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Psychiatry 70(2) Summer 2007
154
Grief and Mourning in Schizophrenia
Daniela Wittmann and Matcheri Keshavan
Depression and suicidality after first episode of psychosis are well-documented responses in patients with schizophrenia (Addington, Williams, Young, & Addington, 2004). The understanding of depression and suicidality has been increasingly
refined through careful study. Researchers have identified a number of factors that
may cause depression such as insight into the illness, feelings of loss and inferiority
about the illness as a damaging life event, hopelessness about having a viable future
with the illness and mourning for losses engendered by the illness. The authors argue that grief and mourning are not just an occasional reaction to the diagnosis of
schizophrenia, but are a necessary part of coming to terms with having the illness.
They offer three case examples, each of which illuminates a distinct way in which
psychosis and mourning may be related—psychosis as a loss of former identity,
psychosis as offering meaning and transformation, and psychosis as a way of coping with the inability to mourn. In their view, recovery depends on mourning illness-related losses, developing personal meaning for the illness, and moving
forward with “usable insight” and new identity (Lewis, 2004) that reflects a new
understanding of one’s strengths and limitations with the illness.
DEPRESSION AND SUICIDALITY
IN SCHIZOPHRENIA
Depression and suicidality are
well-documented responses in patients with
schizophrenia (Addington, Williams, Young,
& Addington, 2004). Following a psychotic
episode, patients are considered at risk for
both and are carefully followed by their treatment providers. While depression was initially viewed as a component of the psychotic
state, the understanding of depression and
suicidality has been increasingly refined
through careful study.
The research on suicidality in schizophrenia has demonstrated that only a small
percentage of patients kill themselves in response to command hallucinations
(Grunebaum et al., 2001; Harkavy-Friedman
et al., 1999; Heila et al., 1997; Power, 2004)
and that depression that follows a psychotic
episode may be related to other factors.
Kimhy and colleagues suggests that the first
few weeks after hospitalization, patients are
at risk because of stresses such as uncertainty
about future hospitalization, employment
concerns, loneliness and relationship problems (Kimhy, Harkavy-Friedman, & Nelson,
2004). Insight and a coping style that tend towards integration of the illness rather than
sealing over and disregarding it are critical to
adjustment to illness (Tait, Birchwood, &
Daniela Wittmann, LMS W, is Assistant Professor at Wayne State University Department of Psychiatry and Behavioral Neurosciences.Mafc/ien Keshavan, MD, is Professor at Wayne State University Department of Psychiatry and Behavioral Neurosciences.
Special thanks to Rocco Marciano, MSEd, for providing clinical material for this paper.
The work of the authors was supported by the Michigan Department of Community Health and the
Joseph F. Young, Sr., Psychiatric Research and Training Program.
Address correspondence to Daniela Wittmann at University Psychiatric Center, 2751 E. Jefferson,
Detroit, MI 48207; E-mail dwittman@med.wayne.edu.
Wittmann and Keshavan
Trower, 2004). They are also associated with
a greater likelihood of depression, suggesting
that patients are driven to unhappiness, perhaps despair, by recognizing the effect that the
illness will have on their lives (McGlashan,
1987). When the depression does not lead to
suicide, it may lead to social withdrawal and
disengagement from services (Tait,
Birchwood, & Trower, 2003). Of significance
may be a little explored finding by Kim and
colleagues who studied factors that contribute
to the suicidal behavior in patients with
schizophrenia. Their major finding was that
the hopelessness was by far the greatest contributor to suicidality, with substance abuse,
insight into illness, and higher cognitive function following suit. In analyzing their data on
333 patients, they also found, interestingly,
that while patients with high scores on lifetime
suicidality had insight into their illness of
schizophrenia, they did not have insight into
being depressed (Kim, Jayathilake, &
Meltzer, 2003)
THE EXPERIENCE OE LOSS IN
SCHIZOPHRENIA
As the field of study moved from a description of symptoms and cognitive styles to
investigations of patients’ internal experiences, the meaning of depression emerged as
an important factor. Building on earlier work
by Mayer-Gross (1920) and McGlashan &
Carpenter (1976), Birchwood and his collaborators were able to develop the concept of
“post psychosis depression” in which an episode of psychosis is responded to as a “life
event” rather than simply experienced as an
illness (Birchwood et al., 2005). Patients in
Birchwood’s study were acutely aware of the
losses experienced as a result of their illness.
