A Case study in sleep paralysis: Rosie

In our assessments of sleep paralysis we came to understand there is a link between sleep paralysis and certain disorders including anxiety, general stress and sleep apnea. The following is a brief diatribe wherein I suggest that there is a greater link between those with schizophrenia and schizophrenia like disorders, who have also been diagnosed with sleep apnea, and sleep paralysis. In particular, I will be providing a brief case study of one client and her apparent symptoms. It must be noted here before proceeding that the suggestions made in this paper are speculative in nature: I can not ascertain their validity or reliability without further assessment and deeper analysis. All qualifying personal information has been removed to uphold confidentiality.

Rosie

Rosie is a geriatric African-Canadian living with an intellectual disability and she has been formally diagnosed with schizoaffective disorder bi-polar type, chronic obstructive pulmonary disease (sleep apnea), and she exhibits obsessive compulsive like behaviours.

She exhibits typical symptoms for her diagnosis including delusional thought (including persecutory delusions), visual and auditory hallucinations, blunted affect, and alogia. She experiences intense mood swings which invariably affect her behaviour, and she has a general negative attitude. This is particularly exhibited in relation to herself, as well as in her relationships with others. She does not appear to put much faith in others’ reliability or loyalty. It is difficult for her to form and maintain relationships, and she is often closed off from others. In times of great stress she will express her anger and frustration with self harm, screams, shouts, expletives, and eventually aggression towards others. This sort of anxiety can be mediated successfully with anticipatory interventions, and due to her propensity towards anxious states it is best to avoid causing more anxiety or stress.

When Rosie is experiencing a hallucination she appears engrossed in the event as if she is watching a film. It is difficult to pull her from this engrossment and she pays little attention to voices and actions outside of the hallucination. She has demonstrated interaction with her hallucinations through her actions and her speech. At times it appears she is talking to herself, when it is more likely that she is actually communicating or interacting with her hallucination. She does not appear to be negatively affected by these hallucinations or delusions, during the day.

It appears that the ferocity and frequency of her hallucinations increase throughout the day, peaking particularly prior to sleep. I am not sure if this is due to added stress about completing nighttime routine, the thought of sleep, or anticipation of increased hallucinatory experiences.

Rosie uses a continuous positive airway pressure (CPAP) machine on a nightly basis. She averages 12 hours of sleep a night, but it appears this sleep is interrupted. This being due primarily to her sleep apnea and COPD. It is my estimation that her hallucinations worsen during sleep, and that this invariably contributes to her interrupted sleep. Not only does this contribute to disrupted sleep, it contributes to her heightened anxiety and stress related to sleep. This in turn increases the likelihood of more hallucinations. I am not sure if these hallucinations stem from her schizoaffective disorder, or if they more likely are linked to sleep paralysis. I can not confidently determine one way or the other.

In moments of sleep paralysis, the dreamer typically is witness to hallucinations, particularly insidious and persecutory hallucinations that cause great fear and stress. In these moments the dreamer tries to escape the situation. Due to the their vividness, these hallucinations appear real, instilling great fear in the one experiencing them.

As Rosie sleeps and dreams she shouts, uses expletives, and screams. Upon arriving to her room to offer assistance, she can be seen with her body twitching, convulsing and thrashing gently. It appears as if she is trying to wake herself up. These may be nightmares, but it is my estimation that she is in fact experiencing sleep paralysis related hallucinations.

I am led to believe this because of the sheer intensity of these hallucinations in comparison to those experienced throughout the day. They appear to be much more intensely felt, and she appears to be much more fearful of these. This indicates to me that they are outside of the realm of normalcy for her. Her attitude towards these hallucinations is that of concern and fear, and it appears as though she is trying to escape the situation both physically and mentally: evidenced by body thrashing and twitching upon regaining control of the body.

Further evidence points towards Rosie’s condition as being related to sleep paralysis. Hishikawa and Shimizu (1995) inform us that motor paralysis due to REM sleep can cause breathing difficulties, including what may appear like choking or suffocating. It may feel as if there is a weight or pressure on the chest, making it difficult to breathe deeply without feeling as if one is being suffocated. This is interesting to note because Rosie has been diagnosed with COPD. Could these feelings also be intensified through sleep paralysis? We know sleep apnea to be one disorder that contributes to the onset of sleep paralysis. While Rosie is diagnosed similarly, could this be contributing to her (as of yet undiagnosed) sleep paralysis? Simply put, her pre-existing breathing condition contributes to sleep paralysis, and her sleep paralysis contributes to her breathing condition, ad infinitum.

