Excerpts from Must Read Books & Articles on Mental Health Topics, Articles- Part II

Changes in Psychoanalytic Ideas: Transference Interpretation
Arnold M. Cooper
Journal of the American Psychoanalytic Association 35 (1987): 77-98

Interpretation of the transference is central to all psychoanalytic models. Definitions of transference and transference interpretation have changed greatly during the past half-century, influenced by major movements in philosophy, advances in psychoanalytic research and theory, and changes in our understanding of Freud. This paper suggests that historical, relatively simple, concepts of the transference as the reproduction in the present of significant relationships from the past do not adequately meet current clinical and theoretical demands. Modernist views of the transference emphasize as additional sources of transference responses, the role of the analytic background of safety, the constant modification of unconscious fantasy and internal representations, and the interactive nature of transference responses, with important interpersonal and intersubjective components. It is suggested that the evolving modernist views of transference and transference interpretation permit a fuller accounting for transference phenomena and open the way for better informed interventions. A brief discussion of the issue of psychological "truth" and "distortion" as applied to transference phenomena is presented. The themes are illustrated with clinical vignettes.
   Psychoanalysts, since the earliest days of the Studies on Hysteria (Breuer and Freud, 1893-1905), have always given special attention to the transference and to the interpretation of transference, believing it to be central in our theory and technique. While there has never been a lack of interest in transference interpretation, it has recently become a particular focus of study and discussion. It is not clear why this is so, and the reasons may vary in different parts of the international psychoanalytic community. In America, at least, Gill's (1982) recent, and somewhat radical presentation of transference interpretation has surely helped to grab our attention. I believe another reason for our intensified interest in transference interpretation is the opportunity it provides for discussion of the full panoply of diverse analytic theories and techniques that today compete for our attention and allegiance. In this respect transference interpretation seems to have replaced self-psychology as the encompassing topic that allows analysts of varied persuasions to discuss almost every aspect of psychoanalysis.
    Despite the diversity of analytic views that abound today, analysts seem to agree on the centrality of the transference and its interpretation in analytic process and cure, differing only in whether transference is everything or almost everything. This somewhat unusual degree of agreement may be aided by our inability to give a clear definition of what transference is.

Laplanche and Pontalis (1973), in their dictionary, write, with some sense of despair, "The reason it is so difficult to propose a definition of transference is that for many authors the notion has taken on a very broad extension, even coming to connote all the phenomena which constitute the patient's relationship with the psychoanalyst. As a result the concept is burdened down more than any other with each analyst's particular views on the treatment-on its objective, dynamics, tactics, scope, etc. The question of the transference is thus beset by a whole series of difficulties which have been the subject of debate in classical psychoanalysis" (p. 456).
    Sandler (1983) has discussed how the terms transference and transference resistance as well as other terms have undergone profound changes in meaning as new discoveries and new trends in psychoanalytic technique assumed ascendancy. He said, ". . . major changes in technical emphasis brought about the extension of the transference concept, which now has dimensions of meaning which differ from the official definition of the term" (p. 10). I am not sure there has ever been a simple official definition of the term. While a certain flexibility of definition makes conversation possible in a field of diverse views, that we may never be clear on what any two people mean when they use the term is a significant handicap to our discourse.
    With this in mind we might review one of Freud's last comments on transference. In An Outline of Psycho-Analysis (1940), published posthumously, he wrote of the analytic situation:

The most remarkable thing is this. The patient is not satisfied with regarding the analyst in the light of reality as a helper and advisor who, moreover, is remunerated for the trouble he takes and who would himself be content with some such role as that of a guide on a difficult mountain climb. On the contrary, the patient sees in him the return, the reincarnation, of some important figure out of his childhood or past, and consequently transfers on to him feelings and reactions which undoubtedly applied to this prototype. This fact of transference soon proves to be a factor of undreamt-of importance, on the one hand an instrument of irreplaceable value and on the other hand a source of serious dangers. . . . The analyst may shamefacedly admit to himself that he set out on a difficult undertaking without any suspicion of the extraordinary powers that would be at his command. . . . Another advantage of transference, too, is that in it the patient produces before us with plastic clarity an important part of his life-story, of which he would otherwise have probably given us only an insufficient account. He acts it before us, as it were, instead of reporting it to us [pp. 174-176].

