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Dr. Carpenter’s BLOG

 

From time to time I will be adding posts here.  Some will be short essays, some will be pictures or photographs, some will be poems.  All will touch on the topic of psychotherapy to some extent or other.  Current software permits no responses from readers on this page, although I would be interested in responses.  If you wish, you can email me your reactions:  info@DrJimCarpenter.com.

 

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What I Know About Crazy

 

There is a tape that I have kept for 46 years that I have never considered throwing away but that I have never dared to listen to.  Perhaps I couldn’t now, it is old technology (reel to reel) and it would be hard to find a player.  It is a therapy session with a patient that somehow made me crazy.  I have been afraid it might hurt me again.

 

What do I mean by crazy?  A couple hours after that session I went to lunch with a usual group of friends and colleagues in the cafeteria of that state hospital.  I sat there talking, a young woman on my left who was interested in something about political satire and a quiet male friend on my right who smiled and kept mostly quiet.  I was listening but I grew radically apart inside.  I was different and separate.  I imagined myself standing up and shouting obscenities and tearing off my clothes and the instant I imagined it I knew that I might do it.  Nothing separated me from doing it.  I was washed about the room by waves of fear.  All that anyone else saw was that I was quiet, perhaps pale and distracted.  I got through the lunch somehow but then back in my office the panic grew.  I understood insanity.  I paced.  Finally I went next door to talk with my quiet friend and told him I was upset, all shaken up, maybe I was losing my mind.  It probably didn’t make much sense.  He suggested we take a walk around the grounds.  We did, walked and walked and I calmed down.  I remembered the tape of the session.  I knew it had to do with the session.  After I got back to my office I was more settled in my sane self and put the tape in its box where I can still find it if I look, but I do not.

 

What I remember about the session is that I had asked my patient to explain her hallucination to me and she did and I had fallen into an uncanny sense of understanding it.  I had fallen into a chasm that felt like drawings she did of a little girl falling in open space, her eyes hard dots and her mouth a huge O.  She was a just-14 year old girl.  Her hallucination was a picture on my blank wall opposite her.  She said she could see it clearly and I believed her.  Her name was Debbie and what she saw on the wall was only a picture that she could see but it was the real Debbie and she herself was the not-real Debbie.  She explained all of this to me.  I looked at the wall in a certain way that I cannot remember and saw the picture and understood why it was the real one.  That’s all I remember of the session.  After she left I was amazed at learning something so strange and felt unsteady in an unusual way.   

 

A couple of weeks later while on vacation I talked with an old friend about this experience.  He is also a psychologist and therapist.  I needed to give him context for my reaction, so I told him this story:

 

 I had been working with Debbie very intensely for several months.  I began meeting with her because I was interested in a new treatment technique called rage reduction that involved physically holding and restraining children diagnosed with autism.  A friend and colleague had experience with the technique and agreed to teach me about it.  The treatment was based upon a psychological theory of autism which held that young children for whatever reason might come to find human contact very aversive and become determined to avoid it.   According to the theory, this leads to a pattern of behavior and experience that is radically disconnected from others.  The treatment involved sessions of holding the patient in the laps of one or two people (bigger ones required more holders) and continuing to hold and physically control them in a firm and flexible way without hurting them.  A predictable rage would peak and pass and then after that, there could be some quiet talk.  Then the patient was released and the session ended. 

 

I approached the director of the children’s unit and asked if there was any patient there who was doing so poorly with normal behavioral and pharmaceutical treatment that he would consider a trial with the experimental approach.  There was a 13-year old girl, Debbie, who he knew to be utterly hopeless and a lot of trouble.  She had never developed any language except a private one that no one understood, and despite heavy sedation she would periodically fly into violent rages and attack staff or her parents when she was home on visits. 

 

She was not a large girl but she had recently thrown a big waiting room chair into the shatter-proof glass protecting the nurses’ station and shattered it.  Then there were long period of quiet self-preoccupation in which she would gesture oddly with her hands near her face, staring at her fingers and uttering odd sounds.  She was so chronically constipated that every few days her bowels had to be emptied with a shiny steel tool by three big attendants who held her while she raged and spit and bit and screamed.   Once enraged the amount of thorazine required to quiet her was so large it was almost fatally toxic.  If he had ever seen a hopeless case, the director said, Debbie was it.  So I got the permission to proceed. 

 

I was fascinated by rage reduction because the reported results were so dramatically good, and also because it ran so against my grain.  I was a client-centered therapist, as calm and empathic and gentle as Carl Rogers.  I believed that offering an empathic relationship had healing power and that people’s experiences are real and needed validation.  This included psychotic experiences.  Rage reduction is bullying therapy, control of one person by another verging on violence.  How could that be helpful?  Clearly it aroused lots of fear and disdain among psychiatrists and psychologists.  But the evidence. . . And also, the favored form of treatment, the little blue or orange pills clicking together in all the little paper cups, I saw as equally violent.  A gentle act, handing over the little cup and glass of water, but look deeper and it is an assault upon experience.  “Do not feel and be the way you are,”  we say.  “We will drug you.”  Stupefied, fat faces and shuffling feet are not much trouble but they are the product of thorough, habitual, but very quiet violence.  At least if you credit the validity of all experience it looks that way. 