Although this information helps us in conceptualizing her sleep paralysis condition, what we are most interested in is the hallucinatory components of sleep paralysis, in particular Rosie’s nighttime hallucinations. I am unable to confirm sleep paralysis as a primary diagnosis for Rosie. Sleep paralysis at this point is mere speculation based on variance in hallucination profile from day to night, the intensity of the hallucination, and the apparent escape tactics used while experiencing these hallucinations. I do believe however, that due to the constant state of stress and anxiety Rosie is in daily, along with her diagnosis of COPD/sleep apnea, that it would be highly likely for her to experience sleep paralysis from time to time. Anywhere from 8% to 44% of people will experience sleep paralysis at one point in their lives, and according to psychologists at Penn State and Pennsylvania University, sleep paralysis occurs more frequently in students and psychiatric patients (Penn State News, 2011). Further, the sleep paralysis project reports that sleep paralysis more often occurs in African American individuals (www.thesleepparalysisproject.org). These statistics do not determine with any clarity that Rosie is in fact experiencing sleep paralysis, they merely contribute to my belief that she is.

In order to determine if Rosie is experiencing sleep paralysis we would need to study her case much further. We are still left with three unanswered questions. Does Schizophrenia contribute to sleep paralysis hallucinations (and what should we consider the primary diagnosis: sleep paralysis or schizophrenia?) Are hallucinations experienced by persons diagnosed with schizophrenia and schizophrenia like disorders more vivid, insidious or threatening in sleep paralysis? And does schizophrenia heighten one’s awareness of hallucinatory experiences, thus making it not only more likely for a person with schizophrenia to experience sleep paralysis, but for them to also be more aware of the accompanying hallucinations?

We are left wondering if the diagnosis of schizoaffective disorder is correct, or if perhaps hallucinatory complications arise due to sleep paralysis. Constant stress and anxiety contribute to sleep paralysis, and sleep paralysis is accompanied by hallucinations. We must consider daytime hallucinations. These could be explained by hypnagogic sleep paralysis: sleep paralysis which occurs prior to sleep. It would make sense for Rosie to be in a constant state of exhaustion due to her disrupted sleep caused by COPD. This could be cause for a general lethargy, perpetuated of course by anxiety and stress. The cycle of over-tiredness due to the avoidance of sleep or experiencing disrupted sleep is continuous and unrelenting. This lays way for sleep paralysis and hallucinations, the fear of which contributes to the avoidance and disruption of sleep.

Due to our prior observation that daytime hallucinations appear different from nighttime hallucinations, it would not make sense for us to dismiss schizoaffective disorder as the primary diagnosis. Although I am sure upon further analysis we could make a compelling case for why daytime hallucinations occur, and are experienced differently from nighttime hallucinations, we will not expel resources to do so now.

Rosie is but one case of many, and I believe it is important to conduct further research into the relationship between schizophrenia and schizophrenia like disorders and sleep paralysis. I propose some of our questions would be answered, and upon uncovering these answers we would lay way for many many more questions.

References:

Hishikawa, Y., & Shimizu, T. (1995). Physiology of REM sleep, cataplexy, and sleep paralysis. In S. Fahn, M. Hallett, H.O. Lüders, & C. D. Marsden (Eds.). Advances in neurology (Vol. 67, pp. 245-271). Philadelphia: Lippincott-Raven.

Psychologists chase down sleep demons. (2011). Retrieved from: http://news.psu.edu/story/154433/2011/10/17/research/psychologists-chase-down-sleep-demons

Prevalence. (2017). Retrieved from: http://www.thesleepparalysisproject.org/about-sleep-paralysis/prevalence/

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Saying Goodbye & What I’ve Learned

We work in a vulnerable profession. The people we work with are considered part of the “vulnerable populations”, and through working and living with them they teach us how to become vulnerable. Through our caring for them we start to break down our own walls and open ourselves up to growth, change and learning about ourselves and others. As with any relationship, we form attachments. These relationships are symbiotic, and very rarely do we recognize this. We see ourselves as a sort of essential component in their lives without recognizing the overwhelming impact they have on ours. Our lives become shared experiences –they are very much a part of our lives as we are a part of theirs. I think it isn’t until we face the challenge of living without these people do we realize just how much of an impact they have made.

The people we work with teach us how to communicate, how to express our feelings, and how to foster and maintain relationships. Typically this occurs in such an atypical fashion that we fail to recognize it as a learning experience, or an opportunity for growth. In my experience working in this profession our learning occurs in a very nuanced and subtle way.

