The Compassionate Practice of Psychotherapy Part II: A Design for Treatment: Mind and Environment

This is a transcript of an intensive training seminar given by Edward M. Podvoll, M.D. at the Karme Chöling meditation center in Vermont on October 1–4, 1982. It has been lightly edited by Jeffrey Fortuna and Skye Levy.

Part I: Foundations of Clinical Recovery

Part II: A Design for Treatment: Mind and Environment

Part III: Intensive Psychotherapy: Intimacy and Exchange

Part IV: The Nature of Courage in Psychotherapy

Listen to Part II

Transcript of Part II

Dr. Podvoll: Our discussion of recovery continues with how we know it, how we can apply it, and how other people can recover along with us. We want to talk about the actual application of what we understand about recovery and what we experience about it.

One of the applications is a treatment program, a model that we have been working with in Boulder, Colorado, designed to work with highly disturbed people using some of the principles about the nature and experience of recovery. We have said that recovery begins with mind. How we relate to mind becomes the possibility of recovery from illness. One could awake from the interminable self-preoccupation of illness.

Of course, we are talking about the seeds of illness, incipient illness, the continuous potentiality of illness, which begins with self-preoccupation. Just like severe alcoholism begins with taking a drink, the desire for a drink, a social drink with the desire to be more social. In the same way, we mean that illness born from self-preoccupation becomes a fascination and then intoxicates one. Recovery is possible, in terms of waking up out of that intoxication, with the experience of a moment of vividness. Recovery has its own natural history. It arises and decays, just like everything else. Nevertheless it can be recognized, and the recognition of the space of awakening during moments of recovery takes place through relationship.

Relationships have a power to acknowledge and possibly enrich such moments of recovery. That puts psychotherapy in a unique position. A relationship could be the bridge for recovery to become a process that is continuously related to. That seems to be our little specialty in this culture: people who look carefully at the nature of human intimacy and who are able to apply what they know about recovery in the service of other people. At this point, that is all we are saying a psychotherapist is.

Beyond that we find that we can relate to the enormity and intensity of another person’s illness and see where the connection can be made within the complexity of illness to experiences of awakening and recovery. With that principle in mind, we would like to discuss an actual person and the possibility of that person’s recovery. That person is in a treatment situation, which specifies an environment and relationships, which we believe can bring about and foster recovery.

I am sure everyone knows that presenting a case in a short time and in public might involve us in endless possibilities and complexities of detail, especially when it is about such an interesting person. So we will have to do just a quick sketch and not linger too much on history and origin, but just who this person is. We could make it brief because who he is is already the total manifestation of where he came from and how he got to be that way. We will call him “Mr. California,” for reasons that will become clear.

He is a twenty-nine-year-old young man and he is trapped in a delusion. The delusion has endless intricacies, and if we looked at the delusion in more and more depth we would see how the delusion reveals and exposes the step-wise function of his falling ill. So it is necessary to give a summary of the delusion which has made him nonfunctional and needing others to survive. He would be offended by my using the term “delusion,” because that makes him sound insane. But I have no other choice for the purpose of communication. If I presented his dilemma as something other than a delusion, I would sound insane. It is a principle of this kind of work that one can be deluded and sane at the same time.

It is a case of possession. This man is possessed by a woman who manifests to him through the “astral plane.” She has been with him for almost three years, never leaving him, always watching him. She controls his body, his thought processes, his energy level, his communication, and the way he thinks about the world. He defines himself in terms of this delusion. Everything that takes place in his body or in his relationship to his mind, he says is “not me.” He is almost saying, “I am not-me. I am under control. I am possessed by her. I have no will-power. I cannot exert my own will.” And, interestingly enough, this person under whose control he is continuously in, he calls “Willow.”

