The care and treatment of the severely and chronically mentally ill is the most common problem faced by the mental health profession despite the fact that to date the care of these individuals has probably had the lowest priority in the entire area of human services. In a recently published family manual, Torrey (1983) asserts that the magnitude of schizophrenia as a national calamity is exceeded only by the magnitude of our ignorance in dealing with it. In his words, "Schizophrenics are the lepers of the 20th century."
As the trend of "deinstitutionalizing" the severely mentally ill has followed that of "warehousing" them in state hospitals, it has become clear that, primarily due to lack of planning and funding for adequate community resources, many tend to function marginally in the community and that hospital readmissions have created a "revolving door syndrome." The problems of getting schizophrenic persons adequate care in a state hospital setting are magnified exponentially by the difficult conditions awaiting patients after discharge.
The following paper is a description of a unique treatment approach within an innovative community setting in the Boston, Massachusetts, area. It has been written as a means of sharing a story of success in work with individuals designated as mentally ill in a period described by many as the national "debacle of deinstitutionalization."
When I joined the staff of this community aftercare program approximately two years ago, I was intrigued by a sense of vitality, dynamic optimism, and clarity of purpose which appeared to bond colleagues together. Clients gathered daily to participate in milieu, group, and individual therapy, to spend time with one another, and to soak in a sense of belonging. Clients' family members eagerly participated in groups designed for support, education, and self-help. Frequently, they expressed their sincere gratitude to staff - strongly contrasting with numerous past instances of feeling accused or ignored in dealing with mental health professionals. Clearly, something was working.
In recent years, I had also made acquaintance of psychosynthesis, a therapeutic approach designed to facilitate the growth and integration of the human mind, heart, and spirit. As its founder Roberto Assagioli (1965) stated, the basic premise or hypothesis of psychosynthesis is that there exists, in addition to aspects of the unconscious revealed by psychoanalysis, "another vast realm of our inner being which has been for the most part neglected by the science of psychology although its nature and its human value are of a superior nature." As such, psychosynthesis represents a new branch of psychology which has been given the name "transpersonal" and which incorporates a "height" as well as "depth" dimension. Seeking to understand and relate to the totality of the human psyche, it exists as a clear contrast and complement to the more reductionist approaches which tend to consider all human experience as either an adaptive or a defensive process. Psychosynthesis seeks to direct our vision toward potentials for growth and evolution latent within - toward, as Assagioli (1969) writes, "the grand promise of what each person could become."
In my work as an aftercare therapist with the clinic, I applied the principles of psychosynthesis. Most individuals, who had been discharged from a state hospital near Boston, carried a primary diagnosis of schizophrenia although diagnoses of borderline personality disorder and bipolar affective disorder (manic-depressive illness) were also common. For the sake of simplicity, I am limiting this discussion to work with individuals diagnosed as schizophrenic.
Due to the nature of the therapy team of which I was a part, and its place in the delivery system of mental health services, much work was involved with the family members of clients. I functioned as both family therapist and group leader in the network of support and education groups developed by the therapy team. Extensive contact with other professionals was involved in both hospital and community settings. Such a setting has been ideal for the testing and integration of a psychosynthesis approach within a variety of situations. Application of concepts within a psychosynthetic framework could be compared with strategic and systemic modes of family treatment, as well as more psychoanalytic, medical, and psychosocial/educational rehabilitation models.
Because the psychoeducational, family-centered approach utilized by the aftercare therapy team was itself an innovative one and because our mandate was to provide a range of aftercare services to the most "difficult" clients in the region, other professionals (trained in more traditional approaches) tended to expect creative, occasionally surprising, clinical plans from team members. This process was, of course, not without disagreements and conflicts, but these situations tended to throw into relief the various clinical assumptions of the care providers.
As time went on, I became aware of an interesting process. Many members of our agency's clinical staff appeared to be applying principles of psychosynthesis instinctively and intuitively despite having had extensive formal training in clinical approaches substantially different from psychosynthesis. Clients were held in a perspective of "wellness" as well as "illness," and client "disempowerment" due to diagnostic labeling and self-fulfilling negative expectations was kept to a minimum. The atmosphere of the clinic was often joyful and sincerely caring, despite the severe dysfunction of many clients and the high case-load of staff members.
I began to notice that what was held by the staff as a group (though not articulated as such) was an "attitude of synthesis." This "attitude of synthesis" had to do with an openness of mind in being willing to innovate in search of practical therapeutic results. It had to do with a faith in people's innate inner resources and an openness of heart which embraced clients and colleagues in an ongoing demonstration of the power of love and acceptance. It had to do with the reality that often it is only through the combined efforts of staff members that a client is able to take their next step in growth, or simply be kept from relapse and breakdown. It was understood that to be effective, colleagues needed to intervene with clients at multiple levels, and to utilize data from many points of view. While such an "attitude" is difficult to express in words, it appears to be essential to the human growth process itself such that opposite qualities - work and play, feelings and mind, love and will, practical and ideal - can interweave and play upon one another toward ever higher levels of integration. As Ferrucci ( 1982) notes, such syntheses release enormous amounts of psychological energy, leading to a positively spiraling growth process.
