Provocative Therapy Articles

I am about to start a series of Provocative Change Works events across the globe, starting in Japan next week. During trainings I always explain the meaning of the term “provocative” in the context of therapy and how it is also used to best effect in all kinds of other communication situations. Unfortunately the term “provocative” can be seen by some folks as either “an aggressive approach” or “a comedic approach”. Yes there can be humour in provocative exchanges, but the purpose of a provocative session is not to “try and be funny!” and certainly not to be aggressive with the client.
Provocative Change Works is inspired by Frank Farrelly’s Provocative Therapy and learning these PCW skills takes a great deal of skill and application. The challenge for me when running workshops is to find the right balance between demonstrations, explanation and group exercises and to ensure workshop attendees maintain the right manner when using these skills. Since I first met Frank Farrelly I have promoted both his work and my own PCW approach at every opportunity and departed from teaching classic NLP courses. This has led to setting up some great provocative online resources, but regardless of how much information I put out it seems that some folks just don’t get that provocative does not mean “aggressive” or “sarcastic!” Interestingly it’s usually those who have a CBT or NLP background who struggle most with this approach. I do have some sympathy for such folks though; I too was totally confused when I first attended a Frank workshop. Fortunately I had the good sense to appreciate that it would take more than a few days to grasp his work and many years later the investment in time and energy has truly paid off.  I have found that the PCW approach is far more dynamic and creative than what I was taught on my certificated NLP trainings from years ago! However these trainings really helped me figure out what Frank does and formulate my own PCW approach.
The Provocative Icon System I use in PCW and PT trainings is excellent in teaching the many different stances a practitioner can adopt to create client change. These icons represent 36 different potential stances and combinations of these stances are highly effective in provoking useful change. However it’s not enough to merely teach how to adopt these stances. The PCW practitioner needs to also have the manner of working with a client that Frank Farrelly describes “as if talking to an old friend” Despite all the talk of flexibility in workshops, this seems for many to be one of the biggest challenges. I have only seen a few people able to work effectively as provocative therapists and most of these have studied with Frank for many years. In 2006 I set up The Association for Provocative Therapy (AFPT) with Frank’s blessing and I am pleased that Dr Noni Höefner a Provocative therapist of 26 years standing is also a key promoter of AFPT standards in trainings. Noni is one of the smartest trainers I have met with superb flexibility and creative skills.
One of the main challenges for therapists and practitioners watching a provocative session for the first time is accepting that it is very different to NLP, Hypnosis or other types of therapy. The client in the session has an experience that is very different to those who are observing the session. Sometimes well-meaning observers want to “rescue the client” rather than allowing the process to unfold so the client can process the interaction in their own time. This can produce some quite interesting scenarios in trainings where groups find that they have also had their preexisting ideas about communication seriously challenged. A PCW practitioner seeks to provoke new insights for the client and this is always done in a conversational manner. In order to achieve this, the practitioner needs to pay close attention to the client’s responses and while maintaining his or her own excellent state control.  Many new to this kind of approach find this very difficult and if the client shows any kind of emotion the therapist often immediately backs off or tries to placate the client, not realizing that this is often not the most useful strategy. In my experience many clients have had decades of tea and sympathy, psychoanalysis and counseling none of which has been especially useful. This is not to say that these approaches have no merit but rather, not provoking any real change in the client leaves the client in the problem state. Some talk therapy approaches even insist that a practitioner should refrain from influencing the client at all! Many such enthusiasts treat therapeutic situations like an academic discussion, which is fine, but often not especially useful for the client. Provocative Change Works is a conversational jargon free way of working. This absence of jargon in my opinion makes for a more honest and natural communication and my experience is that clients find they need far less session time to resolve their issues.
I have noticed that the obsession with “quick fixes” “fast phobia cures” in the personal change market has increasingly created a level of expectation for both therapists and clients that is in my view both unhelpful and unrealistic. I have blogged about this previously and of course I am accused of “attacking X approach” which of course is not the case at all. I am simply pointing out that it you over hype expectations then ultimately no claims are seen as credible. Developing the skills needed to provoke useful change for a client requires the practitioner to be able to improvise on the fly and to have an extensive range of verbal and non-verbal responses. I rarely see practitioners, trainers and therapists who can demonstrate this ability and this is a far cry from the academic, logical, digital and analytical approaches that are often found in some approaches. I have also noticed that some people have started to add the term “provocative” to their therapeutic descriptions with little awareness or regard to Farrelly’s work. I receive all kinds of communications about how to become a provocative therapist and many enquirers are disappointed that they can’t get a weekend certificate to add to their existing certifications! This week I had an enquiry by e-mail asking if you could become a provocative therapist by reading Frank’s original book!
The new revised PCW site – www.provocativechangeworks.com has a wealth of information on PCW in articles and videos. In many ways PCW and PT are the polar opposite in approach to many traditional talk therapy approaches. In many instances talk therapy approaches are conducted in such a disassociated manner that the sessions become little more than role playing scenarios in which either therapist or client believe that anything useful will occur. That is not to say that these approaches have no value. However I suspect that the success with these approaches is more due to the therapist’s manner than the actual techniques used.
I have personally used the Provocative Change Works approach with over 3000 clients and have found this approach to be the most effective method to help with client change. Most who study with me can learn the provocative stances, but those who really become proficient in this approach have a great sense of humour, don’t take themselves too seriously and have a genuine care for helping others. I always make it clear that PCW is not the only way to produce excellent client results but my interest in any model of communication is in what you can do with it, rather than any academic style study. There seems to be many who agree with this sentiment and I have never been busier either with trainings or with seeing private clients in my UK clinics.
 The full schedule for 2012 international PCW training events can be found at http://www.nickkemptraining.com/calendar.php and this May I will be running a skills development day for previous workshop attendees who want to explore PCW in greater depth.

