Reflections on the Use of Leverage in Treating Psychosis:
When I was in psychosis, or what I prefer to call message crisis, I was extremely angry when my family used leverage to force me into treatment. For starters, they contacted the police and supported a three-month hospitalization that kept me from seeking asylum in Canada. I concluded that they were a mafia family and the reason I was getting followed and harassed.
Perhaps this scenario sounds familiar to the reader? It lasted for two years after I was released from the hospital.
I continue to feel hurt by many of the things that transpired due to leverage. I may be able to act like I forgive; but I will never forget what it was like to experience such cruelty alone.
Thank god I was wrong about some of it!
Back in those days, I never imagined that I would someday write a blog about how to effectively leverage a message receiver into treatment. I would have sworn that I would never sell out so much to even suggest such an action.
Rethinking the Issue of Leverage:
Thanks to the word, “recovery,” I have been blessed with an opportunity to return to my career in mental health and work toward providing treatment for those who suffer from message crisis. It’s true, I have had to look the other way and swim against the tide a bit, but I have seen a few things work. I have witnessed how even things that I think would have been detrimental to me, can be helpful for some people.
Now, with hindsight as twenty-twenty, I ponder the issue of leverage for the conscientious family member, loved one, or helper who deals with the message receiver who is stuck. While a lot of my work emphasizes the fact that message receivers have a lot in common; there is also vast diversity in terms of strengths, preferences, support, and resources. I want to consider the message receiver who withdraws from their support and the world into the confines of their room or board and care with nothing but, perhaps cigarette smoke, and the wonderland of their messages to comfort or torment them. A recent Facebook post and personal conversation, encouraged me to reconsider this issue.
Establishing Treatment Instead of Confinement:
I think the first hurdle to clear is to assure that there is treatment available. This means that message receivers need to work with people who do not engage in senseless confinement and exploitation.
In my opinion it is rare that using leverage to impose hospitalization and involuntary medication works out. Unless the person is on board due to their own large amount of suffering, imposing involuntary hospitalization or medication may sabotage future treatment. Let involuntary hospitalization happen as a natural consequence, not something to leverage. Anyone who is familiar with trauma research might tell you, it can take a long time for a person to work through being punished for an involuntary experience that is already traumatic.
Finding real treatment is a very tall order in a public system that primarily trains the message receiver to use medication via the revolving door of incarceration. Many therapists go against their licensure training to even attempt to treat a person in psychosis. I was taught to refer out or utilize the psychiatric emergency room.
I have found that developing treatment often involves a space to process how traumatic and confusing incarceration feels.
Additionally, I have come to believe that treatment involves workers and supporters who are curious and knowledgeable about psychosis with copious and flexible coping strategies, and the humility to engage in ongoing learning. I do not believe true treatment can happen when the content of psychosis is not welcome in the relationship. I think when the reality of psychosis is always suppressed, exploitive confinement might be as good as it gets.
The Natural Benefit of Community and Structure:
During crisis, when the message receiver responds to their terrorizing or spiritual messages via social withdrawal, treatment may require community and structure of intriguing tasks and efforts that helps draw the message receiver out. In the process of trying to create such an environment, teaching the message receiver to be interested in and respect their peers can really help.
While good treatment offers the safety of time to heal, it might also require an ongoing nudge toward challenging the message receiver to move on to their hopes and dreams when they are ready. If treatment doesn’t do this, it may easily get misunderstood as confinement. I do not believe productive trust can truly exist until the full extent of recovery hopes and dreams are supported.
I acknowledge that the function of having treatment communities available, which are costly and often scarce is a real service to the special message community. Still, I am not saying that they are for everyone. Treatment might also involve the freedom to say no, but the option of less restrictive alternative actions, such as individual treatment mixed with self-support activities away from the treatment team.
Yes, a treatment facility needs to sustain itself by making money, but it also needs to not treat the message receiver like they are a commodity. It may be okay to ask for some level of commitment to services, but it is not fair to push commitment if it does not lead to something that involves substantial sustainable community integration.
Importance of Supporting Structured Activities Outside of Treatment Milieus:
Even if community and structured activity treatment exists, it is important not to overly leverage them. If they don’t exist or if they are unwanted, it may be important for the message receiver to receive support towards the social rehab endeavors that most matter to them and to have support in those endeavors.