The following discussion is designed to be of interest to two audiences: those who are acquainted with psychosynthesis but have little knowledge of chronic mental illness and those who wish to provide comfort and therapeutic help to the mentally ill but have little or no experience in the discipline of psychosynthesis. Herein, I seek to describe some hazards as well as advantages of a psychosynthesis approach.
As anyone who has worked with a schizophrenic population knows, the potential for "burn out," or what one person called "chronic staffrenia" (weariness, apathy, mini- mal personal involvement, decreased expectations for patients' rehabilitation), is very great indeed. The reader is asked to be alert to the advantages of the psychosynthesis approach in preventing burn out and in promoting hope.
The process of synthesis is visible at all levels of existence: cells assemble to form an organism, letters join together to form a word, musical notes combine to form a melody, individuals unite to form family units, and so on.
Proceeding from the basic observation that serious difficulties in the human psyche - emotional pain, a sense of imbalance, or meaninglessness - result when the natural process of synthesis is blocked, Roberto Assagioli devised a system of theory and techniques to evoke and facilitate the process of synthesis in human life. To this system he gave the name "psychosynthesis" (see Ferrucci, 1982).
Contrasting psychoanalysis with psychosynthesis, Friedman (1984) states that the former fails to adequately recognize the higher developmental levels discussed by Assagioli under the headings of "crises of spiritual awakening" and "spiritual psychosynthesis." What is suggested are deeper questions of identity and purpose than are provided by the ego and superego which negotiate the rules and roles of society but offer little beyond. As will be discussed in the final section of this paper, principles of psychosynthesis, if not always its active techniques, can be used beneficially in a therapeutic context with clients at even comparatively low levels of differentiation and ego development. It is, of course, essential with such clients to evaluate clearly and distinguish the tasks of growth and the particular psychological functions relevant to each unique case.
Friedman acknowledges that despite the strength of psychosynthesis as a most comprehensive model of human nature the therapist who is primarily trained in psychosynthesis will very likely be less effective with clients at lower developmental levels. In this respect, recent theoretical developments from psychoanalysis (such as object relations) have proved to be of great use with clients diagnosed as borderline who are rightly regarded as significantly more disabled than neurotic clients. While psychosynthesis can be surprisingly potent with persons who have more stable identities (such as neurotic clients), data from work with borderline clients suggest that the therapist who wishes to serve individuals at a variety of developmental levels should be trained in more traditional approaches as well. Friedman emphasizes that what is of primary importance is an "attitude of synthesis" on the part of the therapist - an attitude which is always seeking and silently affirming the emerging potential of the client.
There are over 2 million people in the United States who have or will have schizophrenia. It strikes one out of every 100 Americans sometime during their lifetime (in the urban slum, however, l out of 20 persons will be affected). On any given day, there are 600,000 people with schizophrenia under active treatment, and each year another 100,000 Americans are diagnosed with it for the first time. As Torrey (1983) notes, the most remarkable thing about schizophrenia is how little attention has been paid to it given its prevalence and severity. It is time, Torrey asserts, to face schizophrenia for what it is - the most tragic chronic disease remaining in 20th-century Western civilization.
Sympathy for those affected is sparse, particularly because it is difficult for most people to put themselves in the place of the sufferer. Those who are ill engage in bizarre actions, say strange things, withdraw, and may attempt to harm themselves or a family member. Families of the ill individual try initially to deny or ignore these occurrences, hiding their feelings - resentment, fear, and guilt - from the ill individual and hiding the reality from friends and other relatives. Usually manifesting when the individual is in his or her late teens and early 20s, parents are torn between "letting go" or "holding on" to their adult son or daughter who is ill in ways they do not understand. They enter a "new world" of mental hospitals, psychiatrists, and ward attendants. In recent years, debate about causal factors of the illness have led many professionals to view parents with suspicion and judgment. Families react by feeling helpless, abandoned, guilty, and blamed.
For the ill person, the experience of insanity is almost always a terrifying one. Inner imaginings are mistaken for external events. Fantasy and reality become indistinguishable. Because he has lost the sense of the "usual" reality, he feels very much alone. His distortions confuse him; his confusion frightens him; his fear becomes overwhelming and he withdraws from other people; in this withdrawal from human contact he is painfully alone. Yet being alone is in itself full of anguish, for it prevents his easing the confusion, perpetuating the madness. Having lost touch with the life and thought of his community, old meanings and purposes are senseless. Describing this profound state of wretchedness and disintegration, R.D. Laing (1979) states: "He is a stranger, an exile ... signaling us from the void in which he is foundering, a void which may be peopled by presences we do not even dream of."
The term "schizophrenia" currently refers to a number of disorders. Two broad descriptive categories are often used to differentiate two forms of schizophrenia: acute and chronic. Acute schizophrenia tends to last for brief periods only, often allowing a person to return to his previous level of functioning. Chronic schizophrenia is the most common type and takes longer to develop and improve. The person with chronic schizophrenia usually does not fully recover normal functioning and is typically treated with symptom-controlling medication and rehabilitative procedures, including counseling.