The code of loyalty among delinquents, prison inmates, criminals, and certain oppressed minority groups is a well-known social phenomenon.  This code of behaviour represents not only the acceptance of socially deviant group values but specifically prohibits a member of the group from consorting with members of other groups, especially those representing “authority”.  A breach of code, resulting in the apprehension or punishment of other group members, is likely to result in social ostracism, ridicule, physical punishment or death for the transgressing member.  Such epithets as “stool pigeon,” “stoolie,” “rat fink,” “teachers pet,” “ass-kisser,” and “brown-noser” are reserved for those individuals who cooperate with authority figures responsible for controlling or modifying the behaviour of the group in which these individual belong.  Of interest is the ambivalent attitude of those in authority toward “informers”.  On the one hand they are dependant on these people for vital information; and the other hand they regard informers as traitorous and despicable.  In a sense, then, both the deviant sub cultural group and the group vested with authority have formed an unwritten and informal pact to withhold sanctuary and solace from people who break the group code.

Although such codes have been commented on widely, little has been written about the existence of similar type codes among hospitalised chronic schizophrenic patients.  Not only are such codes operative in a closed ward setting, but attitude
of staff toward patients breaking the code often parallel those of persons in

 
1.    Chairman, Department of Psychiatry, university of Kentucky Medical School, Lexington, Kentucky
2.    Clinical Director, Family Social & Psychotherapy Services, Madison, Wisconsin

authority toward informers.  A situation, therefore, is unwittingly created whereby patients find it difficult to relinquish their identification as chronic patients and to adopt more socialised values and attitudes.

To the degree that the foregoing is true, then one of the central problems in dealing with groups of chronic schizophrenics is to cope somehow with this code; as long as this rehabilitating the chronic schizophrenic becomes overwhelming.

The existence of such a code became readily apparent curing the early phase of our experimental treatment program for 30 chronic hospitalised schizophrenics.  These patients, consisting of 16 males and 14 females, were selected from various wards throughout the hospital and housed together in a single building where the new intensive treatment program would take place.  Included in this group were not only patients who had made themselves inconspicuous during their years of hospitalisation by virtually “crawling into the woodwork,” but also patients with a history of multiple elopements from the hospital and serious aggressive and sexual acting-out problems.  All these patients had been intensively treated with a variety of activity, pharmacological and psychotherapies; the net result was pervasive staff pessimism about their response and prognosis.

Since a primary purpose of the ward was to evaluate various psych-social techniques for the modification of behaviours and the rehabilitation of patients, the general ward policy was to control patient behaviour without ready access to such convenient EST, tranquillisers and sedatives.  For most patients and staff, this was a new experience and soon brought to the fore many therapeutic problems which previously had been suppressed by these traditional practices and procedures.  For example, a heavily tranquillised patient is not likely to engage in either deviant of therapeutic group interaction.