He grew up in California and is a product of a particularly exaggerated form of new-age spirituality which we sometimes associate with the supermarket variety of spirituality. He has been involved in every conceivable spiritual adventure that could take place on the west coast. For the past ten years or more he has been completely immersed in a variety of practices of almost every religious movement or offshoot. But it is Willow that he sees as his final religious movement. The delusion being that her possession of him is for the sole purpose of his bending his will towards her, surrendering towards the demands she makes on him in the form of voices, and visual and somatic manifestations. They demand surrender, submission. One demand on him is to strip himself naked in the middle of the street. Sometimes the command might come in terms of his hurting himself physically and perhaps even killing himself in her service. “Eat, don’t eat.” They are often contradictory. The purpose of all that is for his liberation, his freedom from the bondage of his own ego-ridden will. 

If he comes through, performs the acts of surrender and submission that are required of him, he will clean the slate of his wrongdoings and the sense of guilt that he has carried with him for eons. When he accomplishes such a thing by the proper performance of self-surrender, and actually cleanses himself in such a way, he will achieve a sense of purity and liberation which will be a model and somehow useful to all human beings. He feels this to be something of a personal burden that he carries. In this lifetime he can be of enormous service to the species. He cannot fathom why he was the one chosen for this presumptuous task, but, nevertheless, he is the one who has been given the opportunity and the privilege to perform these actions. If he fails, a precious event in human history will be lost for all of us.

His big problem in life is that he “procrastinates.” On the edge of self-surrender he holds back, he hesitates, and is unable to follow through with the actions required of him. And then he sinks into depression and self-loathing for not having used this opportunity. The guilt of ingratitude is added to his problems. He is a very loveable person. He is extremely gentle, almost exaggeratedly so. Not in the sense of being a non-entity, but in his firm belief that he is gentle, beyond aggression, and cannot do anything to hurt another being. But it is actually more than that. Ever since he was a little boy, people noticed how gentle he was and even as a three-year-old child he was careful not to step on insects. That principle of not harming things has suffused his personality, but at the same time it has become a hindrance to his path of self-surrender because true submission requires him to perform violent acts. Not to submit is also violent. It has become his Catch-22: how to perform this type of submission and not be violent at the same time.

We began working with him about seven months ago using a basic recipe. It is a simple recipe and the essence of the whole treatment approach has been one of simplicity. It involves about a dozen people working with him. Now that sounds like a lot . . . a dozen people working with one person. It sounds almost un-American, so many working with so few, rather than the other way around. But nevertheless, it is not so time-consuming as it sounds. We are talking of roughly seven or eight hours a week of anyone’s time. And because of that, the same team can work with several people at once.

We began him in this treatment program which consists of . . . first establishing him in an ordinary household situation: a simple one but quite decent and dignified without being too brilliant and thus frighten him. It was essentially a student situation, an apartment with two bedrooms. He lives with a roommate who is a member of the treatment team also. We think of the roommate in terms of being a “foster-friend,” a companion, helper, and at times, a basic administrator of the needs of the patient.

A schedule is established for the patient, with the patient, that involves giving a structure of time, a sense of orderliness to the day. That involves everything from sleeping, waking, food, and exercise, to the structure of relationships. It is not very rigid but it is very clear. And the boundaries of activity are quite clear. The principle behind that is that the boundaries, the demarcations of action during the day, become models of how to discriminate the boundaries between delusion and non-delusion, between being awake and being asleep, between being in a daydream and relating to reality. What demarcate that schedule most vividly are the relationships: the patient is involved with several people throughout a single day. The group that works with him spends blocks of time (three hours each) with him, and he might see people a minimum of two or three blocks of time each day. Other times, he is with his roommate or spends some time alone. But it amounts to a great deal of time with other people. On top of that is his involvement in intensive psychotherapy with me, which is four times a week. So it is quite interpersonally active.