When one listens to persons with schizophrenia and observes their behavior, some or all of the following symptoms can be noted: Alterations of the senses may be either in the direction of extreme enhancement or blunting, and all sensory modalities may be affected. The mind itself may seem flooded with thoughts. A fundamental defect of the schizophrenic mind is the inability to sort, synthesize, and respond to incoming data. Logical thinking and attention span are often radically impaired, and persons at times describe an utter lack or "poverty" of thoughts. Delusions refer to ideas strongly believed by the individual, but not by others in his or her culture. These will appear to others to be contrary to reason and logical inference. Hallucinations usually consist of visual or auditory data perceived as real to the individual, but to no one else. Inner voices may admonish, threaten, whine, guide, entertain, or simply narrate, and may vary from a whisper to a thunderous shout. Often, voices take on some special peculiarity such as speaking slowly or in rhythms. There may be one voice or many. Accompanying the variety of phenomena just described is often the sense that one has lost one's sense of "I," that it has died away, and yet one still lives. Emotional life may initially exist as guilt, excitement or fear, shame, rage, or mirth, but these feelings are experienced as foreign and overwhelming. As the dysfunction progresses, a "flattening" of emotions is experienced - the sense that there are no feelings left at all. Associated with this process can be apathy, slowness of movement, underactivity, and lack of drive. Other behavioral changes may include withdrawal, mutism, ritualistic gestures, bizarre dress and actions, and self-mutilation (Jaynes, 1976; Hyde, 1980; Torrey, 1983).
To experience such changes in oneself is to suffer an unspeakable blow to one's sense of being and direction, of hope, and of self-esteem. Understandable in this context are occasional violent outbursts (family members are at greatest risk), suicidal threats or acts, the desire to be completely taken care of (either in hospital or by one's family), and frequent drug and alcohol abuse.
First-hand accounts of acute episodes communicate the phenomenology of schizophrenia, of "losing one's mind":
When I am ill, I lose the sense of where I am. I feel "I" can sit in the chair and yet my body is hurtling out and somersaulting about three feet in front of me.... Gradually, I can no longer distinguish how much of myself is in me and how much is already in others. I am a conglomeration, a monstrosity modeled anew each day.... My ability to think and decide and will to do is torn apart by itself ... instead of wishing to do things they are done by something mechanical and frightening. (Jaynes, 1976)
When I am melting I have no hands. I go into a doorway in order not to be trampled on. It is as if something is thrown in me, bursts me asunder. (ibid.)
The voice said slowly, "You've never been any good or use on earth. There is the ocean. You might just as well drown yourself. Just Walk in and keep walking." As soon as the voice was through I knew by its cold command, I had to obey it. (ibid.)
The noises of the city are different ... with an incessant sound of dismay, sometimes fading away and coming back like waves. There is a whispering in the air, diffuse. Gradually words become clearly distinguishable. They are about her. She looks backward and there they are - peculiar men with grotesque faces who follow her. She runs home in a state of panic. (Arieti, 1979)
As Jaynes (1976) has noted, there is much dispute about what schizophrenia is, whether it is one disease or many, and how those suffering from it can best be helped. The combined effects of hospitalization, antipsychotic drugs, prior therapy, and societal attitudes create a maze of research problems. To date, there is evidence of interactional and causal connections between factors on the genetic, societal, family, biochemical, and brain structural levels. Recent research points to the theory that schizophrenia is a disease of the brain which may include both structural and functional differences from the norm. Although controversial, nutritional remedies have suggested metabolic components to the illness and a need for high dosages of certain vitamins, minerals, or amino acids. Successful approaches to treatment in recent years have been multidimensional, emphasizing the importance of the ill person's maintaining a balanced life style, including exercise, sleep, nutritional intake, and interpersonal relations. Family dynamics and events in infancy are now seen as relatively minor causational factors (Hyde, 1980). However, their interaction with constitutional factors is seen as being important both initially and in regard to cycles of recovery and the on-going management of the illness. While cross-cultural data are still sparse, it is believed that schizophrenia can be distinguished by nuclear features that are present cross culturally (Guthrie, 1973).
In some cases, parents and siblings report indications that set the individual apart who later takes ill: perhaps an extreme sensitivity, or hyperactivity, or tendencies toward hostility. In many other cases, individuals with extraordinary promise (seemingly quite healthy all through childhood) simply develop symptoms at the time of "leaving the family nest." Initial signs are the tendency to withdraw from family, school, or work. Habits begin to change as individuals begin to stay awake all night alone, or become incessantly active in a frenzied manner. Anger, evasiveness, or suspiciousness may lead to incoherent conversation. Family members often report that the person seems humorless, without perspective, and somehow vacant. Thus begins a long and painful journey for individual and family alike - as breakdowns and hospitalizations irrevocably signal entry into a new and difficult life. It is at this juncture that the therapeutic work about to be described takes place.