Because of the limited number of unit staff and virtual elimination of pharmacological restraints to control behaviours, it became obvious that the patients themselves would have to assume the major brunt of the responsibility for modifying and channelling each other’s deviant of potentially harmful behaviour.  In a word, since we could not adequately “police” them patients had to police

themselves.  Once the unit staff had accepted this position, it soon encountered head-on a number of traditional attitudes held by chronic hospitalised patients, as well as staff, which made the enforcement of such a position extremely difficult.

These traditional attitudes and their consequent behaviours we have come to term “The Code of Chronicity.”  This code, partially reinforced by staff and society, tends to perpetuate “crazy” behaviour, helps sustain a staff-patient barrier leads to the acceptance and rationalisation of continued hospitalisations and thus effectively eliminates any incentive for change, improvement, and eventual discharge.

Some of the essential components of the code which we have observed to date are described  below.

Characteristics of Code of Chronicity

A.    The Staff as Jailers

Since the therapeutic zeal of most staff has long since waned toward these patients, the patients eventually come to view hospital staff more as jailers, custodians, wardens, keepers or guards than as therapists.  From the patient’[s perspective, the staff, similar to prison authorities, determine length of sentence (hospitalisation), grant parole (conditional release), award privileges, and mete out punishments,

Although staff may view themselves as therapists and regard all their efforts as “therapeutic2, they (as well as society) seem to reinforce these patient attitudes.  Patients accurately perceive that staff do, in fact, “police” patient behaviour, suppress acting-out and determine privileges.  Although staff may not be permitted to physically “punish2 patients for deviant behaviour, under the banner of “therapy” and the scientific appellation of negative reinforcement, they are permitted great latitude in handling this behaviour.  Restraints, seclusion, EST, and drugs are effective ways for keeping patients “in line.”

B.    The “Model Patient”

Most of our chronic patients seem content to reach the enviable goal of attaining the greatest amount of privileges, the least amount of restrictions, and minimal demands put upon them without having to leave the protective setting of the hospital.  To attain this goal, all patients need to do is to participate perfunctorily in scheduled therapeutic activities, such as occupational and recreational therapy or group therapy meetings, perform a minimal work assignment, remain inconspicuous enough so that some staff member with therapeutic zeal might not be tempted to push them out of the hospital, and not act out overtly (a therapeutic taboo).  If patients can meet these criteria, they are gratefully accepted by the hospital staff and administration as “key workers” who are “co-operative with ward routine” – a source of cheap help and essential to the maintenance and repair of hospital grounds, facilities and services.  Thee model patient this becomes a sub-staff member.

C.    The “Un-Dead” State

In Bram Stoker’s Dracula, there is a description of people who turn into huge vampire bats at night after remaining in an unfeeling, non-reacting, trance-like “un-dead2 state during the day.  The expectation and behaviour of chronic patients often parallel this description.  They can not tolerate emotional stress or discomfort of any kind, be it fear, anxiety, depression, love or human closeness, and immediately seek to quell these feelings.  They seem to prefer the foggy, benumbed calm of tranquillizers, the stuporous feeling of sedatives, or the confused oblivion following EST to the unpleasant experience of their own thoughts and feelings.  Minimal involvement, minimal feeling, minimal thought, and minimal stimulation by others help preserve the equilibrium of chronicity.

Hospital staff, on their part, help meet these patient needs.  Out of sympathy and concern for the patient’s plight, staff minister the mental
healing balm of tranquillisers, sedatives, and anti-depressants as soon as the patient seems upset enough to gain the attention of staff.  Since it is “inhumane” to allow the patient to continue to suffer, it becomes incumbent on empathic staff to dull the edge of patient anxiety or allay his fears.  Moreover, the “quiet ward,” highly valued by administrators and staff, is considered necessary to the smooth functioning of a hospital and to “good therapeutic practice.”

D.    Victims of Society

Though not true of all patients, many regard themselves as social pariahs – outcasts of a disinterested and uncaring society.  They come to view society, or certain social agencies or institutions, as vaguely responsible for their present predicament.  As a result of their being “short-changed,” society owes them recompense.  After years of hospitalisation, they begin to consider themselves entitled to total care.  They become chronically and aggressively dependent and come to feel that everything they receive they have coming to them.

Another variation of this all-pervasive attitude may take the form of a personal vendetta against society for its harshness and rejection.  Patients feel that they have been “dealt a raw deal” by life, and their global response is not flight but fight – to strike back at, get even, and settle accounts.

