My first response to this woman would be to say «Thank God the voices are still there! Otherwise how would you know what to do next? How would you do any planning?» One or two generations earlier, a person who heard voices was characterized as being crazy. That's a statement about how unsophisticated we are in this culture about the organization and processing of the human mind. Voices are one of the three major modes in which we organize our experience to do planning and analysis. That's what distinguishes us from other species. So my first response is «Thank God! And now let's find out what they are trying to communicate to you.» I might say «Good! Let me talk to them, too. Maybe they've got some really good information for us. So go inside and ask the voices what they are trying to tell you.»
Janet: «How I should kill my mother.»
«Good! Now, ask the voices what killing your mother would do for you.» You go to the meta–outcome. If an internal part voices a goal which is morally, ethically, or culturally unacceptable, such as «kill my mother," then you immediately go for a frame in which that is an appropriate behavior. It may sound bizarre as you hear it, but it's quite appropriate given some context. The question is, can you discover the context? «What would killing your mother do for you? Ask the voices what they are trying to get for you by having you kill your mother.»
The person is likely to interrupt you and say, «I don't want to kill my mother!» You can respond «I didn't say to kill your mother. I said to ask the voices.» You need to maintain the dissociation, and then proceed with the standard format of six–step reframing. «Those voices are allies. You don't know that yet, but I'm going to demonstrate that they are. Now, ask them what they are trying to do for you.»
Ben: I'm currently working with a patient who is a chronic schizophrenic. I've discovered that I'm challenging his thirteen–year career as a chronic schizophrenic by working with him. During the last session, he essentially said that he has an investment in maintaining this career. So I applauded his great success at it.
What Ben is saying is really important. He applauds the schizophrenic's thirteen–year–old career. «How well you have done as a schizophrenic for thirteen years.»
Ben: He has the same name as a famous person, and I said that he was as talented at being a career schizophrenic as this person was in his field! He has actually had thirty–two years of treatment, but he has never had adequate family therapy before. In the context of family therapy he told me that he believed his mother would die if he resolved these problems and really became himself.
Was his mother present as he was talking about this belief?
Yes. I explained that she would not die if he got better. In fact, I said she would be pleased. Actually, the mother is somewhat incongruent about wanting him to recover. But I don't know where to go from there. My guess is that I should begin working on the mother.
OK. Ben's been working with a schizophrenic, and now he's going to work on the mother. The next step is the specific way in which he hooks them together. In other words, the mother says to the schizophrenic «I won't die if you get better. Go ahead and get better. In fact, I want you to get better.» (He shakes his head «No.»)
Ben: I didn't read the incongruence that clearly, but I feel that is accurate.
The question is, will the schizophrenic believe that incongruent statement? Definitely not. The schizophrenic is much more sensitive than you and I to those nonverbal signals. He's had a whole lifetime of reading them.
One thing you can do is to get a congruent response from the mother.
You might begin by sorting out the parts of her that do and don't want him to get better. «Ok, pretend that you want him to stay sick. Now tell him all the reasons why it's important that he stay sick.» She says «But I don't," and you say «Well, that will make it easier for you to pretend.» Then later you say «Now pretend you want him to get well.» «Well, I do.» «Of course; that will make it easier to pretend.» The logic of it is flimsy and irrelevant. All that's important is that you make it easy for her to respond. If you want to see something impressive in terms of nonkinesthetic anchors, have the mother alternate between those two behaviors while you watch the schizophrenic. Smoke will come right out of his ears!
Your eventual goal, of course, is to make the schizophrenic independent of whether the mother is congruent or not. In one sense, maturity is reaching a symmetrical relationship that allows a parent to be as incongruent as she wants, and the child can still maintain his own context and momentum in his life.
Whether the schizophrenic believes his mother wants him to stay sick or get well, if you're doing reframing you can say that the purpose the schizophrenic has in staying schizophrenic is to show honor to the mother. His purpose is to demonstrate how much he cares and how concerned he is about her welfare.
This is just standard reframing. I've gone from a piece of behavior, being schizophrenic, to the intent or the purpose of the behavior. I drive a wedge between the behavior «schizophrenia» and the intention or purpose of the behavior, and I validate the outcome. «You're right! Don't you mess around, because you care for your mother and you've got to demonstrate that to her as far as I'm concerned. I care for my mom, too.» Use whatever analogue is appropriate for this particular
guy.
Then you insist that he be schizophrenic until he has tested other ways of showing the respect and caring that his mother deserves and that he wants to give her. You insist that he continue to be schizophrenic until he discovers alternative patterns of behavior that lead to the outcome: showing respect and caring for his mother. «She deserves the best. If schizophrenia is the best, then you need to stay with it. If we can find a better way for you to demonstrate caring and respect for your mother, you'll want to do it that way, because she deserves the best.» By doing this, you operate entirely within his model of the world. At the same time I would also be working with the mother to sort out her behaviors.
Sometimes when someone has come in with aspects of her experience dissociated, we have chosen not to go for an outcome of complete integration. A big Dutch woman who had been in this country for twenty years was brought in by her husband, because she was displaying acute schizophrenic symptoms. She heard voices that were constantly propositioning her sexually, and making lewd and incomprehensible statements. She didn't even understand the meaning of those statements, because she was a «clean woman.»
A number of well–intentioned psychiatrists had attempted to deal with this woman. They explained to her that the voices were really her voices, and were a result of the fact that she was angry with her husband who had been involved with some other woman ten years earlier. This woman was extremely religious, and she had no way of accepting that explanation in her world–model. Her rage was unacceptable to her, so it was projected into auditory hallucinations. If she believed that those voices were hers, it would have shattered her conscious appreciation of herself. The voices were saying things and proposing activities that were abhorrent to her as a good, clean, religious woman. By trying to get the woman to accept this, the well–intentioned psychiatrists were running up against a stone wall.
This woman refused to go to psychiatrists because they were insulting her. So her husband and daughter brought her to us. The problem was getting serious, because she was slugging people who she thought were making indecent proposals to her. She was hitting and slapping waiters in restaurants, and people on the street—and she was a formidable opponent! Consequently, she was about to be locked up. We decided on a fairly limited therapeutic goal. The family was poor, and didn't have any interest in generative change. Mama just wanted to be comfortable, and the rest of the family just wanted Mama to be all right.