Therapists and peer supporters learn not to impose their beliefs on the people they help as part of their cultural competence training. Why, then, do so many people who suffer from psychosis flagrantly have beliefs imposed on them in treatment?
A huge part of knowing how to provide treatment that does not impose beliefs involves understanding and acknowledging the extent to which beliefs are being systemically imposed and countering with an oasis of techniques that counter that tendency. If you stick with me through this you will attain a sense of what it feels like to have reality imposed upon you and the need for skilled treatment providers who know how to recognize and counter this.
Many of us who endure treatment in the mental health system develop refined radars that detect when beliefs are being imposed. When supporters do this, they may immediately link themselves back to the system of involuntary care that can be equated with detainment, involuntary medication, and a fundamental loss of human rights.
Perhaps the tendency to impose beliefs stems from the misguided cultural norm that expects people in psychosis to suppress the experiences that lead to their immediate crisis. The concept that involuntary ideas can be changed by physical punishment and containment may work immediately but is fundamentally flawed.
The fact is that this often is the only help available to families is an assault on people who experience psychosis. As supportive healers, it is essential to offer places where experiences are honored and explored with coping strategies in mind. I believe the way to do this is to build a relationship that does not impose beliefs. However, as you will learn, this may require working against the grain and a willingness to explore those experiences, even though everyone else isn’t.
Imposing Beliefs Statistically Extends Periods of Suffering:
I got better from two-years of continuous psychosis. The fact that I was expected to suppress my psychosis through punishment prevented me from learning some very simple lessons that could have saved me a lot of grief. All I needed was someone to teach me about the rules and regulations of the black market. I learned those lesson from trial and error without guidance or support. The sense of punishment was unrelenting and I had to utilize all my strengths and privileges to endure.
Although negative, statistics in E. Fuller Torrey;s book, Surviving Schizophrenia, suggest that sixty-five percent of people learn to suppress behavior and thrive like I have, they also suggest that half of us who do endure ten years of rocky and traumatic experiences and loss. Many of us fall into periods of extreme poverty that makes social rehab very challenging.
Usually, treatment starts with experiences of involuntary hospitalization during which victims are held until they start to suppress. This can seem like a nightmare for many of us who already have trauma and struggle to suppress. It is my intention to put a face to this struggle and motivate healers towards establishing non punitive places where experiences associated with psychosis can be explored and mindfully expressed.
Imposing Beliefs via Containing Behavior Results in Resistance to Treatment:
The message in the local public psychiatric emergency room is, “you can’t beat us. You must contain your behavior.” If you object and cannot control your behavior involuntary medication may be used and the incarceration is extended. Other counties and states throughout the country set up distinct strategies to impose and contain. In Montana, I was held for three months and spent the first two weeks locked up on the ward. A month of that experience involved exposure to warehouse conditions which are very degrading to one’s self esteem. Being treated in that way seemed to speak to me that was what was inevitable and that there was no use trying.
Many people who are released from this situation will not want to follow up with therapy because injustices witnessed during incarceration. It can take years of decline and high degrees of suffering before many suffers willingly accept treatment.
This is often blamed on a nonexistent disease (instead of a neurodevelopmental difference as science suggests) and I assure you there is very little reflection on the process within social institutions. For many who work in such contexts, it often isn’t clear whether the goal is social rehabilitation and recovery or to fuel the mental health industry with passive contained smokers and coffee drinkers who will stay out of the way.
While experienced patients may learn to utilize a given hospital and system to contain themselves or get a break from the stress of being on the streets, the situation is not likely to springboard social rehab efforts in the community. The set up is more likely to reinforce isolation rather than rehabilitation and for many this may decrease the idea that therapeutic encounters can help.