First, let me begin by introducing you to one client in particular who had a significant impact on my life. Let us call him “Barry. Barry is a middle aged man with an intellectual disability on the Autism Spectrum Disorder. He uses cryptic language to communicate, talks through his stuffed bears, and exhibits typical symptoms found on the DSM scale for Autism. Typical interventions used are visual stories, following a set schedule, and providing Barry with different options to choose from. Typical of ASD is a stunted ability to express emotions, which we can see when Barry becomes frustrated or upset and is unable to share with those around him, either through body language or words, how he is feeling. This can be frustrating for someone who uses typical modes of communication, and quite often, things get lost in translation. In these situations you need to stop and ask yourself how frustrating would it be to know how you’re feeling, but be unable to share that with another person so that they too understand how you’re feeling? That must be hard. You then have to ask yourself, how can I express empathy and understanding, without being able to understand fully? Carl Rogers shows us how important and essential empathy is in any relationship (Rogers, C., 1951;1961). The ability to understand another person’s soul. The ability to understand the pain, joy, anger, frustration they are experiencing is one of the most intimate and connecting abilities we as humans have. When we emote with another person and they are able to express their complete understanding and acceptance of that we feel a new sort of connection with them, we feel seen and understood. Empathy fosters connectivity and a deeper level of intimacy with others, and it opens doors for stronger communication and relationships. Erich Fromm details the eight basic human needs, one of which is relatedness (Fromm, E., 1941; 1997). Relatedness can be achieved through the relationships we form, sharing our innermost feelings with others, and having them understand those feelings through empathic understanding. Now imagine being a person who has an inability to connect in such a way, a block of some sort which makes it difficult, sometimes what may feel near impossible, to connect with another person in such a way. How would you feel? Perhaps lost, disconnected, frustrated, angry, irritated? The list could go on. What are we to do? Are we to alter our communication, tailor our interactions with this man and others like him?

The reality is that those living with ASD are no less able of communicating, emoting, or experiencing fulfilling empathic relationships, it just takes a bit longer, and it may display itself in a different way. If relatedness is a basic human need, even those with alternative ways of communicating or emoting, will find a way to fulfill that basic human need. What has Barry taught me then? Barry has taught me that we communicate in different ways and the only way we will be able to understand each other is if we are open to and willing to understand each other, even if that involves extra work. With most of our relationships communication comes much more easily, we speak the same language, we express similar emotions to the same triggers, we become comfortable while around each other. This makes us lazy. We are so keen to believe we understand each other we fail to try. Barry shows us to listen to the silence, to attend to the potentially cryptic language, to ask the right questions and to make room for each other. Sometimes in relationships one person takes up more space and that’s okay. In our laziness we fail to see how hard others may be trying. We need to recognize how easy it is for us to emote and connect with others, and how potentially scary it may be for someone like Barry to do the same. This teaches us to be more understanding, patient, and open to forming relationships and perhaps helping others form the same relationships. We don’t all speak the same language, and we’d certainly be boring as a species if we did.

We are so wont to believe that they need us just to live and in the process we other them, believing that without us as their support they would fail to survive. This is the furthest thing from the truth.

Aside from teaching me how to communicate and how to listen, Barry also showed me what it means to be in relation with another person. He showed me how difficult it may be at times, and how two completely different people can develop and foster a meaningful relationship through mutual understanding, trust, and awareness of the other. Although difficult at times, potentially extra-strenuous, the relationship which I built with Barry showed me just how important the qualities listed above (trust, understanding, awareness) are in building a relationship with another person. A quality I did not list but which is equally as important is acceptance. Rogers presents unconditional positive regard as an essential component in a therapeutic relationship (Rogers, C., 1951; 1961) and there is nowhere in my life I have been able to experience this quality more than in my relationship with Barry. In fact, he showed me just what it looks like.

Regardless of what I wore, how I acted, or how I was feeling, he continued to accept me as I was, and continued to acknowledge me as an autonomous person. This may not have happened instantaneously, in fact, there were times where he needed to process why I wasn’t wearing jeans when he asked me to, or why I was upset with something he said to me – but after this period of processing, he would be able to look at me and see me for who I was, and still accept me as my self. This was one of the most powerful experiences I had while living and working with Barry.

As I reflect upon what I have learned from the people I have met and worked with, I come to think very fondly of the intimate moments I shared with the persons I was charged with caring for. Care-work is much more than a profession, it seeps into every facet of your life, and what you learn while working with others stays with you once you’ve severed ties. Throughout my time in this profession I learned not only how to care for others and come to understand the myriad of ways in which we as humans can care for and express our care for others; I learned how to care for myself. Care-work and self-care are inextricably intertwined, and I’ve touched on this before – the importance of caring for yourself and replenishing your energies so that you do not experience burnout. Even outside of care-work however, it is an important take-away: make time for yourself. I will not outline here the endless ways in which you can practice self-care because that would be an interminable digression. The important thing to remember is that care-work teaches you how to handle yourself in a much more understanding, forgiving fashion: and this attitude extrapolates to all other relationships you currently have or are in the process of building.

The next client I would like to discuss is someone who has taught me a number of things including self-acceptance, self-awareness and forgiveness. Let us call her “Rosie”.

