In 1995 my associate and wife Ann and I were in Russia. We had accepted two invitations to develop treatment centers and train mental health staff in the Far East of Russia - in the Cities of Nahodka, Vladivostok, Ussirsk and Krasnoyarsk, in Siberia
Our efforts were directed towards integrating active psychotherapy techniques and psychosocial treatment modalities in psychiatric hospitals. The reaction to our efforts was mixed, that is, there were those who were rigidly opposed to any deviation from their practices. Not unusual in any country, but exacerbated by the very poor pay scale they, the professionals, were paid. On the other hand there were some who were curious about our treatment approach, but at the same time skeptical. The psychosocial efforts were directed at activating very seriously disturbed patients, who had become accustomed to a program of inactivity, passivity and staff apathy. When we look at the field of mental health, in many parts of the world, this staff apathy is the obstacle that does not allow for better outcome in treatment. Too often the complexities in the schizophrenic process is blamed for the lack of significant progress with the serious mentally ill patient. However, it is my considered professional opinion as a result of 43 years of experience, that the fault lies with the professionals rather than with the patient and his/her condition. If we do not try or give it the effort it requires, progress doesn’t take place. If we do not or refuse to understand the enormous needs of our patients to trust us enough to join us in the battle for change, then change doesn’t happen. If we refuse to acknowledge their fears and loneliness and do not join them in an effort to redirect their energies from pathology to a greater sense of accomplishment and self worth, then they continue to be comforted and also tormented by hallucinations delusions and paranoid fears.
When we undertook to train and work with our Russian colleagues we thought and found that our greatest barriers were not cultural and language barriers. The greatest resistance to change was and is the refusal of professionals throughout the world to regard the importance of being open to new ideas and innovative treatment directions. This by the way constitutes the schizophrenics greatest resistance to change. We are the hopeless ones.
With this in mind we set forth our program in the far east of Russia. We were very fortunate in having the support of a revered psychologist in Vladivostok, a Dr. Lenid Petrovich Yatskoff, who as the Director of Treatment in the Primore District, was determined that changes would take place.
Our beginning efforts, psychosocially, was to create an atmosphere of harmony between the staff disciplines and to help them understand the importance of spending time with patients, outside of the hospital. To help them understand that hospitals can be iatrogenic if patients are left without stimulation and are able as a result, to concentrate and reinforce their sick selves. Aerobics was introduced as were some other productive physical efforts in the hospitals. Staff took patients outside of the hospitals. The patients became increasingly spirited and their growing optimism was almost palpable. The staff became more energized and worked together with respect and growing determination. A very active psychotherapy was introduced and the patients pathology was depersonalized from their healthier qualities. Many years ago the great American contributor, Harry Stack Sullivan stated that no one is utterly schizophrenic.
In three far eastern hospitals we were successful in setting forth the basic principles of more progressive treatment through demonstration and as we progressed, we could see a weakening of the opposition. In every hospital, we were able to train a small cadre of staff who took over and adapted the methods we introduced to the environment they worked in. As they felt surer, their feelings were conveyed to their patients and a sense of promise and hope was revived. Patients became aware of their basic hygiene needs. Their social interaction improved and we could see their lives expand.
Krasnoyarsk represented the same challenge, however, there was an additional variable, that is, I was asked to work daily with a young Russian patient from a nearby Russian industrial city. Of course all the work we did was through interpreters, since Ann, nor myself know the Russian language. Again, the question of desire makes the task of treatment less difficult and the language doesn’t need to constitute a barrier to successful treatment.
My sessions with this young man took place in the early morning at our hotel, before we began at the hospital.
The patient was 25 years of age, with a 10 year history of schizophrenia, paranoid type. He came from a well to do Russian family, his father is an important person in industry in the area. The patient actively hallucinated, was very paranoid and suffered from delusions of reference. He was difficult, but I made contact with him rapidly and we forged a therapeutic relationship that was intended to prepare the patient for treatment and also to set short term goals that would help this person feel a sense of greater productivity and self worth. The initial treatment was to last three weeks, which is indeed brief, in terms of the length and severity of his illness. However, keep in mind that there were two issues to be considered, that is, preparing this man for more treatment and establishing goals that if met, might prevent this very sick human being from recurrent acute exacerbations.
It is my belief that the achievement of goals leads to so called ego building and reinforces the individuals tolerance to stress. Every human being has doubts and weaknesses and a certain degree of anxiety. These feelings can be used creatively, but if they are too great, as they can be with the schizophrenic, then this anxiety, this great angst, can be catastrophic.