Following hospitalization (usually involuntary) in the locked ward of the local state facility, clients are referred to the aftercare agency of which I am a member. The clinic, which houses a staffed "drop-in center" and activities program, as well as a team of therapists, functions as a link in a larger network providing services to chronically ill clients. These include the locked ward of the state hospital, a quarter-way house on the grounds of the hospital, two open wards at nearby general hospitals, staffed and cooperative apartments in the community, a number of sheltered workshops, a day hospital, and a mental health clinic.
The therapy team itself utilizes a family system, psychoeducational model incorporating the recent research of Anderson et al. (1980), Dincin et al. (1978), Brown et al. (1972), and Bowen (1978). This model is implemented via individual and family therapy as well as through a network of groups led by team therapists. (Currently, the network includes regular meetings of a "next step" group for clients preparing to leave the locked ward, a client education group for clients in the community, two multiple-family groups [composed of schizophrenic clients and their parents], a parent support group, a sibling group, and a family education evening.) Key aspects of work with clients include aiding them in accepting and taking responsibility for their illness, the provision of up-to-date information on the dysfunction itself, and open discussion of the feelings associated with rehabilitation. Key discussions for family members include sharing of research data concerning family management in chronic mental illness and provision of relevant data about the illness and current treatments. A non-blaming attitude (either toward themselves or the affected family member) was stressed. Themes discussed include violence, negotiations with professionals, and the need for limit-setting with the ill member. Keeping an on-going, satisfying family life in the midst of financial and social disarray is another common topic. Providing warmth and sustenance to the ill family member without overprotection was yet another concern.
The self-help aspects of such groups provide immediate opportunities for family members to care for and to offer knowledge to others, as well as to receive them from others. Professionals play roles as facilitators, psychotherapists, and teachers. Yet a clear message is given: family members and agency clients have much to contribute to one another. Grief, rage, guilt, frustration, shame, and anguish are the difficult feelings often accompanying these discussions. "At least," family members comment, "we are not alone."
Aftercare programs for clients and families such as this one are still quite rare. Financial and legislative realities often make for understaffed programs and overworked professionals. And as Torrey (1983) notes: "Those who defy the laws of social gravity and devote their careers to the seriously ill stand out as exceptions. ..they are however always considered somewhat aberrant by their peers." As Torrey also states, the majority of mental health workers, including psychiatrists, want to treat comparatively healthy and insightful clients. Schizophrenic patients tend to be seen as dull and difficult, their families unimportant.
In this final section, an overview of the use of psychosynthesis principles is presented in three contexts: (1) as individual counseling with schizophrenic individuals; (2) as utilized with families; and (3) as employed within a milieu treatment setting for the benefit of both staff and clients. Basic to work at each of these levels is the need to mobilize the natural helping and healing energies within a network of people - be they impaired individuals, family members, or staff persons. Creating an atmosphere of trusting communication, good will, and intensive learning is the primary mode by which persons are able to redefine themselves as resources for, and helpers of, one another. Because the principles of psychosynthesis are embedded in the process of life itself, and only articulated and formalized through theory and practice, it need not come as a surprise that healers dedicated to meeting the challenge of chronic mental illness have come upon, without needing formal training, the pragmatic approach described below. My individual work with clients has been informed by the conscious use of psychosynthesis as well as family systems and object relations theory; however, others who have contributed to the work with individuals and families and to the creation of the climate of the treatment setting have had no formal training in psychosynthesis. Rather, they have accumulated a rich fund of theory and experience through years of work with the mentally ill.
Individual work with schizophrenic individuals must be done on a scaled-down basis in contrast to work with individuals diagnosed as "borderline" or "neurotic." Generally, work is much more concrete since, for many clients, attention span and abstract thinking are quite impaired. Facilitating the client's development of ego functions is a basis for therapy, and these include the ability to observe and think rationally (instead of regressing to primary-process thinking), to learn self-soothing techniques, and to control anxiety and impulses so that they are not overwhelming. Also important is the client's learning to recognize and put limits on projections and regressive patterns. In these respects, such directions in individual work are parallel to work with borderline clients as listed by Friedman (1984), but at a slower and more gradual pace. It can be seen that much of the work centers on the creation of defenses (e.g., the ability to control drives and feelings); in contrast, work with neurotic clients often consists of allowing greater spontaneity, deeper contact with and expression of emotion, and so on.
Research states unequivocally that deeper insight-oriented individual therapy is not only useless but also detrimental to schizophrenic clients. A predictable consequence of such therapy can be described as analogous to directing a flood into a town already ravaged by a tornado. It is "unleashing a cacophony of repressed thoughts and wishes into the existing internal maelstrom" (Torrey, 1983). Assagioli (1965) was in basic agreement with the need to offer caution concerning the use of active techniques with such clients, noting, for instance, that work with imagination and imagery should be employed with great caution and only after a certain consolidation and stabilization of the personality has been achieved. He stressed the importance of the client's gaining a clear understanding of the laws and mechanisms of his or her unique psychological reality, adding that regression to more primitive stages and uncontrolled release of explosive emotions would be likely results of premature explorations.
