A Brief Meditation
A Sufi tale:
The biggest difficulty with the concept of "rehabilitation" in psychiatry is the in-built paradox of "helping someone to become independent". This is similar to the "be spontaneous" paradox described by Watzlawick where the command itself paralyses any compliant response that the individual might offer.
This paralysis of response will be familiar to many "schizophrenics" who have found themselves repeatedly caught in the Batesonian "double bind" where the individual is caught in a lose-lose situation.
The process of the double bind was beautifully illustrated for me whilst listening to the stories of bullied children. I was curious about the ingredients that were necessary to take a normal "rough and tumble" game that establishes a pecking order in the playground into a scenario that produced a psychological damage to particular child.
One child explained it to me - First we gang up on a child, we corner him into a position from which he cannot escape. This child will then engage in whatever behavior is available to him at that moment, in order to attempt an impossible escape. It is then that we pick on the child's futile attempts at escape and ridicule him. We bully him for his inability to escape from the situation into which we have placed him.
I have met many "chronic psychiatric patients" who feel their situation is similar. No matter what they do, their behavior is scrutinized for signs of mental illness by ever vigilant nurses. One morning I was sat in an office with two psychiatric nurses when a patient arrived and politely requested "a quick word" with Mary, the senior nurse.
Patient: "Mary, I was wondering if I could have a quick word."
Mary: (In soothing, professional tones) "Sure, John, what's wrong?"
Patient: "I'm a bit concerned that you might have misunderstood me earlier. I just want to make sure that you understand what it was I was trying to tell you."
Mary: (In professional, concerned tones) "John, have you taken your medication today?"
Patient: (Taken aback, starting to look uncomfortable) "Yes, I mean no. No, Mary this isn't about medication, I just want to make sure you don't write the wrong thing into my notes"
Mary: (Interrupting) "Calm down John, you are getting agitated."
Patient: (Interrupting, and now getting a bit agitated) "I'm not agitated, I just want to..."
Mary: (Interrupting, calmly, emphatically and controlled) "Calm down, now! John I want you to go sit down and calm down." (turns to me) "Please pass me John's [drug] chart."
Patient: (Now angry, trying to contain himself, shouting) "FOR CHRIST'S SAKE, LISTEN TO ME!! WHY DON'T YOU PEOPLE EVER FUCKING LISTEN!?"
Mary calmly reached over and pressed the emergency button, five nurses arrive and engage in that activity called 'control and restraint'. John is given a "PRN" dose of haloperidol and taken back to his room.
This scene that occurred before me took place in a secure psychiatric unit - a section called the "Intensive Treatment Unit" (ITU). I was astonished, especially as later in the day a case conference was held to discuss John's problems and it was all agreed that he needed a higher dose of medication. No-one could see the double binds and appalling situation that they were forcing John to inhabit. I attempted to point out the situation from John's perspective, but this was dismissed - poor John was very ill they told me sympathetically, his outburst earlier was simple proof of this fact. There was no doubt in anyone's mind that John would need to be detained for a very long time - a lot of therapy and medication was needed before he would ever be considered "reasonably stable".
Ultimately, the aim of rehabilitation is to stop people being patients. And yet, in order to stop them being patients, we need to make them our patients in order to unmake them again. This therapeutic position is as inanely stupid as many of the practices I have witnessed in psychiatric rehabilitation centers.
One 'leading' rehabilitation center of excellence that employed some highly qualified people who prided themselves in getting their residents to be able to cook and do their own washing up. I was incredulous - at what point during "schizophrenia" do people become amnesic for how to make a cup of tea? This was the same place that organized people into groups - a music group (they sat around and bashed tambourines), a woodwork group (all preformed bits of wood, glue, no metallic tools - too risky) an exercise group (they sat in a circle and bashed a balloon to each other) a cookery group (rice crispies and sickly melted cooking chocolate) or an encounter group (everyone sat round in a circle trying awkwardly to think of something to say).
Overtly, I guess that the intention of all this was to help to stop these people from being patients. Actually, all that was happening was the patients were behaving like performing seals in order that the staff could fulfill the needs of their therapy rota. The biggest irony was that when a patient declined to join in this embarrassing faŤade, his mind and soul would be scrutinized in order to elicit what was wrong with him. Peer pressure to join in this faŤade can be very strong and a statement of "I'm not joining in, because I am mentally well" would simply be dismissed as a delusional complex and therefore evidence of mental illness. Thus this person would need the therapy more than anyone else.
It is our duty to bring up our children to love,
Honor and obey us.
If they don't, they must be punished,
Otherwise we would not be doing our duty.If they grow up to love, honor and obey us
Either we have brought them up properly
Or we have not:
If we have
There must be something the matter with them;
If we have not
There is something the matter with us.