 

I began cautiously with Debbie with attempts at verbal therapy.  I was in no hurry to impose something so controversial as rage reduction on anyone if something gentler would help.  Our sessions got absolutely nowhere.  She did seem to understand what I said sometimes but she refused to talk or draw or play games or relate in any way.  If I tried a walk she ran into a corner and shrieked.  After a couple of months we still had zero relationship and the sessions were clearly doing her no good.  I tried some sessions with her and her parents, who lived in the community.  Equally no good.  I got to know the parents well (he was an odd shape-shifter and she was stuffed with hate), but our meetings weren’t doing anybody much good.

 

So I decided to use my permission and try rage reduction.  A friend agreed to help me and once a week he and I changed into sweat clothes and took Debbie to a quiet room on the children’s ward.  We sat in two close chairs side-by-side and placed her over our laps.  I had the shoulders and held her arms and did the talking, and Steve held her hips and legs.  We said “Debbie, you act like a baby, so we are going to treat you like a baby.  We are going to hold you until we are ready to let you go.  You won’t like it but we really are doing this because we care about you.  We won’t hurt you, but we won’t let you go until we are finished.  We will let you go after a while but there is nothing you can do to make us let you go.” 

 

If you have ever been to a rodeo and watched the cowboys ride the bulls and broncs, you have a sense of how physical and strenuous these sessions were.  The first session went according to script.  She raged and struggled and we held her and talked to her and were very careful to not hurt her.  We had enough advantage of size and strength and our positions were such that we could do this safely.  We responded especially to any behavior or expressions approaching normal communication.  After her rage peaked she then calmed and then the three of us related in an astonishingly calm and intimate way.  She sat across from us in a separate chair and spoke to us in normal English!  She clearly had known real language for a good while.  She said she cared about us too and tolerated long gazes at us.  She talked about her experiences and fantasy figures and told us that she loved us.  Then at the beginning of the next session, shrieking and fighting again, and so on.

 

After a single session the ward staff reported remarkable changes.  Debbie communicated, began to relate to other patients, cooperated with requests, showed understandable emotions when emotional things happened.  Then her parents began to cause a lot of trouble.  They saw changes at home too after the first session but didn’t like them.  She was much worse, they said.  She was no longer so compliant.  They were glad she talked but not glad that she talked back.  And she cried!  The mother was furious that Debbie now cried, since she had not since she had been a baby.  I asked why she had cried.  “She’s crazy,” mom said.  “She has no reason to do anything!”

 

They demanded that the director stop the “baby treatments” (as Debbie called them) and that I be fired.  I made a deal with the director to turn it into a research project.  I taught nurses and staff in other treatment settings to carry out behavioral ratings of Debbie each day.  How disruptive was she, how many incidents of odd and inscrutable behavior?  On the other hand, how much communication and relating and cooperating and engagement in mutual activities was there?  Ratings after sessions could be compared to ratings before.  And changes in ratings over time could be assessed. The minute that there was evidence that the treatments were hurting her we would stop them.  The staff was for it because of how much better Debbie was (in spite of the bloody-murder screams that came from that little room every week).  The parents reluctantly agreed.

 

So we continued.  The rages were briefer, and we tried to stir them up with tickling (as the protocol suggested), and then the talks afterward were longer and deeper.  What were the odd sounds she used to make (and still would when upset)?  She translated some words for us.  What was she doing with her hands?  Her fingers in different arrangements were puppets with different names and personalities and Steve and I became acquainted with them.  Why wouldn’t she go to the bathroom?  Because she was coming apart when the shit left.  We reassured her about that and she began to experiment with voluntary defecation.  What memories did she have?  She told some heart-rending ones that I won’t repeat. 

 

Debbie turned 14 during this time, but the changes in her were greater than turning the page of a calendar.  The ratings all showed her getting better after each session and better over time.  The ratings of autistic behaviors dropped to zero and stayed there only to reappear occasionally after visits home until the next session when they would vanish again.  The social behavior increased and became more mature.  The parents had signed on and couldn’t complain too much.  There were still winds of controversy blowing in the hospital.  The project gained some notoriety and some psychiatrists were very upset by it, results or not.  I think it shook a core belief, that schizophrenia comes from a defective brain and can only be treated by medication.  This is still the prevailing view.

 

Although Debbie liked changing to some extent, she still had odd experiences and still generally hated the baby treatments.  Her hatred was now not so much psychotic terror as teenage defiance.  She didn’t like being controlled against her will.  Would you?  About that time Debbie and I had the individual session that made me crazy.

 

This was the story I told my old friend.  After I filled him in, he offered an interesting opinion.  He thought that with all the control I’d been inflicting upon Debbie she might have been wanting to get me back by making me crazy.  Maybe she had done it on purpose! 

 

I wasn’t sure, but after I got back from my trip, in our next verbal session I asked her about the idea.  She looked abashed and quiet, seemed busted.  Yes, she said, she had tried to do that.  Was there meanness in that?  Sure.  But also a wish to be understood and have a better relationship.  Sort of like dealing with a 14 year old.  I asked her to promise to not do it again and she agreed.  We also agreed to stop the baby treatments after one more, and we did.

 

Yes, Debbie was still crazy.  The one that people saw was not really Debbie and the invisible one that only she could see was the real one.  When craziness begins to make sense, is it still really crazy?  Well yes, but it also begins to make sense. 

 

 

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