Social rehabilitation support needs to capitalize on healthy, goal directed activities away from psychosis. Thus, any interest needs to be acknowledged and supported regardless of their ability to meet immediate career needs. If the message receiver is working against their psychosis, there is no need to impose leverage towards things they don’t want to do, like treatment.
A savvy supporter will try to help a message receiver do what they can to reflect positively on any activity away from message crisis. Likely these efforts are happening, but in my experience, they are not always talked about because they may seem to pale in comparison to the rat race we are all supposed to be in. Championing them may mean uncovering them and holding them up to the light instead of presuming that all is lost.
Processing and Reflecting on Messages:
I think it is fair to presume that the message receiver will need to take some time to process and reflect on their voices or other relevant experiences. As I suggested earlier, not inquiring about the magnificent learnings and focusing only on their inactivity with negative comments is rarely fruitful. Rather, encouraging a message receiver to schedule reflection/process time is important, as is encouraging them to join others this endeavor. The message receiver might be encouraged to do so with a therapist or mentors in a self-support group, or at least during exercise.
If a message receiver comes to therapy, it is important to be curious about the experiences they are going through and marvel and champion them, just as you marvel and champion activities away from psychosis. Support groups that bring out the silenced stories and give them time and perhaps some collective wisdom are important.
My Own Experience with Leverage and the Importance of Picking Your Poison:
My parents required me to take six hours in addition to my sixty-hour work week (two-125$-hours, plus travel time to and from the office) to meet with a therapist. A modest but life-sustaining amount of financial support was attached.
Had I been able to talk to this therapist about my messages without getting judged or treated disrespectfully, I may not have resented the large chunk she was taking away from my future nest egg. I may have been thankful. The exercise on the way to therapy plus the exercise I got on the way to my job was helpful.
Even though I did feel like a resentful slave or a piece of human traffic, what did help me get through this trying time was the fact that I had chosen it.
I wanted to work. I had happened to have worked in too many structured programs to feel they were worth my time. I felt that many programs I had worked in were too disempowering and provided little future.
I knew deep down that being a social worker was likely not feasible. Indeed, I had obtained a social work job and had an opportunity to risk homelessness for that job, or work at an Italian Deli when I believed my family was the mafia. That opportune choice was key to enduring a large amount of torment and suffering.
As a result, I did do my best to make the exercise time and therapy time work. It could have been easier for sure, but I avoided jail, homelessness and more psychiatric incarceration—things I was truly scared of.
Consequences of Using No Leverage:
While now one might argue that such drastic, do-or-die leveraging as I went through was harsh, I now reflect on how life might be with no leverage at all.
I work with some people who were once warehoused in State Hospitals and who live in board and care homes. When people are trained to withdraw into messages for years, stories become buried and goal-directed behavior get blunted. I am also aware that there are people who withdraw into messages who live at home. I am aware of the natural consequences of this: when their loved ones die, they are likely to become sequestered in board and care homes.
Thus, I think that there are times when working with leverage can make sense in lieu of negative consequences that may lie in wait. If treatment means getting to know people who are worse off, it can be an eye-opener that can help motivate. I think knowing local services and getting help with communication during the leveraging process can be helpful.
I have seen small, slow, humane amounts of leverage work without causing trauma. I think protecting a person from the harsh realities of the mental health system needs to be done with reason. Helping suffers know their choices and lead the lives they want to live even if it does not fit your own hopes and dreams for the person is certainly a brave thing to do.
The Need for Ongoing Support and Encouragement When Leverage is Used:
I still reflect on times I wanted to give up. I can say that it was helpful and redeeming when my parents credited my efforts as mattering and being financially relevant. Being encouraged at these times was very important.
I feel compelled to add that if the leveraged message receiver tries and fails, all is not lost. It is important to remember that important learning can be capitalized upon from any failure. Good support does not use a failure to impose an agenda, but rather is there to support the learning that can happen. Advocate to apply the learning to the next opportunity of their choice! Good support maintains a positive perspective on the effort put forth regardless of the outcome.
Remember, this is supported by an evidence-based practice that is applied to vocational training (The IPS Model.) If you lose a job, get a new one. Keep going until you get one that sticks.
I still wouldn’t advise using leverage very often. Remember that it is possible that unprocessed ill use of leverage might be part of the problem that is keeping the message receiver stuck. Still, I have come to believe that treatment does exist and can be helpful. Now I can say that apt leverage involves a mixture of timing, series of least restrictive choices and ongoing, attentive support. It involves holding hope for full recovery when the message receiver doesn’t have it.