A Finnish Patient

CLINICAL IMPRESSIONS, OBSERVATIONS AND RECOMMENDATIONS REGARDING THE TREATMENT OF A FINNISH PATIENT

 The following is a summary of clinical impressions, observations and recommendations regarding the treatment of a patient that I saw in a psychiatric hospital in a small town in Finland. For the sake of confidentiality all names will be changed. There is a message herein, that in my opinion, needs to be understood  by the reader. As important as this one individual is, he is one of countless numbers of human beings who have been betrayed by the unwillingness of many professionals throughout the world to understand and fulfill the needs of these unfortunate individuals who have a diagnosis of schizophrenia.

 I wish to quote the English Psychiatrist, Dr. Brian Martindale, Chairman of the XIIth International Symposium for the Psychotherapy of Schizophrenia Schizophrenia and the major psychosis remains serious, distressing and disabling conditions world wide. However, knowledge and skills of contemporary psychological therapies relevant to psychosis and its prevention are woefully unavailable in many parts of many countries. I first saw Pekka in 1995. I was requested by his family to evaluate him and to make therapeutic contact with him in order to determine what his treat ment potential was and to develop with the hospital and his family a program that would improve the quality of his life and perhaps free him from the restraints imposed by the better part of twenty years of psychiatric hospitalization. There were questions to be answered. Was Pekka treatment resistant, was he intractable, was there no hope for him? What program could be developed to meet his specific treatment needs and how could staffing  be deployed to make this program workable. Also critical is finding staffing that would be devoted enough to expend the energy that it would take to persuade him to yield some of his schizophrenic symptomology and build a world with a greater sense of reality.

 I spent several hours a day with him, usually four and even though there  were levels of pathology, depending on the amount of anxiety he felt. The fact that I spent so much time with him is certainly unusual, however, with selective patients, I have found that this amount of time is therapeutically worthy and is also an effective training method. I was able to make rapid contact with him, which turned into a positive relationship that was tantamount to a therapeutic alliance. I would not describe this relationship as a transference phenomenon. It is important to understand the distinction between the alliance and transference. This developing relationship between he and I was based more on reality than on the unreality of the transference. I saw him, as a function of our interaction, being prepared for a more complete treatment. I presented my ideas to the director of the hospital, several other administrative officials and his father. Regretfully I was  told by the head of the hospital that they could not implement my treatment plan because it would not be acceptable to the staff on the ward he lived in.

 I was astonished that such a negative statement could be made by a responsible head of the hospital. However, during the course of my forty three years of practice I had heard this statement made or implied in many countries that I had presented my work. The head doctor made it quite clear that the nurses would not take such orders from him or any of the psychiatric physicians. I was surprised that such a split could exist between staff members, whose efforts should be directed towards healing the so called split in schizophrenia. Finland, from a treatment point of view has some very progressive ideas in some areas of the country but tragically in most of  the country treatment in psychiatric hospitals are inadequate. This is not unlike treatment throughout the world. I was disturbed, but there was not a thing I could do.

 However, his father was very pleased as was his brother with what had happened in that short period of time and I was told after I left, by his brother, that the progress was sustained even though there was a period of depression following my departure. Also, his brother told me after I returned to the United States that Pekka had for the first time in years, joined his family for Christmas and was able to relate in a socially acceptable manner. He also was able to go on a week vacation with some members of his family, after the holidays.

 May 19, 1997, I returned to the same hospital in Finland and began seeing Pekka again. It was a very happy first meeting, I was pleased that he had not forgotten me and that it seemed almost that I had not left him for any period of time. In fact, a physician who was trained in Switzerland, who interpreted for me the first day, told me that he was surprised how quickly I made contact with Pekka and his positive response. This is indicative of the therapeutic alliance, which was not severely ruptured by the period of time between the two contacts.

 Pekka seemed improved after my first visit with him in 1995. Pekka is diagnosed as being schizophrenic. There is some bizarre symptomology, however, at that point in time I did not see any delusional indications even though some of his fantasies could be mistaken as delusional. Often what is seemingly bizarre is an indication of a different level of logic and language that they use, which should be understood for what it is and not perceived in error by the mental health staff. It's very important for us to be very careful before we describe patients verbal or non verbal behavior as being one of the major characteristics of this condition we call schizophrenia. I saw these fantasies as a metaphorical expression of his wish to leave the hospital environment, which is not therapeutic for  him. Even though the wish is expressed in different ways and sometimes with much emphasis and repetition, he understandably has ambivalent feelings because of his fears and anxieties related to the world around him.

 I saw him for two weeks this trip spending two or three hours a day. To refer to the young doctor again, who had recently assumed a position on Pekka's ward , I need to quote what the doctor told me about Pekka, Pekka cannot be helped so therefore I hardly spend any time with him. This attitude of seeing Pekka as being intractable certainly has become a self-fulfilling prophecy. Pekka, as sick as he is , is a sensitive human being, who picks up feelings and certainly his behavior is influenced by the attitude of the people around him. They have no hope,  can he be hopeful? I believe that even under those circumstances his will to live a better life helps him retain some degree of optimism that is stimulated by those who see him as a human being rather than a diagnosis. Why does Pekka seclude himself, both physically and mentally from most people? That is, the patients on his ward with whom he has the most superficial contact as he has with the staff, perhaps with the exception of one male nurse. His isolated life is in my opinion, a product of several factors. Certainly his illness plays a part in this but one can't negate the feeling that he has of being undesirable and a nuisance. So, his illness is perpetuated by the atmosphere he lives in, which has become iatrogenic.