Research indicates, however, that a "supportive, long-term relationship" with a mental health professional combined with symptom-reducing medication and a sustaining social support system provides individuals with the best chances of reduced hospitalizations and greater success adjusting to life in the community. Such a supportive relationship is seen as a blend of caring friendship, advice, and practical help in securing financial and other supportive services in the community. It can be seen that the typical "psychotherapist" role is of less use here than a flexible person-to-person connection. Work with one client may last an hour at a time, while with another, particularly if he or she is involved with other mental health professionals, contacts of short duration (10 to 20 minutes a week) may be optimal. While contact with clients should have the tone of friendship and simplicity, it is important that the therapist bring to bear on the relationship all the clinical sophistication at his or her disposal; he is essentially a guide, enabling one who has lost touch with the life and thought of the community to return gradually to psychological balance and more harmonious participation with others. In psychosynthesis, the word "guide" is often used in place of "therapist" to connote the combination of mutual relation and applied skill in the therapy relationship. Such a term fits nicely with the need to blend simplicity and directness with skillful assessment and practice. Brown (1982) quotes Carl Rogers in emphasizing a basic quality of the psychosynthesis guide: "The more the therapist is him or herself in the relationship, putting up no professional facade, the greater the likelihood that the client will change and grow in a constructive manner."
Schizophrenic individuals, above all, need contact and reconnection with basic human realities; they need to move beyond the broken-off compulsive fantasizing in which they are caged and return to a sense of their own humanness. Moustakas (1967) shares his understanding of such needs for "communion": "Even the person with severe emotional problems does not need (mere) diagnosis and analysis. What he requires is a genuine human experience, meetings with real persons. Then his capacity for living and experiencing may still be able to save him."
The development of trust, of course, requires that the therapist, through voice tone, body language, verbal content, and attention, be able to communicate warmth, acceptance, empathy, firmness, and affirmation of the client's essential self. These must be communicated consistently and at a level the client can experience. Therapists need to take a very active role in initially establishing the relationship itself. This can be facilitated through the therapist's acting as advocate - linking the client with various service providers and coordinating an overall treatment plan. Concrete improvements in the client's life do much to reveal the therapist's caring and commitment to the client.
Keen attunement to the client's mental, emotional, and physical processes is a basic aspect of meeting and "gently remaining with" the client no matter where he or she is (incoherent, hallucinating, silent, and so on). This focus on the present moment is an essential aspect of psychosynthesis guiding, an aspect which emphasizes the primacy of the guide's immediate attention to the client's process over and above any concept, preconception, or theory he or she may have about the client. This direct attunement can often be sensed by the client and can form a very solid basis for trust.
As the client begins to invest in the therapeutic relationship, there emerges the need to grieve the many losses he or she has almost inevitably suffered (of "dreams" for oneself, former relationships with healthy friends, an so on). Accompanying this process is the need, as the illness begins to be accepted, of learning to rely on strengths and abilities which are present and to rebuild, when possible, capacities which have been damaged (e.g., logical thinking).
At these stages, psychosynthesis can offer help to the individual therapist. It can be particularly useful, for instance, in designating and mapping in detail the psychological functions - thinking, emotion, intuition, imagination, desire/impulse, and will - which are essentially intact. Thus, a client with a strong intellect, but suffering from delusions or hallucinations, can be addressed on conceptual levels about accomplishing treatment goals. Alternatively, there are many clients who are deficient intellectually but appear to possess an uncanny intuitive sense concerning interpersonal interactions and subtleties of feeling in others. This, too, can be affirmed using language and idioms which reach this intuitive sensitivity. Because many mentally ill persons are beset by a plethora of internal imaginings, often connected with strong, even overwhelming affect, the use of visualization and guided imagery is discouraged. However, a therapist's familiarity with metaphoric language can aid him immensely in responding to these essential kinds of communications. Sensitivity to a client's "essential images," then, can further strengthen the bond through which the client will eventually be led out of his or her private inner world into communion with others.
Subpersonality work, a cornerstone of psychosynthesis, can be employed on a simple conversational level, helping clients in perceiving and sorting out the various "parts" of themselves. Because such work is concrete and definite in contrast to more general or abstract discussions of thoughts and feelings, clients often have an easier time using it. When basic trust has been established and the client is functioning consistently at predetermined, baseline levels, such work can be gently introduced to receptive clients. In a supportive, caring fashion, client and therapist can then examine together the gamut of subpersonality identifications: the part that "acts out," that withdraws, that is self-hating, that feels anxious and insatiably needy. Should the client show signs of being upset by this work, either during or following the session, it should cease. When used sparingly, and with discrimination, however, such discussions can add freshness and humor to what, for the client, is the arduous process of reconnecting with himself and the external environment. In this context, humor itself, when used with compassion and clarity, can have an almost magical effect in strengthening the therapeutic bond; simultaneously, it aids the client in "stepping back" and taking less seriously the various attitudes, behaviors, and emotions which are the substance of his or her subpersonality identifications. Such a therapist may be said to be aiding the client toward "disidentification through conversation." What follows is the next step in aiding a client rebuild and re-identify with a more mature aspect of self, his "own inner nurturing parent" or her "responsible adult part."
