It seems a good idea to republish this sequence from almost four years ago to complement the current new sequence on collaborative conversation. This is the third of six.
The Importance of Motivation
What perhaps is also worth mentioning is that if Ian had not been desperate to get rid of the voices he probably would not have bothered doing anything I suggested.
P.: What I’m picking up is that, initially, you didn’t have much trust in me and you wondered what on earth I was up to. You didn’t really believe in what I was suggesting you should do.
P.: So, in a sense, why do you think you tried it? And why do you think you stuck with it?
I.: Desperate. I wanted to get better, you see? I didn’t want to go on the way I was going. So, I was desperate. So, I tried what you were telling me to do. It was worth a try. It was something I hadn’t tried before. And it was something new, you know? And it worked.
P.: Were you surprised it worked?
I.: I was very surprised it worked.
I.: It seemed so simple. All that eight years, you know? All the trouble, all the Sections [i.e. compulsory detentions under the Mental Health Act 1983], and all the rest of it, and all the time in hospital and all the talking didn’t count for nothing. Then all of a sudden it just seemed to click! And it come together.
P.: Made sense and gave you relief?
I.: It did give me relief, yeh.
It made very little sense to him beforehand. This is true for a great many people. The more engulfed they are by their experiences the less sense a mind-work approach makes to them. Only desperation or an equivalent motivation will drive them to try what we suggest to them. In Ian’s case we were lucky that he got some results before he gave up trying.
The Balance of Pain and Gain
There was also the issue of the pain involved.
P.: So you think that the pain you experienced as a result of sorting this out was a price worth paying for now having sorted it out?
I.: Yes. It was well worth paying. I didn’t think so at the time. I wanted to stop it, you know? Because it hurt too much.
This was not true later. When he was dying some years later of emphysema and heart failure, I visited him in the hospice and asked him the same question. We had worked on other deeper pain by then. He had changed his mind. The pain was not worth the gain he said then. He had learned to manage the voices by dealing with the pain when they got too bad and he had learned to manage the pain of difficult anniversaries by allowing the voices to surface again more strongly. The torment of the voices at those times was preferable to the pain, anguish and guilt he would otherwise experience. This makes it imperative to consider carefully whether we have the person’s informed consent before we use the depth approach.
The Limitations of Diagnostic Labels
Also interesting is the point he made that the problems he discovered were different from what he thought they would be.
I.:. . . . the questions you asked were painful. And I didn’t want to answer them.
P.: And you didn’t see the point of answering them either, did you?
I.: No, I didn’t see the point in answering them because I didn’t recognise myself that the problem lay there. But once I could see where the problem was I could bargain with the voices.
P.: Yeh. And you had to know where the problem lay, roughly before you could bargain with them?
I.: And talking to you showed me where the problem was. So, I was able to deal with the voices in a positive way.
P.: But before you had gone through this whole process there was no way you would have realised that the problems were what they turned out to be.
I.: No. I thought it was just schizophrenia.
P.: And that was the end of it.
I.: And that was the end of it. I was schizophrenic and that was it. And I had nothing to look forward to except hospital and more medication. And I couldn’t stand the thought of that, you know? So that jumping under a train was looking very attractive. But it doesn’t look attractive now.
P.: Because life seems to have more to offer?
Nonetheless in our subsequent conversations he oscillated between talking about his thoughts/feelings/voices and his illness.
What perhaps matters most is not whether these ways of describing a problem are true or false but whether they are useful or useless to the person at the time. Psychosis is too complex a phenomenon to be successfully explained in our present state of knowledge. My problem with the medical model is not that it is always completely wrong but that it is all too often offered as the only explanation when other explanations would be more useful to the person concerned.
Sleep and Food
Naturally, there are other factors that have a part to play in psychotic experiences and a person’s capacity to cope effectively with them. For example, Ian talked of his need for sleep and food.
He said, ‘Now I come back off the holiday. I was quite well for about a couple of weeks . . ..: . . . and then I went downhill very quickly because [the voices] wouldn’t let me sleep and I stopped eating. And I got very weak, you know. And the voices become louder and more persistent. And I started to believe them.’
We probably all know how important sufficient sleep and good food is for mental health, especially for people suffering from this type of problem. The physical and social environment is also extremely important. However, I am not attempting here a comprehensive list of such factors. That would be too ambitious. I’m trying to give a sense of what constitutes an optimal approach for someone seeking to use conversations to help those who are struggling with these potentially disabling phenomena we call psychosis. The recovery model as a whole package depends upon many other things also being in place such as, where needed, social support, training, education, a spiritual perspective and work.
Perhaps next time we should look more closely at the ingredients of collaborative conversation.