    Freud saw the transference interpretation as a method of strengthening the ego against past unconscious wishes and conflicts.  It is the analyst's task constantly to tear the patient out of his menacing illusion and to show him again and again that what he takes to be new real life is a reflection of the past. And lest he should fall into a state in which he is inaccessible to all evidence, the analyst takes care that neither the love nor the hostility reach an extreme height. Ibis is effected by preparing him in good time for these possibilities and by not overlooking the first signs of them. Careful handling of the transference on these lines is as a rule richly rewarded. If we succeed, as we usually can, in enlightening the patient on the true nature of the phenomena of the transference, we thus shall have struck a powerful weapon out of the hand of his resistance and shall have converted dangers into gains. For a patient never forgets again what he has experienced in the form of transference; it carries a greater force of conviction than anything he can acquire in other ways [p. 177].
    While Freud, at one or another time entertained almost all possible views of the transference, I believe these statements at the end of his career give a clear sense of where he stood. He believed that the transference represents a true reconstruction of the past, a vivid reliving of earlier desires and fears that distort the patient's capacity to perceive the "true nature" of the present reality. The analyst is a wise guide who already knows the path, and the task of the transference interpretation is cognitive "enlightenment" that carries the emotional conviction of lived experience, while preventing excessive emotional regression.
    Although it is a vast oversimplification and the division is not sharp, I shall suggest that there have been two major ideas about the transference and its interpretation during the history of psychoanalysis. One is explicit in Freud, as I quoted him earlier; the other is implicit. The first idea, close to Freud, is that the transference is an enactment of an earlier relationship, and the task of transference interpretation is to gain insight into the ways that the early infantile relationships are distorting or disturbing the relationship to the analyst, a relationship which is, in turn, a model for the patient's life relationships. I shall refer to this as the historical model of transference, implying both that it is older and that it is based on an idea of the centrality of history. The second view regards the transference as a new experience rather than an enactment of an old one. The purpose of transference interpretation is to bring to consciousness all aspects of this new experience including its colorings from the past. I shall refer to this as the modernist model of the transference, implying both that it is newer, in fact still at an early stage of evolution, and that it is based on an idea of the immediacy of experience. I would like to distinguish this discussion of models of transference and transference interpretation from the debate on the "here-and-now" interpretation that Gill has brought to the fore. Gill is primarily interested in issues of technique, and both models that I will discuss lend themselves to interpretive work in the here-and-now. These two models are not entirely mutually exclusive, but they do imply significant differences in basic assumptions and in treatment goals. Although the historical view is clearer and prettier, I believe that the modernist version of transference interpretation is more interesting and more promising.
    In the first, historical, view, the importance of transference interpretation lies in the opportunity it provides in the transference neurosis for the patient to reexperience and undo the partially encapsulated, one might say "toxic," neurosogenic early history. In the second, modernist, view, the purpose of transference interpretation is to help the patient see, in the intensity of the transference, the aims, character, and mode of his current wishes and expectations as influenced by the past.
    The historical view is more likely to regard the infantile neurosis as a "fact" of central importance for the analytic work, to be uncovered and undone. The modernist view regards the infantile neurosis, if acknowledged at all, as an unprivileged set of current fantasies rather than historical fact. From this modernist perspective, the transference resistance is the core of the analysis, to be worked through primarily because of the rigidity it imposes on the patient, not because of an important secret that it conceals.
    Similarly, it is a corollary of the historical conception to view the transference neurosis as a distinct phenomenon that develops during the analysis as a consequence of the expression of resistance to drive-derived aims that are aroused toward the analyst. Those holding the modernist view, much more influenced by object-relational ideas of development, are likely to blur the idea of a specific transference neurosis in favor of viewing all transference responses as reflecting shifting self-and object representations as they are affected by the changing analytic relationship, and significant transferences may be available for interpretation very early in the analysis. There is no doubt that the modernist view also reflects the scarcity of the once classical neurotic patient.
    The historical view is more likely to see the analyst as a more or less neutral screen upon which drive-derived needs will enact themselves. He is observer and interpreter, not coparticipant in the process of change. The person of the analyst is of lesser importance. Those taking the modernist view hold that the analyst is an active participant, a regulator of the analytic process, whose personal characteristics powerfully influence the content and shape of the transference behaviors, and who will himself be changed in the course of the treatment.