As society’s representatives, hospital staff often do, in fact, appropriately feel sympathy toward patients for their past sufferings.  However, through misguided kindness and understanding, they may reinforce a patient’s attitudes and  behaviour by exonerating present “sins” on the basis of the horrible circumstances of his past life.  Moreover, they may refrain from venting anger punishing a patient for acts, which under normal circumstances would be reprehensible, simply

because they understand the psychological genesis of his behaviour.  To understand may be to forgive, but to forgive a deviant act without punishing it (euphemistically termed “negative reinforcement”) may be to condone, encourage and perpetuate it.

E.    Representation Without Taxation

Patients have been well taught the principles of democracy, equality, therapeutic community and the virtues of teamwork – so much so that they vociferously claim their inalienable right to behave as they choose but speak in whispers, if at all, about their corresponding obligations and duties.

Hospital staff have provided patients with numerous opportunities and forums to voice their gripes and participate in decision affecting ward privileges and routine.  However, under the banner of self – determination and therapeutic decision making, patients are frequently granted privileges without corresponding obligations – a situation which had no comparable model in society.  In society, a person gains and prerogative or being heard by assuming the obligation of being productive and consistently fulfilling the role of responsible citizen.  Where the model breaks down in the mental hospital is precisely at this point: patients are all too often granted representation without being expected to pay the taxes of appropriate socialised, responsible behaviour.

F.    Insanity by Convenience

Chronic patients seem to harbour certain paradoxical attitudes whereby they expect to receive the prerogatives of both the crazy and the sane – the best of both worlds.  If they act crazy, they “couldn’t help it”; if they act sane, they deserve rewards.  They regard themselves as responsible and capable of handling things they want to but regard themselves as helpless and incapable of controlling impulses or confirming to unpleasant
staff or group demands.  In other words, they expect plus points for sanity and no deductions for insanity.

Staff respond with double standards to the paradoxical expectational system and behaviours of the crazy-sane patient.  If patients act crazy, they are not to blame; if they behave normally, they are given privileges.  This situation does not pertain to real life; in the extra-hospital society, deviancy is punished, sanity is rewarded.

Anybody who has worked with many chronic schizophrenics over a considerable length of time also can see that their craziness does not remain full-blown constantly, but is a some-time thing.  We have gained the distinct impression that patients may frequently turn their craziness off and on in both a predictable and non-predictable manner.  We believe that the aperiodic nature of many patient’s craziness effectively pays off for them in a variety of ways, not the least of which is continued hospitalisation.

This pattern of patients’ behaviour tends to be met by complementary staff attitudes, which usually include the following components;
    
i.    The patient must be sicker than we thought;
ii.    He obviously is not ready for discharge;
iii.    He had better be kept in the hospital for a while longer, a while longer, a while longer

G.    Not My Brothers Keeper

After years of hospitalisation, patients begin to loos all sense of social or group responsibility.  They regard their own problems as unique or overwhelming, and others be dammed.  If they observe sexual acting – out in others or aggressively destructive behaviour, then it’s the staff’s job to intervene and re-establish equilibrium and ward peace.  They have


enough problems of their own to worry about and can’t be bothered taking the responsibility for others.  Their attitude is one of “me, myself and I”.

For the most part, hospital staff tend to perpetuate this attitude by intervening, subduing the offender, and not placing the burden of responsibility on the shoulders of the patient group.  Unfortunately, staff unwittingly tend to discourage meaningful patient – to –patient interaction by protecting them from each other.

H.    The weapons of Craziness

When a patient does lose control of his behaviour, strikes other patients or staff, he knows that staff cannot retaliate in like manner.  Even when the staff feel that a good kick in the pants or a slap may be infinitely more therapeutic than a tranquilliser pill in controlling patient behaviour, they are bound by the “humane” principles of kindness, understanding or restraint.  Physical punishment is taboo and has no place in a modern therapeutic institution.  In the ongoing struggle for control between patients and staff, the staff must engage in battle with one hand tied behind.  The patient can fight as dirty as he likes using alley rules (thumb in eyeball, knee in groin).  Staff are conscientiously bound by the Marquis of Queensbury rules.

In addition to the limitations (well know by patients) i9mposed upon staff, patients may also utilise the weapon of “if you upset me, I’ll make you wish you hadn’t”.  If confronted by staff, patients may implement this unspoken threat by losing “hard won therapeutic gains” staying up all night and bizarre behaviour.  When patients respond in such a way following staff confrontations, staff inevitably assume that they have pushed the patient too fast and too far.  The possibility of a patient getting upset is, in effect, a club held over the staff’s collective head.

