Provocative Therapy - Articles

An Essay on Provocative Therapy and Neurobiology
Humour affects the Limbic System
In the long, dim and quiet hallways of our holy places of wisdom – our universities! – humour is still considered as dangerous as a lethal virus and therefore it is usually exterminated. Many psychotherapists too still look upon humour as something evil in their work, because, when the client laughs, this means that he is not serious enough. Even if humour is not considered as that bad, for many therapists humour still is nothing more than a cause for a mild and forgiving smile about the clumsy colleague who believes in humour’s power! – Nevertheless, for decades humour and laughter have been considered crucial for personal change in Provocative Therapy. Recent research about the brain gives good reasons to use a lot of humour in psychotherapy, because humour affects the limbic system of the brain which is an important system for the organization of our behaviour.

Change in the Networks of the Brain is equivalent to Change in our Emotions
All of our behaviour is organized by complex neuronal networks in the brain. This applies to psychological and psychosomatic disturbances too, which can be seen as expressions of conflicts or of “faulty” emotional conditionings. They correspond to specific neuronal networks in the limbic system. Once established these networks might continue to exist for our whole life. Each time one is activated it will be strengthened, e.g. by each remembering of a bad experience. Even if the brain should be unable to forget a fact, it will remain able to build new networks compensating older ones till our last day on earth. Our brain has inconceivable possibilities for building fresh connections which shows its immense capacity of learning, adapting and healing itself. As specific emotions correspond to these networks a change in the networks has to go along with a change of the corresponding emotions. Thus, change is possible when a person who is experiencing a negative emotion of a conflict or a restricting conditioning is able to have a positive emotion at the same time. This new experience can be seen as cause for the growth of new neuronal connections in the limbic system around an already existing network. Then change can happen easily and happens on an unconscious level, which means without any further efforts. Probably only this will lead to stable change. Strong positive emotions in the right moment are crucial. Of course, the stronger the existing network the more repetition of this process will be needed in order to achieve permanent change. Gerhard Roth concludes that the positive effect of psychotherapy might be a consequence of positive transference. While talking about something that makes him feel bad the client also feels secure and safe with his therapist at the same time and therefore he trusts him.

Now, what can we conclude from that for the meaning of humour in psychotherapy? Evidently humour is a positive emotion and easier to observe than the quiet development of positive transference, because laughter is an external, loud and instant sign of an inner state. When Frank Farrelly provokes laughter over and over again while clients are in a restricted inner state – feeling fear, anxiety, anger or having tears in their eyes – sure enough new neuronal connections are going to build up in the limbic system at the same time. And because in Provocative Therapy humour is thoroughly provoked around specific negative emotional states, these connections are built up exactly at the right place.

Clients often tell me, that in these moments they are able to see themselves from outside and have to laugh about the absurdity they discover, when they look at their behaviour from that new point of view. Now this point of view is the perspective of the Neocortex, because only this structure in our brain allows us to look at ourselves from outside. Provocative Therapy not only affects the limbic system with adequate emotions for change at the right moment, it also affects the structure of the brain, which is the most developed one and which allows deeper understanding.

Fight and Flight – Using the strong Power of the oldest Structure of the Brain to Provoke Change
In Provocative Therapy you often see clients defend themselves and protest against or run away from their own inadequate behaviour. Such reactions – like laughter – can be understood as specific effects of this method. To interpret them referring to Neurobiology it is necessary as a first step to understand how three basic and very different systems are cooperating constantly in our brain.

The Neocortex – Location of Consciousness
The largest, youngest and most developed system or part of the brain – the Neocortex – is the location of consciousness. Here those events are represented, which happen outside of us – what we see, hear, smell, taste and perceive kinaesthetically – as well as everything that happens inside of us – bodily sensations, feelings, dreams, imaginations and wishes. The Neocortex enables thinking, memorizing, language, the experience of time and certain structures in the frontal lobe enable creativity, intuition and cooperation.

The Limbic System – Location of Emotions and Feelings
The limbic system is an older part of the brain, which we share with all mammals. Here is the origin of social behaviour, brooding, caring and playing. The limbic system operates partially on the basis of inherited programs; partially it is able to learn by conditioning – which means by reward or punishment. One main function of the limbic system is to compare constantly each single experience with former experiences and to guide our behaviour this way. This happens before we can build thoughts about a momentary experience. The limbic system operates unconsciously. We are becoming aware of this process through emotions and feelings with a short delay, which means after having already reacted, and we are becoming aware only of parts of this process.

The Brainstem – Location of Reflexes for Survival
The third and oldest part of the brain is integrated in the limbic system and regulates the most important functions of survival of the individual and of the species. This system works unconsciously, automatically and exclusively on the basis of inherited reflexes. It regulates the very strong functions of fighting, defending and fleeing and further of nutrition, digestion, breathing and reproduction.

Of course the three systems are connected together and are mutually influencing each other all the time. So you may imagine that the older systems, which operate unconsciously and automatically on the basis of fixed programs, could temporarily dominate the conscious process of thinking located in the Neocortex. In that moment they could restrict the activity of the Neocortex to simple loops of ‘thinking’, which we would repeat over and over again. As the older systems operate unconsciously we could be aware of our thoughts in such a moment, but without being aware of what is happening to our thinking right then!

Case study – Desperate Fighting against Laziness
How does the brain of a person operate who complains that she “desperately fights her laziness” instead of starting to do her work? The word “fight” is the representation of an activity of the brainstem in the Neocortex, the word “laziness” the representation of an activity of the limbic system. “Laziness” summarizes one or several undesired habits. These are based on conditioning in order to avoid frustration. In German we have a special noun for this – the ‘innere Schweinehund’. This represents the ‘marriage’ of two mammals inside of us – of a pig and a dog. As the brain of mammals essentially consists of the limbic system, the origin of this noun seems more than symbolic or accidental! – In our case the Neocortex seems to serve as a stage for a fight between the activities of two different structures of the brain: of the strong brainstem and the limbic system. A person fighting against her laziness has no chance to ever change her behaviour this way. On the contrary her intention to start her work will systematically be weakened this way. This is why she is feeling desperate.

Fighting and Fleeing in Provocative Therapy
In Provocative Therapy one often uses the strong power of the brainstem, however, in the opposite direction. One possibility is to direct the fight back against its source to produce a ‘mental short circuit’. The therapist praises the necessity of strongly fighting against oneself until the client begins to oppose. The other possibility is to provoke the client to run away from an inadequate behaviour, which also implies the use of a strong reflex built up for survival. – While listening to a student once who was talking about his fight against laziness I had the disgusting image of a little grey poodle with his hair done in a slushy way, wrapped in a pink blanket, smelling like sweet perfume, whining in a piercing tone and jumping up at the student’s blue jeans trying to sniff his genitals while salivating. The student cracked up with laughter and also reacted with a terrified and disgusted look. The sicker he looked the more detailed I imagined the horrible little dog. Repeatedly he requested me to stop talking about the poodle. Of course this only encouraged my imagination. Immediately after this session he started to study harder. He had run away from his laziness and therefore lost the orientation which had helped him to avoid work… So what else could he do now than to start working?

The fantastic thing about using the powers of fight and flight is that you use very strong, natural powers. Once you have cranked them up they will work by themselves. Why? I suppose because it is just the way our brain operates. Fight and flight are very old reflexes, which - once started - always work automatically. Thus, it is brilliant and comfortable at the same time to use these mechanisms in order to provoke change.

Now, this works really well, however, I suppose that simply reversing the direction of fighting or using fleeing is not always sufficient in order to create permanent change. Why? Looking at the example of the student you can figure out easily, that the laziness and all its conditionings have not really disappeared from his life. They are still very close – in the brain! How long will the change last? That might depend on how rewarding the student will experience his work. Will this experience be positive and strong enough to allow stable new networks to establish in the limbic system after a certain time? If not, he will fall back into fighting against himself.

Fighting against oneself implies conflict. The automatic responses of fighting and fleeing may be intelligent reflexes of the brainstem, when our body is suddenly confronted with danger coming from outside. The intelligence of the limbic system consists in its ability to simplify daily life by using well adapted clusters of behaviour which – once established - will also work automatically after a certain time. However, can this be an intelligent solution to reduce the immeasurable Neocortex to an area for a battle among representatives of the two other systems of the brain? In the first place fighting against oneself leads to a waste of energy. Then fighting always strengthens the ‘enemy’, which here is another part of oneself! Third, remember that the repetition of an activity of the brain strengthens the network of all involved neuronal routines, in our case thoughts (activity of the Neocortex) about fighting (reflex of the brainstem) an undesired habit (conditioning in the limbic system). The logical consequence is that we will never solve a conflict this way, but, that we preserve, complicate and even strengthen it! Fourth, with our “solution” we have obviously added a lot of new problems to the original one, which consisted of the fact of avoiding work. Fantastic, isn’t it?