More specifically, they saw themselves as having been rendered socially inferior by the illness. These patients were not necessarily more
insightful than those who did not develop post
psychotic depression. They were, however,
likely to be more pessimistic than those who
did not develop it. This finding corroborates
Kim and colleagues’ notion that hopelessness
155
is the key factor that predicts whether a
person with schizophrenia will be at risk for
suicide.
In her extensive and comprehensive review of the literature on depression and suicide in schizophrenia, Lewis (2004) speaks to
the fact that some schizophrenic patients must
mourn losses engendered by the illness. She
coins the phrase “usable insight,” insight
based on an accurate perception of what has
been lost which then determines how one
might go on into the future with a realistic appraisal of one’s situation; according to her,
patients have to accept what was lost (job, education, social relationships). They must also
give up their psychotic symptoms which may
have been a way of coping during the illness
(Lewis, 2004).
The experience of the symptoms and diagnosis of a chronic mental illness is a serious
crisis. Any chronic illness brings with it limitations and losses, but schizophrenia is potentially more damaging because it affects the
psyche itself. Positive symptoms bring about
the loss of usual cognitive functioning and a
capacity to orient oneself to both external and
internal reality. Negative symptoms influence
one’s capacity to remain affectively and energetically engaged with the social and occupational world. When such altered capacity to
perceive and engage is experienced as a result
of war, torture, or abuse, we call it trauma. In
schizophrenia, the loss of functioning is a
traumatic loss. McGorry and colleagues, who
interviewed 36 patients (who had experienced
acute psychosis in the past 2-3 years) after discharge from hospital, found that at 4 months,
46% had symptoms of post-traumatic stress
disorder. At 11 months post discharge, 36%
could still be classified to be suffering from
post-traumatic stress disorder according to
DSM-III criteria (McGorry et al., 1991).
Morrison Frame, and Larkin (2003), in their
review and analysis of research on the relationship between trauma and psychosis, conclude that “since the findings of high rates of
post-traumatic stress disorder in response to
psychosis have been replicated in many studies with differing methodologies, it is reasonable to conclude that some people do develop
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Grief and Mourning in Schizophrenia
post-traumatic stress disorder as a response hallucinations and delusions was found when
to psychotic experiences” (Morrison et al., a person who had been abused as a child was
2003).
re-traumatized as an adult. They suggest, simWe may think of the loss of cognitive ilarly to the above authors, that in some cases,
and emotional functioning in schizophrenia psychosis may be a way of integrating trauma.
as the primary loss brought ahout hy the ill- If psychosis is a method of coping with trauma
ness. The losses of independent functioning, or a defense against loss, it must be given up so
such as educational, vocational and social that ordinary grief and mourning can
competencies, and loss of place in a social mi- proceed.
lieu can be described as secondary losses. With
The issue of psychosis as a defense
both primary and secondary losses can come against loss touches on a debate about the
the loss of faith in self, others, and in a viable cause of the development of schizophrenia
future. Birchwood’s description of a sense of since it was first described by Kraepelin and
inferiority or loss of self-esteem is relevant Bleuler (Bleuler, 1911; Kraepelin, 1913). Curhere.
rent views are based in research and present a
When Lewis speaks of the need to give rich picture that spans the gamut of non-bioup the symptoms of psychosis, she is speaking logical to biological causes of schizophrenia.