 Let me just add something that was told to me by one of the professionals at the hospital. The whole hospital staff was required to go to meetings that were intended to help them develop a more positive attitude towards patients. It seems ironic that one needs meetings to develop a more hopeful attitude. Will these meetings accomplish this goal of encouraging rigid and/or jaded professionals to feel more positive? In the many presentations that I have made in hospitals in the United States and in Europe, this is an unfortunate condition that exists in too many cases. Let me make my point as clearly as I can, we are treating people who are mentally ill. These human beings require a great deal from us as mental health professionals. How can we with any degree of conscience, transmit to them negative feelings about their potential to make behavioral changes. We do not have the right to work  with them if our attitudes are not positive. In fact, how many of us, if any, are in a position to make a prognosis that accurately describes how limited, people with schizophrenia are, in developing better coping mechanisms.

 Back to Pekka. He does not suffer from auditory hallucinations, however, there are times that he talks to himself and there are times when he sings softly. Usually songs that are sad and also songs, as I was told, that date back to his earlier years. There can be some irrational expressions which to me are representative of anxiety or confusion. When the anxiety grows greater he seems to reassure himself by touching objects that he passes by when he walks in the hallways in his ward. Pekka is desperately lonely.  He has good reason not to trust many people, however, he does respond favorably to warmth, if he begins to believe that another person has the wish to make a meaningful emotional contact with him. His sensitivity allows him to differentiate from those who are sincere and from those who are not sincere. I am convinced that he wants help. That he wants to change, but he does n't know how. He will take direction from someone whom he trusts. I need to repeat that he has been sick for at least twenty years and creating a relationship with him, that he trusts and accepts will take time and energy. It is critically important not to lose sight of the need to be consistent in order to reinforce a positive relationship. Pekka has a very poor self image, which is one of the characteristics of schizophrenia. He believes that he is not a very good person, he told me this and also he feels ashamed of his sick condition and of his not being productive. He dislikes being in the hospital. But time has created a sick attachment to the facility. His negative self image is perpetuated by his inability to break free enough  from his condition to live independently. To repeat, he is very sensitive to  what staff and family feel about his potential for some degree of recovery. I cannot emphasize enough how important it is for him and of course many other people with similar conditions to have some feeling that the world around them sees them as having good qualities and not simply viewing them as being sick.

 The attitude of others towards Pekka and their fears that he will act badly, persuades him that he has no place in the world. That he does not belong. He suffers  from water intoxication and it appears that this symptom is controlled only by restraining him and not by a concerted human effort to work out the symptom. I was asked by a young woman doctor, how do you stop patients from drinking so much water? What is the answer?  I found this question to be so apparent that I was surprised that it was asked. I tried to answer the question the doctor asked me by asking a question of her. What is the first step in treatment? She answered me by stating that forming a relationship is one of the basics in effective treatment. So, I think that the answer to the question seemed to be so evident, that a positive relationship between human beings can persuade those afflicted with these symptoms to make behavioral changes. Now to reflect for a moment on the question this young woman doctor asked me. It seems to me that this symptom is not uncommon, that it would be cost effective to have a staff member assigned to people with this symptom to restrain them, not by secluding them, but by relating to them in a personal and humane manner.  It is important, I believe, to focus on his capacity to control his impulses and his behavior, so that he presents himself in the most socially acceptable way. This will be of help in improving his self image. He will see that these controls bring positive responses from the world he lives in.

 I took Pekka off the ward daily and he enjoyed himself and felt a sense of relief and pleasure. As we walked in the outside hospital area and ended up in the cafeteria, where we would have a soft drink and a chocolate, I always found him appropriate in his mannerisms and behavior.

 One day towards the latter part of my stay with Pekka, I took him to another city nearby where we met the head of a psychosocial treatment center and we were shown all their rehabilitation activities. They were kind enough to host us for lunch in a large cafeteria, Pekka was very positive. In the taxi ride from the hospital to the other city he carefully put on his seat belt and made sure the door was locked. After the initial anxiety left him, he was obviously delighted with the ride through the countryside. During the entire trip he was both appropriate, cordial and well mannered. He offered to share some of the chocolate he had with me as he did frequently in my stay with him. He told the head of the psycho-social center in the other city that he would like to come there, however, as he put it I have too many fears  and it might take some time to resolve these fears.