Liberation of the Neocortex of restricting Conflicts
This liberation assumes the end of the conflict and happens when the client no longer identifies alternately with one or the other side of a conflict but begins to see himself or herself and the whole conflict from outside – a process which is probably induced by the specific method of Provocative Therapy to mirror the client’s way of life in short vivid sceneries. And what is to be seen from outside? Strange but true: nothing else but the fact, that and how a person uses her brain to artfully construct a conflict in her mind! That is absurd and thus we laugh. This discovery seems to liberate the Neocortex immediately of the activity of neuronal connections, which restrict our thinking, and is opening it to a better utilization… Isn’t that a good reason to feel joy and to laugh?

Frank Wartenweiler, Zurich
(Improvement of language by Anke Könemann, Munich)
Literature
Damasio Antonio R. The Feeling of what Happens. Body and Emotion in the Making of Consciousness.
New York: Harcourt Brace & Company 1999
Farrelly F., Brandsma J.M. Provocative Therapy. Cupertino, CA 95015/USA: Meta Publications, Inc. 1974
Hüther Gerald. Wie aus Stress Gefühle werden. Göttingen: Vandenhoeck & Ruprecht 1999
Hüther Gerald. Bedienungsanleitung für ein menschliches Gehirn. Göttingen:
Vandenhoeck & Ruprecht2001
Hüther Gerald. Die Macht der inneren Bilder. Göttingen: Vandenhoeck & Ruprecht 2004
Krishnamurti Jiddu. To Be Human. Shambala Publications, Inc. © 2000 Krishnamurti Foundation Trust, Ltd.
Ramachandran Vilayanur. The Emerging Mind. London: Profile Books Ltd. 2003
Roth Gerhard. Das Verhältnis von bewusster und unbewusster Verhaltenssteuerung. In: Psychotherapie
Forum. Themenheft: Neurowissenschaften und Psychotherapie. Wien: Vol. 12. No. 2, 2004
Slade Neil. The Frontal Lobes Supercharge. Copyright © 2003 Neil Slade.
Servan-Schreiber David. Guérir le stress, l’anxiété et la dépression sans médicaments ni la psychoanalyse.
Paris: Editions Roberts Laffont 2003
Wartenweiler Frank. Provozieren erwünscht ... aber bitte mit Feingefühl. Paderborn:
Junfermann Verlag, 2003
Wartenweiler Frank. Zauber-Spiegel Spiegel-Zauber. Spiegeln in der Kommunikation: symmetrisch und
antisymmetrisch. Paderborn: Junfermann Verlag 2006.
In English the title means: “Magic mirror – the Magic of Mirroring. About symmetric and
antisymmetic Mirroring in Communication.” Unfortunately only available in German. Translation
pending…

First ‘Case Study’: At the Palace of Louis XIV
One day a Marquis entering his room found his wife in the arms of a bishop. He went to the window calmly and started to bless the people down in the street. Scared his wife asked: “What are you doing?” – “Monsignore is executing my duties, so I execute his duties”, answered the Marquis. (Reported by Hargittai István und Magdolna in their book Symmetrie, Reinbek bei Hamburg, Rowohlt Taschenbuch Verlag 1998)
Antisymmetric Mirroring – What is that?
Mirroring is a concept of natural science and geometry, which has a lot to do with symmetry and therefore with aesthetics too. Since decades it has also been used in a simplified manner by social science to describe certain aspects of relationships between two or more individuals. Once somebody knows the concept he also can use it to improve relationships. Mirroring posture and gestures is a well known nonverbal technique. Carl Rogers’s technique of verbalization is a way of mirroring with words the inner process – especially feelings – of another person. Because we believed that mirroring was just mirroring, we have overseen the differentiation of symmetric and antisymmetric mirroring and therefore identified all the time mirroring only with one of its possibilities: with symmetric mirroring… …except Frank Farrelly of course! Having observed him over years at work I had some ideas about his method, but there still remained a number of answers he gave, which I never was able to put in its proper place, when I was looking for a system. Long time for those statements there seemed to be no system at all.

I gathered many, many examples of such miraculous sentences, till one day I discovered the principle of antisymmtric mirroring. Suddenly I knew: That’s what Frank does, when I don’t understand anything more!

Visualization of the Two Principles of Mirroring

Symmetric mirroring Antisymmetric mirroring

In Words
In both forms of mirroring the form is kept up, in symmetric mirroring also all other qualities like colour, patterns etc. In antisymmetric mirroring at least one quality is reversed into its opposite; in our example white turns into black.

Second Case Study: Mobbing or How to Deal with a difficult Boss.
If you have a boss persistently devaluing you, nagging at you everyday and criticizing little details of your behavior whenever possible, the most common reaction is to protect and defend yourself. But this still leads to a larger disaster. Confronted with someone, who wants you to feel like a stupid little child, this person will do everything to let you know, that you are wrong, whatever you do. So by defending yourself you have a good chance to lose again and to finally end up in feelings of helplessness. Imagine using symmetric mirroring:

If your boss criticizes you, when you don’t deserve it...
...now you are going to criticize him also, when he doesn’t deserve it!

Uups! Well if you want to ruin your career, go for it. That will certainly work. Of course there are other possibilities of symmetric mirroring, finer ones as many psychologists taught us, where you carefully seek for the right words to say it… I wouldn’t recommend them either. They may work in the idealistic atmosphere of a psychological seminar, but in real life?

Now imagine using antisymmetric mirroring. How to do that? – Wait patiently until your boss does obviously a big mistake that nobody can oversee – all of us do such faults, bosses also! That will give you a nice chance to give him a compliment in public, which he really doesn’t deserve. The formula:

If your boss criticizes you, when you don’t deserve it...
...now you are going to praise him, when he doesn’t deserve it!

One of my clients exploded in laughter already by imagining the reactions of his narrow-minded and mean boss, when he would excuse him for having distributed money to several people in the wrong moment. With a warm smile on his face my client would interpret this fault as a sign of great generosity.

The nice thing of this way of answering is that you remain polite and friendly and your behaviour can always set an example to others. At the same time such an answer is so crazy and distorted, that our restricted brain simply must start to look for new possibilities of understanding and reacting. Antisymmetric mirroring therefore is recommended in highly difficult relationships – not only in therapy! That means, when you have to deal with or even are victim of another person making excessive abuse of projection, denying and devaluation.

Frank Farrely's artful way to transform presuppositions of clients statements into the opposite

When the client complains about suffering from the worst evil possible expecting relief from the therapist…
...the therapist explains the suffering as the best possibility of the client warning him in a friendly tone that he could only hope the disaster would not get worse!

Examples: “Some people wouldn’t have any luck at all if they would not at least have bad luck.”
“Your future? – At fifty years of age, you’re future is all behind you, my Irish daddy used to
say.”
”Without this symptom you could get disoriented.“
”You would like to overcome your phobia of deep water and you would like to swim there? You must be crazy. At least you have already thought of the dangers in the deep water. But there is more to it than that. Have you ever considered that even in the pool for non-swimmers you could slip and drown? And this is only one of many, many possible hazards.”

Are you getting curious about this phenomenon and want to know more? Then read my book Zauber-Spiegel Spiegel-Zauber. Spiegeln in der Kommunikation: symmetrisch und antisymmetrisch. Paderborn: Junfermann Verlag 2006. In English the title means: “Magic mirror – the Magic of Mirroring. About symmetric and antisymmetic Mirroring in Communication.” Unfortunately only available in German. Translation pending…

Frank Wartenweiler, Zurich

by Andrew T. Austin

The unfortunate lady say before me might be considered by many doctors and therapists as one of those “heart sink” patients.  A “heart sink” patient is one who displays an apparent inability to connect consciously with anything that might improve their seemingly hopeless life.

My heart actually did sink during the telephone conversation that followed her telephoning me to book an appointment.  Her high expressions of anxiety about treatment, the large number of demands for reassurance and a shamefully pitiful tone of voice led me quickly to conclude that this lady was a prime candidate for a provocative approach.

When she arrived at my office her eyes had that “mad dog” look of the desperate.  Her eyeballs appeared to actually vibrate and her body posture was one of abject helplessness.  And that incessantly pathetic tone of voice?  Well, it actually started to affect me and not in a particularly good way.  I did start to wonder what effect it would have on anyone’s neurology having to listen to that tonality from the inside all day and every day.

It was clear to me that this was one lady who did not find living very easy.

I made some tea and we went over and sat down in my office.

“So Little Miss Anxiety, what can I do for you?” I asked with a smile.  

“I don’t know…I thought you could help me.  Do you think you can help me?”

There was that demand for reassurance again.  Based on my previous telephone conversation with her, I suspected that I might need to cut through this game straight away.  I didn’t want to spend the hour trying to win her approval by giving her the right kind of reassurance that she was seeking.

So, did I think I could help her?

“Well,” I said, “sometimes I get lucky and I can help the client.  Other times, I just look at them and think, ‘oh God! If only they didn’t fill me with such dread and pity, then I could get them back week after week and have this damned mortgage paid off!’”

She laughed at this and said, “So you think there is hope for me then?”

“Hope?” I laugh, “Not hope, certainly not!  What I have here is an opportunity to experiment though, that is sure!  As one of my trainers said to me, ‘Andy’ he said, ‘When you find yourself that truly helpless and wretched case, know well that that is your chance to try out the stuff you’ve been too scared to try with any other client!’ – nothing to lose, see?”