Squandering of Personal Resources and Trauma
Often the support system, if there still is one, is more eager to get the recipient care than the sufferer (post hospitalization) trusts the thought of therapy. Many of us who suffer fear stereotypes associated with our diagnosis. Sometimes, our family may have stronger beliefs in our worthlessness based on stereotypes, than we have in ourselves. If we fear having schizophrenia and being subjected to warehousing, many of us will do everything we can to stay free utilizing our personal resources and avoiding therapy.
Perhaps if the sufferer is not informed of the ill effects of poverty and public warehousing, they may internalize the efforts of the institutions to turn people into contained, powerless compliant cash cows. I was a social worker and knew well the ill effects of being on social security and warehoused. I refused to believe that I needed warehousing and that I couldn’t work.
Currently, if youthful suffers are lucky, they may get discharged back to their family which may not necessarily be part of the problem. Some families can learn how to continue to be a support to things they don’t understand, and some don’t change their minds so easily. For some, early prevention programs help avoid immediate decline into board and care home environments.
When I finally got released from the hospital, I was transient and moved around trying to find work. This added trauma and fear of permanent homelessness as my own cash dwindled. I felt followed and threatened on a daily basis when I ran out of my medication. My perception became populated with threats and symbols. When my resources were getting low and I was unsure of my ability to hold a professional job, I was forced to get help from my family.
Many sufferers are better at surviving on the road or staying independent. They may utilize drugs, alcohol, associated peer connections, and crime or crime syndicates to tolerate these experiences. Currently in Oakland, many are getting into community encampments. I have met many who were resourceful enough to travel. Many do not have families with resources available to them like I had. Many, like me, may have good reasons for not wanting to return to their families.
The Reality of Economic Sanctions Imposed on People with Psychosis:
Released from the hospital, people in psychosis face the high cost of therapy. Specialists for psychosis are few and far in between. The standard of care among many mainstream therapists is to refuse to work with psychosis and refer back to the hospital. A person may need to get on benefits that will pay for treatment if a therapist is even willing to consider it.
Poor prognosis presumptions result in many sufferers being encouraged to go on social security. Consider the several year process of getting on social security. Unstructured time or adjustment to free programs that may expose the participant to sufferers who are impacted by poverty and years of institutionalization. This can be new for some of us. Though this does not have to be a negative experience, to many it feels like it. To many it is just another punishment or poor prognosis reality. Again, early prevention program may fill the void for some.
High cost of therapy is often coupled by disparity in the quality of facility. In the hospital where I work, for example, the facility is an old psychiatric back ward with bubbled widows still intact. While the facilities for most physical conditions are very modern, investment in cleaning services is clearly lower in the historical part of the hospital. I observed this in other programs as well.
If the person is so unlucky as to land in a board and care home or shelter, they might be forced to be out of the house all day and required to attend program. People who are thus subjugated may feel as if they are owned and must comply for others to get paid middle-class salaries. These things are often noticed by participants and they are upsetting. They may suffer just from facing this alternative. These realities may function as economic sanctions that teaches people to underestimate their value to society.
The Devil is in the Details:
Every journey that involves madness is difficult. The details of what one goes through need to be considered. I believe the survivors perspective is important. Thus, I share my perspective on what happened to me to demonstrate how economic sanctions may play out.
When I first went to therapy three months after I was released from the hospital, I tape recorded the interview because I was so afraid that talking at all would get me returned to the hospital. The only reason I went was that it was a requirement for me to get support from my family.
While some part of me knew I needed help, the way I was financially controlled remains unforgettable. I thought my family was the mafia so they arranged to get me a job at an Italian Delicatessen with a twenty mile a day bike ride and two additional hours riding the rails to work. All this effort was needed for a nine-dollar-an-hour job. It has taken me years and covert conversations with family members to unpack and understand the web of relationships that imposed such a reality on me.
Worse, to get financial help with rent, I had to spend $250 a week on imposed therapy. The bike ride and rail ride to therapy was longer than the ride to work. I lived this way for six months using my free time to unsuccessfully get hired elsewhere until my mother relented and gave me three thousand dollars to enable me to purchase a clunker automobile. She defied my father to do this and still feels she made a mistake.
