Working effectively with people who are medicated is a difficult and challenging task. I have done it a half–dozen times, but I don't particularly enjoy it. The medication itself is an extremely powerful anchor that is an obstacle to change.
Let me tell you a little horror story. A young man was wandering down the street of a large city after a party. He was a graduate student at the university there. He'd been smoking some dope and drinking a little bit of booze. He was wandering along, not really drunk, but certainly not sober. At about three o'clock in the morning he was picked up by the police and taken in for being drunk in public. They fingerprinted him and ran a check on him, and it turned out that he had been in the nearby state mental institution several years previously. When he was there, he'd been classified as a schizophrenic, and had the good fortune to run into a psychiatrist who is a really fine communicator. After the psychiatrist worked with this young man, he had altered his behavior, was released, and was doing quite nicely in graduate school. He'd been fine for years.
When the police discovered this history of «mental illness," they decided that his behavior wasn't the result of alcohol or drugs, but rather the result of a psychotic lapse. So they sent him back to the state mental hospital. He was put back on exactly the same ward he'd been on before, and given the same medication he'd been on before. Guess what happened? He became schizophrenic again. He was anchored right back into crazy behavior.
This kind of danger is my reason for insisting that the test for effective work with an alcoholic be exposure to the chemical anchor that used to access the dissociated alcoholic state—to have the client take a drink. Then you need to be able to observe whether taking a drink leads to a radical change in state—whether there is a radical shift in breathing and skin coloring, and all the other nonverbal indications of a change in state. If there is such a shift, then you don't yet have an integrated piece of work; you still have more integration to do.
If you take the challenge of working with institutionalized schizophrenics, you can make your work a lot more comfortable and a lot more effective if you make some arrangement with whomever is in charge of drugs on the ward. Being effective in a reasonable amount of time is going to depend upon your ability to work with people while they are not on drugs, or upon your ability to establish hypnotic dissociated states in which they are essentially independent of chemicals. Those are very difficult tasks; it's a real challenge.
Janet: I have a client who was diagnosed schizophrenic. She was on medication which she's off of now, but she's beginning to hear voices again. That's scaring her. She's very frightened.
Well, first of all, it doesn't frighten her. She has a physiological kinesthetic response to hearing the voices. At the conscious level she has named that response «being frightened.» That may sound like semantics, but it's not. There's a huge difference between the two, and reframing will demonstrate that difference.
My first response to this woman would be to say «Thank God the voices are still there! Otherwise how would you know what to do next? How would you do any planning?» One or two generations earlier, a person who heard voices was characterized as being crazy. That's a statement about how unsophisticated we are in this culture about the organization and processing of the human mind. Voices are one of the three major modes in which we organize our experience to do planning and analysis. That's what distinguishes us from other species. So my first response is «Thank God! And now let's find out what they are trying to communicate to you.» I might say «Good! Let me talk to them, too. Maybe they've got some really good information for us. So go inside and ask the voices what they are trying to tell you.»
Janet: «How I should kill my mother.»
«Good! Now, ask the voices what killing your mother would do for you.» You go to the meta–outcome. If an internal part voices a goal which is morally, ethically, or culturally unacceptable, such as «kill my mother," then you immediately go for a frame in which that is an appropriate behavior. It may sound bizarre as you hear it, but it's quite appropriate given some context. The question is, can you discover the context? «What would killing your mother do for you? Ask the voices what they are trying to get for you by having you kill your mother.»
The person is likely to interrupt you and say, «I don't want to kill my mother!» You can respond «I didn't say to kill your mother. I said to ask the voices.» You need to maintain the dissociation, and then proceed with the standard format of six–step reframing. «Those voices are allies. You don't know that yet, but I'm going to demonstrate that they are. Now, ask them what they are trying to do for you.»
Ben: I'm currently working with a patient who is a chronic schizophrenic. I've discovered that I'm challenging his thirteen–year career as a chronic schizophrenic by working with him. During the last session, he essentially said that he has an investment in maintaining this career. So I applauded his great success at it.
What Ben is saying is really important. He applauds the schizophrenic's thirteen–year–old career. «How well you have done as a schizophrenic for thirteen years.»
Ben: He has the same name as a famous person, and I said that he was as talented at being a career schizophrenic as this person was in his field! He has actually had thirty–two years of treatment, but he has never had adequate family therapy before. In the context of family therapy he told me that he believed his mother would die if he resolved these problems and really became himself.
Was his mother present as he was talking about this belief?
Yes. I explained that she would not die if he got better. In fact, I said she would be pleased. Actually, the mother is somewhat incongruent about wanting him to recover. But I don't know where to go from there. My guess is that I should begin working on the mother.
OK. Ben's been working with a schizophrenic, and now he's going to work on the mother. The next step is the specific way in which he hooks them together. In other words, the mother says to the schizophrenic «I won't die if you get better. Go ahead and get better. In fact, I want you to get better.» (He shakes his head «No.»)
Ben: I didn't read the incongruence that clearly, but I feel that is accurate.
The question is, will the schizophrenic believe that incongruent statement? Definitely not. The schizophrenic is much more sensitive than you and I to those nonverbal signals. He's had a whole lifetime of reading them.
One thing you can do is to get a congruent response from the mother.
You might begin by sorting out the parts of her that do and don't want him to get better. «Ok, pretend that you want him to stay sick. Now tell him all the reasons why it's important that he stay sick.» She says «But I don't," and you say «Well, that will make it easier for you to pretend.» Then later you say «Now pretend you want him to get well.» «Well, I do.» «Of course; that will make it easier to pretend.» The logic of it is flimsy and irrelevant. All that's important is that you make it easy for her to respond. If you want to see something impressive in terms of nonkinesthetic anchors, have the mother alternate between those two behaviors while you watch the schizophrenic. Smoke will come right out of his ears!