Specific Interventions - Helping the Patient Talk

The following are some interventions which you, as a therapist, may find useful in working with schizophrenic patients.
First, you need to place priority on getting the patient to interact verbally. While nonverbal communications are important, you cannot devel op a therapeutic relationship based only on nods, gestures, or grunts. You mu st help the patient reach a place where she can tell her story. At some lev el, every patient wants to tell someone, anyone, what her life has been like. Yet many schizophrenic patients are so uncomfortable in the therapy sett ing that they cannot begin to open up. Others will only want to find out if they can titillate or arouse the therapist's voyeuristic needs. Nevertheless, you should help the patient feel that what she is saying is being understood, which can be accomplished by accepting the reality of the patient's experience as she tells her life story.

A key indicator of probable success is the patient's ability to make eye contact. Patient who maintain eye contact usually want to talk; this doe s not, however, mean that they are comfortable. They may be angry with you for threatening their long established defenses and the eye contact may be intended to scare you off. Yet even this interaction provides you with a n opportunity for interaction, in that the patient has shown through body language that she wants something from you. When the patient lets you kn ow, however subtly, that you may be able to do something for her, no matter h ow alien, remote, or bazarrely formulated, you've made an important first st ep towards making contact.

After the patient begins to talk, you should increase the tension in the relationship by raising the issue of the patient's desire to get better. You need to ascertain whether the patient truly wants help. Further, if it s eems that she wants help, you need to address two questions: What type of hel p does she want? And is she willing to make a contract with you to meet specific objectives? The patient must convey this information in some ov ert way so that the reality of their behavior binds her to the developing relationship.

We must always remember that psychotherapy does not begin when the patien t and therapist begin to talk with each other. Each may be presenting attitudes that have no therapeutic purpose. However, the time they spend together must prepare the patient for the treatment that is to come. For example, when we encourage the patient to acknowledge dysfunctional behavior we make inroads into the self concept that can contribute to future therapeutic change. Further, when we persuade the patient to accept us into her life, the relatedness and emotional involvement that are precursors to psychotherapy become a reality.

Developing a Trusting Relationship.
Of all the elements involved in our approach to making contact, the most important is the creation of a sense of trust between therapist and patient. Patients must feel safe with the therapist and believe that the therapist is strong enough to protect them from the illusory but threatening aspects of their illness. Patients must learn that the therapist provides a sanctuary for their illness and that the therapist will never do anything to harm or violate them.

The patient must openly acknowledge and confirm the fact that she feels safe. If necessary, the therapist must force this issue into the open and insist that the patient share any hidden concerns about safety. This process is centrally important for several reasons. It introduces the concept that trust can be established and maintained on a verbal level. It also reinforces a fundamental aspect of all human relationships; that words between two people can symbolize their mutual obligations and responsibilities in the context of the relationship.

Helping the Patient Share the Experience.
Even after making verbal contact, however, you're still faced with the problem of how to share in the patient's awareness of her own experience. We've learned from our clinical experience that you can learn more about the patient's subjective world by surprising her with the unexpected. This event/surprise must be genuinely unexpected and totally unforeseen. It should truly startle the patient into a reaction that acknowledges the presence of the therapist and to which the therapist can respond. It may be amusing or stern, loud or soft, angry or sad, harsh or gentle. It can arise from a context that is unanticipated or even incongruous. Yet--and this is the key--it must make the patient stop to consider what has just happened. It must make the reality of the therapist's process part of the patient's illness-controled world.

Disrupting the patient in this way may also be disturbing to her illness-based psychological stability. That is, the patient may experience the disruption as a challenge to the integrity of the defenses she has build up. The therapist must be prepared to deal with a wide range of potentially intense feelings; in doing so, you should always remember that this experience of having her confidence shaken can be quite terrifying for the patient. Over time, however, this intervention can help quiet the patient's resistance to the contact process by focusing both patient and therapist on the fact that constructive human interaction is possible and desirable.

Making the Patient Feel Worthwhile.
It's all too easy to take the schizophrenic patient for granted and to forget that everyone needs to feel appreciated for the good that is within them. It is important in any human relationship to make the other individual feel special and worthwhile. As a therapist, you may want to draw attention to the patient's genuine assets; examples would include intellectual resources and interests, sensitivity to others, or strength in the face of the illness. Sometimes an appeal to the patient's exhibitionistic qualities is in order. This may be particularly valuable when the therapist finds something uniquely attractive in the patient.

Avoiding Therapeutic Neutrality.
The therapist who makes a schizophrenic patient feel special and valued can never be truly objective. Every therapist must recognize that he or she does have attitudes about and feelings towards their patients. Patients are not neutral objects with no valence and the therapist cannot afford to give them the impression that they are. The desirable option is to acknowledge your feelings towards the patient, and explore those feelings to better understand your patients' stimulus value as human beings.