It would also be noted that the patients utilise these and other weapons in an unflagging war of attrition against staff’s therapeutic efforts.  The “Hard Core” patients are those who have successfully met and worn down staff group after staff group, until one gets the distinct impression that staff may come and staff may go, but his type of patient remains forever.


The Code in Operation

Shortly after the initiation of our experimental treatment program, it became clear that members of the chronic patient group, in order to enforce group solidarity, cold and did reward one another with affection, conversation, money, cigarettes and companionship.  By the same token they could punish one another by ostracism, threats, physical assaults, and by with holding the above-mentioned rewards.  Because these rewards and punishments given within the patient group were concrete, meaningful and immediately contingent upon certain deviant behaviours they were extremely potent in perpetuating the code of Chronicity.  On the other hand, staff’s reward’s and punishments were viewed by the patients as relatively intangible, meaningless, and boo long-term; by default, then, the code could easily flourish.

Staff soon learned that a number of patients were engaging in various forms of acting out behaviour.  However, few patients felt under any obligation to intervene or even inform staff of what was happening even though the behaviour of these other patients was potentially harmful to themselves or others.  By engaging in this “conspiracy of silence,” the so called innocent patients were truly accessories after the fact.  Many knew when certain patients either had planned to flee, fornicate or fight on the ward but preferred to let staff find out for themselves.  When some patients were confined to the ward and denied coffee and cigarette privileges, others held break these rules by smuggling these items to the restricted patients.  In short, the group of patients either actively or passively, either consciously or unwittingly, undermined staff efforts.



Attempts to Break the Code

Since we came to feel that the existence of such values and behaviour could only prove detrimental to patients and reinforce their Chronicity, we set upon a grogram to break the code.  Obviously, we were not dealing with a group of fragile, broken spirited persons but rather with tough, formidable adversaries who were “pros” and who had successfully contended with many different staffs on various wards in defending their title of “chronic schizophrenia”.  In attempting to break the code held by this group, we were specifically interested both in reinforcing the healthy aspects of group loyalty and eliminating the self and socially destructive aspects of group identification.

To contend successfully with patients, we were forced to adopt certain working assumptions.  Basically, these assumptions, and the tactics derived form them, represented attempts to break away from a number of traditional staff attitudes and behaviours which we believe tended to perpetuate or, at the best were impotent against the code of Chronicity. 

First, even though considered insane by psychiatric and social standards, we regarded all patients as responsible for their behaviour.  If pressed to do so, they could exercise the choice of getting well.  Granted this assumption did not conform to many notions regarding the biochemical etiology of schizophrenia, which may still be valid, but since no pharmacological cure was readily available, the question of such an etiology is purely academic at the present time for the purposes of treatment.  If we were to act, we had no choice other than to adopt a psycho-social basis for patients’ behaviours and psycho- social techniques to modify them.

Second, since all patients were living together in one unit, the behaviour of any one member, for good or bad, reflected on and influenced the whole group.  Just as the deviant behaviour of a family member can affect eh welfare of the whole family, we believed a similar phenomenon to be operating on the ward.  Patients in fact were their brother’s keeper, whether they liked it or not, and they were obliged to intervene to prevent the deviant behaviour of their fellow patients from affecting the welfare of all patients on the ward.  Instead of ward staff having the major

responsibility for modifying patient deviant behaviour, the patients themselves were expected to assume this task.  Moreover, and just as important, in helping others, they were helping themselves.

Third, there was no need to snow someone with medication simply because he happened to be experiencing intolerable feelings of anxiety, fear, depression, or insomnia.  Patients would have to learn to live with and live through these feelings without ready access to agents which would produce mental oblivion.  They would have to find other constructive ways to coping with these feelings or just to bear some suffering, if they were ever going to learn to live humanly and productively on the outside.

Fourth, staff would provide as little reinforcement as possible for pathological or deviant forms of behaviour.  Patients would have their craziness pointed out consistently and insistently.  Furthermore, the privileges they received were not automatically coming to them but were contingent upon the performance of desired behaviours.

Fifth, patients’ present behaviours were judged all important.  Even though we recognised that past experiences had shaped their present conflicts and behaviours, such psychological genesis was deemed irrelevant for two reasons.  A variety of etiologically oriented treatment approaches had been tried with these patients and failed.  In addition, present behaviours were the only ones which we could see, attempt to eliminate or reinforce, and measure.