R.D. Laing. "Knots." p3.
One 17 year old "schizophrenic" told me of his dilemma. As he grew up as a child, he adopted the beliefs and behaviors that his parents that they taught him and wanted him to have. He was a sickly child, and somewhat smothered by his parental attentions. As he got older, he had difficulty fitting in amongst his peers, found it difficult to form friendships and he stood out in the playground and was bullied in the manner previously described. One time he told his mother of the bulling, she advised him to "ignore them" or to "tell the teacher". He intuitively knew that these strategies were na•ve and would do nothing to improve his situation.
He eloquently told me, "The person my mother made me was not a person that could survive or fit into the world that she herself did not inhabit. She is painfully na•ve and fragile and she will not be questioned, ever, sometimes I think she is the devil. The person she made me lacked confidence, I was insecure and suffered terrible anxiety. I did not fit in anywhere in the world except with mother. The person she made me was a dysfunctional person anywhere in the world that wasn't the family. I had no friends - kids up the road would throw stones at me and I still had a pudding bowl haircut until I was fourteen, she used to cut my hair for me."
At fourteen he began changing the way he behaved, started gaining confidence and forging his place in the world. To his mother's horror, one day he stopped at a barber on the way home from school and had his hair cut properly. She was aghast at this rejection and cried all evening.
He went on: "The person that can make it in this world is not the person my mother can cope with as a son - she needs me to be weak - when I stand up to her she breaks down and cannot understand what is happening. I must always apologize for standing up to her." He increasingly started to "stand up" to his mother until at age 16, distraught, she presented him to a psychiatrist. This psychiatrist felt that his awkward history fitted perfectly the pattern of schizophrenia and the young man was institutionalized for a year and was medicated.
During this incarceration, he "deteriorated" rapidly and was considered to be a very sick young man.
"They are playing a game. They are playing at not
Playing a game. If I show them I see they are, I
Shall break the rules and they will punish me.
I must play their game, of not seeing I see the game."
R.D. Laing. "Knots." p1.
Laing and Esterson describe this scenario brilliantly in their book, "Sanity, Madness and The Family." In keeping with Laing's description, this young man became "insane in order to be sane." When he was the unhappy and insecure person his mother had created, he was accepted. When he stood up to the rigors of his mother's behavior, he became insane in her world and in the world of her doctors. He needed treatment - as long as he is ill, everyone can pretend to understand what is happening to him and why he behaves in this peculiar way. As long as the problem result from an illness, we never need to adjust or question our own behaviors. The diagnosis is our savior!
It is this same pattern I see replicated in rehabilitation centers. In order to become "sane", the person undergoing "rehabilitation" must first become "insane" in order to establish a working relationship with the personnel that staff the rehabilitation unit. A refusal to play this game is tantamount to treason and a very serious issue indeed requiring immediate therapy and drugs.
In psychiatry, the emphasis is on what's wrong with the patient. His very being is scrutinized right down to the function of the individual synapses and his behavior is increasingly judged to be a reflection of an erroneous synaptic function that require urgent correction. Rarely is his behavior observed to be a reflection of the environment he inhabits - a phenomenological perspective. What is entirely missed out of the loop is just how bashing tambourines or sitting awkwardly in encounter groups will change this perceived synaptic dysfunction. Tragically, all to frequently the patients perform these tasks in order to please their staff - ie patients undergoing rehabilitation adopt a position whereby they compensate for the naivety and fragility of the institution and it's staff, lest anyone become upset at their refusal to comply. They are forced to adopt the position similar to that of the 17 year old whereby they need to become significantly dysfunctional in the real world in order to fit into and function within the rehabilitation world. They become insane in order to become sane.
The biggest difficulty facing anyone trying to extricate themselves from the role of "psychiatric
patient" is in getting other people to treat him as they would anyone else. The shift from
non-person to person is a difficult task. I can imagine Jesus arriving home after a hard day healing
the sick only to be greeted with:
Mary: "Where do you think you have been, I told you to come straight home after studying with the Pharisees!"
Jesus: "But mum, I'm the Messiah now."
Mary: "Don't speak to me like that! Don't answer me back, boy! Now go to your room!"
Jesus: "For God's sake, Mother, please..."
Mary: (starting to cry) "I only ever wanted the best for you, why are you so ungrateful to me?"
Jesus: "Mother, I'm not ungrateful, it's just..."
Mary: (blotchy faced, interrupting, on verge of tears) "Just go to your room, just go, not everyone is as lucky as you are." (Walks away to prevent any further communication).
Later, Mary (red eyed and blotchy faced) softly approaches Jesus and advises him that not many children (children!) are lucky enough to have such caring parents and using voice tone and posture implies that Jesus should apologize for making her so upset. Surely he can see how he hurt her so?