This advice, of course, is contrary to some schools of psychotherapy which treat therapist neutrality as a central tenet of psychotherapy; the justification is related to the need to avoid countertransference problems. We must remember, however, that making contact with a schizophrenic patient is not a countertransference issue. The patient has a need to be stimulated by the therapist's own strong feelings, in much the same way that the child needs her parent to stimulate, encourage and provide structure.

Thus, the therapist may occasionally have to structure the patient's response in order to make the patient accessible to a vigorous therapeutic thrust. Or, alternatively, the therapist's encouragement may be tender and gentle. In either case, the goal is the same: to make the patient feel that there is someone in their life who genuinely cares about them.

Taking Charge of the Patient's Life.
If contact is going to occur, the therapist must become established as the dominant force in the patient's life. It is this energy that allows the therapist to gain mastery over the patient's reactions to the illness. Only then does the patient understand that the illness has prevented her from directing her life in productive ways. Over a period of time, the patient learns how her previous efforts to adapt to her illness-dominated world were at best inadequate and at worst disastrous. For the first time, the patient may realize that there is a realistic prospect for getting well.

This responsibility, that of controlling others' lives, should not and cannot be taken lightly. Therapists who seek to establish this degree of control over their patients lives must have control of themselves. They must feel confident in their ability to help the patients and comfortable with themselves as human beings.

You cannot direct treatment successfully if you wait for patient approval of the interventions. Whatever happens, you must take charge, whether or not that meets with your patient's approval. You must not yield to the patient's inevitable defensive maneuvers. If you allow the patient to control the growth of the relationship or the course of the therapy, real progress cannot be made (Rosberg & Stunden, 1989).

Rejecting the Patient's Illness.
If the patient is to relate successfully to the therapist, both must understand that the patient has personal qualities that remain uncontaminated by the illness. The therapist must not become so preoccupied with pathology that the positive characteristics of the patient are forgotten. The therapist can sometimes impart this by rejecting the illness and isolating it from the patient. For example, the therapist can become angry at the illness but convey feelings of concern for the patient. Telling the patient that her illness has made her an unpleasant human being may also be appropriate. Note, however, that this would only be verbalized if the converse were true, i.e., that without the illness she would be a more pleasant human being.

The therapist must always be careful not to add to the patient's inappropriate guilt about being sick. Patients often feel responsible for their illness and helpless to do anything about it. You, as the caring therapist, should help the patient understand that she is not to blame for what has happened to her. You should never forget that patients do not seek to become schizophrenic.

Thus, the patient and therapist must not get bogged down in the apparent limitations imposed by the illness. The therapist works with what is there and should not let the illness get in the way. It is important to look ahead and not look back. This tactic reminds both patient and therapist that there is indeed hope and that the illness does not necessarily have to continue to control all aspects of the patient's life.

Treating the Patient With Respect.
It is vital to respect the humanity of the patient at all phases, even during direct efforts to make contact and gain control. One must not take the patient for granted nor deprive her of her dignity through excessive or arbitrary use of authority. Patients should always be given choices, reflecting the therapist's confidence in her ability to know and do the right thing. This action by the therapist communicates both a belief in her ability to improve and a positive regard for her as a human being.

The ability to make decisions, even about seemingly unimportant matters, enhances the patient's self-esteem and heightens her belief in the strength and basic honesty of the therapist. By consistently treating the patient with respect, the therapist can convince her that the primary objective of therapy is really the patient's well-being.

As these interactions become increasingly successful, however, the patient may begin to agree with whatever is said to her. The contact process can become virtually hypnotic, with patient and therapist locked into a distinct world directed by the therapist for the patient's benefit. When this situation develops, you will want to allow the patient as much cognitive control as she can handle. During therapy, you may want to preface certain interpretations with the caveat that they may be wrong; encourage the patient to give feedback, especially if she feels that something is not quite right. Prompting the patient to not let you put words in her mouth may also be quite helpful.

The Role of the Therapist
One of the primary tasks of the therapist is to stimulate the curiosity of the patient. The therapist must become intriguing enough to the patient that she will want to pursue the relationship. To put this in context, it is important to remember that the schizophrenic patient lives in a forbidding world of unwanted rules and restrictions and is conditioned by society and by the treatment process itself to the norms of confinement and control. To often, these experiences have deprived them of any sense of individuality; schizophrenic patients have essentially lost their right to express their feelings about the world around them. They've come to believe that everything they do is contaminated by their illness. They internalize the message that society expects them to be sick.