Sixth, to become well, patients would have to think, feel, and behave similar to staff as persons.  The concepts of normality and sanity as therapeutic goals were too intangible and vague; we would have to deliberately concretise these concepts by insisting that patients employ staff persons as models for behaviour.  Despite our visible faults, foibles and inconsistencies, we would expect patients to “be like staff – warts and all”.  Furthermore, we would not play at democracy in therapeutic community meetings; not the majority, but health and sanity, as defined by staff would rule.


With these initial assumptions as a basis, we began searching for effective methods to implement them.  Our goal was to raise the price of Chronicity.  Initially we tried talking at considerable length about patients’ behaviours at ward group meetings; these discussions and homilies had little if any impact.  Appeals to reason failed, and attempts to compromise were either ignored or viewed as weakness by these patients.  Obviously, if patients were to be rehabilitated, the cold war stalemate between patients and staff could not continue.

Once we had accepted this conclusion we were forced to employ a number of tactics aimed at undermining the unhealthy aspects of patient group solidarity.  If patients chose to fight for and defend their maladaptive and self – destructive way of life, we would have to escalate out efforts in the battle for life, we would have to escalate out efforts in the battle for their sanity.  To pursue the war analogy further, we fully realised that if patients “won” this battle=, the paradoxical outcome was that they would really lose in human and socially meaningful ways.  The only real chance patients had to “win” would be for them to capitulate completely to the therapeutic efforts of staff and accept unconditional surrender to our value system.

Since our ultimate aim for all patients was to help them realise their fullest potential as human beings, we were committed to the notion that an occasionally unhappy but productive, socialised person out of the hospital was infinitely more desirable than a happy, unproductive institutionalised schizophrenic.  Therefore, if we were to break the code of Chronicity, we had no other recourse but to employ strategies designed to “divide and conquer.”  To this end, patients were deliberately played off against each other by making each patient not only suffer the consequences of his own deviant behaviour but also the consequences of other patients behaviours toward one another and toward staff.

In order to undermine further the chronic patients’ value system, we decided to utilise many of the same concrete, meaningful, and immediate rewards and punishments that patients themselves employed to perpetuate it.  Minor infractions of ward rules were met by the usual loss of certain privileges.  However, if any member of members of the patient group went AWOL from the hospital, or

engaged in forbidden aggressive or sexual activities, the entire population would be restricted to the ward and lose all privileges for three days if no one attempted to intervene or to inform staff.

Although we sanctioned and encouraged patients to vent their anger and to defend themselves appropriately against attack, to intervene and restrain other patients engaging in fights and to prevent fellow patients from funning away from the hospital, we never failed to insist that these behaviours be employed within the boundaries of moderation and discretion.  Staff were always present on these occasions to guarantee that these boundaries would be observed.

Basically, the therapeutic rationale for our position was that we were not going to overprotect patients from the consequences of their own behaviours or from offending group members; we hoped to mobilise the potent forces of the peer group to modify inappropriate reactions and to increase coping behaviours.

In addition we clearly communicated the value that “squealing” on or actively controlling other group member’s unacceptable behaviours was good when it was against a bad code.  Contrary to the generally ambivalent reactions of persons in authority toward informants, we offered sanctuary, concrete rewards, and staff approval for those patients who thwarted their own group’s destructive values and behaviours.  The purpose of all these strategies was to make the survival of chronicity a luxury which patients could no longer afford.

After the first several times that the ward was placed on restriction, many patients began breaking out of their shell and directing their anger (which at first they expressed to staff) at the offending persons.  Interaction at ward meetings became heightened, and patients who previously had only the staff to recon with, now had to take on their fallow patients as well.  They soon came to see, in a very concrete way, that the behaviour of other patients did truly affect them and that they had to cope with other patients to preserve their own rights and privileges.

Soon patients began preventing others form eloping, either talking them out of it or informing staff of the proposed escape.  At the encouragement of staff or on their own initiative, they intervened in fights, restraining the offending parties.  They became offended at aberrant sexual behaviour and reported instances of this to the staff.

At the same time, these instances were discussed openly at general ward meetings.  The discussions seemed to become more meaningful, and the topic of responsibility, which at previous meetings had seemed mainly of theoretical interest, now began to become a reality.  Several patients voiced the bind they were in by “squealing” on their fellow patients or acting toward them as staff would.  They felt if they betrayed their code, then they would not know who they were nor to whom they belonged.