Work with the subpersonality known as "the Inner Critic" can be of particular value to the long-term mentally ill client. Clients face the stigma of mental illness, as well as their own subjectively based difficulties in coping. "Shame" is very often coupled with "blame" in the form of pejorative self-judgment. This often is projected onto others with whom the mentally ill individual then struggles. A vicious cycle can be set up whereby professionals place further limits on the diagnosed individual - restricting him to a ward or supervised housing, for example. The client who can "get to know" and disidentify from his Inner Critic gains back much energy and will to use on his journey toward health.
A crucial aspect of psychosynthesis counseling is the therapist's ability to relate to the client as a Self - a center of both awareness and will. The basic understanding one wishes the client to receive is, as Alberti states (1975), "I have an illness, but I am not my illness." This attitude on the part of the therapist consists of relating to the client in the context of his essential nature and his potential for health while acknowledging his current identifications and disabilities. Anne Yeomans describes this attitude in writing about Roberto Assagioli:
He had the remarkable capacity to read through the layers of self-doubt, of anxiety and tension, of fears and insecurities, of false pride, to reach through these false identifications to the very core of a person - to one's essence - and recognize and greet and affirm it. He seemed to be able to see through the pain and the chaos of those who came to him, to their positive and creative inner core, and say to them both with and without words, "This is who you are." We have often said he spoke to the highest in us and we rose to meet him. (cited in Brown, 1982)
This ability is most available to the therapist who has himself learned to disidentify from the various thoughts, emotions, and "perceptual vantage points" of his own psyche, returning to the observing, willing center, the Self.
Of major help in aiding clients to "re-identify" with more mature or life-enhancing aspects of themselves is the principle of identification-that is, to whatever one gives energy and attention grows in power and intensity. This is stated as Law Six of Assagioli's Ten Psychological Laws: attention, interest, affirmations, and repetitions reinforce the ideas, images, and psychological formulations on which they are centered. For many clients, this means moving attention away from images of defeat, substituting in their place a realistic goal they desire to accomplish. One client who had recently found success living in the community after 20 years of hospitalization failed the written "permit test" necessary for getting his driver's license. All childhood experiences of "test taking" were failures, except for one incident in grammar school where he had passed a difficult test and had been lauded before the entire class. It was suggested that he concentrate on and recall this memory for five minutes each night, stating to himself the affirmation: "I am going to pass that permit test." Within a month, he passed the test with a perfect score.
In a related context, the psychosynthesis exercise known as "the Ideal Model" can be adapted for work with this population. The therapist can ask such questions as, "If you were able to nurture and take care of yourself, what would that be like?" The client is then encouraged to flesh out a realistic vision in words, describing the details as carefully as possible. Within attainable limits, the client can be invited to imagine himself possessing an ideal skill or life state. Such a focus of attention when combined with desire can do much, as Hyde states (1980), to "touch the inner core of hopelessness with a firm helping hand." This, Hyde notes, is key for rehabilitation of schizophrenics.
The client's will to grow (or will to health) is a crucial determining factor in successful rehabilitation. Yet, as Peck (1978) states, it is a factor not at all understood or even recognized by contemporary psychiatric theory. He notes that it is possible for an individual to be extremely ill, psychiatrically, and yet at the same time possess an extremely strong "will to grow," in which case, some healing will occur. A person who is only mildly ill, on the other hand, but who lacks the will to grow, "will not budge an inch from an unhealthy position."
Hyde has shown that success, even for very ill psychiatric patients, is based mainly on persistence, hard work, and learning to handle setbacks. But, as Alberti asserted, the will to health is intimately connected with the will to meaning - the client's ability to give "meaning" to the prospect of greater health. Frankl (1969,1975) has said that it was this will to meaning which enabled concentration camp victims to survive their horrific conditions. With schizophrenic clients, the therapist often finds the need to appeal to the client's will to meaning, which takes the form of acceptance of life through trust and faith in life itself.
Assagioli was known to speak of the "blessing of obstacles," pointing out their function in drawing out latent will and permitting us to develop transpersonal qualities in the struggle to overcome difficulties. From this point of view, the difficulties life presents can be seen as opportunities for growth, and obstacles as challenges or stepping stones. In addition to freeing a vast reserve of will, such a reframed perspective can provide great comfort to the schizophrenic client. While action in the outer world may follow, there occurs, just as often, a more relaxed acceptance of the realities of one's current existence. As Crampton (1974) points out, dealing with an obstacle at times simply means accepting a situation which cannot be changed and learning to develop patience and forbearance. This, too, is an act of will, for as Frankl (1975) wrote: "What matters most when one confronts an unavoidable situation is the attitude chosen toward the suffering."
While certain aspects of the will, such as concentration and organization, appear to be seriously damaged by mental illness, these losses are often matched by the strengthening of other qualities in the very act of facing each day amidst psychic pain, confusion, and economic deprivation. These are important assets of which the mentally ill client is often unaware and which frequently go unacknowledged by mental health professionals. The therapist who is alert to the appearance of such strengths should consistently feed this information back to clients, reminding them of their patience, endurance, and courage.