She laughed at this and visibly relaxed, “I can see why they told me to come and see you!” she told me.

“Ah,” I reply, “They probably just know that I’m desperate for the clients.” Which elicited more laughter. “So,” I continued, “What’s the problem?”

Her state immediately changed and her face and body posture demonstrated a person who felt a serious emotional pain.

“If I tell you what I did, you’ll think I am such an awful person.” She told me as she struggled to control her weeping.

“Oh no!” I exclaimed, “not another one!”  Throwing my arms in the air and looking upwards as though to address the Lord, I say, “Lord, why do you send me these people…the child abusers, the killers, the sodomites, the bastard French…why Lord, why?  What did I ever do to deserve this?”

I suddenly shift state and look her straight in the eye, point my finger and say in my sternest and fiercest voice, “Look lady, if you are going to tell me that you keep small, underfed and tortured children locked in your cellar, I’m going straight to the police, do you understand me?”

She changed state again and she laughed, “It is not that bad,” she said.

“Oh here we go again,” I say again melodramatically as though to the Lord, “another guilty one trying to make her heinous crimes just sound ordinary!”

I look at her again and ask, “Do you know the reason that most serial killers give for actually killing their victims?”

She shook her head and looked at me quizzically.

“Because after all that torture and torment, their victims just get plain annoying…” and I trail off looking to her expectantly for a response.

“Can I tell you what happened?” She asked as though she was expecting that I wasn’t ever going to actually give her the opportunity to do so.

“Go ahead…” I offer, “But please go easy on me.  You know my nerves are shot to pieces by this line of work.  It is no wonder I’m usually so heavily medicated.” And I slump back in my chair as though dejected and exhausted.

Briefly her story was this.  Her role in life is a rescuer.  She has taken in homeless people, distant relatives, strays, cats and dogs.  Despite her apparent weakness and vulnerability it appeared that she had great resolve in assisting other people who were down on their luck and seeing them through the hard times.  As Frank might say, she is a “national resource”.  But, one time it went wrong and it was her reaction to this event that was destroying her.

She had acquired a rescue dog.  When she received it the dog demonstrated all the signs of an animal that had been horribly abused over a protracted period of time.

Two weeks later during a walk in the park, it ran out into the road and was killed by a car.

“So, after just two weeks you got annoyed enough with it to let it be killed?” I proffered.

Her face registered both shock and laughter. “I didn’t mean for that to happen…” she started to say.

“Oh sure, you didn’t mean for it to happen…how many prisons the world over are full of both “innocent” people and those who are clearly guilty but are claiming, ‘I didn’t mean for it to happen…’?

“It was just an unfortunate thing…it wasn’t…” she protested, but I interrupted her before she could finish.

“…it wasn’t murder?” I suggested, completing her sentence for her.

“Now look!” she said firmly but smiling.  “It was an accident, the dog got excited and chased a squirrel into the road.  I couldn’t have known…” She trailed off.  Her state changed again and she looked down mournfully.  I mirrored her posture and raised my eyebrows to indicate for her to say more.

“It is just so sad that it only had two weeks of a good life before…” she trailed off again.

“You killed it…?”

“You really think it was my fault?” She asked.

“I’m not sure yet,” I tell her, “but there is another possibility…” she looked up at me expectantly.  “You have to think about the part that the dog played in all of this...maybe it was suicide?”

She laughed again.  An implication here was that the dog, having been abused by its previous owners was depressed and so committed suicide.           

“I mean,” I continue, “the poor pooch is sat in the pound relieved that the traumatic life it had before is over and then…oh, no…it gets you! Arrghhhh!” I say this with great animation.

She laughed at this and with great emphasis said, “Now listen here, you, I am a good person!  I was the best opportunity that poor animal had! It just got excited and chased a squirrel!”

”So,” I say lowering my voice and adjusting my posture to that of a “professional” psychotherapist, “what appears to be the problem?”  

The sudden change of direction acts as a virtual trance induction.  Her eyes glaze over and she becomes very thoughtful for a moment.  I’ve seen this reaction occur when Frank is working.  Often the response is “I don’t know…” or, “I’m not sure any more…” Sometimes they just look concussed and bewildered.

“You know,” she said slowly, “I can’t believe I’ve been so stupid, I’ve been such a door mat…”

“There you go!” I say quickly, “Insight!”

And on the session went for another 20 minutes in a similar vein with each step this previously emotional frail lady becoming increasingly animated and forceful.  Each time she made a negative suggestion about herself it would be reframed to something either ludicrous, into some kind of resource or into something far, far worse than it could possibly be.  It is worth noting that at no point did I give any form or reassurance or even attempt to “help” or advise this client in any way.

The session lasted 40 minutes in total and at the 40-minute mark I cut it dead without any attempt to “round it off” or find conclusion.  In true Farrelly style, I smile and ask, “So, did you have any reactions to me in this [session]?” which of course elicited great laughter.  She did of course have many reactions – one of which was of course the realisation that she let “people walk all over” her and take advantage of her vulnerable nature.  She highlighted her realisation that although she spent her life helping other people, those people rarely offered anything back, using the resources she offered then moving on in their lives when they no longer needed her.  She realised that everyone else was moving on, except her.

The next 40 minutes were spent discussing, with a fair degree of provocation, her motivation strategies and relationships with other people.

What this session demonstrated so nicely was how the provocative therapy approach forced the client to think outside of here usual patterns.  She had attended many dozen therapy sessions with a number of different therapists and all without success.  What I suspect all the previous therapists had in common was that they offered help and advice and responded to this lady’s extreme prompting for reassurance, thus confirming the reality of her fears.

In a single session lasting approximately 90 minutes from start to finish a former “heart sink” patient and regular attendee to her GP surgery gathered together enough resources to put some bigger life changes into place.  Regular follow up via telephone over an 8-month period, with 2 quick and informal meetings demonstrated the changes continued to develop with a marked change in voice tonality, change in appearance and a quite noticeable playful and flirtatious manner.    
 
Clinical Hypnotherapist and Master Practitioner of NLP
Chichester, West Sussex
Tel: 07838 387 580
Email: diggingahole@hotmail.com
This article is included in the excellent "The Rainbow Machine" which is a collection of stories by Andrew Austin
See http://www.therainbowmachine.com and the book can also be purchased from http://www.realpeoplepress.com/rainbow-machine-tales-from-neurolinguists-journal-p-64.html?osCsid=189d4c8ef426bd7407dc6e765459985d

Arnold M Ludwig MD1 and Frank Farrelly ACSW2
Reprinted from American Journal of Psychotherapy
Vol. XXI, No 4 – October 1967

It is becoming fashionable to view mental patients, especially chronic schizophrenics, as poor, helpless, unfortunate creatures made sick by family and society and kept sick by prolonged hospitalisation.  These patients are depicted as hapless victims impotent against the powerful influences which determine their lives and shape their psychopathology.  Such a view dictates a treatment philosophy aimed at reducing all the social and institutional iniquities responsible for the patient’s plight.  However, in the process of levelling the finger of etiologic blame for the production and maintenance of chronic schizophrenia, theoreticians and clinicians have neglected another culprit – the patient himself.  Professionals seem to have overlooked the rather naïve possibility that schizophrenic patients become “chronic” simply because they choose to do so.

Undoubtedly, a myriad of authoritative articles could be quoted to refute such an oversimplified approach to this problem.  We do not deny the complexity of the problem of the multitude of theoretical factors which should be taken into account for the understanding and treatment of chronic schizophrenia.  However, we do claim that all these theoretical considerations have little practical import for the current treatment of these patients.  Since we cannot at this point in time unravel twisted genes, undo the past, reform society, or eliminate mental hospitals, we are left with a more modest, but still formidable task – the treatment of the patient himself.  The major problem is in dealing with what is and not with what should be or might have been.  In our own experience, the problem is not so much modifying factors outside the patient, but rather inc hanging certain patient attitudes and consequent behaviours, as well a complementary, newly traditional attitudes on the part of society and professional staff, which aggravate the basic problem and prevent effective therapeutic intervention.

We have had the opportunity to observe closely and work with a group of 30 male and female chronic schizophrenics, handled with a minimum of medication and housed together on an experimental treatment unit.  In a previous article (1) we outlined a number of characteristic attitudes and behaviours, both on the part of patients and staff, which tended to perpetuate chronicity.  These characteristics comprise what we have called “the Code of Chronicity”.  Implicit in our discussion of the “code” are five important clinical “facts” which, we believe, underlie the behaviours of chronic schizophrenics. 

i. First, these patients can use their insanity to control people land situations. 
ii. Second, they have an indomitable will of their own and are hell bent on getting their own way. 
iii. Third, one of the basic difficulties in rehabilitating these patients is not so much their “lack of motivation” but their intense, negative motivation to remain hospitalised. 
iv. Fourth, insanity and hospitalisation effectively pay off for these patients in a variety of ways. 
v. Fifth, these patients are capable of demonstrating an animal cunning in provoking certain reactions of the part of staff, family, and society at large which guarantee their continued hospitalisation and its consequent rewards.

