceful, in my opinion, means that the therapist is actively involving  himself/herself in the patient's world. It represents an understanding of what  mental illness means to the patient. Does it sound reasonable for us to wait for  the patient's invitation into their world, or do we need to understand their  language and their logic? We must realize that the idea of change, in many cases  is a terrifying prospect for the patient and tends to exacerbate their  resistance. Change is terrifying in view of the fact that repeated failures in  treatment make that patient's condition a more acceptable life style than facing  failure again and/or the unknown that change suggests.

 There are any number of subtle and unsubtle measures that we can take in  convincing these human beings we intend to help them resolve enough of their  fears so they can join in our efforts on their behalf. The message is not  complex. We must change before they can change.

 Treatment for us is a series of direct interpersonal confrontations leading  to a common goal, to force the patient to choose between staying sick and  getting better. In every case we treat, we have to make new decisions about what  we are going to do and how are we going to do it. This process is often  unconscious and automatic and it is only when we look back that we can see what  we have done and understand what it means. Nevertheless, we approach each case  with certain basic principles in mind.

 First, patients deserve our help and we will do everything we can to see  that they have it.

 Second, there is nothing fair about mental illness. It does not 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.

 Third, we cannot help our patients if we allow ourselves to believe they  have a right to be sick. We must press them, over and over again, to join us in  our world, no matter how long it takes, or what we have to do to get them there.  The only tools we have are our human feelings and our understanding of their  illness. In the right combination, these are all we need.

 Most therapists don't view treatment this way at all. The problem they have  is a real one. To accept responsibility for the treatment of mentally ill  patients is a commitment most of them do not even understand or perhaps want to  make. It is always easier to blame the patient for not getting better than to  look at yourself. With this occurrence, it follows that once again the patient  is in a position to defeat the efforts of treatment. We must realize that they  have lost faith in our efforts and they have come to regard their sick system as  a logical way of surviving. In every aspect in the rehabilitation process, we  must review ourselves more carefully and overcome our weakness in treatment so  at the very least we learn how to make contact with our patients, so that we can  help the person understand the nature of their experience. Under the best of  conditions we are trying to help them overcome their mental illness so that  their experience at being mentally ill can recede into the historical background  of their lives and the process of rehabilitation can begin.