Rosie is a senior living with schizoaffective disorder bi-polar type, with observed OCD like behaviours, anxiety and substance over-use/dependency. She spends a significant portion of her time in quiet contemplation and solitude. At times she will scream or yell, shout obscenities or appear to be talking to herself. In these moments it is important to understand who the vocalizations are directed at: are they directed at others, herself, or perhaps her hallucinations? This conundrum eluded me sometimes, but I tried my best to give her her space. In instances where she would exhibit increasing anxiety while vocalizing, it was important to assess whether this anxiety came from my failing to communicate with her, or if it stemmed from an internalized mental experience.

When Rosie exhibits anxiety it may very quickly escalate into self-harmful behaviour. This self-harm is a way to regain power and control, or could very well be a response to a persecutory hallucination. Even though we do not know the reasons behind it, this self-injurious behaviour serves a purpose. Although we do not want Rosie to injure herself, we are unable to control for it at times and the best thing to do is to try to understand her as a person, instead of trying to keep her from injuring herself. Again, here we return to Rogers’ idea of empathic understanding, and unconditional positive regard. The best way to get to know someone, to truly see into their soul and express back to them your complete understanding of them, is to express and practice empathy with them. This becomes difficult with someone like Rosie, who has only ever experienced understanding as controlling. Controlling for anxiety, behavioural issues, injurious behaviour, violent tendencies and so forth. Perhaps the behaviours we fail to understand are her way of trying to communicate and instead of listening and being receptive to this we control the behaviour because it is atypical, therefore wrong. This is how Rosie taught me about self-awareness.

I very quickly became more aware of the things I said, the way I acted, even things as simple as my body language, tone, and facial expressions. Sometimes the way we communicate with each other can misconstrue the things that we are saying. Our tone, body language and facial expressions are saying one thing while our words are saying another. This can cause confusion, and makes it more difficult for trust to flourish. Trust is a fundamental component of any healthy relationship, without trust as our foundation we cannot build a solid relationship. This awareness did not end with myself, I became more aware of others non-verbal communication patterns and was more receptive to deeper meanings. This also led to a greater understanding of the way others communicate and the possibility for their not being alternative meanings. Perhaps, there are other explanations for why the tone did not match the message being shared. Rosie taught me to read into things when needed, and to recognize things at face value when needed.

Along with her lesson in self-awareness she taught me forgiveness and self-acceptance. Forgiveness because we all make mistakes, and she was quick to apologize when needed: sometimes she apologized when there was no need to. Her apologies came quickly, and sometimes she didn’t understand why she was saying she was sorry. I’m sure this stems from something in her past that makes it so easy for her to apologize, sometimes needlessly. The important thing she taught me was that sometimes, even when we don’t know why we’re apologizing, we need to do it anyway. This is because the person we have hurt needs to hear it said – there is always a reason we apologize (to mend broken hearts, hurt feelings and relationships) but sometimes we aren’t always completely aware of why. It isn’t until after the fact do we understand why the apology was needed. Being stubborn about apologizing only increases hurt feelings, making it more difficult to rectify the situation. On the other side of the argument, forgiving someone can be just as hard as apologizing. It’s a matter of pride: Rosie taught me pride means nothing when it comes to mending hurt feelings. Pride merely gets in the way, and relationships are much more important than personal pride. Admitting your faults is a sign of strength.

The last thing Rosie taught me was self-acceptance. Akin to how Barry taught me what unconditional positive regard looks like, Rosie taught me what real self-acceptance looks like. She struggled with body-image issues, and the majority of the time was quite distressed over her weight and the size of her stomach. She would compare herself to others around her wondering why they were so skinny and she wasn’t. Sometimes she would say things that made it clear her desire to be skinny was heavily influenced by those in her life who had told her before how important it was to lose weight and get smaller. There were times of quiet where I’m not sure if she had actually started to think of something else, or if she was sitting ruminating on these negative perceptions of herself. When she didn’t vocalize these feelings, I merely assumed she had forgotten about the issue, but I have a feeling these thoughts remained with her in the back of her mind permeating through every day, and every activity. There were times when she would become increasingly anxious and would vocalize an issue with her stomach or weight. This leads me to believe she was in fact ruminating on these perceptions, and for the most part these fuelled her anxiety. The amount of distress she experienced over something as seemingly insignificant as her weight caused tension in all other areas of her life. I can’t conclude with any authority that Rosie has accepted herself, or that there have been any significant changes in her mindset. She did not lead by example. However, watching Rosie become increasingly distressed over her weight encouraged me to practice self-love and acceptance. She showed me how important it is to accept yourself, be forgiving of your faults and shortcomings, and change what it is about yourself you don’t like.

Just like Barry, Rosie projected acceptance and love more so on others than on herself. In these moments, the importance of self-acceptance was reinforced.