Other aspects of will are often visible in the all too common "control struggles" of mentally ill clients with the mental health professionals in charge of planning and executing their treatment plans. Ineffective and painful past encounters with the mental health system coupled with the client's own urge for self-determination may emerge as sullen stubbornness and wilful lack of compliance. Recent strategic approaches evolved in family therapy (Fischer, 1983; Palazzoli et al., 1978) offer particularly skillful avenues for respecting the client's need for oppositional stances while using these very positions to serve the client's growth. In individual work, this process can be described as encouraging "restraint from change" coupled with the consistent provision of acceptance. Such skillful use of the client's powerful resistance (for example, to a more independent living situation) may be essential for the eventual return of his or her ability to "will positively" later cooperation with treatment plans.
The concept of an ever present directional process, which presses for realization as the client's "next step" toward maturity, is the cornerstone of the psychosynthesis approach with schizophrenic individuals. It acts as a basis of faith and conviction, counteracting the fatigue, helplessness, and hopelessness encountered by client, family, and professional alike. From a psychosynthesis perspective, the action of the professional is that of facilitating this powerful, innate movement toward health. Such an orientation can offset the hazard of current psychiatric diagnoses which, though important for the competent management of medication and treatment, "can lead to a cycle of spiraling negative expectations that may induct the patient into a career as 'mental patient'." This negative view of what can "reasonably be expected" from the diagnosed person still exerts a strong influence on mental health workers. According to Mosher (1978), it may color their outlook to the extent that clients are related to in terms of conceptions inherent in the diagnosis. For clinicians who operate like this, the patient in effect becomes his or her diagnosis and is related to as a label, a non-person. The inevitable results of this process are frustration, loss of hope, and eventual self-devaluation for client and clinician alike.
Yet, as Hillman (1975) has pointed out, while humanistic and existential psychologies have attempted to counterbalance misuses of diagnostic categories, there remains "the very ugliness, misery and madness of psychopathology" with which one must always come to terms, "whitewashing none of its despair." How then can one speak of "discovering meaning" or facilitating the superconscious in what is after all an agonizing chronic dysfunction? Of direct relevance to this question is Crampton's (1974) statement that the obstacles which confront us "belong to us in a particular way ... they have significance and purpose in terms of our own life and each obstacle contains the key to its overcoming." Peck ( 1978) illustrates this process by relating mental illness to the myth of Orestes, who, as punishment from the gods for murder, is plagued by the Furies, an hallucination perceived only by him - a private hell of mental illness. In the end, Orestes, through dint of his own efforts, not only is relieved of the curse, but also transforms the Furies into the Eumenides, loving spirits who through their wise counsel enable Orestes to obtain good fortune.
That psychological suffering can lead to personal and spiritual growth is, of course, not a new concept. Common sense, what Frank! called "the wisdom of the heart," reminds us of the potential of difficult times to bring forth increased sensitivity to others and wise appreciation of life's gifts. In the Alcoholics Anonymous (1953) literature, for example, we read:
Under the lash of alcoholism we are driven to A.A. ... then and only then do we become ... as willing to listen as the dying can be.
An anonymously written book for women alcoholics (Hazelden Foundation, 1982) catalogs the emergence of superconscious qualities out of the crucible of pain:
Suffering softens us, helps us to feel more compassion and love toward one another ... our sense of belonging to the human race, our recognition of the interdependence of all are the most cherished results of the gift of pain.... Our experiences with all other persons thereafter are deeper ... pain offers wisdom. It prepares us to help others whose experiences repeat our own. ... pain invites us to rely on many resources, particularly those within ... paradoxically these periods strengthen our oneness with the Spirit.
And Levine (1982) provides the following observation from his work with the terminally ill and their families:
Grief, the tearing open of the heart, leaves the heart vulnerable and exposed. And the deep lesson of compassion, for which we were born, becomes evident.
Levine's colleague, Ram Dass, a student of the world's mystic traditions and counselor to many terminally ill persons, places similar thoughts in a theistic context. In writing to the parents of an 11-year-old girl who had been killed, he says:
I can't assuage your pain with any words, nor should I ... not that she or I would inflict such pain, by choice, but there it is. And it must burn its purifying way to completion.... For something in you dies when you bear the unbearable. And it is only in that dark night of the soul that you are prepared to see as God sees and to love as God loves. (cited in Levine, 1982)
The stories found daily midst the clients, family, and staff of the clinic I have been discussing are essentially ordinary ones. Yet they suggest the potential of "breakdown" leading to the "breakthrough" of transpersonal qualities. The work clients do on themselves is, of necessity, years long and it must be "one step at a time," "one day at a time."
Acceptance, courage, good will, receptivity, patience, and finally wisdom are the transpersonal qualities which life seems to demand from these individuals as their means to master mental illness. One client simply stated his hope and faith: "For every affliction, something is gained."