Related to these characteristics are a number of other important ones, which are typical of these patients and which we want to elaborate on since they are relevant to our basic thesis concerning patient behaviour.  These additional features have gradually come into focus for us during the various phases of our research treatment program; in this article we shall term them the “weapons of insanity”.  It has become increasingly clear to us that patients both have at their disposal and employ effectively an array of counter therapeutic weapons against staff efforts to rehabilitate them.  These weapons not only reach their targets but have the additional bonus of a “fallout” effect in the form of a series of predictable staff reactions.  Since one of the most effective ways to cope with these weapons is

first to recognise them, we have felt the need to describe them and their effects.  Moreover, since we have become convinced that for rehabilitative purposes these weapons of insanity must be jammed, there is a necessity to consider carefully the therapeutic implications and ethical issues involved.  It is our purpose to do precisely this.

The Arsenal of Weapons

Squatter’s Rights

The prevalent conception of mental hospitals as snake pits or horrible asylums from which all patients eagerly long to depart has little trugh when applied to the chronic schizophrenic.  In fact, one of the major problems in rehabilitatin these patients is their adamant refusal to be dispossessed from their adopted hospital homeland.  For many patients, especially those who feel emotionally and financially deprived, the mental hospital represents a “promised land” where the whole range of their needs is met.

The hospital comes to be a model of the idealised childhood home – a cruise on the “good ship Lollipop”.  Every effort is made to help the patient “feel at home”; not only are the basics of food, clothing and shelter provided, but also, as in the good childhood home, his psychosocial needs are met, he is protected from harm and pain, is relieved of any major responsibilities and demands, and has a wide variety of entertainment and recreation provided for him.  His home gives him a ready made group of companions who, because they share similar experience, give him understanding and sense of belonging.  The good parental surrogates never punish him; they attempt to protect him fro failure and frustration, try conscientiously to meet his immediate needs at all levels, and do not expect him, as a child to make decisions for which he is not ready or mature enough.

The hospital thus comes to represent an emotional gold mine where patients stake their claim.  They seem to grasp intuitively the legal dictum that “possession is nine tenths of the law”.  It some claim jumpers, in the guise of therapeutic staff, threaten to dispossess them, especially after their years of homesteading, chronic patients will fight back with animal ferocity to defend their territory.  This general attitude seems best epitomised by the remark of one patient who told the staff “You’ll never railroad me out of here!”

All or Nothing

Ask any patient whether he wants to be rehabilitated and the invariable answer will be “yes”,  try to do anything to effectively bring this about and the invariable behavioural response will indicate “no”.  One reason for this discrepancy between verbalisation and behaviour is that it requires minimal effort to utter the socially appropriate “yes” and maximum effort to do something about it.

There appears to be four basic components to the patients views concerning rehabilitation. 

i. First they sincerely want all the good things, such as status, power, love, material possessions, which can come with discharge.
ii. Second, they want an iron clad guarantee that they will get these good things.  If they are to prepare themselves for leaving the hospital, they want firm assurance that people will accept them, not derogate them for having been mental patients, not hold their behaviour against them, not reject them and treat them with dignity and respect,
iii. Third, they expect the good things to be given to them free.
iv. And forth, they are unwilling to expend any persistent effort or expose themselves to undue frustration to acquire the good things.

Almost any therapeutic staff working with these patients will recognise the “all or nothing” principle in most of their behaviour.  Patients want the whole pie and are often dissatisfied with only one piece of it at a time.  If they have to experience any emotional pain or stress in achieving socially appropriate goals, their most common response is to give up altogether or say “to hell with it”.  This response is reflected in their whimsical work week or their attendance at and participation in any constructive rehabilitation program where they readily throw away all their gains at the slightest frustration or rejection – knowing full well that they can afford to do so since they can always fall back on the good will and beneficence of the hospital.

Most rehabilitation programs for chronic schizophrenics are bound to founder simple because the staff have not come to grips with these patient attitudes and behaviours.  The patients problems may be explained by invoking such scientific terms as low frustration tolerance, infantile omnipotence of the wish, and poor impulse control, but these terms are only substitutional euphemisms for saying that patients want what they want, the way they want it, when they want I, and effortlessly.

Social Push Buttons

It is an interesting phenomenon that “helpless” and “confused” schizophrenics are often much more expert at producing certain reactions on the part of the staff, the family, and society at large than are the latter at evoking desired patient responses.  Because patients have a far better understanding of our social value system with its inherent limitations than we have of theirs, they can employ a repertoire of behaviours which function as push buttons to elicit the desired staff or social response, thereby insuring the attain of their goal.  These patient behaviours and the reactions they trigger off have an “if then” quality to them.  For example, if the patient presents any one of the following behavioural stimuli then it will elicit a specifiable, related staff response with a high degree of probability:

1. Nuisance behaviour evoked irritation and anger;
2. Overt sexual behaviour evokes outrage;
3. Aggressive combative behaviour evokes fear;
4. Self destructive behaviour evokes pity;
5. Stubborn withdrawal evokes frustration; and
6. Crazy bizarre behaviour evokes confusion and helplessness.

When staff, family or society become irritated and angry, outraged, fearful, pitying, frustrated, or confused and helpless, then they are automatically forced to take action in a variety of forms, the end result of which is continued hospitalisation or re-hospitalisation.

In addition to these push buttons there is another more general one which we have termed the “tyranny of the weak”.  It seems to involve a somewhat different kind of process and appears to lead to a “hands off” effect of therapeutic inaction.  When we begin confronting patients and “picking on them” for therapeutic purposes, they portray themselves as helpless and weak, and vulnerable while simultaneously casting the staff in the role of inhumane bullies.  Because they effect this type casting so convincingly, and because we accept these complementary good – bad roles, the consequent shame and guilt aroused in us cause us to withdraw as effectively as does a wolf in response to the exposed jugular vein of another wolf in a fight.  By employing this tactic, patients frequently exploit their “weakness” tyrannically over others by forcing them to make amends for “mistreating” them.

When patients are confronted with or held accountable for these triggering behaviours, they almost always invoke the following ritualistic formulae:

a. I didn’t do it – you did;
b. If I did do it, you made me do it;
c. Even if I did do it, I’m not to blame 0 I’m emotionally and mentally disturbed.

Aside from the apparent reason of assuring continued hospitalisation, it appears that there are three other factors which keep patients pushing these buttons:

1. First, they attain power and recognition.  By pushing any of these buttons, patients can mobilise social agencies, communities, families, and the hospital staff to cope with their behaviour (“I’ll make you pay attention to me”).
2. Second, this affords them a sense of control which reduces their feelings of helplessness and impotence.
3. Third, they continue to push these buttons simply because they are so effective.  People invariably respond to these patient behaviours and unwittingly continue to reinforce them.

The Divine Right of Kings

One of the central problems in treating the chronic schizophrenic centres around the issue of the patients responsibility for his actions.  At the present time, the label of insanity confers diplomatic immunity or sanctuary for all patients deviant behaviours.  Patients can gratify every impulse or whim without fear of serious retaliation.  They have the sanction to indulge any of their feelings because, by definition, they are presumed not to know any better or are unable to control their impulses and, therefore, cannot beheld accountable for what they do.

Not only is the patient immune for retaliation by society, but he can also buy protection form his own conscience for repugnant actions by employing the ultimate excuse of craziness.  Under the sacrosanct banner of insanity, he can avoid guilt and shame for normally shocking or sickening behaviour,.  If he so desires, he can defecate when or where he chooses, masturbate publicly lash out aggressively, expose himself, remain inert and unproductive or violate any social taboo with the assurance that staff are forced to “understand” rather than punish his behaviour.

In many ways, the modern day patient has prerogatives similar to the medieval absolute monarch with the power and sanction to gratify his every whim,  just as the divine right of kings insured that “the king can do no wrong”, so too the mentally ill can do no wrong; they can only engage in “sick” behaviour.

The divine right of the mentally ill confers other advantages.  Like any monarch with his retinue of servants, chronic patients also have a number of helpers or “servants” to wait on them.  In any well staffed mental hospital professional dieticians prepare their meals, and psychiatric aides serve them; should they need some assistance in dressing, shaving or showering some staff person is always available.  Recreational and occupational therapists make details plans to amuse and keep them from becoming bored.  Should they get upset, some doctor or nurse is always nearby to quell their anxiety or relieve their hurts.  Social workers are ready to act as emissaries with their families and diplomatically explain the patients “illness” to elicit understanding and acceptance.  It is not surprising that several patients “delusionally” have referred to us as their servants – that the hospital exists, as in fact it does to take care of them and minister to their needs.

Let the Healer Beware

Even when patients do occasionally apologise or seem remorseful for their actions, they often employ ritualistic confessions with no sustained, firm purpose of making amends.  Their usual behaviour is to do something bad, contritely confess their wrong doing ask for forgiveness, and shortly afterward repeat the same process, sometimes in a different form, which calls into question the credibility of their acts of contrition.  Their behaviour can be summarised in the formula “slap – ‘I’m sorry’ ……. Slap – ‘I’m sorry’ …… slap ………..”  When staff members find these repetitive acts of contrition unbelievable and convey their disbelief to patients, the typical patient response is to become hurt or furious at the staff or not being gullible and naïve enough to accept the magic words “I’m sorry”.