We consider ourselves as care-workers to be the leaders, the teachers, the guides, when in all reality it is our clients who are teaching, leading and guiding us. They open our eyes and minds to a plethora of experiences we would not be open to experiencing if not for them. They also provide us with different ways of seeing and understanding things. There is nowhere in my life where the sentiment of different intelligence’s is more obvious than in care-work. Not only are you exposed to these different forms of intelligence, you are exposed to varying presentations of these intelligence’s. Each new day is a marvel, learning how others see and make sense of the world around them, and coming to the realization that you, sadly, are missing a large percent of the world and its happenings because you are stuck in the monotony of typical modes of intelligence. Your being stuck in these modes not only limits your ability and willingness to see the world from a different perspective, it blocks you from experiencing life to your fullest ability.

I have learned a great many things in this profession, particularly that care-work can be stressful, frightening, and challenging. At times these challenges may overwhelm us, leaving us feeling drained and empty. When we step back and reflect on our experiences we are able to see the work we’ve done has made a difference, but our work is just the beginning. Our care-work is much more a self-reflective experience than it is a mode of treatment or assistance for others. Through this self-reflection, and of course our close work with our clients, we form meaningful attachments. These attachments strengthen our sense of self, and bolster our understanding of the world around us. When we sever these ties we feel the aftershocks of detachment. If there is one thing I can take away from these experiences with any confidence it is that there is nothing more challenging, frightening or stressful than saying goodbye.

Fromm, Erich. (1997). On Being Human. London: The Continuum International Publishing Group Ltd.

Fromm, Erich. (1941). Escape from Freedom.

Rogers, Carl. (1951). Client-Centered Therapy: Its Current Practice, Implications and Theory. London: Constable.

Rogers, Carl. (1961). On Becoming a Person: A Therapist’s View of Psychotherapy. London: Constable

Understanding Schizophrenia

Schizophrenia is a neuropsychiatric disorder most easily defined as a distortion in thought, social behaviour and cognitive functioning. Around 1 % of the world’s population has been diagnosed with schizophrenia. There are a number of theories surrounding the onset of the disorder. Prevalent theories are steeped in the bio-medical model, while other less popular theories stem from a more psycholinguistic approach. The word “schizophrenia” comes from the Greek word “skhizein” meaning to split and “phren” meaning mind (Online Etymology Dictionary); schizophrenia therefore, can be translated as a splitting of the mind. This understanding has confused some individuals who are not necessarily familiar with the symptomatology of the disorder. It should not be confused with dissociative identity disorder, where there is a split between personalities; rather, the split that occurs in schizophrenia is a split between self and reality (how one internally conceptualizes reality).

This confusion does not end with the definition of schizophrenia. Most do not understand the presentation of symptoms, what the symptoms mean, or how to interact with these symptoms. I have witnessed many times, individuals interacting with someone with schizophrenia and not understanding just how to do so – it can be a complicated and at some times frustrating experience, when you do not fully understand the disorder. I am here to outline some major symptoms of schizophrenia, and how they present themselves, along with some ways to interact with clients while they are demonstrating these symptoms.

First, let us differentiate between positive and negative symptoms. Positive symptoms can easily be thought of as additions to a persons’ behaviour or cognition. Common examples of positive symptoms are hallucinations and delusions. Negative symptoms are subtractions from a persons’ normal range of functioning. Common examples of negative symptoms would be blunted affect and alogia.

Now that we have identified positive and negative symptoms we can assess the full range of symptoms presented in persons with schizophrenia[1].

Positive symptoms

Hallucinations and delusions are the most commonly known symptoms of schizophrenia, in fact, most people will not know many symptoms aside from these two.

Hallucinations can manifest in 5 different ways, these being auditory, visual, olfactory, gustatory and tactile. Visual hallucinations are things that are seen by the client which are not there, or that other people cannot see. Auditory hallucinations are characterized by hearing voices that others are unable to hear, tactile hallucinations are characterized by feeling things which are not there, or which other people do not feel. Tasting, or smelling things, which are not present, or that other people do not taste or smell characterizes the final two categories of hallucinations – gustatory and olfactory (American Psychiatric Association, 2013).

Delusions are identified as false beliefs held with strong conviction, regardless of evidence to the contrary. These can be characterized in 4 categories, which are delusions of paranoia, delusions of grandeur, somatic delusions and delusions of reference (American Psychiatric Association, 2013). Paranoid delusions are false beliefs centered on the idea that others are out to get you, or that others are doing things when there is no clear evidence. Delusions of grandeur are centered on the idea that you are important, special or significant outside of the normal realm. For instance, believing you are a religious prophet, or the reincarnation of Christ. Somatic delusions are false beliefs about your body – internally or externally. Delusions of reference are false beliefs that things in the environment are directed towards you, when they are not. For instance, a TV show or radio broadcaster is talking about a certain event, and you believe that this is directed at you specifically.