The quality of these relationships is something that we want to talk more about later; that is, what it means to do the kinds of things we do with this patient which seem to be somewhat different from what one ordinarily finds and yet it is not so obvious on the surface. On the surface what we do are household activities: we go shopping with the patient, we take hikes with the patient, we sit and talk over a lot of coffee with the patient, go to movies, concerts, be with him, take occasional classes (he is a musician), and so on. These are quite ordinary, practical things. But what takes place in those relationships is something very intimate and very sane. The function, for the most part, of these relationships is a sense of introduction, a connection from the world of delusion into the vivid real world. There is a sense of mediation between those two worlds, the world of fascination and intoxication with the world of vividness and also of sadness, at the same time. How one provides that sense of introduction and bridge we will describe later, but we call it the nature of being a “therapist-friend,” and the action is one “basic attendance.”

What we are doing is working with the possibilities of body and mind being tuned together. We recognize that the basis of his illness is the continuous attempt to unhinge, or desynchronize, his body and mind and live within the space and possibilities of that disconnection. It is there that he elaborates his delusional world. The more that we bring body and mind together, the more clearly he sees things, his environment, relationships, and qualities of his mind. The more clearly he sees things, the more he begins to recognize some things. He recognizes that the voices that talk to him are remarkably unreliable. They never come through with their promises. When he sees that clearly, doubt arises. The doubt is basically whether he is dreaming or awake. Then a doubt about everything he has lived through. It is an instant of awakening, of recognition, and curiosity, and it has a great deal of pain in it at the same time. He has devoted himself body and soul to his peculiar spiritual path and every moment of doubt is a moment not only of clarity but of intense pain and excruciating humiliation. Because of that, his progress—or it might be better called his “journey”—in his relationships with us is one of continuous oscillation. This fact also seems to tell us something about the nature of recovery. That is, recovery is happening in bits and pieces. There is awakening and there is pain and there is desire to fall asleep and dream again. It is an unending cycle and progression. Recovery is not a linear phenomenon.

What we have seen in the past seven months are particular phases that we think are “phases of recovery.” We can say that because the patient does seem to be moving, which for us means the shifting of allegiance from a world of intense imagination and death, to an allegiance and yearning for the intensity of human contact—actual passionate relationships with the people that he works with. That shift is having consequences on the nature of his delusion and how he is living his life. We can identify some phases of how that seems to be happening. We have some confidence that it is part of the process of recovery from severe delusion because we have seen exactly the same thing happen with others before who have been in the treatment situation I am describing.

The recipe continues. First, an ordinary household situation with a roommate, then a schedule, and intimacy and intensity of relationships are established. Beyond that, the group itself has met in group supervision to talk about the patient and our reactions to him, and to discuss where the obstacles are to the patient’s recovery, such as we understand the principles of recovery. At a certain point, the patient is invited into this group and becomes a part of the group itself. That usually happens from two to four months into our work with people. At that point, the team becomes less of a thing imposed on a patient and has a lot of the characteristics of an extended family. We begin to have picnics together. We begin to actually host the parents when they visit. And when the parents do visit and have meetings with the team, they meet with the team that includes the patient. It has a peculiar effect on the family situation, which at this point is not easy to describe. Essentially the effect is this: when the family members enter the team environment, they seem to begin to appreciate each other more than they had for a long time. It becomes a meeting place for a family to gather as if in a family reunion. Although on the surface the meeting is around the focal point of the patient’s illness, it actually takes place on the basis of a sense of enjoyment of the patient’s recovery. Even peripheral members of the family seem to partake and enjoy each other, which might not have happened since childhood.

We see phases developing out of this kind of situation, within this kind of environment. We think of it as a “sane environment.” “Sane” in the sense that the patient is surrounded by sane people, people who are working on their own intelligence and their own process of recovery through meditation practices. Being in the midst of such people there is not much choice: either one goes deeper into madness to escape such things or one changes one’s allegiance. It is an old story but to us in this culture it seems new. The old story is that when you put an insane person together with other insane people, he gets less healthy. When you put an insane person together with healthy people, he becomes healthier. It is a simple formula, which our hospital system has not quite seemed to discover yet.