The purpose of the repetitive utilisation of these magic words seems three- fold:

1. First, to be granted a suspended sentence form any guilt or shame they themselves might feel at their behaviour;
2. Second, to placate the staff’s animosity through this show of penance; and
3. Third, to secure the restoration of full privileges.

The Syndrome of “Chronic Staffrenia”

Part of the real difficulty in establishing an effective treatment and rehabilitation program for chronic schizophrenics resides in the reaction of the hospital staff toward working with these patients.  Caught between what they have been taught represents “good” professional treatment and their own personal (often equated with “bad”) reactions provoked by the tactics and behaviours of patients, staff members eventually become incapacitated in their treatment efforts.  The conflict is between how the staff should treat patients and how they spontaneously want to respond.

It is easy to understand the genesis of this bind.  If the staff accept the view that the mentally ill patient is not responsible for his actions, then it follows that the essentials of any humanitarian treatment approach must always be comprised of love, kindness, acceptance and understand; above all, it is professionally inappropriate to criticise strongly, to react angrily or punish patients for their behaviours, since such behaviour has been caused by factors beyond their control.  On the other hand, day to day experience with these patients invariably arouses in the staff reactions which are diametrically opposed to those which they are expected to feel.

If staff attitudes must under all circumstances be those of patience, helpfulness, love and acceptance, what options do staff members have when they frequently find themselves impatient, helpless, angry and revolted by patients behaviours?  Not only is it difficult for the staff to act persistently one way when they feel another but this same hypocritical façade weakens the therapeutic effectiveness of their efforts.  Despite the loud and clear messages from their adrenals and viscera, staff members are permitted only a very limited response repertoire to the behavioural weapons employed by patients.  The staff members tend to resolve the conflicts of this bind by assuming an observable set of attitudes and behaviours which oftentimes complements those of patients.  We have labelled this characteristic staff reaction the syndrome of “chronic staffrenia”.  The components of this syndrome include apathy, weariness, minimal personal involvement, decreased enthusiasm, lack of emotional investment and markedly decreased expectations for patient rehabilitation.  Staff attitudes are depicted by such statements as “let well enough alone”, or “to hell with it – it just isn’t worth it”.  Staff members increasingly withdraw and engage in perfunctory therapeutic activities which, regardless of their name, at best resemble good custodial care, and they become all too happy to settle for patient co-operator in lieu of patient rehabilitation.  Any program that aims at rehabilitating chronic schizophrenics (in contract to one that merely provides good custodial care) must anticipate this syndrome and take measures to prevent or cope with its development.

Implications for Treatment

Any therapeutic program primarily employing psychosocial techniques for the modification of chronic schizophrenic behaviour must make certain operational assumptions as a basis for effective therapeutic action.  The primary and most important assumption is that the patient is responsible for his actions and can muster up the necessary will power to act sanely and decently if he should choose, or be made to choose to do so.  Given this assumption, certain treatment implications follow.

First, the staff must hold patients accountable for their actions, rewarding appropriate behaviour and punishing inappropriate or deviant behaviour.  One of the problems in such a seemingly simple philosophy is that it runs counter to much current clinical thought.  It is our feeling that today’s dynamically oriented theoreticians have placed the onus of responsibility for the patients behaviour on such scapegoat devils as mother, society, or mythical biochemical abnormalities, rather than on the individual patient himself.  With such convenient whipping boys, where everyone is to blame, nobody is to blame.  If the patient cannot be blamed, then, it follows; he cannot take credit for healthy sane behaviour.  We contend that holding patients responsible for both their good and bad behaviour invests them with human dignity and hope; not holding them responsible is tantamount to pronouncing them hopeless.

Our own simplified view of psychotherapy dictates that the assumption of responsibility by the patient represents a prerequisite for any further constructional behavioural change.  If patients are to be receptive to treatment, their attitude must include four successive components or stages which are as follows:

a. I am responsible for my behaviour;
b. I want to change my behaviour since it dissatisfies me;
c. I need help; and
d. I will co-operate with the help you give me.

These stages not only hold for the rehabilitation of the alcoholic, juvenile delinquent, criminal, the patient with a character disorder and the psychoneurotic patient but for the chronic schizophrenic patient as well.  The major problem with the chronic patient is to get him to move form a position where he denies all responsibility for his behaviour or excuses it under the banner of insanity to the first of these states.  Once this id done a major barrier is crossed.

Since staff members have been commissioned to intervene therapeutically with these patients, the second treatment implication is that the staff must have certain rights consonant with their obligations.  In out current and legitimate concern for the rights of patients, we have overlooked or ignored the rights of those working with them.  What currently obtains in most treatment programs is that the staff members have “the right” to being cursed, threatened, or assaulted by ungrateful patients without being able to punish them for their actions or to vent openly their genuine feelings.  However, we insist that the staff should and do have certain rights, the right to expect gratitude form patients and safely from physical harm to interact honestly with patients, to be creative, and to derive a sense of accomplishment from their work.  These are not idealised luxuries but absolute necessities for treatment staff.  Unless their necessary right are encourages, implemented and insured, we are convinced that no intensive, persistent, and concerted staff treatment effort can occur.  Unless the staff can demand responsible behaviour and respect for their rights from patients, the counter therapeutic tactics of patients will surely and inevitably extinguish any remnants of staff rehabilitative efforts of their behalf.

A third treatment implication is that the staff be genuine with patients.  We propose that the staff not be pressured to hide behind pseudo-humanitarian treatment slogans which decree that love and understanding are the only appropriate responses to all patients behaviours and that anger and even occasional hatred are anti-therapeutic.  There is nothing inherently wrong in admiring and liking the good qualities of patients while, at the same time, disliking and rejecting their undesirable qualities.  If staff members are forced to conform to hackneyed platitudes, their response, at best will consist of perfunctory love, phoney acceptance, misguided kindness or biased understanding.  We believe in most appropriate that the staff be allowed to give patients accurate and honest human feedback concerning the impact and social consequences of their behaviour.  For example, it is unreasonable to insist that the staff adopt inappropriate smiles or act kindly toward patients while brimming with anger.  Our contention is that “love and understanding” are not simply insufficient, but at times are actually incongruous and damaging in response to certain patient behaviours.  The staff should be allowed and encouraged to use a whole relationship: both to be positive, warm and loving when patients behave sanely and well, and also to be angry, rebuking, rejecting and punishing when patients are obnoxious or bad.  Them combination of Pollyanna plus Scrooge represents a more whole, integrated, human response, either along is a travesty.

A fourth implication pertains to the so –called rights and prerogatives of the chronic patient.  From our assumptions it follows that patients not be allowed to become too comfortable or settled in the hospital.  It is imperative that the staff feel free to usurp and confiscate the patients “squatters” rights and convey insistently and persistently to patients that they are not only do not have the right to remain in the hospital, but that the only virgin land available for homesteading lies outside the hospital.

Other treatment implications pertain directly to jamming the various weapons which patients employ.  It makes little sense to continue to treat these patients as perpetual convalescents and invalids by waiting on them and thereby encouraging and reinforcing dependency.  As long as patients can continue to gain all the prerogatives and privileges without effort, there is little incentive for them to change.  As long as their craziness continues to pay off without uncomfortable repercussions or sanctions, we encourage the development and perpetuation of chronicity.

Ethical Issues

In evolving a treatment philosophy for chronic schizophrenics, we have had to grapple with a number of ethical issues, posed by ourselves and respected colleagues, concerning staff attitudes and treatment approaches toward these patients.  Since the direction and development of any treatment program is contingent upon how these issues are resolved, their importance cannot be stressed enough.

One of the immediate ethical issues involves the use of punishment for patients.  Without delving into all aspects of this problem, which would require a separate paper to do full justice to it, we will simply say that this issue is largely artificial or moot, for there are no psychosocial techniques for instituting human behavioural change which do not employ the very potent tools of both reward and punishment.  Even those programs which espouse only benevolent approaches make liberal use of such negative reinforcements as withholding privileges, withdrawing love or approval restraints and seclusion, ECT and drugs for the avowed purpose of “controlling” patient behaviour, but eh rationales offered are often only euphemistic or socially condoned excuses for subtle or blatant punishments.  The issue is not whether punishments should be used; they are and will be – this is simple a fact of all clinical and social life.  The real issue is whether punishments will be administered openly, non-apologetically, and in a consistent, systematic,  goal-oriented manner rather than on a disguised, apologetic, whimsical and haphazard basis.

There are those who fear that once the use of punishment is openly acknowledged and condoned, it might well serve as a vehicle for sadism.  We sympathise with and share this concern; however, the essence of the problem is whether the therapist uses punishment solely for his own gratification or for the patient’s welfare.  Our position is simply that if a therapist is sadistic, he will be ingenious enough to find a vehicle for his sadism in any type of therapeutic approach, even in benign non directive therapies.  Or to put it differently, the beatific smile of the therapist does not guarantee that there are not fangs hidden behind it.