to yet another loss. For some people, the de- Read and colleagues, in their review of the hisvelopment of psychosis may be an uncon- tory of schizophrenia in a scientific and
scious method, a strategy, with which to face sociopolitical context, question the methodolunbearable loss. In their book The Cognitive ogy in genetic and biological research and
Psychotherapy of Schizophrenia, Kingdon point to the influence of social engineering
and Turkington propose trauma as one of the that affected the theory and treatment of peofour predispositions that can lead to psychosis ple with severe mental illness in the early
(Kingdon & Turkington, 2005). Morrison twentieth century. They suggest that these
and colleagues (2003) go so far as to suggest flawed approaches are still present in the
that post-traumatic stress disorder and psy- bio-psycho-social model of schizophrenia.
chosis may lie on a spectrum of responses to They propose that societal as well as familial
trauma. Allen, and Console (1997) in their dysfunction, abuse, and trauma may be by far
study of 266 women who were hospitalized the most important precursors of a psychotic
for a number of conditions related to trauma, disorder (Read et al., 2004). The influence of
found a relationship between dissociation and the environment is also examined by other aupsychosis. While cautioning against thors. Spauwen and colleagues studied 2524
misdiagnosing psychotic decompensation in adolescents between ages 14 and 24 through
traumatized individuals as a primary psy- self-reports of trauma and psychosis pronechotic disorder, they hypothesized that indi- ness. They found that approximately 42
viduals who use dissociation as a way of cop- months later, a larger proportion of adolesing are sufficiently out of touch with internal cents who were severely traumatized and were
and external reality to be susceptible to psy- prone towards psychosis (had schizotypal feachosis (Allen et al., 1997). Read, Mosher, and tures) were more likely to develop psychotic
Bentall (2004) reviewed studies that exam- symptoms (Spauwen et al., 2006). Cannon
ined the relationship between childhood and Clarke reviewed the hterature that looked
trauma, loss and stress, and psychosis (Read at the perinatal environment, developmental
et al., 2004). In most of the studies, they found issues, and genetic and societal influences.
a strong relationship between early physical They concluded that these issues have to be
and sexual abuse and hallucinations and delu- taken into account when defining vulnerabilsions, while no relationship or a weak rela- ity for schizophrenia and that early interventionship was found between trauma and nega- tion aimed at prevention is indicated (Cannon
tive symptoms and thought disorder. A yet & Clarke, 2005). The precise interplay of the
stronger relationship between trauma and pathways to psychosis is far from being fully
Wittmann and Keshavan
understood. It is necessary to consider biological, psychological, social, and cultural factors
in order to do full justice to understanding
schizophrenia and psychosis. This paper can
only touch on these issues, but appreciation of
all aspects of this complex disorder underlies
our thinking about loss, grief, and mourning
in schizophrenia.
In the following discussion, the authors
will propose that developing the capacity to
grieve and mourn losses related to the illness is
not just a by-product of the adjustment to the
illness for some patients; it is a necessary process aimed at psychological integration of the
illness for all patients diagnosed with schizophrenia. It is a process that is complex and can
take many forms.
GRIEF AND MOURNING
IN SCHIZOPHRENIA
Grief is a necessary response to loss and
is defined as “the process of experiencing the
psychological, behavioral, social and physical
reactions to the perception of loss” (Rando,
1993, p. 24). Mourning is “the cultural or
public display of grief through one’s behaviors.” To paraphrase, it is a conscious and unconscious process which serves to untie attachment to the past, to adapt to the loss and
develop a new identity without what is lost
(Rando, 1994, p. 23). There is a need for the
person experiencing the loss to suspend defensive responses long enough to experience the
powerlessness that comes from not being able
to restore the past.
After an episode of psychosis, a person
needs to find meaning for what happened so
as to integrate it into a sense of self that has
been irrevocably changed. Larsen, in his paper
on the meaning in first episode psychosis, uses
an anthropological prism through which to
describe this process (Larsen, 2004). According to him, people who experience psychosis
use “a cultural repertoire,” at least initially, to
label what has happened to them. They may
shift between various explanatory models sequentially or in a complementary fashion,
such as the medical model, the stress-vulnera-
157
bility model, the stigma model, or the spiritual
model, to make the experience of psychosis
meaningful and acceptable. He suggests that
while using already existing models, persons
with psychosis take an active role in constructing the integration of their experience.