  1. The first phase seems to be a kind of infectiousness of sanity. That means that mind and environment etch each other, because of the simplicity of schedule, and of action, and of doing things, and the boundary between activities. Then mind quiets down. The psychotic confusion and speed seems to be almost immediately affected by an atmosphere of simplicity and some kind of soft discipline at the same time. First, some quietness appears within the delusion itself. What seems to happen, when the relationships begin, is a kind of drawing of fire from the patient. Passion begins to develop. The patient, even in spite of himself, begins to like these people and is attracted to their health. As this happens, he begins to recognize moments of interest and curiosity and beyond that, moments of concern draw him, almost drag him, out of himself.

  2. When this appears, the next phase seems to be a cleavage of the delusion. Cleavage in the sense that as the relationships develop with team members, they seem to have a life of their own, independent of the delusion. The patient begins to discover that he is living a double life and he has to maintain a lot of energy to live as if in two worlds at the same time. What happens so often in other kinds of treatment environments is that the outer world gets covered by the delusion: “My doctor is so and so” in the delusion, and the nurse and whomever become engulfed in the delusion. But that does not seem to be the case with the people we have worked with. What seems to happen is that a double life gets imposed on the patient.

  3. The effect of that is that the delusion does not seem to propagate itself. The delusion stops at a certain boundary and it does not invade the relationship. Beyond that, the delusion itself does not grow much further, even though it seems to have a subterranean life of its own. It is like the delusion does not have much oxygen.

  4. Then, from within this split life, the islands of healthy relationships that develop with a wide variety of people also have an independent life. They are relatively free from delusion and begin to make the patient very curious about how these people live, how they work with their own lives, how they have relationships to people in their lives. And the patient is not shielded from any of this. The patient sees as much as he wants to see.

  5. There occurs a kind of occasional flicker, a shift of allegiance into wanting to live that way. Each desire in that direction leads to the problem I mentioned earlier. First, there is an awakening, being drawn to live like another, and then fear, guilt, and self-aggression. It is a crucial part of the work itself, to recognize the whole natural history of these moments of recovery and the deterioration of recovery. It is necessary to include all of that: to be able to accommodate the whole cycle of events in our relationship with the patient. Our desire for the patient’s health is recognized to include the same cycle of events. Because of our accommodation, the patient can accommodate the awakening of his curiosity and also his fear of humiliation.

What we mean by a healing environment then is not only the structure, but the potentiality of including all of the events of the patient’s psychology: the moments of recovery and the moments of illness, as well as the possibilities of further illness. In the same way, we include our own process of not clinging to the patient’s moments of recovery, not being drawn into any reward system, and not becoming discouraged as we see the unfolding natural history of those moments, which could lead to pain and depression. All of that is part of this environment, and it is used and related to precisely. We believe that this patient is in the process of recovery, which has this oscillating and vulnerable character.

Student: I wonder if your commitment to this man is to stay with him as long as his allegiance flickers back and forth, eventually going more and more toward recovery. Will you work with him around his choice to go back into the delusion, and to stay with that, and make that more complete, in a way? What I need to know is if your commitment is to stay with him as long as he is oscillating until he makes the choice clear?

Edward Podvoll: It is more of a sense of the gathering and accumulation of the flickerings. One image we might use is of islands of sanity that coagulate so that he spends longer times in it and less time in delusion. But much more than that is how he might learn to come out of the delusion. That is a further sense of journey, beyond his relationship to us. The sense of commitment is seeing him through his oscillations knowing all the time that his oscillations are our oscillations, and our commitment is to relate to our oscillations of, “Oh, he’s getting better. Oh, he’s getting worse.” It is going on all the time . . . hope and disappointment. How do we relate to his oscillations? That seems to be a large part of our work, both individually when we are with him, and collectively as a group. Our commitment is to work with ourselves and to work with him. We begin to learn more about the details of the process of how we might come out of the delusion, or at least stop it. That means him learning more about what this issue is of his “procrastination and hesitation.”

