How to Deal with Madness?
First of all, I want to clarify that in this chapter I am using the term ‘madness’ to highlight the colloquial use of the phrase, and others like it, to refer to certain mental disorders. You will understand more of why I chose that particular term once you read this chapter.
When I was 22-year old I had the chance to work in a treatment center for people diagnosed with psychosis. This institution had been established as a response to a request from the authorities of a municipality located in the capital of Chile. This area had been overloaded by the consequences of this kind of diagnose — difficulty in having a job, for example, and the consequent homelessness — and their own lack of resources to provide care. The municipality asked a well-known Church congregation to address the issue. During the last decade, national government had dramatically reduced the number of psychiatric beds available in our hospitals, leaving individuals in need without access any form of treatment and, in many cases, without anywhere to even live.
The congregation in this area, in response to the request, established a small asylum for patients who were diagnosed with psychotic disorders such as: delusions, hallucinations, disorganized thinking, abnormal motor behavior, and negative symptoms (such as diminished emotional expression and severe lack of motivation to perform life activities), thus helping the neighborhood by addressing the most severe behaviors. There were thirty male patients living in this asylum, aged between thirty and fifty years old.
The conditions were theoretically not bad, at least compared to other asylums. There was a room for each patient, plus a living room and outdoor yard for common use. Unfortunately, the living room door was kept locked and it was only used when one of the staff brought a movie for everyone to watch. The yard was a space of nearly 100 square meters of bare dirt and nothing else. Not even a chair or a table. Not a single thing.
The only office in the asylum, used exclusively by the staff team, had a corner filled with a great number of boxes full of the patients’ files. The first thing I did, of course, was to read the files of the current patients. They contained nothing but diagnoses.
One after the other, each file contained multiple diagnoses, often contradicting each other, that were made by dozens of interns or psychology students who came to do their assignments in this institution, and then left.
The director of the asylum, who was the only psychologist working there, told me that the reason there was nothing written about treatment in the patient files was simple: the only kind of psychological treatment that was carried out in the asylum was the weekly body psychotherapy carried out by her. This treatment approach is a physical rather than verbal modality that involves moving and touching the body. This treatment was offered in addition to a pharmacological-based assessment made by a psychiatrist once a year to assess what medications were to be administered to that patient for the entire year. These two treatment combined — especially with the low frequency that they were administered — do not configure the adequate psychological or psychiatric care at all.
After reading the files, I proceeded to make my own diagnoses for each of the patients. What for? I needed clear diagnoses, free from the contradictions in the files, that would allow me to define what would be useful for the patients, for their benefit, for their dignity. A patient is not interested in knowing what kind of psychosis they are suffering from, if it is not reflected in the treatment they receive. I wanted information about each one of them, what was their opinion about living here, what things did not seem right to them, what changes they would make. I wanted to treat them like any human being deserves to be treated.
After deciding I needed to make these diagnoses, I realized I had to look for a place where I could see the individual patients in order to make them. Even though each patient had a room of his own, they only contained a bed and a bedside table. I finally chose to take one of the chairs from the living room and turn it into ‘the therapist’s chair’, bringing it to the room of the patient I was seeing at that time. After a while the patients were able to perfectly distinguish between the psychotherapeutic context when the chair was in their room and the informal context when we were in the yard or having breakfast.
What did I find out? I think that the first conversation I had with a patient reflects the situation quite well:
Jorge: How about talking for a while?
Patient: Yes, no problem. I like talking, no one here talks with anyone. Sometimes other psychologists come. Are you going to show me some spots or something like that?
J: No, none of that… the idea is just to talk, maybe more than once, so I can get to know you better.
P: Hmm… I’m not someone interesting… my life has become something pretty boring… the only thing I want is to get away from here, I don’t want to be here anymore… I don’t have any problem talking with you, but if you ask me what I want, I want that, I want to get away from here… every time someone asks me how I’m doing, I say the same thing… I want to get away from here… but nobody listens, nobody does anything…
When I asked him about what he would like to do, he said “a lot of things… being able to do things with my hands… we can’t do anything here… we just lie down in our rooms and that’s it. They don’t understand that we’re still alive, we have faults but we can live, it’s not a death sentence…”
The rest of the first interviews with the patients were practically identical. Everyone was bored and tired of not being able to do anything. However, shortly after I began talking with each one of them every week, they became more active and started to spend a little more time with each other in the yard.
The director told me that it seemed odd to her that they spend time in the yard during the day, instead of being in their rooms. “Why do they go to the yard if there are not even chairs?” she said.
I contacted the congregation running the asylum and managed to obtain some secondhand tables and chairs that we put in the yard. I then had the idea of painting a checkerboard on each of their surfaces and giving each patient two sets of checkers to keep in his room so that they were not dependent on staff for access.
When I came back a week after setting up the tables, the staff who worked at the asylum were not so happy with the results.
The patients now spent most of the day in the yard, either playing checkers with each other or talking. Some of them had asked the director for chess pieces, a request that had not yet received an answer. The staff members explained to me that when the patients spent all day long in their rooms, staff worried less about them and could focus on the administrative duties of the asylum instead (cooking, cleaning, etc.). But now that the patients were spending time together, the staff had to watch them all the time, which made their work more difficult.
In response to this position of the staff, the director told me that they would leave the tables and chairs where they were for one more month, since maybe the patients were interested in them simply because they were something new, but she also told me to be less encouraging of interaction and to stop “causing trouble for the staff.”
After a month, the situation just got “worse.” The patients kept playing in the yard and talking with each other. The daily meals were not in silence anymore, but with the human noise of conversation. Some of them even told me their ideas about new changes they wanted to see in the asylum. Above everything, they wanted to do more things. They wanted to feel useful. They wanted to feel human.
The staff, however, did not know what other things the patients could do in the asylum without causing more work for them. Finally, after an exhausting meeting between myself and the fulltime staff, they agreed to give the patients a dusting cloth so they could help clean their rooms. You cannot imagine the smiles that this simple right brought to the faces of the patients.
The few relatives who visited the patients were aware of the changes, mostly because of the fact that their relatives now talked with them more easily and pleasantly. It was not like the conversations they could have with other people, but to them the change was significant. The frequency of these family visits increased, and we managed to have them bring movies for the patients to watch.
The lesson I learned from all of this is that the most basic elements of how we treat the people that society had deemed ‘mad’ — particularly in a treatment center that will house most of the patients for the rest of their lives — is fundamental to their recovery. This may seem obvious to you but, as you can see, in this account there is not a single psychological technique applied, just a little common sense, empathy, and compassion, and yet the intervention resulted in dramatic change in the lives of the individuals.
I would have loved to immediately start applying the treatments of the school where I was trained, meeting the problems of psychosis and facing them with the tools I learned at university. Yes, I would have loved to, because I love my profession. But first I had to just listen to them, trying to grasp their subjective position even amidst these peculiar circumstances.
Unfortunately, this story does not have a happy ending. After maintaining the new setup for a couple of months, the director told me that the asylum could not go on like that. Due to the increased activity of the patients such as interacting in the yard, going to visit each other in the rooms, the presence of relatives, etc. it was necessary to have more staff members on active duty at any given time. She said that there were simply not funds to expand staffing and so they had to make the patients spend more time in their rooms, set a schedule for use of the yard, and limit the frequency of the relatives’ visits to the weekend.
In an institution supposedly dedicated to the care and treatment of human beings, basic human needs for socialization and activity were not allowed.
It is not clear who is mad, the patients or our society.