He borrows the term “bricolage” (used by anthropologist Levi-Straus in his book The Savage Mind which deals with societal development) as a term that best describes the accrual
of ever-developing explanations for reworking a new identity. Bricolage, which means a
“do-it-yourself” job in French (Collins Gem,
2000) is described by Levi-Straus as an “attribute of human creativity in life and a proof
of individual analytic and theory- generating
capabilities (Levi-Straus, 1966, p. 462). This
approach assumes an agency on the part of the
person with psychosis and echoes descriptions
offered by people who have described this experience from within. As Patricia Deegan,
Program Director of the Northeast Independent Living Program and a person in recovery
from schizophrenia, suggests: “We are fully
human subjects who can act and in acting,
change our situation” (Deegan, 1997).
In the grief and mourning literature, a
sense of agency is similarly assumed. In his
generally accepted theory, Worden, in his
study of children’s grief, proposes four tasks
rather than stages of grief and mourning to accentuate the dynamic nature of the mourner’s
work (Worden, 1996). The tasks are: 1) To
accept the reality of the loss, 2) to experience
the pain or emotional aspects of the loss, 3) to
adjust to an environment in which the deceased is missing, and 4) to relocate the dead
person within one’s life and find ways to memorialize the person. Although the person recovering from psychosis is not grieving the
loss of another person, he/she is grieving the
loss of the person he/she used to be and in that
sense must complete these tasks in order to
cope with the loss of the past self and achieve a
new identity.
It must be noted that a person with a
chronic illness may experience temporary
re-«mergence of intense grief and mourning at
significant milestones or anniversaries and
that such “short upsurges of grief” (STUGs)
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Grief and Mourning in Schizophrenia
can be expected (Rando, 1993, p.64). Johnson and Rosenblatt describe this as
“maturationai grief” in order to distinguish it
from complicated mourning (Johnson &
Rosenblatt, 1981).
COMPLICATED MOURNING
IN SCHIZOPHRENIA
“Comphcated mourning means that,
given the amount of time since the [loss], there
is some compromise, distortion or failure of..
. processes of mourning” (Rando, 1993, p.
149). Complicated mourning can develop in
individuals newly diagnosed with severe mental illness who have insight into their illness,
but have been unable to cope with the losses
and changed identity inherent in the acquisition of the illness. It becomes chronic, and
Bowlby describes this as a state in which “the
individual becomes and remains sadly disorganized” (Bowlby, p.lO9, in Rando, 1993).
There is an extensive literature on complicated mourning, but complicated mourning in
schizophrenia is an uncharted sea that
beckons exploration.
First, we must distinguish between
complicated mourning and depression since it
is depression that is typically described as a reaction to psychosis. Efforts have been made to
elucidate the distinction. Horowitz and colleagues developed criteria for complicated
grief disorder which relate primarily to the
loss of a person, but could be adapted to the
experience of complicated grief due to losses
engendered by psychosis (Horowitz et al.,
1997). Ogrodniczuk and colleagues, in a
study of bereaved individuals, were able to
isolate three dimensions of complicated grief:
1) grief (intrusive thoughts, feelings about the
lost person, searching for the lost person), 2)
grief experience (persistent emotional distress
related to death/loss, propensity to ruminate
about the lost person, painful feelings associated with the death), and 3) grief avoidance
(active avoidance of thoughts and feelings associated with the lost person) (Ogrodniczuk et
al., 2003). Coming to terms with psychotic illness involves many of the above-mentioned
experiences: intrusive thoughts, search for
past identity, persistent emotional distress related to the way the illness affected the person’s life, possible avoidance of any thoughts
or feelings about it, or using psychosis as a defense against loss. It would not be a stretch to
consider examining and adapting
Ogrodniczuk’s concepts to an emotional
response to the experience of psychosis.
