How Non-Diagnostic Listening Led to "Recovery" from Paranoid Schizophrenia

by Al Siebert, Ph.D.

Excerpted from Journal of Humanistic Psychology, Vol. 40, No. 1, Winter, 2000. pp. 34-58.

My Questions

The Interview with Molly

References

Summary

When I was a staff psychologist at a neuropsychiatric institute in 1965, I conducted an experimental interview with an 18-year-old woman diagnosed as "acute paranoid schizophrenic." I'd been influenced by the writings of Carl Jung, Thomas Szasz, and Ayn Rand, and was puzzled about methods for training psychiatric residents that are unreported in the literature. I prepared for the interview by asking myself questions. I wondered what would happen if I listened to the woman as a friend, avoided letting my mind diagnose her, and questioned her to see if there was a link between events in her life and her feelings of self-esteem. My interview with her was followed by her quick remission.

This account raises important questions about:

the powerful influence of the interviewer's mind set and way of relating to patients perceived as "schizophrenic,"

aspects of psychiatric training and practices that have never been researched,

why psychiatrists misrepresent what is scientifically known about "schizophrenia," and

why the psychiatric literature is silent about the personality characteristics of people who fully recover from their so-called "schizophrenia" and the processes by which they recover.

My duties as a staff psychologist at the Neuropsychiatric Institute at the University of Michigan Hospital in 1965 included attending morning "rounds." The staff gathered in a small conference room at 7:30 a.m. to hear various announcements and reports about patient admissions and discharges.

One morning the head nurse of the locked ward reported the admission of an 18-year-old woman. The psychiatric resident who admitted her the previous evening said "Molly's parents brought her in. They told us Molly claims God talked to her. My provisional diagnosis is that she is a paranoid schizophrenic. She is very withdrawn. She won't talk to me or the nurses."

For several weeks the morning reports about Molly were the same. She would not participate in any ward activities. She would not talk to the nurses, her case worker, or her doctor. The nurses couldn't get her to comb her hair or put on make-up.

Because of her withdrawal and lack of response to staff efforts, the supervising psychiatrist, David Bostian, told the resident in charge of Molly to begin plans to commit her to Ypsilanti State Hospital. Bostian said the university hospital was a teaching facility, not one that could hold patients who need long-term treatment. The staff consensus was that she was so severely paranoid schizophrenic she would probably spend the rest of her life in the back ward.

I decided that since she was headed for the "snake pit," this was an opportunity to interview a psychiatric patient in a way very different from how I'd been trained in my clinical psychology program. I asked Molly's doctor, a third-year resident, for permission to administer some psychological tests and interview her before she was transferred to the state hospital. The resident said I could try, although she expected nothing to come of my efforts.

I contacted the head nurse and arranged to meet with Molly the next morning in the ward dining room. At home that evening I prepared myself for the interview with Molly by reflecting on a cluster of the following four issues and concerns:

After reading The Myth of Mental Illness by Thomas Szasz(1961), I began to notice that the only time I saw "mental illness" in anyone was when I was at the hospital wearing my long white coat, working as a psychologist. When I was outside the hospital I never thought of anything people said as "sick," no matter how outrageous their words or actions. I found it interesting that my perception of "mental illness" in people was so situationally influenced.

I'd been puzzled about an unresearched, unreported aspect of the way psychiatric residents talked to newly admitted mental patients. At our institute the psychiatric residents were required to convince each of their patients that they were "mentally ill." I was present in the office of a resident, for example, during a shouting match with a patient, Tony, who refused to believe he was "mentally ill." Tony was a 20-year-old unemployed factory worker. He was in our facility for a court-ordered examination because he had beat up his father in a fist fight. Also present in the room were his wife, a social worker, and a large male aide.

The psychiatric resident said "Tony, your behavior is sick. We can treat you here as an out-patient, but you must understand you are mentally ill before we can make any progress."

Tony shouted "No, I'm not! You doctors are crazy if you think I'm mentally ill!"

Resident: (voice raised) "We've argued about this before. You must believe you are mentally ill or we can't help you!"

