February - 1998

The Anne Sippi Clinic began in 1976 as a day care treatment center. In 1978, it became a residential treatment center, housing patients with a diagnosis of schizophrenia and related disorders. The clinic is a pioneering effort as a treatment alternative to a psychiatric hospital. Its efforts are dedicated to helping its residents overcome long histories of serious mental illness. The program began with the goal of providing a unified treatment program with the judicious use of medication, psychosocial rehabilitation and an untraditional psychotherapy that I call Direct Confrontation. The clinic has been called a prototype and it did and should influence the professional world to undertake the treatment of patients who have long been considered untreatable. However, to describe the development of this very important treatment center, I think it would be useful to talk about the beginning of my career and how the succeeding years directed me towards developing this center for treatment.

The Early Years

In 1954, I became aware of the work of John N. Rosen and felt that his treatment methods constituted a unique contribution to the psychotherapy of schizophrenia. I began working with him that year in Bucks County Pennsylvania. His method of dealing with patients, I considered to be unprecedented and felt that from the very beginning of my working with him, that his patients were freed from the constraints of psychiatric hospitals wherein they had to spend long periods of time. Because his patients were treated in individual treatment homes, they had a much better chance of making recoveries. I spent two and a half years with Dr. Rosen. During that time, I had the privilege of meeting some very distinguished contributors including Bertram Lewin, Carl Whitaker, Gregory Bateson who was the leader of the Palo Alto Communications Research and later the renowned Gaetano Benedetti, not to forget O. Spurgeon English and Albert E. Scheflen. These individuals were impressed by Rosen’s approach to these very disturbed patients. In the beginning I was influenced by some of his theories which he called The Direct Psychoanalysis. However, it became apparent to me that his ability to make rapid contact with even the most severely regressed patients, was not a product of his theories, but more a result of his intuitive understanding of the schizophrenic process and his abilities to relate to patients in a manner that persuaded them to make behavioral changes. Dr. Rosen permitted me the freedom to work with many of his patients and even in the earliest stages of my development, I was able to make contact with them that led to a treatment alliance which helped some of the patients make good social recoveries. I need to emphasize that my therapeutic efforts were more intuitive than conceptual and that it took an enormous effort on my part to reach the unreachable. During my stay with Rosen, a colleague, Bertram Karon and I wrote four papers that were published in American Journals. Interestingly, the papers were based on some of the theoretical ideas that were like some of the Direct Psychoanalytic concepts that Rosen established as an extension of the Freudian method. However, this was not in any sense of the word the foundation of my work with these patients, but it did in some ways represent a point of departure towards the development of my Direction Confrontation methods of treatment. I have found that the creative parts of treatment are very difficult to describe, at least for me. I think that at that time what I did, I did not say and what I said, I didn’t do. This was also true of Rosen. This was confirmed, by the way, in some of the works by Albert E. Scheflen who observed Rosen’s work during the research of Direct Psychoanalysis at Temple University, in Philadelphia, Pennsylvania. As Scheflen said "many therapists who say that it is impossible to form contact with schizophrenic patients make an effort to do so, but do not seem to know how. Some therapists, however, are remarkably able to develop relationships with schizophrenic people. John Rosen could do so quickly with even the more paranoid patient (both Frieda Fromm Reichman and Lawrence Kubie amongst others saw him as being able to make contact with these patients more rapidly than anyone else). In my view, he did so with a combination of aggressive insistence and continued reassurance that the patient would be released from custody and control as soon as he was able to take care of himself (Scheflen, 1960)". So you can see, from Scheflen’s perception of Rosen’s efforts, that Rosen’s theories had nothing to do with Rosen’s powers of persuasion. Over the years my treatment evolved to the point where I was not bound by any one theoretical frame, it became increasingly apparent that making contact with these very regressed patients required a flexible approach. No one direction was influential enough to change the course of the illness and that strategies of treatment had to be initiated by the psychotherapist.

After I Left Rosen

I came to Los Angeles, California and began in private practice, with a general practice that included schizophrenia, addiction, and some of the neurotic groups of patients. It became obvious to me, in the early days of my private practice that my greatest interest was in the area of schizophrenia. I was on the attending staff of several psychiatric hospitals and practiced my active treatment approach with schizophrenia and found the reaction from those traditional professionals to be constricting. There were other professionals who expressed interest in my work and I soon began receiving invitations to lecture throughout California and later on, in other states.