S: Is there a sense, then, of his becoming sane in the delusion?

EP: Exactly. It is in the phenomenon of procrastination that we find the intricacies of little practices. There is nothing to call them but “little practices,” because they are very heavy, intense disciplines of giving in, surrender, not exerting his will. There has developed a tremendous precision over the years in accurately seeing when and where he could not do them, when and where he procrastinates, and when he does not. He is down to micro-moments of mind’s existence, which has become a very accurate field of observation. The pinpoint of accuracy of his whole existence is sharpened in his delusion and so we have to work with where he is most accurate in his life. This seems to be the only place where he is truly accurate. It would be nice to just sweep away the delusion, but we cannot. Nor can he. Because that is where his intelligence is actually manifesting as his greatest precision and his pride.

S: I’m thinking about the treatment model and the old issue that we used to call “secondary gains,” and I wonder if an ideal world is being created for him that will be lost if he regains sanity. I wonder if he manifests concerns about that?

EP: The ideal world being the treatment environment itself?

S: Of course. It is wonderful. It is lovely. And I wonder if that is being built into his delusion in the sense of feeding the procrastination.

EP: Sure. This is one of the reasons why he is procrastinating. He does not want to leave us. He knows that if he harms himself in any serious way he endangers our being together. He occasionally burns himself with cigarettes, or shaves his head in an attempt to surrender, but these things are not quite working like they are supposed to. He is hesitating at the edge of more drastic acts, like taking his clothes off in the middle of Main Street, because then the police pick him up, then they take him to jail, then the hospital, and at best he gets out in six months, at worst two years. He knows the actual facts of his spiritual path. He knows all of that. But he does not want to leave us. He likes his little life. But it has a lot of irritations at the same time. We make him clean up the house (we do it with him) and change his clothes. There is a constant interruption to his love of television. He likes the people and he does not want to do anything to hurt us. So that is promoting the procrastination. We are a monkey wrench.

Now the next question would obviously be: since we throw a monkey wrench into his fully entering the world of delusions, we may also be a monkey wrench to his entering a more complex world that does not involve so many friends all the time. We have actually lived through that with another patient, the woman we talked about last January. She was very concerned about losing her friends as she became healthy but that turned out to be quite a good thing to worry about, a healthy thing to worry about. When any of us become healthier and more independent, there is a concern about losing people. Or that their only attraction to us has been because of our need for them. There is a lot to learn from that. We did not know what was going to happen, how it was going to turn out. As it turned out, she has not lost us. We see her socially without any real dependence taking place and losing the team has not been a dramatic event. At some point it was her desire to say, “Stop, I want to see what happens.” What she wanted to do was not only to live more independently and feel like a person who could actually live and work without the constant companionship which she had had for almost a year, she also wanted to know how she would relate to these people when they were no longer in her service. We also wanted to see. We did not know. Would we just drop her and say she’s gone? No. Instead there has been a continuing contact that has been very friendly. And we see that it might never end. It might go on for a long time . . . the continuing social contact no matter where she lives. That seems fine.

S: How did this man get in treatment with you, find out about you, and come into the program?

EP: That seems to have been an accident with both patients we worked with.

S: Did the patient bring himself in?

EP: That seems to be so, in any case, no matter who first discovers Maitri Psychological Services, whether it be a family member or the patient himself. The final common denominator is that the patient has to say, “Yes, that is the way I want to do it … not in a hospital, or a half-way house, or with lots of drugs.” The patient has to say, “That sounds right.”

S: I’d like to know at what point you discontinue the round-the-clock program. Do you gradually phase out?

EP: From everything we are saying, it is gradually phasing out so that even a patient that we stopped working with last March is still in some kind of contact with us and that is going through certain phases. It means that if we are talking about a sane, healing relationship, it may never end.

S: But do you make a conscious effort to eliminate blocks of time that person spends with therapists?