Disorganized speech, otherwise known as word salad, is characterized by derailment or incoherence in speech (American Psychiatric Association, 2013).

The final positive symptom in schizophrenia is known as catatonia, or catatonic behaviour. This behaviour is characterized by rigidity, stupor, inactivity, mania, or extreme flexibility of limbs, (American Psychiatric Association, 2013).

Negative symptoms

Negative symptoms, as mentioned before, are characterized by a lack of certain behaviour. These are as follows:

Alogia, which is characterized by a difficulty or inability to speak.

Affective flattening (or blunted affect), which is characterized blunted facial expressions, or less lively facial or bodily movements.

Lack of emotion or, the inability to enjoy activities to the same degree as before.

Social isolation, in which the individual spends most of their time away from others, or when they do, it tends to be close family only.

Low energy, in which the individual does not exert a lot of energy, spends most of their time sitting around or sleeping.

Lack of motivation, in which the individual does not have much motivation or interest in life.

Inappropriate social skills or, a lack interest in, or ability in socializing with others

and finally, inability to make friends, in which the individual finds it difficult to make new friends, or keep friends they already have. They may not care for their friends.

There is one more category of symptoms that typically gets ignored when discussing schizophrenia. These are categorized as cognitive symptoms, and refer to difficulties with concentration and thinking.

They are as follows:

  • Disorganized thinking
  • Slow thinking
  • Difficulty understanding
  • Poor concentration
  • Poor memory
  • Difficulty expressing thoughts, and
  • Difficulty integrating thoughts feelings and behaviour

In treating and individual with schizophrenia, understanding the symptoms of the disorder is half the battle. It is not enough to simply be aware of these symptoms, you must too understand their presentation and be able to differentiate between the symptom, and the person. What I mean by this is you must have the ability to separate the person from the expression of the symptom. For instance, a woman experiencing an auditory hallucination may be feeling anxious, or aggressive. She may be feeling attacked, and may yell or swear out loud in response to the hallucination. You may think she is yelling or swearing at you, and you may involve yourself in the situation. This should be avoided. That is not to say that you are not able to communicate with her while she is experiencing these symptoms, but you should avoid centering the conversation on them. The reason I say this is because you are not experiencing the symptom, you are not aware of what exactly is being said. This is based almost entirely on whether or not you have gained the client’s trust. Do not pretend to hear the voices as well – she is able to recognize that you do not hear them. Do not pretend that you know how to make them go away – because when she realizes you are unable to do this, you lose even more trust.

You can ask the client what the voices are saying. I believe that by doing this, you are demonstrating to them that you care, and it opens a window to strengthen the trust that is already there. You can also ask the client if they believe what the voices are saying. If they are able to, ask them to challenge the voices. You can re-direct the negativity into positivity.

Albert Ellis proposed rational emotive behaviour therapy (REBT) in 1955, which is the pioneering cognitive behaviour therapy. The goal of REBT is to challenge thoughts in order to avoid certain behaviours. He proposed an ABCDE model, with A meaning action (activating event) B meaning belief system, C meaning emotional consequence, D meaning disputing and E meaning cognitive/emotional effects of revised beliefs. In a situation such as the one outlined above, we can easily apply this model to the clients’ hallucination. The beauty of REBT is that it involves rationalizing the situation prior to the onset of behaviour. By asking the client to challenge the thought, voice, hallucination, or delusion, we are going straight to the disputing stage of our model. It is perfectly all right for a client to dispute their delusions or hallucinations. In fact, it should be encouraged. By ignoring or trying to avoid the symptoms, we end up encouraging repression, which means that the symptoms will likely return.

You should avoid invalidating their symptoms because though they may not be real to you, they are very real to your client. Invalidating their experience breaks down trust, and creates a divide between you and them.

While interacting with someone with schizophrenia we should always be mindful of our own attitudes and behaviors, specifically while they are being symptomatic. You should avoid teasing or mocking the client’s behaviour. I have witnessed caregivers laugh at a client’s word salad, or mock their catatonic behaviour. There is a misconception that because these individuals are experiencing things outside of the realm of normalcy that they do not understand our behaviour, or do not notice it. This is not true, and you should always be aware of your attitudes, language use, tone, and behaviour.

Experiencing schizophrenic symptoms puts the client in a very vulnerable state. There is a need for trust, without the ability to trust. Not only, will a client with schizophrenia find it more difficult to trust you due to their illness, they will also find it difficult to trust you because they have been taken advantage of so many times before. With that in mind, their delusions hold some truth. It is difficult to give your entire trust to someone else, to give up your power and to rely on someone else’s.

