July - 1998

 By Ken Bagnis, Counselor

 Assistant to Jack Rosberg

Overcoming Resistance in the Treatment Resistant Patient

Case Example and Specific Treatment Techniques: Dan

 On the day I met Dan he was helping a staff member rearrange some large pieces of furniture in one of the resident's bedrooms. I was amazed by Dan's physical strength and I remember thinking he would have no problem moving the entire bed on his own. Two separate offers made by myself to help with the lifting were ignored. The only response I received from Dan was a quick glance and a grunt. Later that day I was properly introduced to Dan and I asked him if he was tired from all of the strenuous work he had done. Dan nervously answered by quickly stating "Dan's not tired. I'm a good worker, right?". I agreed and walked with him down to the kitchen were he would help the staff clean up after lunch.

 Dan is a 39 year old client at the Anne Sippi Clinic and is currently being treated for schizophrenia undifferentiated type. He is most recently living in an apartment setting, coming into the clinic on a daily basis for intensive social therapy, medication management, and psychotherapy. Dan is fairly well socialized, spending most of his free time with the clinic kitchen and maintenance staff. With minimal prompting he helps with various tasks and enjoys the staff's company, stating that, "I feel like he's (I'm) part of the kitchen family back there." Most of the staff would agree that Dan has come a long way in the clinic's program since he first arrived in September, 1988.

 At the time Dan was admitted to the Anne Sippi Clinic he had a long history of psychiatric hospitalizations. No medications seemed to help with his symptomotology, the most predominate being paranoid delusions. Since the inception of his illness at the age of 18, Dan remained quite withdrawn from society. It was his family's hope that the Anne Sippi Clinic could, to some degree, help Dan with his resocialization as they saw his social withdrawal as his primary disability.

 As Dan's treatment began at the Anne Sippi Clinic he was extremely aggressive. Although he seemed conscious not to hurt other people he was very violent towards himself. At that time he was having many auditory hallucinations. The strong persecutory voices would command him to hurt himself. The voices would get so bad Dan would often put his fist or head through a wall in an attempt to get rid of them. Dan would also lash out at his voices by punching himself in the head. A high level of anxiety could also be seen (and heard) in Dan as he would often loudly grunt or scream for no apparent reason. Aside from these sounds, Dan made little attempt to communicate with anyone. Although never formally diagnosed, a suitable way to describe Dan's condition would be catatonic. In looking back at this distressful time in his life Dan felt there was no hope for himself, recently explaining to me, "It was like I was going to be alone forever. I thought someone was going to kill me."

 His primary therapist Jack Rosberg quickly made good inroads to Dan's condition. Jack believed it was very important to keep Dan centered on expressing his anger verbally. The problem was getting Dan to express himself at all. In order for the clinic to provide supportive socialization Jack had to first make contact. I watched some videotaped sessions from 1986 of Jack working with Dan, in which I witnessed this initial contact take place. In the session Dan had a vacant stare on his face and answered only a few questions with a grunt or a nervous "yes" or "no". As the session continued Jack seemed to become frustrated with Dan's lack of responses and shouted out the word "fuck". Dan's empty stare quickly turned into a smile as he heard Jack say this word. Having finally received a response from Dan, Jack continued with more profanities. Dan began to laugh and finally talk to Jack about the terrifying and demanding voices he was hearing. Holding Dan's hand, Jack promised to "kill the fucking voices" so he could begin to live and be free. It would seem that Jack shocked Dan with his unconventional approach allowing a line of communication to open. At last contact was made.

 In another videotaped session I watched Jack use an effective paradoxical technique on a more verbal Dan. Jack asked Dan if he was hearing the voices. When Dan answered, "No, not right now," Jack demanded that he bring the voices back and hear them. Dan replied, "I don't want to hear the voices but I have to hear them." Once again, Jack ordered Dan to hear the voices. Dan replied, "The voices are gone."

 Jack used this same paradoxical approach with Dan in another instance, asking him to smash his head against the wall. This was a behavior that Dan believed to be uncontrollable and the only way to get rid of the voices he was hearing. However, when Jack demanded the he put his head through the wall, Dan only lightly tapped it. The voices were silenced and his head was uninjured. This began to prove to Dan that his violent impulses were controllable. In Dan's case a paradoxical approach continuously acted as a very effective mechanism.