However, there is a positive and constructive alternative. What if the therapist is comfortable with the patient's feelings? What if the therapist communicates this comfort to the patient, stimulating her and encouraging her to re-emerge? Might she then become interested, with her intense curiosity leading her to take halting steps toward making contact? In this framework, making contact symbolizes an opportunity for the therapist to engage in controlled abandonment. Perhaps most fundamentally, the therapist commits to do whatever is necessary to reach the patient.

Making Contact, Psychotherapy and the Future of Treating Schizophrenia
The practical problems associated with treating the patient whose illness mandates a retreat from human contact overwhelm many therapists. The issues and problems involved are totally foreign to their clinical training and experience and they may just not feel ready or able to proceed with therapeutic interventions. The ready availability and effectiveness of neuroleptic medications permits the therapist to withdraw from the patient at the most difficult phase of the illness. As a consequence, further attempts to make contact and initiate psychotherapy may be postponed until the patient is seen as willing or able to accept it (Rosberg & Stunden, 1990). This approach assumes that human contact can be of little benefit to someone who has become isolated by the rigors of the illness. The therapist, by internalizing this assumption, may continue to avoid contact altogether. Brody's admonition to the therapist to make contact through any means possible goes by the wayside.

We feel that the approach described here, centrally involving the active "reaching out" to the schizophrenic patient, provides a constructive and effective alternative to avoidance. The techniques do not require the therapist to give up the use of medications if that is helpful in accessing the patient. We also recognize that the demands of the illness may in some cases prevent the patient from accepting the therapist's offer to make contact. However, the responsibility for assessing the situation lies in the hands of the therapist, who must always remain accountable for fostering a sense of relatedness with the patient. The therapist should consistently seek to nurture a meaningful relationship with the patient, a relationship which will, over time, permit other kinds of treatment-oriented contact to take place.

This approach provides a method for creating a meaningful history which can provide the foundation for a human relationship. The sharing of time and experience creates a history unique to the evolving process between therapist and patient. How often have we stood with someone in an elevator, going from floor to floor, with any potential relationship remaining only nascent? What if one passenger imposes in some way on another, perhaps asking the time or for directions? While the seeds of relatedness will begin to stir, they will not take root. The interaction requires nothing more than a casual and impersonal reply. Yet, if the elevator get stuck between floors, a relationship centered on the shared history quickly develops among the elevator's passengers.

Therapist and patient too often ride silently from floor to floor, only dimly aware of one another, each hopeing to be ignored until the other reaches his floor and walks out the door. Casual thoughts might be shared, perhaps even with some purpose beyond an impersonal exchange of information. But what if they do not understand each other? What is one becomes upset? What it one attacks the other? How will they react, who will try to deal with it? If both therapist and patient simply get off the elevator and ignore their mutual journey the history they created will have gone for naught.

The contact process invites the therapist to enter the patient's life with a hopefulness quite different from the patient's previous experience. The patient is not likely to get better if the therapist lacks hope. As therapists, we make a powerful statement about our feelings of self worth when we treat patients who themselves believe they are hopeless. When we share our hope with such patients we encourage them to believe in human values that foster growth and self-fulfillment. The therapist's positive attitude and tactics can help the patient move from a position that denies the worth of human relationships to one permitting relationships to be examined for what they are.

When we try to make contact with out patients we must also remember that schizophrenia is seldom a matter of life and death. Schizophrenia is not an acute "battlefield" type wound requiring immediate, drastic intervention; is is not a medical triage situation. The patient who is not yet ready for treatment may still eventually benefit from making human contact. Even though people with schizophrenia seldom die of the disorder, their lives are significantly diminished if human contact is denied them. To abandon them to their illness is to deny their humanity.

If psychotherapy of any type is to succeed, both patient and therapist must believe that a sense of relatedness between them can indeed be formulated. If nothing else, this belief persuades both parties that the patient is not beyond reach. Neither therapist nor patient can afford to wait. It doesn't matter whether the clinician views the patient as sick biologically or well defended psychologically. In successful treatment, theory is seldom as important as practice.

This is the core of the issue. Treatment must be approached with a focus on the human being with the illness. Successful treatment is more dependent on the patient-therapist relationship than on the application of any particular treatment technique. While we know that a relationship can never be substitute for treatment, we also know that without such a relationship treatment itself cannot exist.

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Will, O.A. (1975). The Conditions of Being Therapeutic. In J. Gunderson & L.R. Mosher (Eds.), Psychotherapy of Schizophrenia. New York: Jason Aronson.suffering with schizophrenia, in particular the and other common treatment resistant who are successfully helped. We approach the treatment of schizophrenia with alot of care and love for these individuals suffering from this mental illness