 The majority of the treatment was done through an interpreter since I do  not speak Finnish and Pekka has very little understanding of English. I made some suggestions as to his treatment as follows: I think that he is a candidate for a reality oriented psychotherapy. I have had on the two occasions that I was at the hospital the pleasure of having considerable contact with the head social worker, who is very progressive in her thinking. She has had contact with Pekka over a period of time and it is obvious that he has good feelings about her and I think as I reported, that she should be his psychotherapist. He needs this involvement and I believe that after all these years, he deserves to have a chance. He should be taken off the ward everyday for increasing periods of time, as his tolerance to stress grows, a ride and lunch at a restaurant in another little city should happen, frequently. Being out of his ward is a positive experience. I am aware of the fact that there are people who go out of the ward with some frequency, but during my stay with Pekka, it became quite obvious to me that he was not off the ward very often, which the staff admitted. Whoever is supervising Pekka, I stated, should be creative in normalizing his life. He is well oriented in almost every sphere. The reality of the present, not the past, should be the focus. Let me add that when indicated, family therapy might be an important consideration. He needs to have more quality contact with his relatives.

 Activities on the ward should be done, with some understanding that time  is a factor in achieving goals that are developed with him. There is no successful treatment without developing achievable goals with the patient. I continued in my report to recommend that he should be involved in a schedule of daily activities, such as reading the newspaper, being aware of current events, drawing, painting, chess, ping pong, which he enjoys playing, also if this is acceptable doing some cleaning activities and developing other interests that can distract Pekka from being preoccupied with sick thoughts and ideas and redirect his energies in a more positive and rewarding way. In my opinion, the ability of individuals with schizophrenia to be productive, one way or another, has  too long been underestimated. Those individuals who work and supervise Pekka , I stated, must be verbally involved in order to draw him into discussions that are reality oriented. The ultimate goal, of course, is to find a less restrictive environment that will improve the quality of his life and permit him a sense of dignity and self respect.

 It is my considered professional opinion after a great deal of time with Pekka on two different occasions that his prognosis for change is favorable. I have seen some progress take place between 1995 and 1997. It must be understood, to quote Harry Stack Sullivan, no one is utterly schizophrenic. We need to understand that patients are not only symptomatic, they have healthy areas that should be sought out and reinforced in treatment. This progress that I am talking about depends on the units of care assigned to Pekka and those individuals utilizing these units of care working with interest, energy and harmony and sustaining and further refining the suggested program over a period of time. Consistency and deliberateness, are critical, along with realistic expectations in terms of his development over a period of time. It is important to be aware that these individuals working with Pekka have an attitude about him as an individual who can progress and make life style changes. Because of the difficulties involved in this treatment it is so very easy for people to yield to fatigue, which could persuade them not to give their best efforts to treatment.

 It is also hoped that his relatives will offer him the family support system, that he needs so much of and that they will confer with an assigned professional to eliminate any feelings of conflict with Pekka and between themselves, that could handicap this united effort. It is clear to me that all the participants in this program should have a common goal - and that includes family members - which is to help him recover as much as possible. In order to accomplish this humanitarian mission, they cannot let their egos stand in the way. What happened to Pekka in the past is in the past. History does NOT have to repeat itself. We should not have preconceived ideas that will conspire with his condition. This, by the way, happens much too often in the treatment of patients with schizophrenia. They, much too often are seen  as being treatment resistant. It is well known that Pekka has been treated only with medication. This  is not enough.  Research that has been replicated in many parts of the world has clearly demonstrated that medication is only effective when it is a part of an overall treatment program, which includes supportive and reality oriented psychotherapy, along with some forms of psycho- social rehabilitation. The English Researcher, Philip May, in a land mark study pointed this out more than thirty years ago. Dr. Thomas McGlashan the Chief of Psychiatry at Yale University recently pointed out that medication masks symptoms and is effective as long as it is taken by the patient. It becomes increasingly clearer as a function of experience, that medication is effective only insofar as it is taken. It is quite clear that the effectiveness of medication, by itself, is at best, palliative and temporary. Even though many biologically oriented people talk about this being the decade of the brain, it is my opinion, that if one has a more global picture of this condition, one has to also talk about this being the decade of the mind. It should be apparent that these ideas are not a priori that there  are many treatment facets that need to come together and work as an inseparable unit. There is no longer a question of whether these individuals can make good social recoveries, the issue is how quickly can it happen (Robert P. Liberman, Professor of Psychiatry, Researcher, University of California,  Los Angeles). To repeat, these studies have been replicated many times throughout the world. In the last twenty years, psychosocial modalities of treatment along with other therapeutic approaches have added to the success rate with the long term schizophrenic.  In a lecture that I gave in Tampere, Finland one of the attendees was a distinguished psychiatrist, who had participated with Yrjo Alanen in the Finnish study. He was completely in agreement with me when I discussed that the long term schizophrenic individual was part of the legion of the forgotten. I believe very strongly, that Pekka's failure to recover is due to the limited treatment he receives. He has become a prisoner of the system. He has not committed any crimes. He is basically like every other human being with the same needs and wants for pleasure and survival. He  is one of many that represents mental health's greatest challenge to the psychiatric world. I believe we owe him more than he has received. Also , as a human being and as a professional, it appears necessary to me to find f ault and criticize my own efforts. I think that we should also do that with those areas of treatment that have failed to produce the results that people deserve to receive. We need to look at ourselves critically in order to find the areas in treatment that need to be changed or refined. We cannot continue to blame the patient for not improving. It is our responsibility to make that happen.