A critical ethical question is to what lengths will be go to implement our treatment goals?  Should the goal be to maintain a chronic schizophrenic comfortable in the hospital or to undertake the more ambitious task of helping him become a relatively whole, occasionally uncomfortable person functioning outside the hospital?  If we choose the latter goal (a formidable task), then, it follows, that certain procedures, which might be considered drastic or extreme, will have to be employed.

It cannot be overemphasized how serious and malignant a problem chronic schizophrenia is.  As the situation now stands, these patients represent serious economic, social, political and psychologic debits not only to society by themselves as well.  Many represent the psychologic equivalents of terminal cancer patients devoid of any prospects of a productive existence.  Therefore, we have to make the operational value choice of either preparing them for a comfortable psychologic demise of using, if necessary, radical procedures which measurable increase their chance for responsible meaningful living.

In any radical procedure there must be a willingness for balance the potential risks against the possible gains.  It is our impression that most professionals working in this area have been reluctant to confront the issue of risk and have chosen instead to play it safe.  One way of playing it safe has been to settle for more modest treatment goals for these patients.  Another way (but a valuable one at that) is to concentrate exclusively on the etiologic and preventative aspects of the problem.  It is riskier, but at least equally important, to engage the problem here and now – that is, if we are not going to let patients psychologically rot in the mental hospitals until we engineer social change or determine the presumed biochemical abnormality underlying this disorder.

The bind we are in, whether we like it or not, is that we must deal with these patients.  In doing so, we have to choose between two options.  We can employ palliative procedures with the risk or keeping patients psychologically moribund or of leading to their psychologic death; or we can try radical psychosocial procedures with the possibility of curing the patient, but the risk of his getting worse.  Should this latter possibility occur, the therapist lays himself open to being labelled anti-therapeutic or destructive; we suspect that one reason many therapist have chosen palliative procedures is not to risk censure form colleagues and to void receiving such labels.  Unfortunately for patients, we have been too bound to the principle of primum non nocere (“first do no harm”), and as a result have been employing a variety of gum drop therapies for a very malignant problem.

Long ago Archimedes stated that if he had a lever long enough and a fulcrum on which to rest it, he could move the earth.  It is our contention that we already have at our disposal some therapeutic levers or techniques for dealing with chronic schizophrenics.  If out goal is the ultimate rehabilitation of these patients, we must begin to search for even more potent and effective levers, which may involve to some degree the use of pain, deprivation, and punishment – all socially sensitive areas in the treatment of patients.  It is not enough simply to theorise about these techniques, we must demonstrate a willingness to use and evaluate them.

A final ethical issue concern the question of whether patients should have the right to opt out of living in normal society.  For those who find life and responsibility too stressful should we provide some haven or retreat in the form of mental hospitals, where they can spend the remainder of their days in relative peace and quiet?  Perhaps the ramifications of this issue could be debated endlessly; we have resolved this issue for ourselves by arbitrarily claiming that just as a person does not have the social or legal right to commit suicide, so too the chronic schizophrenic does not have the right to commit psychologic suicide by giving up or opting out through prolonged hospitalisation.  Again just as when a person attempts suicide, every possible technique or treatment, not mater how drastic, is employed by the physician to aid him, so too, we contend that every possible therapeutic technique even those seemingly drastic should be brought to bear psychosocially to revive the chronic schizophrenic.

Summary

In this age of psychologic understanding, modern clinical theoreticians have emphasised the importance of familial, social and institutional iniquities as largely responsible for the production and maintenance of chronic schizophrenia.  Chronic schizophrenics are usually portrayed as hapless, helpless creatures impotent against the powerful forces which shape their pathology.  Unfortunately, such a view completely overlooks the rather “naïve” possibility that patients themselves become chronic simply because they choose to.

From the clinical experience, we have become convinced that chronic patients are anything but fragile, helpless people.  In fact, they are quite ingenious in employing an array or counter therapeutic weapons or tactics which are highly effective in achieving their goal – namely, continued hospitalisation.  We have described many of these weapons within the body of the article.

One of the major problems in establishing and maintaining an intensive, enthusiastic therapeutic program for patients pertains to the reaction of the hospital staff (the syndrome of “chronic staffrenia”) to the tactics of patients.  Unless this staff reaction can be prevented, it is unlikely that any treatment program will prove effective.

Starting with the assumption that patients must be regarded as responsible for their behaviour, we have presented a number of treatment principles which seem crucial for the treatment and rehabilitation of chronic schizophrenics.  The principles outlines raise a number of serious ethical issues which are also discussed within the article.

Reference:
1. The Code of Chronicity.

The code of loyalty among delinquents, prison inmates, criminals, and certain oppressed minority groups is a well-known social phenomenon.  This code of behaviour represents not only the acceptance of socially deviant group values but specifically prohibits a member of the group from consorting with members of other groups, especially those representing “authority”.  A breach of code, resulting in the apprehension or punishment of other group members, is likely to result in social ostracism, ridicule, physical punishment or death for the transgressing member.  Such epithets as “stool pigeon,” “stoolie,” “rat fink,” “teachers pet,” “ass-kisser,” and “brown-noser” are reserved for those individuals who cooperate with authority figures responsible for controlling or modifying the behaviour of the group in which these individual belong.  Of interest is the ambivalent attitude of those in authority toward “informers”.  On the one hand they are dependant on these people for vital information; and the other hand they regard informers as traitorous and despicable.  In a sense, then, both the deviant sub cultural group and the group vested with authority have formed an unwritten and informal pact to withhold sanctuary and solace from people who break the group code.

Although such codes have been commented on widely, little has been written about the existence of similar type codes among hospitalised chronic schizophrenic patients.  Not only are such codes operative in a closed ward setting, but attitude
of staff toward patients breaking the code often parallel those of persons in

 
1.    Chairman, Department of Psychiatry, university of Kentucky Medical School, Lexington, Kentucky
2.    Clinical Director, Family Social & Psychotherapy Services, Madison, Wisconsin

authority toward informers.  A situation, therefore, is unwittingly created whereby patients find it difficult to relinquish their identification as chronic patients and to adopt more socialised values and attitudes.

To the degree that the foregoing is true, then one of the central problems in dealing with groups of chronic schizophrenics is to cope somehow with this code; as long as this rehabilitating the chronic schizophrenic becomes overwhelming.

The existence of such a code became readily apparent curing the early phase of our experimental treatment program for 30 chronic hospitalised schizophrenics.  These patients, consisting of 16 males and 14 females, were selected from various wards throughout the hospital and housed together in a single building where the new intensive treatment program would take place.  Included in this group were not only patients who had made themselves inconspicuous during their years of hospitalisation by virtually “crawling into the woodwork,” but also patients with a history of multiple elopements from the hospital and serious aggressive and sexual acting-out problems.  All these patients had been intensively treated with a variety of activity, pharmacological and psychotherapies; the net result was pervasive staff pessimism about their response and prognosis.

Since a primary purpose of the ward was to evaluate various psych-social techniques for the modification of behaviours and the rehabilitation of patients, the general ward policy was to control patient behaviour without ready access to such convenient EST, tranquillisers and sedatives.  For most patients and staff, this was a new experience and soon brought to the fore many therapeutic problems which previously had been suppressed by these traditional practices and procedures.  For example, a heavily tranquillised patient is not likely to engage in either deviant of therapeutic group interaction.

Because of the limited number of unit staff and virtual elimination of pharmacological restraints to control behaviours, it became obvious that the patients themselves would have to assume the major brunt of the responsibility for modifying and channelling each other’s deviant of potentially harmful behaviour.  In a word, since we could not adequately “police” them patients had to police

themselves.  Once the unit staff had accepted this position, it soon encountered head-on a number of traditional attitudes held by chronic hospitalised patients, as well as staff, which made the enforcement of such a position extremely difficult.

These traditional attitudes and their consequent behaviours we have come to term “The Code of Chronicity.”  This code, partially reinforced by staff and society, tends to perpetuate “crazy” behaviour, helps sustain a staff-patient barrier leads to the acceptance and rationalisation of continued hospitalisations and thus effectively eliminates any incentive for change, improvement, and eventual discharge.

Some of the essential components of the code which we have observed to date are described  below.

Characteristics of Code of Chronicity

A.    The Staff as Jailers

Since the therapeutic zeal of most staff has long since waned toward these patients, the patients eventually come to view hospital staff more as jailers, custodians, wardens, keepers or guards than as therapists.  From the patient’[s perspective, the staff, similar to prison authorities, determine length of sentence (hospitalisation), grant parole (conditional release), award privileges, and mete out punishments,

Although staff may view themselves as therapists and regard all their efforts as “therapeutic2, they (as well as society) seem to reinforce these patient attitudes.  Patients accurately perceive that staff do, in fact, “police” patient behaviour, suppress acting-out and determine privileges.  Although staff may not be permitted to physically “punish2 patients for deviant behaviour, under the banner of “therapy” and the scientific appellation of negative reinforcement, they are permitted great latitude in handling this behaviour.  Restraints, seclusion, EST, and drugs are effective ways for keeping patients “in line.”