There are better ways we could and should be interacting with these clients. It may sound obvious, but the two most important traits are patience and kindness. Due to the combination of cognitive delays and positive/negative symptoms experienced by the client, it is sometimes difficult to make it through a conversation with them. This should not discourage you; in fact, you should seek out any opportunity you have to share a conversation with them. This not only builds trust, but it helps you understand the client more, so that in the future you may be able to differentiate between symptomatic expression and non-symptomatic expression.

Empathy is the most important thing we can offer the client. Carl Rogers explains the importance of empathy in understanding our clients, and in aiding them in their healing process (Rogers, 1951, 1959, 1961, 1974). To be empathetic is also to demonstrate unconditional positive regard, also identified by Rogers as a key factor in successful therapy/treatment (Rogers, 1951, 1959, 1961, 1974).

When communicating with a client with schizophrenia, you should be mindful to communicate with them the same way you would with any other client. Attempt to include them in social activities – they may say they do not want to each time, which is fine, but eventually they may change their mind. What matters, however, is that you made the offer; this shows them that you care.

Understanding schizophrenia is a difficult task, however it is far more difficult to live with it. By attempting to understand, show empathy, and build trust with our clients, we are helping them heal. We are helping them make it through a very difficult disorder. The key to understanding schizophrenia is education and the ability to listen.

References:
American Personnel and Guidance Association. (1974). Carl Rogers’s 1974 lecture on empathy. Retrieved from https://www.youtube.com/watch?v=iMi7uY83z-U&feature=share&list=PL9w3l7GkGUr1yxU4s2PiggyCbOO3XfpRf

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Ellis, Albert. (1957). How To Live with a Neurotic. Oxford, England: Crown Publishers, 1957.

Rogers, Carl. (1951). Client-Centered Therapy: Its Current Practice, Implications and Theory. London: Constable

Rogers, Carl. (1959). A Theory of Therapy, Personality and Interpersonal Relationships as Developed in the Client-centered Framework. In (ed.) S. Koch,Psychology: A Study of a Science. Vol. 3: Formulations of the Person and the Social Context. New York: McGraw Hill.

Rogers, Carl. (1961). On Becoming a Person: A Therapist’s View of Psychotherapy. London: Constable.

Schizophrenia. (n.d). Online Etymology Dictionary. Retrieved from http://www.etymonline.com/index.php?term=schizophrenia

[1]                  It should be noted that not every individual diagnosed with schizophrenia would present all or the same symptoms.

What are the Voices Saying?

Schizophrenia is one of the most misunderstood disorders of the mind; it presents differently for most people, and there are a number of different symptoms outside of the most commonly known delusions and hallucinations. Due to this misunderstanding, a number of treatment methods are bypassed to subdue the client, or “quiet” the symptoms. Although medication can be helpful to many, both atypical and typical antipsychotics have a number of severe side effects that may cause more damage than help (Leucht et al., 2009/Stroup & Marder, 2013/McKim, 2007). Of course, the best approach to any mental illness is the incorporation of both medication and therapy, but sadly, this is not always the case. Typical psychotherapy is sometimes regarded as fruitless in regards to treating schizophrenia, possibly because there are a significant amount of symptoms that could “get in the way” of a therapy session. However, R.D. Laing was very successful in treating individuals with schizophrenia through therapy (Laing, 1960), and by implementing a very humanistic approach, through his use of compassion for the client. I believe that this approach should be revisited, and when dealing with hallucinations and delusions in particular, we should be asking the client and ourselves “what are the voices saying?”

Typically, the response to a delusional thought or hallucination is to either 1.) get rid of it or 2.) play into it. Neither is the proper response. If we do not know where this delusion is coming from, how will we be able to properly treat it? We won’t be doing anything other than taking a shot in the dark. By asking the client what the voice is saying, we get a closer look into their psyche, and a closer look into the root of the problem. Understandably parents wish to separate themselves from their child’s mental illness; they do not wish to be blamed for it. Freud was, however, correct in identifying the impact parents have (genetically and environmentally) on the child’s development (Freud, 1918/1923/1949). Early childhood experiences are undeniably, a contributing factor to any mental illness and we should not be ignoring this impact.

How we were treated in our childhood (by parents, peers, other adults), has a significant impact on how we view ourselves, and by extension how we behave. For an individual with schizophrenia, these memories and experiences are quite possibly repressed, and just now, manifesting in negative, neurotic ways. For instance, a client who is hearing a persecutory voice telling them they are worthless, ugly, or that they do everything wrong/can’t do anything right, is a client who quite likely has heard these phrases prior to the onset of symptoms. I have discussed in a previous article the impact a disintegrated self has on the psyche, so too has Laing (Laing, 1960). This inability to integrate certain aspects into the self (memories, experiences, aspects of personality), will present themselves later in the form of symptoms. For those with schizophrenia, this typically manifests in hallucinations and delusions.

By way of simply knowing what the voices are saying, we are able to perform psychoanalysis successfully. Instead of shying away from treating schizophrenia with therapy, we should be approaching it the same as any other mental disorder. Let me give an example.

