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Those of us who are involved in the treatment and rehabilitation of the mentally ill are, or should be, aware of how vital the treatment alliance is to a successful outcome. It would appear to me that to ensure an effective
effort, it is mandatory on the part of the treatment team, which is a composition of therapists and rehabilitation specialists, to concentrate on what must be done to accomplish the goals set forth in the planning for
rehabilitation.
The attitude in treatment regarding the patient's potential for rehabilitation and some of the steps in the treatment process will be stated as I go along. But first, some questions. When does treatment begin? Does it
start when two people sit down together and start a discussion? Is that mentally ill patient ready, at that point, to engage in and commit himself to rehabilitation process?
Does the preparatory period include the beginning of an alliance? Or, does it suggest that protracted periods of time are necessary to create that vital relationship?
It is my experience that treatment and rehabilitation can begin at first contact. The quality of that first contact can very well determine how rapidly the alliance will forge into a meaningful therapeutic force. There is
every reason to believe that without this alliance, no meaningful treatment will come to exist or will any substantive gains be made or will any gains be of any lasting nature.
I will point out some steps that can lead to the rapid development of the treatment relationship and alliance. These concepts can be assimilated by those who make the necessary commitment to the treatment. This commitment
often requires a strong emotional investment which can become a powerful therapeutic tool and also difficult for the therapist to experience at first. However, these problems can be resolved if the therapist faces these
difficult experiences with a positive attitude.
At this point in the history of treatment the most reliable research point out that in the overall rehabilitation of the mentally ill, a variety of treatment modalities that are contiguous offer that person the best
chance for recovery. Psychotherapy, medication, resocialization and a number of rehabilitation measures may enable that person to function productively to some degree. However, knowing this does not necessarily ensure its
delivery.
One of the major obstacles obstructing the rehabilitation of the person who is mentally ill is the difficulty experienced in establishing a level of rapport that will lead to a meaningful alliance. This occurs because the
nature of the illness often produces bizarre patterns of behavior that interfere with normal communication and inhibit the expression of common social conventions typically used to initiate and maintain human
relationships. These conditions may be beyond the experience of most mental health therapists and even fewer have had the training in the specific treatment paradigms necessary to overcome them. These therapists are often
severely challenged when asked to treat the person who is mentally ill. They have little or no awareness of how to work as a participant in the life of the patient or, as Freda Fromm Reichman said, '. . . how to meet the
patient in the spirit and with the expression of simply meaningful spontaneity and frankness.'
Although many clinicians have recognized the need to establish a relationship with the mentally ill person as a precursor to initiating treatment and rehabilitation, few have been able to view this requirement as a
special skill to be developed if treatment is to be successful. Fewer still have understood the techniques required to help patients reestablish human contact, which is different from those techniques used in more
traditional therapeutic interactions as, for example, those leading to the development of transference.
A thoughtful examination of the problems encountered in the initial phase of treatment is found in the monograph 'Psychotherapy with Schizophrenics,' edited by Brody and Redlich. In Brody's review of the several steps
necessary to conduct individual psychotherapy with schizophrenic patients one can readily see the leveling influence the phenomena of schizophrenia has had on the character of psychotherapy. For example, in his
description of what he calls 'establishment of contact,' Brody reflects on the variety of nontraditional approaches that have been used. He cites the innovative work of Schwing and Federn and credits Grotjohn as among the
first to recognize the need to reach out actively to establish contact with the psychotic patient by any means possible.
Many of the treatment tactics are clearly not consistent with psychoanalytic or other psychotherapeutic points of view, but they do represent serious attempts at trying to cope phenomenologically with the behavior
presented by patient, i.e., in doing what works! Thus, although written by professionals whose identity with psychoanalysis is well known, a level of eclecticism and an unspoken emphasis on an existential approach to
treatment is presented that derives from the practical recognition that the clinician must ultimately deal with the demands the illness imposes on the patient.