The first step I made therapeutically was to establish a positive relationship with this young man. Without this first step, nothing else would happen. The father of the patient was irritated with me because I was less concerned with his past history than I was in the history that began when the patient and I met.
So we have a diagnosis of schizophrenia. He hears voices, is paranoid, is delusional. What does this mean? He is schizophrenic. What is schizophrenia? Is it a brain disease, a neuro-biologic condition, a series of symptoms and characteristics? Does the above explain the condition to us so that we can find treatment focii? The onset of this condition begins with an outbreak of tremendous anxiety and dissolution of identity which tends to increase the fear. These human beings are terrified. They lose track of who they are and where they came from. They have annihilation fears and they are lost in a world that they see as life threatening. Something has to happen to this great fear. Medication only masks these feelings and the anxiety is processed into symptoms that reduce the tremendous anxiety and schizophrenia becomes a something to that person who felt like he/she was nothing and lost. So we can see the logic to this system because it represents survival! To those human beings, the feelings, the logic they have is their reality. We can’t argue that. So we are faced with a person who feels some relief from fear, as this young man did, even though there still remains fear and anxiety, that increases or decreases with whatever he sees as dangerous. Because of this, Pavlov (a pseudonym) kept everyone at arms length. I found him to be intelligent, aware and able to control much of his behavior that would be considered irrational by those individuals who have no comprehension of the language and logic of this condition called schizophrenia. He was, obviously concerned with people around him. It became apparent, at times, that he was ashamed of his condition.
I began my work with him by being open and friendly and looking for some qualities beyond his symptoms that I could point to and help him redefine. As I said above, the first step was to establish a relationship with him that he found safe and that permitted me to share his experience with him.
Since I do not speak or understand Russian and he the same with English, we required the services of an interpreter. The interpreter is a psychotherapist who had been working with me since 1992 and was aware of my personality sufficiently, I thought, to be accurate. It became clear in the next number of days that other factors involved created what appeared to be serious problems in this triad.
However, as we met daily, the relationship grew, there was indications of an alliance, but Pavlov made every effort to disrupt this and challenge me by posing his delusional system that had become well organized or crystallized (as Sylvano Arieti would put it). On the other hand was this enormous hunger that Pavlov had for a closer and mutually respectful relationship and I had a growing sense of affection and respect for him.. No matter what he did, he was unable to persuade me to violate him in any way. I did not conspire with his system, there were times I challenged it and at other times I went on to other issues in his life to distract him, in order to return to some achievable goals in order to redirect his attention and energies. I thought that too direct a challenge to his psychotic system was not an appropriate approach given the brief duration of therapy. I repeatedly stated that I would leave the area at the specific time. I was concerned that my departure would be too painful to him because our relationship was not one of transference, but more reality based. It seemed like what was happening was more of a corrective relational experience.
After our session we went to the hospital where I lectured, worked with patients and trained staff. Pavlov, trained in video taping, was there with me all day video taping my work, which he did somewhat erratically, but he was consistent and I believe that these efforts and hearing and watching my work, was very therapeutic for him.
Pavlov is the only male of three children of a wealthy family. Both of his sisters are married and have children. His mother is a physician, a cardiologist and his father is the director of an oil refinery. The sons-in-law work for the father, they are unusually well housed and the father, a powerful man, runs the family like a dictator. Pavlov is married, childless and has a nice apartment, car and the very fine household amenities, all paid for by his father. There is a mixture of love and resentment towards Pavlov by his family and his mother continues to cook for him. His wife has contempt for him, works, demands money, refuses to cook for him and shuns him sexually. However, under the fathers aegis they, the family, remain united in their declared support of Pavlov. Palov was hospitalized at least once or more times per year with no observable change in his condition. He is a strong man with a potential for violence and had attacked some people without provocation.
Pavlov’s father learned of a clinic in Germany and he sent his son, supervised, there for treatment. The treatment was only physical, with massage, diet and medication, including vitamins which seemed to help him sleep, which as important at it is, did not do anything beyond this. So Pavlov remained very symptomatic and unable to do anything productive. His father is a sports minded person, always pressing his son to work and to do physical activities, nothing helped. His father heard of me through Russian professionals and when I met him in Vladavostok, he asked me to treat Pavlov. I agreed to a three week period of treatment.
As my work with Pavlov continued, it became clear that besides his resistance to change which all people possess, there were a number of other obstacles to cope with. This became a strange situation, I had never encountered anything of this sort in more than forty years of practice. Let me briefly state what happened.