A young woman, aged 26, has been experiencing delusions for the past year and a half. She is hearing voices telling her that she will “never amount to anything” and “without me you’re worthless.” These voices are of course, very distressing to her, and cause a significant amount of anxiety and worry, which leads to depressive feelings. She begins to believe these voices, and her lifestyle changes significantly from “normal” functioning prior to the onset of symptoms, to a disorganized, chaotic, and dysfunctional lifestyle. She finds it difficult to get out of bed, to eat properly, to get dressed –all of which are simple, everyday tasks most of us are able to perform without thinking consciously about it. This is because she is focused on the voices, combating them, and struggling so hard to repress them.

If we were to ask her “what are the voices saying?” we could discover the source. These thoughts have been repressed for some time, and perhaps, they originate from previous feelings of self-worth (or lack thereof). If we analyze and assess the clients’ history (childhood and beyond), we may get a better understanding of where these thoughts are coming from. It is normal for each of us, from time to time, to have negative thoughts about the self – but do we not also understand, with a little introspection, to some degree where they are coming from?

Say for instance, we were to discover, through our analysis, that all throughout her childhood her parents verbally and physically abused her. When she went into school it was difficult for her to make friends, and she was teased and bullied all throughout middle and high school. She tried her best to ignore this negativity, in an attempt to “survive” her years in school until graduation. This is of course, a very extreme case, however, by ignoring and repressing these negative thoughts and behaviours, they resurface later.

In order to combat these thoughts and experiences properly, we should be counseling, and employing cognitive behavioral therapy (CBT) (Beck, 1967). By counseling, I am referring particularly to counseling parent-child relationships (should this be found to be one of the main sources of negativity). By communicating our feelings, and working through the negativity instead of keeping it inside and ruminating about it, we are more likely to deal effectively with the source. This should not be the only resource we rely on for combating these delusions. We should also be employing CBT – challenging thoughts and behaviours.

By getting to the root of the problem, that is, the source of these thoughts and voices, we can address them directly. We can ask the source (parent, friend, teacher etcetera), why. We may also be able to determine that this is not a fundamental aspect of the clients’ personality. They are in fact not worthless, or ugly, and whatever else the voices may be saying. The first step is of course to confront the source, and the next step is to combat the continuing voices. Just because we have addressed the source does not mean the voices will dissipate. We must change the way in which we think, because this thought pattern, although separate from our selves, has become somewhat integrated into the self. We are able to combat these thoughts and change them, through CBT – by using exercises and homework. These must be taken seriously in order to experience change, because we are trying to alter negative thought patterns that have been with the client since childhood or beyond. As we know, it is very difficult to break a habit, so too is it difficult to break a thought cycle.

Therefore, we must confront those with schizophrenia not as helpless and beyond cure. Instead, we should confront these clients with compassion and new ways of understanding their illness. For many, these thoughts will represent something very real to them. These thoughts should be regarded as a manifestation of repressed thoughts, experiences and memories. As Freud has taught us, when we understand the impact a memory has on an individual, we are able to treat it effectively (Freud, 1895). Even just speaking of the source is cathartic. Instead of ignoring the voices, and repressing them even more, we should be asking what are they saying, and what does this mean?

 

References:

 

Beck, A.T. (1967). The diagnosis and management of depression. Philadelphia, PA: University of Pennsylvania Press. ISBN 0-8122-7674-4

Freud, Sigmund., & Breuer, Josef. (1955). Studies on Hysteria. (James Strachey, Trans.). London: Hogarth press. (Original work published 1895).

Freud, Sigmund. (1918). “From the History of an Infantile Neurosis”, reprinted in Peter GayThe Freud Reader (London: Vintage, 1995).

Freud, Sigmund. (1927). The Ego and the Id. (Joan Riviere, Trans.). London: Hogarth Press (original work published 1923).

Freud, Sigmund.(1989). An Outline of Psycho-Analysis. (James Strachey, Trans.). New York: Norton & Company. (Original work published 1949).

Laing, R.D. (1960).The Divided Self: An Existential Study in Sanity and Madness. Harmondsworth: Penguin

Leucht, S., Corves, C., Arbter, D., Engel, R.R., Li,C., & Davis, J.M. (2009). Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis. Lancet, 373 (9657): 31-41. doi: 10.1016/S0140-6736(08)61764-X.

McKim, W. (2007). Psychomotor Stimulants. Drugs and behaviour: An Introduction to behaviour pharmacology. Pearson Prentice Hall.

Stroup TS, and Marder S. (2013). Pharmacotherapy for schizophrenia: Acute and maintenance phase treatment. Retrieved from http://www.uptodate.com/contents/pharmacotherapy-for-schizophrenia-acute-and-maintenance-phase-treatment