Tony's face got red. His nostrils flared. His breathing quickened. He yelled, "I'm not mentally ill!"

Tony's wife reached over and put her hand on his arm.

The resident yelled "Yes you are!"

Tony: "No I'm not!"

Resident: "Yes you are!"

And so it went.

Finally the resident shook his head and said to the aide "take him back."

Such arguments between psychiatric residents and patients were common. I searched through the psychiatric literature, but could not find any research about why it is essential in the early stages of psychiatric treatment to convince patients they must believe they are mentally ill. How to Live with Schizophrenia, by psychiatrists Abram Hoffer and Humphry Osmond (1966), contains a written statement typical of what patients were commonly told:

As a patient, you have a grave responsibility to yourself and to your family to get well. You will have no problem if you are convinced that you are ill. But no matter what you think, you must do all you can to accept the statement of your doctor that you are ill... (p. 153).

The psychiatric literature contains a few articles and discussions about "lack of insight" in patients (McEvoy et al. 1989), but there is no research exploring the validity or therapeutic rationale of efforts to convince people they are ill.

Such efforts, routine at our institute, created some weird situations. For example, we heard at staff rounds about a man admitted to our service with a diagnosis of "acute paranoid state." His main complaint was that people were trying to force thoughts into his mind. I was curious about his experience from his point of view. I obtained permission from his psychiatric resident to interview him. An aide brought the man, whom I will call Ron, to my office. He was 25 years old, about six feet tall, clean-shaven, in good physical shape, and nicely dressed in slacks and a clean shirt. He shook hands with me and moved with confidence.

After he sat down I asked him "Why are you here in the hospital?"

Ron: "My wife and family say I don't think right (clenches jaw). They say I talk crazy. They pressured me into this place."

"You're a voluntary admission, aren't you?"

Ron: "Yes. It won't do any good though; they're the ones who need a psychiatrist."

"Why do you say that?"

Ron: "I work in sales in a big company. Everyone there is out for themselves. I don't like it. I don't like to pressure people or trick them into buying to put bucks in my pocket. The others seem to go for it...selfish, clawing to get ahead. I tried to talk to my boss, but he says I have the wrong attitude. He rides me all the time."

"So what is the problem with your family?"

Ron: "I've talked about quitting and going to veterinarian school. I like animals. I'd like that work. My wife says I'm not thinking right. She wants me to stay with the company and work up into management. She went to my parents and got them on her side."

We talked for a while about how his wife and parents wanted him to live up to their dreams for him. I said "I still don't see the reason for your being here."

Ron: "They're upset because I started yelling at them how selfish they are. My wife wants a husband who earns big money, owns a fancy home, and drives an expensive car. She doesn't want to be the wife of a veterinarian. They can't see how selfish they are in trying to make me fit into a slot so they can be happy. Everyone is telling me what I should think and what should make me happy."

"So you told them how selfish they are?"

Ron: "Yes. They couldn't take it because they believe they are only interested in my welfare. " He sagged in his chair and held his face in his hands.

"Did you tell the admitting physician about them trying to make you think right?"

Ron: "Yes. Everyone is trying to brainwash me. My wife, my parents, the sales manager. Everyone is trying to push their thinking into my head."

"How do you feel about all this?"

Ron: "I feel angry. They say they have done this to help me, but they don't care about me. They're all selfish. Afraid I'll upset their tight little worlds. I shouldn't be here."

I saw that Ron's doctor was obediently acting as trained when he diagnosed Ron as paranoid. The consequence, however, was a "crazy-making" double-bind for Ron. His doctor was saying to him, in essence, "Because you believe that people are trying to force thoughts into your mind, you must accept into your mind the thought that you are mentally ill." Two days later Ron signed out. It was rumored that he took off for California.

These incidents helped me see how hard psychiatrists try to force their words and thoughts into patients' minds without insight into what they are doing. When a patient disagrees, this is diagnosed as "resistance," "lack of insight," and viewed as another sign of "mental illness."