A Consultation with Anne Sippi

In 1975, I was asked to do a consultation by a psychiatrist who was treating a patient named Anne Sippi, in a small psychiatric hospital in Los Angeles. I was told that Anne Sippi was sick from early childhood and had been treated by a number of different professionals and in a number of psychiatric hospitals for many years. She was 23 years old at that time. I was told that she was a violent patient and she was in restraints 75% of the time and spoke only several words. It was told to me by the staff at the hospital that she attacked people by hitting, biting, kicking, scratching and that even though she was medicated, the medication did not diminish her violent behavior. In my consultation with her, I challenged her aggression, by telling her that I also did the same things that she did. This statement on my part had a shocking effect on her and she was frightened by my verbal assault enough so that she controlled her aggression, but made an effort to retreat from me with the hope that her retreat would keep me at arms length. I discussed my observations with her psychiatrist and told him that I believed her to be treatable. He consulted with her mother and it was agreed that I should begin treatment, which I did immediately. I saw her every day including the weekends, confronting her aggression with my verbal aggression, which controlled her behavior and she became increasingly verbal. In several weeks, she was transferred to the open unit and I engaged a man and a woman to support my efforts. What happened was unprecedented, in my opinion. We began, a psychosocial rehab program very early in the treatment. The couple took her out of the hospital, five days a week after my therapy session, for several hours a day. Even though there were many resistance’s manifested in her behavior, she began to improve and over the course of time, about a year, she was discharged from the hospital, into a board and care home and we continued our treatment with her along with a growing group of long term schizophrenic patients in a day care center, that we called The Anne Sippi Clinic, because she represented an inspiration. She was considered a hopeless case and it was stated that she was to be sent to a public institution for custodial treatment for life. This did not happen.

The Anne Sippi Clinic

Her mother and I, because of our respective experiences, determined to create an alternative to hospitals because we both believed that hospitals are iatrogenic. We were fortunate enough to attract the attention of a noted rock star, who volunteered to do a concert for us, which he did and so the development of a residential treatment center became a reality. We soon found the facility that we now have and opened its doors in 1978. When Anne Sippi’s mother and I concluded that we wanted to create an alternative treatment center, there were many professionals who told us that this was an unrealistic ambition and that it could not be done. However, this did not deter us and we found our way of arriving at our goals. Prior to the opening of the clinic there were only several facilities in the whole of the United States that represented an alternative to the psychiatric hospital and that was the Fountain House in New York City and the Soteria House in San Francisco. The Fountain House remains and the Soteria House which was founded by the distinguished psychiatrist Loren Mosher, unfortunately, closed its doors because of funding problems. However, as good as they were, they did not do what the Anne Sippi Clinic was making an effort to do. Initially, our treatment focus was active psychotherapy, with the very regressed schizophrenic patient. We had a series of recreational activities, that were designed to facilitate the patient’s detachment to the mental health system. We had found through our experience, that the more the patient in treatment had the opportunity of making contact with the outside world, the more reality began to invade the pathology of the patient.

A very interesting part of the initial experience was the contact that we made with the neighborhood surrounding the clinic. We made no effort to contact the neighborhood to inform them of our existence, because it did not occur to me that it was necessary to do so. One day I was called to a meeting at the councilman’s office and was faced with a large number of very angry neighbors. We had one discussion after the other. I certainly have to admit that I was wrong in not introducing the idea to the people surrounding us, however, after awhile the neighborhood did find it less frightening for us to be there and many of them came to visit and were introduced to the clinic’s residents and much of their fears were overcome. These are not professional people, they are hard working people who had no understanding of schizophrenia and saw our residence as a threat to them and their relatives. They never understood the process but their fears were overcome and they became solid supporters of our treatment center. During the twenty years of our existence, there were never any serious problems with our neighbors and to me it has been a wonderful testimony of how human beings can establish peaceful relations and develop a sense of respect for each other.