We recognised their dilemma as painfully real; nonetheless, we actively manipulated ward situations and meetings in order to force them to stop procrastinating and make the agonising choice or which values they would adopt – patients or staffs.  However, they knew that if they made the “wrong” choice, we would make it uncomfortable for them.  In effect, we attempted to out – bind them.


Final Remarks

At this point, it seems appropriate to change our focus and discuss briefly the process of modifying staff attitudes and behaviours toward the chronic schizophrenic.  Such modification cannot take place without much soul searching.  Most professional staff have been taught and have come to adopt a variety of humane and therapeutic attitudes concerning the general care of psychiatric patients.  These notions, which are largely appropriate and helpful for the majority of patients, from our experience do not seem efficacious for institutionalised hard – core hospitalised chronic schizophrenics.  The perpetuation of such staff attitudes and their concomitant behaviours had proven futile in the previous treatment of this particular category of patients.


Although the experimental treatment unit staff, for the most part, showed a great willingness and enthusiasm to change their treatment orientation toward these patients, we were (and probably will continue to be) confronted with a number of our own doubts and questions and those of respected colleagues – all of which constitute considerable pressure against such change.  The pressures for therapeutic conformity are great, especially when staff receive opinions from others that the procedures employed are “punitive,” “unfair” and “inhumane”.  None of us are immune or insensitive to the negative remarks of highly regarded colleagues or to our own doubts about the validity of non-traditional procedures.  As a result, the unit staff have all spent many struggling, self-questioning hours at meetings focused on the ethics and efficacy of the procedures.  Nonetheless, the one over-riding consideration remains the rehabilitation of these patients, and, at this juncture, we feel we are on the right track.

Finally, in presenting our conceptualisations and experiences, we do not wish to give the impression that we have successfully broken the code of chronicity at this point or that every patient has responded to our efforts.  We are still in an early phase of our treatment research program and plan on employing and evaluation a variety of other techniques.  At best we are engaged in on ongoing struggle with these chronic patients and our successes have been limited but discernible.  A number of patients still seem too disorganised or uninvolved to respond to these techniques or even to attend to what is transpiring.  Moreover, we also wish to emphasis that we do not necessarily regard our efforts to break the code as a therapeutic end-point in itself but rather as a beginning.  We conceive of these assumptions and techniques as a sine qua non in making these patients more accessible to other forms of therapeutic intervention.

Arnold M Ludwig MD1 and Frank Farrelly ACSW2
Published in archives of General Psychiatry, December 15 1966

I’m Dick Goldberg and today we’re going to be talking with a man who can talk about almost anything and everything to do with people, the mind, psychology, therapy, you name it.  Frank Farrelly, the founder, the inventor, the practitioner of provocative therapy.  Therapy which sort of makes people laugh at their problems.  Frank was with us a few weeks ago.  We were going to talk about dealing with teenagers.  We get off the subject and I’m totally responsible under the subject of power, who has it, how they get it.  It was a fascinating discussion but we never got to the subject at hand.  I got an irate phone call from some one  understandably saying you’re dumping on teenagers like they’re typically dumped on and we promised to have Frank back soon and do this show, so here we are.

Frank Farrelly, I know you’re a therapist, we all know that.  What are your credentials to tell us about teenagers?

Are you sure it’s just kids?

There are a lot of therapists who practise in the area of working with children, working with teenagers, who are 30 years old.  30 too is old not of course yet a teenager Are they qualified?  

Your youngest child is now how old?

So you’re through it?

I have a hard time liking teenage boys.  I’ve never had a teenage boy, but um

Teenage girls are as difficult eh?

How about your experience as a parent?

If you look at those periods from birth to 5, then from 5 - 10 then 10 – 13 then teenage years, which do you enjoy most as a parent?

I would suspect most parents would report the teens are the toughest time to be a parent. 

What?

A grown up or a kid?

What is so tough about that Frank, if, let’s say we’re talking about a 15 year old girl who at one moment seems quite adult and then the next moment quite dependent.  What does that do to the parent?

She wanted you to put the limit on her?

Do you then, act to the teenager as primarily a parent figure, a friend, a counsellor?

What about 15 year olds, 16 year olds?

You’d still be clearly the parent when they’re 16, do they still need the structure?  Should you be a friend, a peer or a parent?

"Provocative Change Works for Phobias" DVD set can be purchased from www.human-alchemy.net