Rapid contact is a series of therapeutic strategies aimed at reaching those patients who are considered treatment resistant. We are talking about people who are long term mentally ill patients. These patients who have had
some or many psychotherapeutic experiences. These are patients who have become crafty in their resistances and have come to expect that the treatment efforts they presently face will be comparable to what they experienced
in the past. Instead, they find somebody who may be willing to use any number of therapeutic strategies with them that might shock them into some semblance of reality. These moments of reality can add up to a substantial
sum as treatment continues. We should consider the possibility that symptomatic changes can become significant in that they allow for redirected energies toward healthier goals. The phenomenon called rapid contact is
aimed at persuading the person that their experience of being mentally ill can be understood by other people and that help is possible.
Also, that their experience can be shared in order for them to believe that the changes can be made. That one doesn't have to wait for what appears to the patient to be endless periods of time before understanding and
reassurance can take place and to reassure the patient that they are understood and there is somebody capable of helping them. This as contrasted with the slow methods that are typically used with excessive care and
concern that only seems to suggest to the patient that the persons employing these methods do not know what they are doing and the patient is once again faced with failure. I must emphasize the patient does not fail in
the treatment effort, we, the professionals fail. They are sick and do not know how to recover, we must point out the direction in a flexible and spontaneous way that gives rise to greater hope.
In the early stages of treatment either in the initial session and/or sessions, we are preparing the patient for change, from apathy to interest and some measure of productivity. If therapy is to end properly, it must
begin properly. Of course readiness for treatment varies with each individual. We must understand that we are treating individual human beings, not diagnosis. However, I believe that the question of when a patient is
ready for treatment is more a function of the therapist's needs and abilities than the patient's capacities to respond in a positive manner. To reach these difficult treatment cases, the therapist needs to be free enough
to use newer or older established methods depending on the needs expressed by the patient. This requires a therapist with an eclectic mentality. Treatment of any kind is an influence process that should begin as rapidly
as possible given the resistance to change that is part of both patients and the therapist in the therapeutic interaction.
Understanding what mental illness comes to represent to the patient recommends the therapist's forceful intrusion into the patient's world. Being forceful, in my opinion, means that the therapist is actively
involving himself/herself in the patient's world. It represents an understanding of what mental illness means to the patient. Does it sound reasonable for us to wait for the patient's invitation into their world, or do we
need to understand their language and their logic? We must realize that the idea of change, in many cases is a terrifying prospect for the patient and tends to exacerbate their resistance. Change is terrifying in view of
the fact that repeated failures in treatment make that patient's condition a more acceptable life style than facing failure again and/or the unknown that change suggests.
There are any number of subtle and unsubtle measures that we can take in convincing these human beings we intend to help them resolve enough of their fears so they can join in our efforts on their behalf. The message is
not complex. We must change before they can change.
Treatment for us is a series of direct interpersonal confrontations leading to a common goal, to force the patient to choose between staying sick and getting better. In every case we treat, we have to make new decisions
about what we are going to do and how are we going to do it. This process is often unconscious and automatic and it is only when we look back that we can see what we have done and understand what it means. Nevertheless,
we approach each case with certain basic principles in mind.
First, patients deserve our help and we will do everything we can to see that they have it.
Second, there is nothing fair about mental illness. It does not let people do what they want to do with their lives. It interferes with their humanity. It robs them of their dignity and deprives them of their happiness.
Third, we cannot help our patients if we allow ourselves to believe they have a right to be sick. We must press them, over and over again, to join us in our world, no matter how long it takes, or what we have to do to get
them there. The only tools we have are our human feelings and our understanding of their illness. In the right combination, these are all we need.
Most therapists don't view treatment this way at all. The problem they have is a real one. To accept responsibility for the treatment of mentally ill patients is a commitment most of them do not even understand or perhaps
want to make. It is always easier to blame the patient for not getting better than to look at yourself. With this occurrence, it follows that once again the patient is in a position to defeat the efforts of treatment. We
must realize that they have lost faith in our efforts and they have come to regard their sick system as a logical way of surviving. In every aspect in the rehabilitation process, we must review ourselves more carefully
and overcome our weakness in treatment so at the very least we learn how to make contact with our patients, so that we can help the person understand the nature of their experience. Under the best of conditions we are
trying to help them overcome their mental illness so that their experience at being mentally ill can recede into the historical background of their lives and the process of rehabilitation can begin.
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