During admissions meetings I'd observed that when a patient was reported as talking in bizarre ways, the staff would reflexively declare the person "schizophrenic." Diagnosis seemed more important than understanding. No one seemed influenced by Carl Jung (1961), who said in his autobiography, "Through my work with the patients I realized that paranoid ideas and hallucinations contain a germ of meaning....The fault is ours if we do not understand them....It was always astounding to me that psychiatry should have taken so long to look into the content of the psychoses" (p. 127).

I'd just finished Ayn Rand's book Atlas Shrugged (1957). I was impressed with her portrayal of how the need for self-esteem influences what people do, say, think, and feel. I'd been noticing, for example, that when someone made a statement of extremely high self-esteem, most people reacted negatively and tried to tear the person down. I wondered what was wrong with thinking highly of oneself.

My Questions

As I prepared myself for my interview with Molly the next day, I developed four questions for myself:

What would happen if I just listen to her and don't allow my mind to put any psychiatric labels on her?

What would happen if I talk to her believing that she could turn out to be my best friend?

What would happen if I accept everything she reports about herself as being the truth?

What would happen if I question her to find out if there's a link between her self-esteem, the workings of her mind, and the way that others have been treating her?

The Interview With Molly

The next morning I took my Wechsler Adult Intelligence Scale testing kit and Bender-Gestalt cards with me to the ward. I laid out the materials on a table in the dining room and waited until the nurse brought Molly in.

Molly was about average height and looked slightly overweight. Her shoulders slumped forward. She was a plain looking young woman wearing no make-up. Her straight, light brown, shoulder-length hair needed washing. She wore a loose, faded cotton dress. "Dowdy" was the word that came to mind.

When the nurse introduced us, Molly glanced quickly at me. She didn't say anything, even though I could feel her attention on me. She seemed frightened and lonely.

I seated her at the end of a table and I sat at the side. Instead of trying to talk with her, I put her to work copying Bender-Gestalt designs onto sheets of paper. She cooperated and did what I asked.

I wasn't especially interested in how well she could draw; I just wanted her to become comfortable with me. I sat relaxed and quiet. When she finished a drawing I'd say, "Good," or "That's fine," or "Okay, here's the next one."

When she finished the drawings, I started her on the Wechsler block design test. She followed instructions accurately and worked at a good speed. I could see that she was not depressed and had no obvious neurological problems.

She gradually warmed up to me and relaxed as we proceeded. After about 15 minutes she peeked out from under her hair and looked cautiously into my eyes.

At the first moment of good eye contact, I smiled and said "Hello." She blushed and ducked her head.

I felt a rapport with her and felt that I could start a conversation. It went like this:

A.S.: "Molly?...(she looks up at me)...I am curious about something. Why are you here in a psychiatric hospital?"

Molly: "God spoke to me and said I was going to give birth to the second Savior."

A.S.: "That may be, but why are you here in this hospital.?"

Molly: (startled, puzzled) "Well, that's crazy talk."

A.S.: "According to whom?"

Molly: "What?"

A.S.: "Did you decide when God spoke to you that you were crazy?"

Molly: "Oh. No. They told me I was crazy."

A.S.: "Do you believe you are crazy?"

Molly: "No, but I am, aren't I." (dejected)

A.S.: "If you will put that in the form of a question, I'll answer you."

Molly: (slightly puzzled, pauses to think) "Do you think I am crazy?"

A.S.: "No."

Molly: "But that couldn't have happened, could it?"

A.S.: "As far as I am concerned, you are the only person who knows what happens in your mind. Did it seem real at the time?"

Molly: "Oh yes!"

A.S.: "Tell me what you did after God spoke to you."

Molly: "What do you mean?"

A.S.: "Did you start knitting booties and sweaters and things?"

Molly: (laughs) "No, but I did pack my clothes and wait by the door several times."

A.S.: "Why?"

Molly: "I felt like I would be taken someplace."

A.S.: "It wasn't where you expected, was it!"

Molly: (laughing) "No!"

A.S.: "One thing I'm curious about."

Molly: "What?"

A.S.: "Why is it that of all women in the world, God chose you to be the mother of the second Savior?"

Molly: (breaks into a big grin) "You know, I've been trying to figure that out myself!"