CASE STUDIES
We herein describe three patients, each
of whom illustrates the key issues pertaining
to the relationship between mourning and
psychosis. All patients have verbally consented to parts of their story being incorporated in this manuscript. We have avoided
providing, and modified where necessary, any
aspects of their history that might identify
them.
1. Grief and Mourning of
a Former Self
Latoya is a 26-year-old African American woman who was a third-year college student at the time of her first episode of psychosis. Social withdrawal and increasingly poor
hygiene as well as increasing paranoia for
nearly 4 years led her family to seek psychiatric care for Latoya. Latoya believed that there
was a family secret and that her parents were
planning to kill her. She was finally hospitalized after she physically attacked her father.
Latoya cooperated with medical treatment (Olanzapine, later Aripiprazol and finally Risperidone Consta), but was reluctant
to engage in psychotherapy: “I didn’t trust my
doctor and my therapist.” Her attendance in
groups was also half hearted. She participated, but with little enthusiasm. By her own
admission, she was having difficulty accepting
that she had a mental illness.
Although she tried to return to academic and work projects, Latoya was not successful initially because her field is fairly rare.
She was not interested in other activities. Her
motivation flagged. Her activities centered on
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Wittmann and Keshavan
her home where she lived with her parents.
She was not socially involved. After a year of
enrolment in a treatment program, Latoya
was asked to participate in a research study
that involved the description of losses engendered by the experience of psychosis. Latoya
was eager to speak about what had happened
to her and how she felt about it.
Latoya was aware that she had experienced a number of losses. She named “time,
school, job, friends, apartment” as the concrete things that she no longer had in her life.
But the loss that meant the most to her was the
loss of confidence, the loss of personal identity: “I am more nervous and shy now, I didn’t
used to be like that.” Latoya said that she had
experienced fears that her parents would have
to take care of her for the rest of her life and
that she had felt depressed to see that everything that she wanted to do in her life had to
take a back seat to her illness.
When asked, Latoya was able identify
periods of depression since diagnosis. She was
relieved to hear that some of those feelings
might be grief and that grief is a normal part of
adjustment to a chronic illness. She thought
that she had not grieved her losses. She had
not cried and she had not felt angry. Instead,
she said, “I overthink”. She was curious about
grief and had many questions about the process and when and how she might see some
changes in herself.
During the following six months,
Latoya continued to work with her therapist
on recovery. She gradually came to accept that
she had a mental illness which she had to manage while she tried to return to building a life
for herself. She has steadily increased her activities, but has done so in a carefully calibrated manner. She has moved into the social
arena very slowly, too. She is aware that her
friends have moved on in their lives at a faster
pace. Her social experiment now involves
co-workers. Friendly banter is comfortable
for her now, but she is not ready for more.
While her parents support her and she appreciates it, she does not confide. Her therapist
appears to be a valuable sounding board, but
Latoya remains reserved. She can share humor and discuss concerns, but not vulnerable
feelings. This may be due to pre-illness personality development or to a wish not to be
overwhelmed with unbearable feelings. As
she is no longer denying her illness and is
moving forward, this seems to be a reasonable
pace for Latoya.
Analysis. Latoya’s reaction is an example of Birchwood’s post-psychosis depression.
Psychosis was a life event which altered her irretrievably. She has identified her losses and
her feehngs about them and she has used individual psychotherapy and the research project
to attempt to integrate them. Early on, she
was able to name several secondary losses and
fearfulness about the future. As is typical in
grief, she ruminated about how she got ill,
what happened to her and how she could get
her life back. The slow and deliberate rate at
which she is now recovering may in part reflect a desire not to jeopardize her progress. In
order to reconstruct her life more fully, she
may need to allow herself to feel the feelings of
grief and come to terms with her new identity
more deeply as a woman with a serious mental
illness. Then she can build the future with
greater confidence, and pursue goals that are
relevant and attainable.