If the therapist had referred me to food stamps and made the therapy voluntary, I might not still suffer the way I do. However, the therapist insisted that the situation was fair and refused to validate or acknowledge the hardship I endured. “I believe you are working hard, but believe me working at a Deli is not so hard. You are giving your power away to those teenage kids. They are not so bad, really. You are letting them bully you!”
By the time I finally left this therapeutic relationship two years later tens of thousands of dollars later, I knew better than to contest the therapist. She said she was not a greedy capitalist. She told me not to become a wounded healer. She told me that in reality I hadn’t been close to homelessness.
I agreed that I was not really hungry and strapped for cash during this process. I concealed all the night terrors and peeing the bed at night during the process. Of course, I lied! I worked until I got my Marriage and Family Therapy License and I wrote an award-winning book about my experience.
I have become a wounded healer! I use insurance rather than demand cash for my services. At least I am not a pretender.
But still, my life is limited due to affects of trauma and mistrust.
Using Therapy Techniques that Don’t Impose Reality!
I think it is important for healers to halt the process of imposing reality upon sufferers and give them choices and options as to how to manage their situations. Instead of siding with forced treatment and using this to impose your values and ideas on the vulnerable individual, listen to the story of what they went through to get to you. Give them resources that give them choices about whether they want to work with you.
Instead of telling the sufferer what to do and what is safe, be curious about what they are experiencing that causes them distress or delight. Know that real important experiences are behind the alternate reality that they are facing. Know that alternate reality has meaning and purpose that can be understood and supported. Alternate realities may be profoundly different from the world you understand, but be brave and curious. If your conduct becomes part of the problem be curious and learn more about what you are doing.
Don’t use the threat of hospitalization to silence or disrupt behavior associated with alternative experience. Instead, go down the rabbit hole with the sufferer with a road map of coping strategies. Know what your doing if you are going to make coping strategy suggestions. If you don’t know what your doing, it’s okay, admit it. Problems with voices and alternate realities are hard. Just being there without imposing reality will really help. Also, it is usually appreciated if you puzzle through the muck to the best of your ability.
Consider that dangerous and scary experiences are not going to be openly shared with you if you are going to laugh and call them crazy. I would not tell my therapist real experiences that were disturbing because she wouldn’t take my less-disturbing experiences seriously. What ensued was entirely unhelpful to me. It was a total thorn in my side.
I concealed as much as I could and she had absolutely no understanding. Then, when I did things that could have got me killed, like call the FBI, she threatened me with what seemed to be hospitalization instead of understanding and exploring the experiences that led me to do so. That is an example of what happens when treatment is imposed!
A Challenge to the Status Quo Best Practice:
Throughout I have referenced the existence of early prevention programs. Locally and nationally they usually utilize a best practice called CBT for Psychosis.
I’d like to argue that when the best practice for psychosis, CBT for psychosis, allows healers to separate themselves from the beliefs of the client, it makes the process of safe connection much harder. This is a boundary and policy that makes it harder for recipients of treatment to trust because it reinforces the idea that reality may be imposed. Especially, if the helper turns and refers them back to the meatgrinder of psychiatric inpatient to send them a message, it can add to trauma.
I am not saying that challenging irrational thinking cannot be helpful at times. However, not everyone who is abused can control their thoughts. Experiences like disassociation and hypervigilance often interfere with cognition control. Let those who can learn use cognitive therapy use it, but don’t come with a cookie cutter mentality. You may help some, but don’t presume that those who you can’t help aren’t reachable. Consider learning additional strategies.
I utilize broader strategies that include mindfulness strategies, curious inquiry about psychosis as a culture, medication, positive psychology, trauma informed reprocessing, behavioral strategies in addition to cognitive strategies. I believe broader strategies are needed and will leave far fewer people behind. There is a lot that can happen when reality isn’t imposed.