Some parents and siblings have attested to a richer quality in their lives, a new unexpected dimension, since finding the company of others going through familiar trials. Many have learned about love and joy through realizing their power to contribute to the lives of others. Others are simply learning what it is to be given to, to open to the valuable experience that other parents or siblings have to share. Parents who years ago would have withdrawn in fear and loathing from the mentally ill now regularly walk through the locked ward, spending time with this patient or that (often each other's children), comfortable in understanding the pain of that patient, as of their own child.
Parents who have faced threats or violence from their own children, who have faced grief, rage, helplessness, and despair, become strong indeed. To have endured loss, to have accepted the unknown, and still to find joy and value in one's own life; to have surmounted shame and humiliation, guilt, and self-blame and to have grown in self-love and self-affirmation; to have faced the darkest abysses of the mind in a son or daughter or in themselves; to have experienced the creative power and resourcefulness of a group of individuals who have joined together to rise above their pain through compassionate action; to experience within oneself clarity and the new ability to create more authentic relationships with others, including one's own family; to realize that far from being victimized by life he or she has been chosen to grow in wisdom and to share this with others coming their way ... all these are signs of increased personal and spiritual growth.
Concretely, the parents in the clinic's education group were the originators in 1980 of Alliance for the Mentally Ill, a local self-help group committed to political advocacy and mutual support. Beginning with less than ten members, it now has over 125 members and has functioned as a seed organization for inspiring the creation of 38 groups as well as a State Alliance. A core group is writing a manual for families who encounter mental illness, and it is now common for family members to lead workshops on mental illness both with or without professional co-leaders. A growing interest of Alliance families is the nutritional and orthomolecular approaches to treating mental illness.
These case examples are manifestations of what Assagioli has called the "will to good," a synthesis of love and will. An aspect of both the personal and transpersonal will, it is best taught by example. Such acts, motivated by compassion, may take on great force, gaining power in a contagious way. Examples of figures who have been known for their influence through the "will to good" are Schweitzer, Martin Luther King, and Gandhi.
The creation of this climate occurred in the aftercare program I have been describing through the combined efforts and inspiration of the clinic staff. Through establishing harmonious and cooperative relationships with others and through aligning with transpersonal qualities within, "the psychic energies of the group tend to combine synergistically or like batteries connected in series to generate more power for the common (endeavor) rather than cancelling each other out through conflict" (Crampton, 1974). For a treatment staff, these conditions are manifested through creativity, expressions of acceptance, caring and acknowledgment, and the open airing of conflicts and differences. The creation and sustaining of this kind of atmosphere is always, of course, imperfect, subject to all the contingencies of any work group - problems with funding, overworked staff, personal disagreements, political differences with other agencies, and so on. But altruistic activities themselves provide deep satisfaction; joining with others in this endeavor (motivated by what psychosynthesis calls "the impulse to serve") creates an atmosphere of good will which is vital and energizing and which can increase in exponential proportions.
It is the "impulse to serve" - the desire to contribute to the evolution, health, and well-being of others in a meaningful way - that is at the foundation of psychosynthesis. It is, as well, at the basis of the work with the chronically mentally ill I have attempted to elucidate in this paper. When held as a group context in a work setting, it can constitute a powerful antidote to the psychological toxins experienced by the mentally ill and by those who work with them. It is, as well, a powerful antidote to staff burn out, which is a constant hazard in work with highly traumatized, politically powerless individuals. This is primarily so because the "will to good" is the basis for a harmonious, joyful atmosphere. As Gandhi stated so very clearly: "Such service to others can have no meaning unless one takes pleasure in it.... Service which is rendered without joy helps neither the servant nor the served. But all pleasures and possessions pale into nothingness before service which is rendered in a spirit of joy." (cited in Fischer, 1983)
This paper has attempted a description of the psychosynthesis perspective as applied, purposefully and instinctively, in a clinic whose mandate was to meet the challenge of mental illness. The success of this program reveals an essential truth: a focus on positive aspects, on the emerging next step, and on the potential capacity and willingness of human beings to aid one another can be the basis for meaning, hope, and growth. This is itself a strong argument for building bridges between professionals and the natural healing networks of the families of the chronically mentally ill. They have many resources waiting to be tapped.
For mental health professionals, psychosynthesis can serve as a means for utilizing, systematically, the powerful healing forces both within and between individuals. This need not be construed as a contradiction of the medical model of psychopathology since chronic mental illness needs to be precisely assessed and treated. It is, however, an invitation to expand the context of treatment such that the psyche in its totality is taken into account, including its innate potential for growth and healing.
For supervisors and participants in milieu treatment centers, the psychosynthesis approach suggests forms of management and cooperation which can bring forth the best in therapeutic staff through establishing relationships which are nourishing to clients and staff members. Such an orientation is a powerful antidote to burn out, which is especially prevalent in the public sector of the human service delivery system. This kind of work group - which is encouraged to get in touch with inner resources, strengths, potentials, and beauty in a setting marked by a high degree of acceptance, genuine concern, and sharing - can liberate healing forces of tremendously powerful dimensions.
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Last revised: June 24, 2002