The ultimate tragedy is that all too many institutionalized patients have been subjected to this type of game in the genesis of their "illness" and the very diagnostic construct of psychiatric rehabilitation continues the perpetration of this same game.
Rehabilitation is about compliance - mostly it is about compliance with the needs of the staff. Most patients know to moderate their behavior according to which members of staff are on duty. The same staff record "objectively" in each patient's progress in his records, ignorant of the effect they themselves have upon their patient. I found the worse question is to ask "why?" I asked a nurse what her intended outcome was for the people that were sat in a circle bashing tambourines. A patient piped up, "Yeah, why do we have to do this?" The nurse was obviously mildly offended and caught off guard. Her reply was simple, "Because I say so."
A minor rebellion set in and the other dozen patients downed their tambourines and demanded to go to the pub for drinks. This was not allowed, said the nurse emphatically, these were patients in rehabilitation and patients in rehabilitation do not go to the pub."And the point of rehabilitation is to stop them from being patients, right?" Said I, seizing the moment. The nurse was now flustered and getting quite red in the face. I did wonder if she was going to cry.
The pressure was on.
"Right." She agreed.
"And," I continued politely, "if they don't play the tambourines and go to the pub, then they have stopped behaving like patients, right?"
Mini-mutinies of this sort are just not tolerated. There are unspoken rules that must be followed and this unfortunate nurse was currently the primary custodian of these rules. Usually it is assumed that we all play by the rules via common unspoken consent. Ha!
"Don't speak to me like that!" She snapped and fled the room blotchy faced.
"This feels familiar," said the patient, "very familiar indeed." As he proceeded to pick up his tambourine and start bashing it fearfully as I was called to the managers office to explain my actions.
R.D. Laing summarized the bind faced by these patients:
There must be something the matter with him
because he would not be acting as he does
unless there was
therefore he is acting as he is
because there is something the matter with him
He does not think there is anything the matter with him
one of the things that is
the matter with him
is that he does not think that there is anything
the matter with him
we have to help him realize that,
the fact that he does not think there is anything
the matter with him
ts one of the things that is
the matter with him."
Now, let us consider the peculiar predicament now facing our man with the tambourine. He started off sat in the "music therapy" circle where he was expected to bash the tambourine to the music provided by the nurse (a somewhat pointless and inane activity). This was a task he became reluctant to perform when the possibility of cocktails (a preferable activity) at the nearest bar presented itself.
He is a man that has been labeled "abnormal" and he is "in therapy" to become normal again and yet the opportunity to "be normal" is denied to him (ie no cocktails allowed).
Now, he is aware that the nurse is upset because he didn't bash his tambourine and so, in order to return to his appropriate role, now sits in his chair anxiously bashing his tambourine, alone, without any music being played by the nurse.
It is at this point that the nurse became utterly annoyed, placed hands on hips, turned to our man and yells,
"Will you stop bashing that fucking tambourine!"
Later, about the same time that I am being requested by the management to explain my reasons for "disrupting the music therapy group", she enters into his notes that he was observed to be behaving abnormally and was not compliant with therapy. His "attitude" is brought into question.
So was mine.
What we can see here is the same pattern described by the 17 year old "schizophrenic" where the meaning of the patient's experience is reframed (and/or "outframed") - he is asked to sit in a circle and bash a tambourine, he'd rather go to the pub for cocktails. Sitting in a circle and bashing a tambourine is framed as "therapy" and his preference for cocktails is framed as "non-compliance" with this "therapy". Yet he is expected to choose to do the things that a normal person would choose to do.
Once his escape from this situation is cut off, he anxiously partakes in the activity and is promptly told to fucking stop. His validity as a person (as opposed to "non-person" in Laingian terminology) is measured against his behavior during an activity where he was expected to carry out an inordinately inane exercise outlined by the therapy rota.
Thus, there once was a mystic. As he was sitting in quiet meditation, he noticed that there was a
small devil sitting near him. The mystic said, "Why are you sat near me, making no mischief in the
manner common of small devils?"
The devil raised his head wearily and replied, "Since the experts and so called teachers of wisdom appeared in such numbers, there is nothing left for me to do!"
Meanwhile a wise man faced a test of his wisdom, so the authorities could decide whether he presented a danger to the public at large. On the day of the test he paraded past the court room sat on a donkey, facing the donkey's rear.
When the time came for him to speak for himself, he said to the judges, "When you saw me just now, which way was I facing?"
The judges replied, "Of course, you were facing the wrong way."
"You illustrate my point," said the wise man, "For I was facing the right way, it was the donkey that was back to front!"