A.S.: "I'm curious. What things happened in your life before God spoke to you?"

It took about 30 minutes to draw out her story. Molly was an only child who had tried unsuccessfully to earn love and praise from her parents. They only gave her a little love once in a while, just enough to give her hope she could get more. She voluntarily did many things around the house such as cooking and cleaning. Her father had been a musician so she joined the school orchestra. She thought this would please him. She practiced hard and the day she was promoted to first chair in the clarinet section, she ran home from school to tell her father. She expected him to be very proud of her, but his reaction was to smash her clarinet across the kitchen table and tell her, "You'll never amount to anything."

After graduation from high school, Molly entered nursing school. She chose nursing because she believed that in the hospital the patients would appreciate the nice things she would do for them. She was eager and excited about her first clinical assignment, but it turned into a shattering experience. The two women patients she was assigned to criticized her. She couldn't do anything right for them. She felt "like the world fell in." She ran away from school and took a bus to the town where her high school boyfriend was in college. She went to see him, but he told her to go home and write to him. He said they could still be friends, but he wanted to date other girls.

A.S.: "How did you feel after that?"

Molly: "Awful lonely."

A.S.: "So your dad and mom didn't love you, the patients were critical and didn't like you, and your boyfriend just wanted to be friends. That made you feel very sad and lonely."

Molly: (head down, dejected) "Yes, there didn't seem to be anyone in the whole world who cared for me at all."

A.S.: "And then God spoke to you."

Molly: "Yes." (quietly)

A.S.: "How did you feel after God gave you the good news?"

Molly: (looks up, smiles warmly at me) "I felt like the most special person in the whole world."

A.S.: "That's a nice feeling, isn't it?"

Molly: "Yes, it is."

(The kitchen crew came into the dining room to set up for lunch.)

A.S.: "I must go now."

Molly: "Please don't tell them what we've been talking about. No one seems to understand."

A.S.: "I know what you mean. I promise not to tell if you won't."

Molly: "I promise."

Two days later I was walking through the locked ward to see another patient. When Molly saw me she walked over and stopped me by putting her hand on my arm. "I've been thinking about what we talked about," she said. "I've been wondering. Do you think I imagined God's voice to make myself feel better?"

She surprised me. I didn't intend to do therapy, but she seemed to see the connection. I paused. I thought to myself "maybe so, but if there is an old-fashioned God who does things like this, then He is watching! I didn't care what the other doctors and nurses do, I am not going to give her a rough time. I am going to be her friend!" I shrugged my shoulders. I said, "perhaps" and smiled at her. She smiled back with good eye contact, then turned and walked away.

At staff rounds the head nurse reported a dramatic improvement in Molly. She was now a cheerful, talkative teen-ager. She spoke easily with her doctor, the nurses, and other patients. She started participating in patient activities. She brushed and combed her hair, put on make-up, and asked for nicer looking dresses.

At rounds a week later Dr. Bostian described her amazing recovery as "a case of spontaneous remission." The plans to commit her were dropped. A few days later she was transferred to the open ward and she did so well the doctors and nurses expected her to be discharged soon. I left the hospital soon after, so I was not able to follow-up. What would have happened to her if I had not taken time to listen to her with an open mind and affirm her reality? The psychiatric staff's prediction that she was destined to spend many years in the back ward of the state hospital would, most likely, have been validated.

All patients' names in this article are pseudonyms.

References

Hoffer, A., & Osmond, H. (1966). How to live with schizophrenia. New York: University Press.

Jung, C. G. (1961). Memories, dreams, reflections. New York: Random House.

McEvoy, J. P., Freter, S., Everett, G., Geller, J. L., Appelbaum, P., Apperson, J. L., & Roth, L. (1989). "Insight and the clinical outcome of schizophrenic patients." Journal of Nervous and Mental Disease, 177(1), 48-51.

Rand, A. (1957). Atlas shrugged. New York: Random House.

Szasz, T. (1961). The myth of mental illness. New York: Harper & Row.

Also see file "What's Wrong With Psychiatry. "

email: [email protected].