We have the patient, the son of a rich man from a small city near Krasnoyarsk. He had been treated there unsuccessfully in the past. To make a long story short, there were three psychiatrists who came to my presentations, each one wanted to work with Pavlov, they gathered around him like sharks in a feeding frenzy. My interpreter became part of this conspiracy, he also wanted to work with Pavlov. One of the psychiatrists stayed with Pavlov as a companion, but the others continued their efforts at taking over. I finally ordered them to leave and they backed away. I threatened my interpreter with non- payment and he was then neutralized. We continued our work together. Pavlov and I had developed a working relationship, but then the time to leave approached. We had made progress during these three weeks. Basically that he and I had established a close relationship and that he felt more optimistic about his life. I met with his parents and they urged me to see him in America and continue the treatment. Pavlov wanted very much to continue with me, first I refused, however, after a great deal of discussion with the parents and Pavlov, practically pleading with me to continue, I left with the understanding I would consider it and inform them of my decision after returning to the U.S.A. I still had another month of work in Ekaterinburg, a city in the Urals, away from Pavlov.
When we returned to the U.S. after some thought, I concluded that a three month effort might be useful and notified Pavlov’s father of my decision.
In this paper, I believe I emphasized the importance of a program that combined psychotherapy, medication and psychosocial modalities. It is apparent to me that these treatment concepts must act in a contiguous manner and as much as possible be adapted to fit the capacities and needs of each individual patient. I talked about the patients resistance to change because his/her condition not only has become an identity or an IT but also represents a survival system. I also referred to the resistance of the mental health professional to change. So many of us get caught up in theoretical dogma that it becomes almost impossible to break the shackles of theory. We need some theoretical structure to lessen the disorganization that happens as a result of dealing with the most difficult problem we have in mental health, but we must be open to change and new directions. We must embrace whatever is useful, to quote Harry Stack Sullivan we must use any means at our disposal to reach these human beings.
Treatment has not succeeded well enough because we have been unwilling to invest the energies required to reach these unfortunate victims of schizophrenia. In the U.S and other countries, the training offered in this area is totally inadequate. The medical model has talked in terms of cure through the development of better physical methods of treatment. This cannot happen, however, we do know through experience that many severely regressed schizophrenics do recover, if not fully at least partially. Which by itself has been overlooked as a major contribution. We must understand that they will never be as intact as they were before the onset of their illness. Evaluate any soldier who has been in battle long enough and you see the changes wrought by their experience.
Pavlov was able to get a visa from the American Embassy in Moscow, with the help of an influential American Company. The visa was for medical reasons. He was coming with his brother-in-law who spoke some English and would live with him and supervise his activities.
The treatment would be on an out patient basis and I intended structuring an intensive program that would fit his needs.
We rented an apartment not far from the Anne Sippi Clinic, where I served as Clinical Director and where the treatment would take place. The apartment was large and in a nice residential area. I engaged the services of a woman translator who had immigrated from Russia. She had no psychological background, but was fluent in both languages and would bring Pavlov to the clinic and take him home when the day ended.
We met them at the airport in Los Angeles when they arrived and the greetings were warm. We were happy to see each other again. The translator, Dina, was reassured when she met both Russians. There were no signs or observable symptoms of mental illness. However, this did not last the entire treatment period. Treatment began at the Clinic.
Initially, that is for several days, I concentrated on examining the relationship between Pavlov and myself. I wanted to re-establish the alliance, to make sure that time hadn’t eroded it and to overcome whatever weaknesses I found. At the same time I found it necessary to evaluate the depth and flavor of his delusional system and its relationship to his voices and his self image. I had the impression in Russia that his sick system could be breached by separating one aspect of his personality from the other, that is, the sick from the healthy.
His belief was that two people in Russia, the parents of a girl that he had sex with in his early teens, created a powerful machine that was responsible for two voices that insulted and ordered his thoughts and that he was enslaved by these forces and had no control over his life. They made him think dirty and terrible thoughts and his very life was in their hands.
His feelings about himself were very bad in every respect. He felt ashamed of himself, unsuccessful in his life, as a son, husband and in his work life. He was angry at his wife, who constantly demanded money and showed him no affection. Our relationship expanded and there were more indications of affection and respect in our daily meetings. I arrived at a treatment direction as I saw the increasing depth of our relationship and believed that I needed to find as many ways as I could to contradict his sick system and embellish the healthy structure. I concluded that I would see him four hours a day in treatment as long as it seemed indicated to me and also making sure the intensity of our meeting would not rupture the alliance.