 Progress began to grow even more in Dan as he started to work closely in conjunction with Jack and his wife Ann Rosberg. Ann set up an extensive, daily exercise program for Dan and another clinic resident. Together the three would jog several laps around the clinic grounds and continue on with a number of sit-ups and push-ups. As Dan would exercise his extreme rigidity would begun to diminish. Dan began to express his fondness for the exercise sessions and got involved with other clinic sporting events and activities. A growing awareness of his illness was evident and attributed to his heightened ability to communicate more clearly and effectively. In time Dan became a close friend and reliable helper to the staff that works in the clinic's kitchen. Dan helped serve food, wash dishes, mop floors, and eventually even help with weekly shopping trips to the grocery store.

 Dan had obviously made significant progress, but he seemed to settle into an almost obsessive routine of working, eating, and going home to his apartment. Jack believed a change was needed in his treatment plan. The new direction in treatment needed to focus more on Dan's negative symptoms (withdrawal, sparse communication, and rigidity) rather than removal of his positive symptoms, which at this point were mostly under control. Jack believed it would be beneficial for Dan to see me on a daily basis for regular supportive counseling sessions. Jack would act as my supervisor and join us in our meetings on various occasions.

 Outside of working in the kitchen Dan had made little effort in building relationships with staff or other residents. He was having a very hard time staying focused on one topic of conversation and his stature still remained quite rigid. Jack and I agreed that I should continue an exercise program with Dan as a part of our daily get-togethers. As our sessions began Dan seemed very uncomfortable and anxious leaving his regular routine behind to spend time talking with me. If we sat in my office he would complain about feeling closed in and having difficulty breathing in such a small space. As we continued our session outside on the clinic grounds this anxiety did not seem to lessen. Only after we jogged around the building a couple of times did Dan begin to loosen up and tell me a story about dropping a football in an important high school football game. The essence of this story seemed to be that Dan was aware of his great physical strength, but also believed himself to be unintelligent. I told Dan he seemed to be a very intelligent, good man. He quickly disagreed with me saying, "I have a low I.Q., right? It's got to be really low for me to be like this." At this point I realized how important it was for me to not only focus on physical exercise, but also to direct my attention to some mental exercise for Dan.

 On the next day we met I handed Dan a copy of Robin Hood and told him it was his to keep and read. He told me his I.Q. was too low to read it, but he would be happy to exercise with me again. After running a few laps Dan agreed to read a couple of sentences out of the book for me. He unclearly mumbled through the two sentences and continued on for three more pages. I asked Dan to explain to me what was going on in the portion of the story he had just completed. He quickly summed up the pages in a few sentences. I complemented Dan and expressed to him that it takes a very intelligent person to comprehend text as well as he had. Dan loosened up even more and requested that we continue reading in our next session.

 Exercise and reading continued on a regular basis. In time Dan's speech became much more clear and comprehendible. The more he read and exercised the more comfortable he seemed in social situations. Dan was making new friends and having conversations with staff members he would usually ignore. Dan would often credit the books with his improvement and began reading them at home in his spare time. At one point Dan purchased a copy of The Call of the Wild and brought it into our sessions to read. He believed the Pinocchio book I chose for him was, "really not smart enough, it's for children." In fact, Dan began seeing himself as a competent and quality person, stating that, "the books have helped me raise my I.Q. It used to be 50, now it's like 500." Dan further showed his enthusiasm for his mental exercises by voluntarily writing a two part book report on the book Robin Hood for the January issue of the clinic's in house news paper.

 It is clear to me that Dan has made a considerable amount of progress in the past few months. What's more exciting is that Dan is aware of his own progress. Recently Dan told Jack and I that he can feel that he is "coming out" of his illness. He feels excited, but somewhat anxious about this fact, and understands it may be a long process. Perhaps the most important thing that Dan has come to realize in the past few months is that he finally fits in somewhere and seems to be developing a great sense of belonging. Early on in our sessions Dan asked me, "Is there someplace on Earth for me or am I going to spend the rest of my life in Hell?" This question has now been answered for Dan and he sees his future in a much more positive perspective.