    The historical view emphasizes the content and precision of the transference interpretation, especially as it reconstructs the past. The modernist view, at least in some hands, is likely to deemphasize reconstructive content and see the transference interpretation as one aspect of the interpersonal relationship in the present, acting as a new emotional and behavioral regulator, when past relationships have been inadequate or absent. Incidentally, this concept of a relationship as an organismic regulator is consonant with current research on grieving men and motherless mice and monkeys, in all of whom a missing relationship creates vast neuroendocrine and emotional consequences.

The increasing influence of the modernist version of transference and its interpretation represents an adaptation to several long-term philosophical, scientific, and cultural shifts we can now recognize. This changing view of transference is also the most visible emblem of the deep changes in psychoanalytic theory that are now quietly taking place, and of the theoretical pluralism that is so prevalent today (Cooper, 1985).
    One of these long-term changes in the climate in which psychoanalysis dwells results from a large philosophical debate concerning the nature of history, veridicality, and narrative. Kermode (1985) has written of the change during this century in our modes of understanding and interpreting the past and the present: "Once upon a time it seemed obvious that you could best understand how things are by asking how they got to be that way. Now attention [is] directed to how things are in all their immediate complexity. There is a switch, to use the linguists' expressions, from the diachronic to the synchronic view. Diachrony, roughly speaking, studies things in their coming to be as they are; synchrony concerns itself with things as they are and ignores the question how they got that way" (p. 3). This distinction, put forth by de Saussure (1915), has achieved philosophical dominance today and is the clear source of the hermeneutic view so prevalent in psychoanalysis, proposed by Ricoeur (1970). From here it is a short distance to Schafer (1981), or Gill (1982), or Spence (1982), who in varying ways adopt the synchronic view. In this view, the analytic task is interpretation, with the patient, of the events of the analytic situation-usually broadly labeled transference-with a construction rather than a reconstruction of the past. In effect, while there is a past of "there and then" it is knowable only through the filter of the present, of "here and now." There is no other past than the one we construct, and there is no way of understanding the past except through its relation to the present.
    I would emphasize that psychoanalysis, like history but unlike fiction, does have anchoring points. History's anchoring points are the evidences that events did occur. There was a Roman empire, it did have dates, actual persons lived and died. These "facts" place a limit on the narratives and interpretations that may seriously be entertained. Psychoanalysis is anchored in its scientific base in developmental psychology and in the biology of attachment and affects. Biology confers regularities and limits on possible histories, and our constructions of the past must accord with this scientific knowledge. Constructions of childhood that are incompatible with what we know of developmental possibilities may open our eyes to new concepts of development, but more likely they alert us to maimed childhoods that have led our patients to unusual narrative constructions in the effort to maintain self-esteem and internal coherence. A second, far less secure, anchor is the enormous amount of convergent data that accumulate during the course of an analysis, which are likely to give the analyst the impression that he is reconstructing rather than constructing the figures and the circumstances of his patient's past. While a diachronic view may no longer suffice, it may also not be fully dispensable if our patients' histories are to maintain psychoanalytic coherence, rooted in bodily experience, and the loving, hating and terrifying affects accompanying the fantastic world of infantile psychic reality. Not all analysts are yet as ready as Spence, for example, to give up all claim to the truth value or explanatory power of the understanding of the past, even if it is limited to knowing past constructions of the past. Nevertheless, the change in philosophical outlook during our century is profound and contributes to our changing view of the analytic process as exemplified in the transference and its interpretation.
    Approaching the same issue from an entirely different vantage point, Emde (1981), speaking for the "baby-watchers" and discussing changing models of infancy and early development, details a second source of the major change of climate to which I refer. He writes, "The models suggest that what we reconstruct, and what may be extraordinarily helpful to the patient in 'making a biography,' may never have happened. The human being, infant and child, is understood to be fundamentally active in constructing his experience. Reality is neither given nor necessarily registered in an unmodifiable form. Perhaps it makes sense for the psychoanalyst to place renewed emphasis on recent and current experience-first, as a context for interpreting early experience and second, because it contains within it the ingredients for potential amelioration. . . . Psychoanalysts are specialists in dealing with the intrapsychic world and in particular with the dynamic unconscious. But we need to pay attention not only to the intrapsychic realm, conflict-laden and conflict-free, but also to the interpersonal realm" (pp. 217-218). He concludes, ". . . we have probably placed far too much emphasis on early experience itself as opposed to the process by which it is modified or made use of by subsequent experience" (p. 219).
    This view of psychic development, discarding the timeless unconscious and so powerfully at odds with the views that were held by psychoanalysts during the time when most of our ideas of transference interpretation were formed, clearly suggests the modernist model of transference interpretation.