B.    The “Model Patient”

Most of our chronic patients seem content to reach the enviable goal of attaining the greatest amount of privileges, the least amount of restrictions, and minimal demands put upon them without having to leave the protective setting of the hospital.  To attain this goal, all patients need to do is to participate perfunctorily in scheduled therapeutic activities, such as occupational and recreational therapy or group therapy meetings, perform a minimal work assignment, remain inconspicuous enough so that some staff member with therapeutic zeal might not be tempted to push them out of the hospital, and not act out overtly (a therapeutic taboo).  If patients can meet these criteria, they are gratefully accepted by the hospital staff and administration as “key workers” who are “co-operative with ward routine” – a source of cheap help and essential to the maintenance and repair of hospital grounds, facilities and services.  Thee model patient this becomes a sub-staff member.

C.    The “Un-Dead” State

In Bram Stoker’s Dracula, there is a description of people who turn into huge vampire bats at night after remaining in an unfeeling, non-reacting, trance-like “un-dead2 state during the day.  The expectation and behaviour of chronic patients often parallel this description.  They can not tolerate emotional stress or discomfort of any kind, be it fear, anxiety, depression, love or human closeness, and immediately seek to quell these feelings.  They seem to prefer the foggy, benumbed calm of tranquillizers, the stuporous feeling of sedatives, or the confused oblivion following EST to the unpleasant experience of their own thoughts and feelings.  Minimal involvement, minimal feeling, minimal thought, and minimal stimulation by others help preserve the equilibrium of chronicity.

Hospital staff, on their part, help meet these patient needs.  Out of sympathy and concern for the patient’s plight, staff minister the mental
healing balm of tranquillisers, sedatives, and anti-depressants as soon as the patient seems upset enough to gain the attention of staff.  Since it is “inhumane” to allow the patient to continue to suffer, it becomes incumbent on empathic staff to dull the edge of patient anxiety or allay his fears.  Moreover, the “quiet ward,” highly valued by administrators and staff, is considered necessary to the smooth functioning of a hospital and to “good therapeutic practice.”

D.    Victims of Society

Though not true of all patients, many regard themselves as social pariahs – outcasts of a disinterested and uncaring society.  They come to view society, or certain social agencies or institutions, as vaguely responsible for their present predicament.  As a result of their being “short-changed,” society owes them recompense.  After years of hospitalisation, they begin to consider themselves entitled to total care.  They become chronically and aggressively dependent and come to feel that everything they receive they have coming to them.

Another variation of this all-pervasive attitude may take the form of a personal vendetta against society for its harshness and rejection.  Patients feel that they have been “dealt a raw deal” by life, and their global response is not flight but fight – to strike back at, get even, and settle accounts.

As society’s representatives, hospital staff often do, in fact, appropriately feel sympathy toward patients for their past sufferings.  However, through misguided kindness and understanding, they may reinforce a patient’s attitudes and  behaviour by exonerating present “sins” on the basis of the horrible circumstances of his past life.  Moreover, they may refrain from venting anger punishing a patient for acts, which under normal circumstances would be reprehensible, simply

because they understand the psychological genesis of his behaviour.  To understand may be to forgive, but to forgive a deviant act without punishing it (euphemistically termed “negative reinforcement”) may be to condone, encourage and perpetuate it.

E.    Representation Without Taxation

Patients have been well taught the principles of democracy, equality, therapeutic community and the virtues of teamwork – so much so that they vociferously claim their inalienable right to behave as they choose but speak in whispers, if at all, about their corresponding obligations and duties.

Hospital staff have provided patients with numerous opportunities and forums to voice their gripes and participate in decision affecting ward privileges and routine.  However, under the banner of self – determination and therapeutic decision making, patients are frequently granted privileges without corresponding obligations – a situation which had no comparable model in society.  In society, a person gains and prerogative or being heard by assuming the obligation of being productive and consistently fulfilling the role of responsible citizen.  Where the model breaks down in the mental hospital is precisely at this point: patients are all too often granted representation without being expected to pay the taxes of appropriate socialised, responsible behaviour.

F.    Insanity by Convenience

Chronic patients seem to harbour certain paradoxical attitudes whereby they expect to receive the prerogatives of both the crazy and the sane – the best of both worlds.  If they act crazy, they “couldn’t help it”; if they act sane, they deserve rewards.  They regard themselves as responsible and capable of handling things they want to but regard themselves as helpless and incapable of controlling impulses or confirming to unpleasant
staff or group demands.  In other words, they expect plus points for sanity and no deductions for insanity.

Staff respond with double standards to the paradoxical expectational system and behaviours of the crazy-sane patient.  If patients act crazy, they are not to blame; if they behave normally, they are given privileges.  This situation does not pertain to real life; in the extra-hospital society, deviancy is punished, sanity is rewarded.

Anybody who has worked with many chronic schizophrenics over a considerable length of time also can see that their craziness does not remain full-blown constantly, but is a some-time thing.  We have gained the distinct impression that patients may frequently turn their craziness off and on in both a predictable and non-predictable manner.  We believe that the aperiodic nature of many patient’s craziness effectively pays off for them in a variety of ways, not the least of which is continued hospitalisation.

This pattern of patients’ behaviour tends to be met by complementary staff attitudes, which usually include the following components;
    
i.    The patient must be sicker than we thought;
ii.    He obviously is not ready for discharge;
iii.    He had better be kept in the hospital for a while longer, a while longer, a while longer

G.    Not My Brothers Keeper

After years of hospitalisation, patients begin to loos all sense of social or group responsibility.  They regard their own problems as unique or overwhelming, and others be dammed.  If they observe sexual acting – out in others or aggressively destructive behaviour, then it’s the staff’s job to intervene and re-establish equilibrium and ward peace.  They have


enough problems of their own to worry about and can’t be bothered taking the responsibility for others.  Their attitude is one of “me, myself and I”.

For the most part, hospital staff tend to perpetuate this attitude by intervening, subduing the offender, and not placing the burden of responsibility on the shoulders of the patient group.  Unfortunately, staff unwittingly tend to discourage meaningful patient – to –patient interaction by protecting them from each other.

H.    The weapons of Craziness

When a patient does lose control of his behaviour, strikes other patients or staff, he knows that staff cannot retaliate in like manner.  Even when the staff feel that a good kick in the pants or a slap may be infinitely more therapeutic than a tranquilliser pill in controlling patient behaviour, they are bound by the “humane” principles of kindness, understanding or restraint.  Physical punishment is taboo and has no place in a modern therapeutic institution.  In the ongoing struggle for control between patients and staff, the staff must engage in battle with one hand tied behind.  The patient can fight as dirty as he likes using alley rules (thumb in eyeball, knee in groin).  Staff are conscientiously bound by the Marquis of Queensbury rules.

In addition to the limitations (well know by patients) i9mposed upon staff, patients may also utilise the weapon of “if you upset me, I’ll make you wish you hadn’t”.  If confronted by staff, patients may implement this unspoken threat by losing “hard won therapeutic gains” staying up all night and bizarre behaviour.  When patients respond in such a way following staff confrontations, staff inevitably assume that they have pushed the patient too fast and too far.  The possibility of a patient getting upset is, in effect, a club held over the staff’s collective head.

It would also be noted that the patients utilise these and other weapons in an unflagging war of attrition against staff’s therapeutic efforts.  The “Hard Core” patients are those who have successfully met and worn down staff group after staff group, until one gets the distinct impression that staff may come and staff may go, but his type of patient remains forever.


The Code in Operation

Shortly after the initiation of our experimental treatment program, it became clear that members of the chronic patient group, in order to enforce group solidarity, cold and did reward one another with affection, conversation, money, cigarettes and companionship.  By the same token they could punish one another by ostracism, threats, physical assaults, and by with holding the above-mentioned rewards.  Because these rewards and punishments given within the patient group were concrete, meaningful and immediately contingent upon certain deviant behaviours they were extremely potent in perpetuating the code of Chronicity.  On the other hand, staff’s reward’s and punishments were viewed by the patients as relatively intangible, meaningless, and boo long-term; by default, then, the code could easily flourish.

Staff soon learned that a number of patients were engaging in various forms of acting out behaviour.  However, few patients felt under any obligation to intervene or even inform staff of what was happening even though the behaviour of these other patients was potentially harmful to themselves or others.  By engaging in this “conspiracy of silence,” the so called innocent patients were truly accessories after the fact.  Many knew when certain patients either had planned to flee, fornicate or fight on the ward but preferred to let staff find out for themselves.  When some patients were confined to the ward and denied coffee and cigarette privileges, others held break these rules by smuggling these items to the restricted patients.  In short, the group of patients either actively or passively, either consciously or unwittingly, undermined staff efforts.



Attempts to Break the Code

Since we came to feel that the existence of such values and behaviour could only prove detrimental to patients and reinforce their Chronicity, we set upon a grogram to break the code.  Obviously, we were not dealing with a group of fragile, broken spirited persons but rather with tough, formidable adversaries who were “pros” and who had successfully contended with many different staffs on various wards in defending their title of “chronic schizophrenia”.  In attempting to break the code held by this group, we were specifically interested both in reinforcing the healthy aspects of group loyalty and eliminating the self and socially destructive aspects of group identification.