EP: To make it more efficient? 

S: No, just to phase out the contact he has with the therapist?

EP: What are the signs? I’m not sure. A lot of it comes from the patients—where they want to have more free time, more time to do things on their own. I think the edge of it is that they want to test the reality of this friendship, whether it is paid for or not. I think this becomes an intriguing point of where they want to cut down. “This person who says she is my friend, and acts like my friend, and does everything a friend is supposed to do, and makes me feel that way towards them … if there is no money involved, what is that going to be like?” I think they are intrigued with the possibility of testing that out. And then they want to have some room to see what is going to happen.

S: Could you say something more about how the staff works with their own oscillations of hope and disappointment? How does that relate to the patient doing the same thing? I wonder if it involves, if not common discipline, at least parallel disciplines. I can see how the staff would be working with experience in meditation and knowledge of the nature of mind oscillations in general. How would the patient find a way of working with his own oscillations and what the connections would be?

EP: Meditation practice alone is not quite enough to work with the clinging to the hopes and disappointments of another person’s health, about another person’s recovery. It seems that meditation experience has to be turned on by relationships, has to be further enriched or catalyzed by the intensity of relationship. That is one of the reasons we bring the patient into the group, into the extended family situation, so that we can talk exactly about this: that we are working with our own disappointments and our own tendency to reward health in an attempt to stabilize it and solidify it. We openly discuss how to not get caught up in each other’s moods, how our health and our functioning is not dependent on our moods. The patient actually watches us processing this and perhaps is internalizing that, but nobody knows what that means. At least, there is a model of how it could be done in an interpersonal context that he actually witnesses. It is in front of his eyes, how we relate to him, relate to other team members, and relate to our children. He sees us in a wide variety of life circumstances. He goes to dinner with team members. He babysits. He sees us in not just a professional, properly disciplined role in an office. He sees us on the line, on the spot, all the time. So, hopefully the saner we are the better the model is.

S: It sounds like a mutual commitment for working with others. You described this seminar in the brochure as working with Mahayana vision and it seems the patient could become infected in a sense with this way of going beyond the continual momentary obstacles that seem to come up, towards dedication to someone else and longing to not undermine that.

EP: It goes both ways. Even in the crudest sense of our working with people as professionals—which takes a lot of unlearning, a lot of recovery to do—we are depending on him. He is the cutting edge for us to be able to practice. Our recovery and our development as healers are totally locked into our relationship with him. It is interdependent recovery.

S: I’m wondering about your intensive psychotherapy with him and how it fits in. Moments of recovery are fleeting and it seems that part of what any recovery process would involve would be lessening the contrast or the distance with what he identifies as his experience and the moments of recovery he wishes for. Do you try to decrease that kind of contrast and whether that happens? That is traditionally what happens in a transference relationship with an analyst like yourself.

EP: I’ll attempt to discuss some of that later in a talk about the more intimate qualities of relationship. But, as you said, his idea of recovery is “liberation” and “enlightenment,” which means his concept of that. Our idea of recovery is that he might begin to reevaluate what liberation is and what his life might be like. It is true. We are at odds about that. We have gone through some quite intense episodes about that. We don’t understand him and certainly we can’t understand him, not having his unique and spectacular bodily and perceptual experiences. Nevertheless, we seem to come to some kind of reconciliation, that he has his path and we have our path and they are both quite valid. He knows all about our meditation practice. Occasionally his roommate does a retreat and comes back. He knows all about that. And he has met teachers of the Kagyu lineage—he has been quite fortunate to have done that, actually. But we have lived through a mutual respect for the essence of the spirituality that seems to be involved. That is, to transcend ego.