2. Transformation of Identity
through Psychosis
Jeffrey is a 28-year-old Caucasian single man. He was 23 at the time of his first episode of psychosis. According to him, he had
suffered mild depression and lack of focus for
many years, but his condition escalated over
several months into an acute episode of psychosis, depression, and suicidality. He describes himself as having lost a sense of meaning and purpose in life and could not find his
place in the world which he saw as competitive, individualistic, materialistic, and violent.
He was hospitalized for several weeks. Jeffrey
describes his symptoms during his hospitahzation as “hallucinations, paranoid delusions
and illusions, being catatonic and obsessed
with trivial aspects of my physical features.”
He thought he had gone to hell because he had
caused world destruction. When family mem-
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Grief and Mourning in Schizophrenia
bers called or visited, he was rendered mute by ing for the well-being and blessings of others,
the disbelief that they had survived. When his praying that I might improve as a person in
sister caringly tried to suggest that he might be kindness, love, unselfishness and generosity.”
going through a formative experience and He used his experience with depression as a
could see this as a blessing, he saw this as being lesson that negative thoughts, words, and feelmocked by God through her.
ings were not worthwhile, but promoted the
Initially, Jeffrey saw himself as not ill at very experiences they were supposed to help
all, but as receiving messages from God with. As a result of having mental illness,
through the Internet and the walls of the hos- Jeffrey found himself feeling “a much stronger
pital, telling him that he was being punished. sense of empathy and compassion… for those
He felt responsible for his own misdeeds and who are experiencing pain and suffering . . .
for the suffering of others. His discussions and a desire to alleviate it.” Having been ill
with his psychiatrist who gently challenged his taught Jeffrey that he and others were vulnerthinking led to his recognition that he was ex- able and interdependent which gave him a
periencing hallucinations and delusions that sense of community with fellow human bewere related to a biological illness, but that the ings. At the same time, unlike before, he felt a
content of his delusions and hallucinations clear sense of responsibility for himself as a bemight be an avenue to a deeper understanding ing “created in the image and hkeness of God”
of his own spiritual beliefs. In a sense, he could with “the gift of free will.” Jeffrey felt that he
use the insight into his nature brought about had found the “best known psychological
by the psychosis to pursue his search for remedy for worry, stress and anxiety,” in
meaning as he was recovering from the illness. entrusting himself to God and Jesus’s
Jeffrey was not resistant to this thinking. Hav- teachings.
ing had caring and supportive family relationToday, he may superficially look the
ships predisposed him to an ability to develop same. But inside, Jeffrey is transformed. With
a solid therapeutic alliance with his doctor. He clear insight into the illness and without denyreasoned that through psychosis, God had ing the need for treatment, he has developed a
given him a sense of direction to be helpful to new meaning for his experience. As he deothers and to be good.
scribed it, “the true miracle isn’t that our own
After hospitalization, with unwavering or others’ suffering, physical or psychological,
family support, Jeffrey resumed his work and has been completely eliminated, but rather
academic life, and gradually increased his so- that we change (with God’s help) the real root
cial activities. He experienced the usual anxi- of the suffering and pain: how we view it, how
ety about re-entry—was he different or the we respond to it. It can become . . . the ‘myssame, how would he be accepted? He was wel- tery’ and ‘challenge’ of suffering rather than
comed positively, and this boosted his merely the ‘problem’ of suffering. We can
self-confidence. Following up on a come to realize that it has been a ‘blessing in
long-standing interest, he turned to reading disguise.'” Jeffrey looks on his experience
spiritual literature, to prayer, and to music in with psychosis as an opportunity to find his
order to ease his residual anxiety and appre- spirituality, his true nature, his compassion
hension about the future. In these activities, he for others, and an inner peace: he sees himself
found solace. He was treated initially with as having benefited from it in the long run.