The therapeutic assault increased, his resistances were mobilized and the question of who or what would yield, grew greater each day. To give the reader more specific information about our verbal exchanges is almost impossible at this point. The daily sessions were extrodinarily active, no pauses, except for toilet relief and lunch. Every therapeutic effort was designed to fragment his system allowing me greater access to the best parts, that is, his healthier system, which as it grew would assist in overcoming more of his illness. Most professionals understand how pathology and/or symptoms act defensively when the sick organism is attacked. It was mandatory as I continued this procedure that I do not allow any rupture in the alliance to be left unrepaired. If I did not attend to this, the therapy would have been destroyed. I felt a great deal of energy in my work to overcome some of the basic parts of his schizophrenia. As we proceeded, I began to sense a weakening of his defenses which fueled my energies. I felt stronger than his sick condition.
There are those who would find fault with my treatment strategies. However, in the words of Jay Haley, strategic treatment is initiated by the therapist. Strategic treatment is not theoretical. There are those who might criticize my aggressive approach. I find no need to defend my tactics, the major issue, involved a human being who was repeatedly hospitalized, in agony and whose many treatments found no relief from his painful condition.
Increasing his anxiety and being fully aware of the fact that in our relationship, alliance was key, it made it possible to help him reach out, as he did initially in his illness for help. I was determined to use everything available to give him the help he deserved. That is our mission, to promote change that leads to insight and relief from this painful and destructive condition called schizophrenia.
As a psychotherapist and a training therapist I will always do everything I can to help those unfortunate victims of schizophrenia improve and live free of institutional life with a sense of dignity.
The intensity of my approach continued however, always changing with the changing needs of the patient. Our relationship remained positive, even thought at times he lashed out at me hoping to dissuade me from my persistent attack on his illness. It came to the point where I was able to express my admiration for him and my disgust for those sick parts that he expressed. We began to renew our efforts at regarding his image of himself focusing on his good qualities and he gradually began to improve how he viewed himself. The voices grew more distant and one day he came to my office and without any prompting on my part, stated that the voices and the rest of his system was an unreality. However, this did not persist and he tried to retrieve these symptoms. It was apparent that I needed to make a greater effort to fill the emptiness that he felt as the strength of these symptoms diminished. They were important, even though they were unpleasant but they came to represent something to him that sustained him. Our concentration on his good qualities was intensified and there was some relief, but not enough. Time was running out. That is, the three months was fast coming to an end. Further treatment was necessary, but could not take place in the U. S. The patient and his family agreed that I would follow him back to his city and construct a program there with professionals and train them in follow up procedures.
The time for departure arrived. Pavlov was quite anxious about leaving me and afraid of what he would find at home in Russia. Ann and I had already made arrangements to follow him in the succeeding weeks which was somewhat reassuring. His medication regimen was low however, we hoped that it would be sufficient to modify his anxieties for the trip home.
We took Pavlov and his brother-in-law to the airport, had dinner with them and they boarded the plane to Moscow. He seemed somewhat shakey, but with no apparent regressive indications. Our next contact was in Krasnoyarsk several weeks later. He met us at the airport, we were happy to see each other and we drove to our hotel in his city. He helped us to our room, Ann myself and our new interpreter and left us with the word that he would see us after we rested. We had arrived the day before from Los Angeles and were fatigued, perhaps that’s why we did not see anything unusual in Pavlov.
Pavlov did not return that day. We assumed that he was giving us some time to recover from our journey, However, the next morning the psychiatrist Pavlov chose to work with him came to our hotel and informed us that he, Pavlov, had locked himself inside his apartment with his wife and refused to allow anyone, including his father and other family members and his psychiatrist entrance. In most Russian apartments there are two doors for security reasons. The outer door is made of heavy metal and impossible to break into.
The psychiatrist stated that Pavlov had an acute schizophrenic reaction and in his opinion, was dangerous to everyone and especially to his wife who he had with him in his apartment. He did not know if he had any weapons but did not know what he should do, short of calling the police.