One might say, “How can you respect such a weirdo system as his?” Well, what we are respecting is his desire to free himself from the bondage of ego, which is excruciatingly painful to him. In some ways it is more painful to him than it is to a lot of us more ordinary folk. He has a recognition of constriction, of the painfulness of ego, and he is doing battle with it even unto death. William James talked about such people and said that basically the reason why they go so headlong, get so maniacally involved, with such spiritual paths is that they felt the pain of ego more than most of us do. We could say that about him. We’ve seen things like that about him and we respect that. We know that from time immemorial people have tried to deal with their lives and attempted to transcend the limitations of conditioned personality by throwing themselves into a do-or-die spiritual path. It must bring them to the edge of insanity. It is an old story. We have talked about that with him. He is one of those people who might cross into total lunacy or he might have some kind of spiritual development. But if he does it totally on his own without guidance or companionship, then most likely he will go crazy and he seems to understand that. So, it is a kind of mutual respect. That is what allowed us to put an end to the warfare of whose way was better, or who was doing the right thing, and who was doing the wrong thing, or who understood and who did not.

S: Could you say more about his family? I was struck by the fact that the most dysfunctional family member can bring about a positive process in his family, which seems different from what one is usually able to see in a treatment situation.

EP: Family work . . . people have talked for a long time about the family involvement, especially in psychosis, and the sense of “sacrifice.” That is, patients present themselves as a ritual sacrifice to a family that seems absolutely crippled to the patient. It is said that in this way the patient’s distorted and sometimes grotesque ways are attempts to heal the family. I think you could say there is a touch of that here, but for the most part it is not a very disturbed family. They have always loved this boy and his gentleness, in spite of the fact that they could not understand it. His father is diametrically opposed to him, or to put it the other way around, he is diametrically opposed to his father in terms of temperament. For example, this boy, who would not step on an ant at the age of three has a father who is a mountain of a man and a champion arm-wrestler. It is an interesting juxtaposition. They are actually quite friendly. The father loves this boy dearly even though he always wanted him to be more aggressive, and the boy recognizes the very soft quality of his father at the same time. But occasionally there are struggles about who is right. It is hard to fit it into any neat category. The family continues to visit more and they enjoy being around the team members.

Our general attitude to the family can be described by the example of our relationship to his sister, whom we have never met. The patient’s younger sister is disturbed by what happened to her brother. They had been very close until the time he went further and further into esoteric spirituality and she lost contact with him. When he entered a world of delusion, she felt angry at him and was frightened by contact with him. So we have invited her to visit. Our attitude is that we advise the parents that she should come here and make friends with him. He is not so difficult to be with and we can help her do this. For her benefit, he could actually be quite sane for a period of time. It would be very important for her to experience that and important for him to be able to do that for her. So fundamentally, our attitude to a family is the same as in any other healing environment: to provide opportunities for compassionate action to take place.

S: Do you think the staff will feel successful if the patient does choose to be insane?

EP: Probably not. Our work with him could be described as making him more conscious or aware and precise about what that choice is—to go further into his imagination or come out of it—and to make him more responsible for that choice. But that means that not making a choice is actually part of the process. The more he is aware of the minute details of the psychological phenomena of making such a choice, the less likely he is to make it. He becomes stuck on the edge of doubt.

I’ve wondered what it would be like if one of our patients committed suicide. We are working with disturbed people and sometimes they wake up, look around, and see what they have done with their lives. It is a poignant time. It could lead to wild despair. Will the group completely collapse or will it keep on going?

S: Actually, your answer reveals an assumption in being therapeutic: that helping this patient to be more aware of his own situation is the forecast that he will make the choice to be sane.

EP: That is the assumption. The assumption is that the joyfulness of ordinary life will be more attractive to him than the torment, bliss, and hell of his imagination. Do you think that is a good assumption?

S: I think so? 

EP: Well, sometimes we wonder, because psychotic ecstasy and sense of power is never forgotten. There is no way it is ever just put aside. Even those who recover most vigorously never forget, are haunted by the possibility of that kind of bliss. It is a constant magnetic draw and the choice has to be made over and over and over again. It is the issue of continuing effort beyond hesitation.