Risperidone which was eventually phased
It appears to have been so for Jeffrey.
out. He is maintained on a small dose of According to him, he was mildly depressed
Fluoxetine.
and unfocused prior to his psychosis. Now, he
Jeffrey wrote a paper about his experi- sees himself as able to think as more posience of psychosis and its outcome. He de- tively, more compassionate about others’ sufscribed his prayer life as having changed from fering, more able to accept help, and as able to
one of “requesting, pleading or bargaining for assume personal responsibility for himself. He
favors or personal satisfaction to one of pray- is in graduate school, working, and active in
Wittmann and Keshavan
the community as a volunteer. He was able to
care for his dying father and has come to terms
with his death without exacerbation of
symptoms.
Analysis. Jeffrey appears to have engaged with his illness by seeking a spiritual answer to his suffering. As Larsen (2004)
indicates, people struck with psychosis search
for an explanatory model which would enable
them to integrate the illness into their identity.
Jeffrey’s recovery appears to have been very
quick and rather successful. It appears that the
major loss he experienced was the frightening
intrusion of the psychosis with its attendant
distortion of cognitive and emotional functioning. However, the loss of functioning was
quickly reversed by medication and
psychosocial treatment. He was able to read
and think. He began to practice his own version of cognitive therapy—engaging in positive thinking with which to face life
experience. Recovery from psychosis gave
him an opportunity to seek long-desired spiritual guidance. In the Judeo-Christian tradition, suffering is often seen as a test of faith. In
the Eastern traditions, worldly suffering is a
lesson in compassion and selflessness. Jeffrey
adopted the teachings of both traditions and
actively transformed the meaning of his illness
from loss into a gift. In that sense, he is not
grieving. He is transcending the illness
experience and incorporating it into his
identity as God’s plan to make him a better
person.
3. Psychosis as a Defense against Loss
Brent is a 29 year old single white man.
He is college educated and until 2 years ago
worked as an administrator in a technical
field. He came to the outpatient treatment
program after 6 years of uncertain diagnosis
and unsuccessful treatment with mood stabilizers and antipsychotic agents. Brent had suffered from paranoid delusions, mood swings
and overpowering ideas of reference which led
to obsessive/compulsive activity. He had also
made 2 major suicide attempts as a result of
feeling utterly worthless. Immediately prior to
161
her arrival in the program, he was placed on
Aripiprazol. He gained crystal clear insight
and wished to engage in treatment that would
lead to his recovery. His primary motive was
the care of his young daughter whose custody
he wished to retain and whose well being he
had guarded surprisingly well even while quite
psychotic.
Brent had returned to his city of origin
in order to be cared for and supported by his
mother while he was recovering from his illness. His father who had a volatile temper had
died during his adolescence and his mother, a
woman who appeared to have a severe personality disorder was remarried. It became
immediately obvious that the relationship
with his mother had been very disturbed since
childhood, including ongoing criticism, demeaning attitude and sexual abuse. At the
time of admission. Brent’s mother was allegedly denying his illness, refused to become educated about it and maintained a highly controlling and critical stance with him. When
Brent asserted himself in the slightest manner,
his mother severed contact. She also controlled all of Brent’s relationships with the extended family. Brent internalized some of the
criticisms, particularly vis-a-vis his weight and
overly high expectations about achievement.
When the Brent was ill, he was highly
dependent on his mother, not trusting his own
judgment in anything.
Within 3 months of clear insight. Brent
began to use more independent judgment in
all areas of his life. This included his relationship with his mother and incurred his
mother’s wrath and criticism. Eventually,
Brent decided that maintaining a relationship
with his mother would be too destructive to
himself and his daughter. He decreased contact which led to his mother abandoning
contact altogether.
Brent became tearful and depressed in
response to these events. He felt alone and
frightened, uncertain of his ability to go on.
He recalled the many years of psychotic functioning which robbed him of his career and his
confidence to support himself and his daughter. He