The Clinic Program

As our program at the clinic evolved, we began training students and professionals and attracted large numbers of lay individuals interested in our practices. The emphasis was on a non traditional psychotherapy that was designed to be a part of a unified treatment direction with these very very sick human beings. Medication that was used judiciously was a part of the treatment. Active psychotherapy was designed to make contact as rapidly as possible using any means at our disposal (this statement was first made by Harry Stack Sullivan and repeated by Martin Grotjahn). We knew from the very beginning as a function of long years of experience that traditional psychotherapy was too passive a method to make contact with these individuals that lead to a therapeutic alliance. Without that treatment alliance, it was obvious that patients would not recover in any meaningful way.

Continued Development

As time progressed, we incorporated some of the psychosocial treatment methods; we were always concerned about personal hygiene and knew that these very sick patients required retraining in some of the basic skills of living. We recognize the importance of training in interpersonal relations and many of our group therapies were designed to achieve this goal. We knew that therapy of any kind without establishing achievable goals was an endless process and that insight did not lead to behavioral changes with most people. Quite to the contrary, I believe that behavioral changes leads to insight. We saw that there were certain fundamental issues that had to be addressed. Impulse control is critical. Dealing with the here and now at least in the beginning of treatment, is vital. To quote Harry Stack Sullivan, recognizing "that no one is utterly schizophrenic" is of paramount importance. When we see a patient with a diagnosis of schizophrenia, we find it therapeutically necessary to distinguish the healthy parts of that individual from the unhealthy parts. Talking about symptoms all the time, I believe, may reinforce them. Helping the patient understand that he/she also have some good qualities, helps that person recognize that he/she is not only a disturbed person, but those good qualities need to be reinforced so he/she will improve their self image.

Some Treatment Strategies

When dealing with auditory hallucinations, using some of the distracting strategies recommended by Sylvano Arieti, is very useful. He talks about the anticipatory set of the patient in reference to the hallucinations. Briefly what that means is that patients that hear voices, tend to expect to hear them. When they wake up in the morning, they anticipate the appearance of these voices and they do in fact appear. Training the patient to find measures that will distract him/her from hearing these voices can be a very effective treatment tool. Also, when the therapist concentrates on helping the patient improve their self image, voices tend to disappear. Treating the voices like they are the manifest content of a dream, in my opinion, is not useful, especially with the most difficult treatment population. Delusional systems are based on tremendous fears that create paranoia and/or a low self esteem that leads to grandiosity. So understanding that treatment is a relationship, a sharing of experiences a strategic intervention initiated by the therapist serves to overcome dulusional systems and very often leads to better social recoveries. We are given to understand that it is good for individuals with this condition, to have pleasure. But we find it considerably important as much as we can, to establish a routine that has as its objective a day of productivity. We believe, very strongly, that the abilities of these human beings have always been underestimated and given an opportunity they can work, effectively. Our training program remains constant. We feel an obligation to share our knowledge and experience with people who are interested. There is a mandate to find alternative treatment methods. The psychiatric hospital in most cases, has outlived its usefulness. Their cost factor is prohibitive, ours is effectively lower. Also, our treatment program is without question, more complete.

In Conclusion

We have had the good fortune to present our treatment approach in fifteen different countries and throughout the United States. We are gratified to have helped the establishment of psychosocial treatment centers in several other countries, including Russia. We are also pleased, with some of our interns, who have graduated and are currently working creatively with patients diagnosed as having schizophrenia.

Recently, another Anne Sippi Clinic, number two, was opened in Kern County, called the Riverside Ranch which is currently thriving. I might add that both clinics combined have sixty-two beds. I as the Clinical Director Emeritus am delighted that Chess Brodnick, Ph.D. and my son, Michael Rosberg, Ph.D. have taken over the direction of both the Los Angeles branch and the Kern County branch of the Anne Sippi Clinic. We hope that what we have accomplished over the past twenty years will help pave the way for comparable treatment centers that will provide a greater sense of hope and determination for those very unfortunate victims of schizophrenia. We firmly believe as a function of our experience, that with the right treatment and attitude, these human beings can live independent of the mental health system.

The Anne Sippi Foundation will continue its training of students and professionals and we are preparing ourselves to do research in the near future.

Till we meet again,

Jack Rosberg