To contend successfully with patients, we were forced to adopt certain working assumptions.  Basically, these assumptions, and the tactics derived form them, represented attempts to break away from a number of traditional staff attitudes and behaviours which we believe tended to perpetuate or, at the best were impotent against the code of Chronicity. 

First, even though considered insane by psychiatric and social standards, we regarded all patients as responsible for their behaviour.  If pressed to do so, they could exercise the choice of getting well.  Granted this assumption did not conform to many notions regarding the biochemical etiology of schizophrenia, which may still be valid, but since no pharmacological cure was readily available, the question of such an etiology is purely academic at the present time for the purposes of treatment.  If we were to act, we had no choice other than to adopt a psycho-social basis for patients’ behaviours and psycho- social techniques to modify them.

Second, since all patients were living together in one unit, the behaviour of any one member, for good or bad, reflected on and influenced the whole group.  Just as the deviant behaviour of a family member can affect eh welfare of the whole family, we believed a similar phenomenon to be operating on the ward.  Patients in fact were their brother’s keeper, whether they liked it or not, and they were obliged to intervene to prevent the deviant behaviour of their fellow patients from affecting the welfare of all patients on the ward.  Instead of ward staff having the major

responsibility for modifying patient deviant behaviour, the patients themselves were expected to assume this task.  Moreover, and just as important, in helping others, they were helping themselves.

Third, there was no need to snow someone with medication simply because he happened to be experiencing intolerable feelings of anxiety, fear, depression, or insomnia.  Patients would have to learn to live with and live through these feelings without ready access to agents which would produce mental oblivion.  They would have to find other constructive ways to coping with these feelings or just to bear some suffering, if they were ever going to learn to live humanly and productively on the outside.

Fourth, staff would provide as little reinforcement as possible for pathological or deviant forms of behaviour.  Patients would have their craziness pointed out consistently and insistently.  Furthermore, the privileges they received were not automatically coming to them but were contingent upon the performance of desired behaviours.

Fifth, patients’ present behaviours were judged all important.  Even though we recognised that past experiences had shaped their present conflicts and behaviours, such psychological genesis was deemed irrelevant for two reasons.  A variety of etiologically oriented treatment approaches had been tried with these patients and failed.  In addition, present behaviours were the only ones which we could see, attempt to eliminate or reinforce, and measure.

Sixth, to become well, patients would have to think, feel, and behave similar to staff as persons.  The concepts of normality and sanity as therapeutic goals were too intangible and vague; we would have to deliberately concretise these concepts by insisting that patients employ staff persons as models for behaviour.  Despite our visible faults, foibles and inconsistencies, we would expect patients to “be like staff – warts and all”.  Furthermore, we would not play at democracy in therapeutic community meetings; not the majority, but health and sanity, as defined by staff would rule.


With these initial assumptions as a basis, we began searching for effective methods to implement them.  Our goal was to raise the price of Chronicity.  Initially we tried talking at considerable length about patients’ behaviours at ward group meetings; these discussions and homilies had little if any impact.  Appeals to reason failed, and attempts to compromise were either ignored or viewed as weakness by these patients.  Obviously, if patients were to be rehabilitated, the cold war stalemate between patients and staff could not continue.

Once we had accepted this conclusion we were forced to employ a number of tactics aimed at undermining the unhealthy aspects of patient group solidarity.  If patients chose to fight for and defend their maladaptive and self – destructive way of life, we would have to escalate out efforts in the battle for life, we would have to escalate out efforts in the battle for their sanity.  To pursue the war analogy further, we fully realised that if patients “won” this battle=, the paradoxical outcome was that they would really lose in human and socially meaningful ways.  The only real chance patients had to “win” would be for them to capitulate completely to the therapeutic efforts of staff and accept unconditional surrender to our value system.

Since our ultimate aim for all patients was to help them realise their fullest potential as human beings, we were committed to the notion that an occasionally unhappy but productive, socialised person out of the hospital was infinitely more desirable than a happy, unproductive institutionalised schizophrenic.  Therefore, if we were to break the code of Chronicity, we had no other recourse but to employ strategies designed to “divide and conquer.”  To this end, patients were deliberately played off against each other by making each patient not only suffer the consequences of his own deviant behaviour but also the consequences of other patients behaviours toward one another and toward staff.

In order to undermine further the chronic patients’ value system, we decided to utilise many of the same concrete, meaningful, and immediate rewards and punishments that patients themselves employed to perpetuate it.  Minor infractions of ward rules were met by the usual loss of certain privileges.  However, if any member of members of the patient group went AWOL from the hospital, or

engaged in forbidden aggressive or sexual activities, the entire population would be restricted to the ward and lose all privileges for three days if no one attempted to intervene or to inform staff.

Although we sanctioned and encouraged patients to vent their anger and to defend themselves appropriately against attack, to intervene and restrain other patients engaging in fights and to prevent fellow patients from funning away from the hospital, we never failed to insist that these behaviours be employed within the boundaries of moderation and discretion.  Staff were always present on these occasions to guarantee that these boundaries would be observed.

Basically, the therapeutic rationale for our position was that we were not going to overprotect patients from the consequences of their own behaviours or from offending group members; we hoped to mobilise the potent forces of the peer group to modify inappropriate reactions and to increase coping behaviours.

In addition we clearly communicated the value that “squealing” on or actively controlling other group member’s unacceptable behaviours was good when it was against a bad code.  Contrary to the generally ambivalent reactions of persons in authority toward informants, we offered sanctuary, concrete rewards, and staff approval for those patients who thwarted their own group’s destructive values and behaviours.  The purpose of all these strategies was to make the survival of chronicity a luxury which patients could no longer afford.

After the first several times that the ward was placed on restriction, many patients began breaking out of their shell and directing their anger (which at first they expressed to staff) at the offending persons.  Interaction at ward meetings became heightened, and patients who previously had only the staff to recon with, now had to take on their fallow patients as well.  They soon came to see, in a very concrete way, that the behaviour of other patients did truly affect them and that they had to cope with other patients to preserve their own rights and privileges.

Soon patients began preventing others form eloping, either talking them out of it or informing staff of the proposed escape.  At the encouragement of staff or on their own initiative, they intervened in fights, restraining the offending parties.  They became offended at aberrant sexual behaviour and reported instances of this to the staff.

At the same time, these instances were discussed openly at general ward meetings.  The discussions seemed to become more meaningful, and the topic of responsibility, which at previous meetings had seemed mainly of theoretical interest, now began to become a reality.  Several patients voiced the bind they were in by “squealing” on their fellow patients or acting toward them as staff would.  They felt if they betrayed their code, then they would not know who they were nor to whom they belonged.

We recognised their dilemma as painfully real; nonetheless, we actively manipulated ward situations and meetings in order to force them to stop procrastinating and make the agonising choice or which values they would adopt – patients or staffs.  However, they knew that if they made the “wrong” choice, we would make it uncomfortable for them.  In effect, we attempted to out – bind them.


Final Remarks

At this point, it seems appropriate to change our focus and discuss briefly the process of modifying staff attitudes and behaviours toward the chronic schizophrenic.  Such modification cannot take place without much soul searching.  Most professional staff have been taught and have come to adopt a variety of humane and therapeutic attitudes concerning the general care of psychiatric patients.  These notions, which are largely appropriate and helpful for the majority of patients, from our experience do not seem efficacious for institutionalised hard – core hospitalised chronic schizophrenics.  The perpetuation of such staff attitudes and their concomitant behaviours had proven futile in the previous treatment of this particular category of patients.


Although the experimental treatment unit staff, for the most part, showed a great willingness and enthusiasm to change their treatment orientation toward these patients, we were (and probably will continue to be) confronted with a number of our own doubts and questions and those of respected colleagues – all of which constitute considerable pressure against such change.  The pressures for therapeutic conformity are great, especially when staff receive opinions from others that the procedures employed are “punitive,” “unfair” and “inhumane”.  None of us are immune or insensitive to the negative remarks of highly regarded colleagues or to our own doubts about the validity of non-traditional procedures.  As a result, the unit staff have all spent many struggling, self-questioning hours at meetings focused on the ethics and efficacy of the procedures.  Nonetheless, the one over-riding consideration remains the rehabilitation of these patients, and, at this juncture, we feel we are on the right track.

Finally, in presenting our conceptualisations and experiences, we do not wish to give the impression that we have successfully broken the code of chronicity at this point or that every patient has responded to our efforts.  We are still in an early phase of our treatment research program and plan on employing and evaluation a variety of other techniques.  At best we are engaged in on ongoing struggle with these chronic patients and our successes have been limited but discernible.  A number of patients still seem too disorganised or uninvolved to respond to these techniques or even to attend to what is transpiring.  Moreover, we also wish to emphasis that we do not necessarily regard our efforts to break the code as a therapeutic end-point in itself but rather as a beginning.  We conceive of these assumptions and techniques as a sine qua non in making these patients more accessible to other forms of therapeutic intervention.

Arnold M Ludwig MD1 and Frank Farrelly ACSW2
Published in archives of General Psychiatry, December 15 1966