I decided to go to his apartment with his psychiatrist, Ann and the Russian Interpreter. We knocked on his door, no answer. After some time, I asked him to let me in. The door opened and he allowed me, Ann and the Interpreter entrance. He ordered the psychiatrist to leave. Pavlov was obviously very angry, but not at all verbal. We saw his wife, very frightened, but fortunately not injured. There were no weapons as far as we could tell. He made a gesture towards a sitting area, no chairs were there so the three of us had sit on the floor. This man was in control of the environment and his manner suggested that he might become violent. I spoke to him gently asking him to come with us to the clinic so we could discuss issues that related to our coming to his city to finalize treatment. He refused, he was defiant and intimidating. What I saw was a very angry man, also quite frightened, but did not see any delusional signs. He waited for us to come to his city and he felt that it was safe for him to "lose control", but no voices commanded him. This was my conclusion and after ten to fifteen minutes, I stood up and said"that’s enough, we go to the clinic". He offered some resistance but I would not back away from challenging his aggression. According to his psychiatrist, he had not taken his medication since his return to Russia, which of course, intensified his anxieties, however, I was able, to persuade him to leave his apartment and his wife and come to the psychiatric clinic. Our relationship our alliance had endured even through the separation period. I was able to reach beyond the anger and fear that he felt and help him feel safer. We proceeded to the clinic, all of us, including the psychiatrist, where we sat down and I began reinforcing our relationship. I then suggested to his psychiatrist that it might be helpful to Pavlov if he were to agree to an injection of some anti-psychotic medication. The patient was very much opposed to this but after some discussion accepted this treatment. According to other reliable sources, he never accepted this in the past. So this was another indication of his wish to overcome his condition as much as possible. We then spent a considerable period of time discussing what direction treatment should take. Pavlov was calmer and said he was very hungry so all of us went to our hotel and had lunch.
Pavlov was exhausted and engaged another hotel room, so that he could sleep, which he did and we requested that he spend the day and night with us which he agreed to do. After supper, when he went back to bed, his father appeared. He was very angry at me for what he saw as Pavlovs regression. I did not see this as regression. In my opinion it was part of the recovery process. His delusional system was gone, as were the voices. The anger and fear he felt was not converted into symptoms that had tormented him in the past. It was virtually impossible to explain to his father the process of change that his son was undergoing and he left in a bitter and almost threatening way. This is a powerful and controlling man who was not easy to convince. Especially by me, who symbolized so many mental health professionals who did not help his son. To understand the fathers desperation, it was told to me, that he had sent his son to a shaman, some distance away, who according to the reporter, was himself (the shaman) quite"crazy and destructive".
Pavlov left the hotel late at night, without informing us, returned to his apartment to change his clothes and came back to the hotel without any incidents. We had breakfast and went to the clinic and he felt comforted by our being with him. His fathers reaction had to be dealt with because he constituted a danger in several ways, that is, he could sabotage treatment, he could harm us, he could prevent us from leaving the city. He had that much power and he didn’t see that Pavlov was improving. Unfortunately this is not at all unusual with relatives anywhere, that is the difficulty in seeing their child improve.
The head of the clinic and Pavlovs psychiatrist saw the improvement and it was recommended that I write a description of his treatment in the U.S. and what my goals had been and also a treatment plan for Pavlov following our departure from his city. I did, the head of the clinic and the psychiatrist supported it and I began to develop a treatment team with the available resources. At the same time Pavlov, with treatment, continued to improve.
Soon thereafter, his father and I met and he happily told me that a friend of his, someone I had not met had seen his son and never saw him look more intact. This changed his whole attitude towards me and the entire family became more social and allowed me to approach them in a very brief family therapy. Pavlov continued to improve. We spent a great deal of time working with him, seven days a week and he continued improving.
We were able to work out with Pavlov a separation from his wife. He readily agreed, she didn’t want it, but it was accomplished. Interestingly the mother was opposed to it. She didn’t feel Pavlov would find anyone else because of his condition. Our intention was to have both of them in separate psychotherapy to determine in time, whether there was enough in the relationship to build a happier life together.
Pavlov was involved in psychotherapy, I worked with his therapist to help her focus on basic and relevant issues. My major concern was a retraining program directed towards improving his self-image as a result of making behavioral changes that made him more socially acceptable. Medication was used, but judiciously, with a low therapeutic dosage.
We all did social activities together, which could be treacherous if not dealt with discreetly, this seemed to bring the entire family into more harmony. The father was very competitive and especially with me, he had a strong urge to best me. He was a sportsman and even challenged me to a tennis match. I beat him badly, which made him very angry, but this was good for Pavlov. We overcame the fathers anger, Pavlov was very much improved and the time for us to leave had come. We had spent much time preparing Pavlov for our departure and working with the psychiatrist and therapist to effect a transfer a successful transfer. It seemed that this was accomplished.
We left Pavlov, happy that he had gained so much, but relieved to leave that city where so many experiences good and uncomfortable had taken place in such a short period of time. We went to another Russian City, Ekaterinburg to construct a treatment program in a psychiatric hospital. When we returned to the U. S. we immediately contacted Pavlov’s father by fax and he informed us that his son was doing well. We have kept in contact with Pavlov and he continues to improve the quality of his life. We are sure that our efforts are successful.
The approach to Pavlovs condition is a way that I have traveled with selected patients for many years.
It is not THE answer, but it is a way.