    A change in the cultural environment of psychoanalysis provides a third source for the changing model of transference interpretation. Valenstein (personal communication) describes oscillations in psychoanalytic outlook between an emphasis on cognition at one end, and on affect at the other. One might see these as differences between old-fashioned scientific and romantic world views. Surely the period of ego psychology, perhaps reflected in the English translation of Freud, and certainly reflected in the effort to insist on the libidinal energetic point of view, represented the attempt to see psychoanalysis as Freud usually did, as an objective science in the nineteenth century style, with hypotheses created out of naive observation. It accorded with that view to see the transference as an objective reflection of history. We are currently in one of our more romantic periods. It is consonant with that view to see transference as an activity-stormy, romantic, active, affective-a kind of adventure from which the two individuals emerge changed and renewed. In this romantic view, interpretations of the transference are intended to remove obstacles interfering with the heightening and intimacy of the experience, with the implication that self-knowledge and change will result from the encounter. As romantic figures, the patient and analyst set forth on a quest into the unknown, and whether or not one of them returns with a Holy Grail, they return with many new stories to tell and a new life experience-the analysis. Gardner's (1983) book, Self Inquiry, epitomizes this romantic view of analyst and patient as a poet-pair engaged in mutual self-inquiry. It is clear that many analysts would rather be artists than scientists. By contrast, the older, cognitive view of the transference is of an intellectual journey, emotionally loaded of course, but basically a trip back in history, seeking truth and insight.
    Finally, our newer ideas of transference interpretation come from the rereading and reinterpreting of Freud that necessarily accompany the changes in outlook that I have been describing. Corresponding to the swings of analytic culture between classical and romantic, there were swings in psychoanalytic technique from Freud's actual technique, as reconstructed from his notes and the reports of his patients, to the so-called "classical" technique that held sway after Freud's death, and again to the currently changing technical scene. Lipton (1977) has insisted that in the 1940's and 1950's the so-called "classical" technique replaced Freud's own more personal and relaxed technique, probably in reaction to Alexander's suggestion of the corrective emotional experience. It was Lipton's view that the misnamed "classical" technique, in contrast to Freud's, emphasized rules for the analyst's behavior and sacrificed the purpose of the analysis. Eissler's 1953 description of analysis as an activity that ideally uses only interpretation became the paradigm for "classical" analysis. It was, Lipton says, a serious and severe distortion of the mature analytic technique developed by Freud. Freud regarded the analyst's personal behaviors, the personality of the analyst, and the living conditions of the patient as nontechnical parts of every analysis, as exemplified for Lipton in the case of the Rat Man. The so-called "classical" (and in his view non-Freudian) technique attempted to include every aspect of the analytic situation as a part of technique and led to the model of the silent, restrained psychoanalyst. Lipton's argument is persuasive.
    These two different models of technique have obvious implications concerning the transference and its interpretation. Unless we believe in an extreme version of the historical model, we must expect that the silent, restrained, non-participatory psychoanalyst will elicit different responses from his patient than will the vivid, less-hidden, more responsive analyst. The range of personal behaviors available to the analyst before we need be concerned that the analyst is engaging in activities that are excessively self-revelatory or that force the patient into a social relationship is probably much broader than we thought a few years ago. But we also know that almost any behavior of the analyst, including restraint or silence, immediately influences the patient's responses. In these newer views of the analytic situation it is not easy to know what in the transference are iatrogenic consequences of analyst behaviors rather than intrapsychically derived patient behaviors.
    It is evident today that psychoanalysts, under the sway of their theories and personalities, differ greatly concerning matters to which they are sensitive, and, of course, we can interpret only the transferences we perceive. Despite this limitation, a review of the literature reveals, along with the usual rigidities, a laudable tendency to describe one's experience as fully as possible, without heed to how it contradicts belief, often blurring over when experience and theory do not match. However, we have always been better at what we do than at what we say we do. This is exemplified in Heimann's (1956) paper. Speaking from a modified Kleinian perspective, and holding the historical theory of transference interpretation, Heimann managed 30 years ago to describe vividly and to support passionately much of what today is under discussion as the modernist version. That her positions were contradictory bothered her not at all. While many of us prefer to think we are following our theories, like all good scientists, good psychoanalysts, beginning with Freud, have always seen and responded to far more than our theories admit. When we have seen too much, we change our theories.
    I have spoken of long-term trends in philosophy, child development, cultural attitudes, and psychoanalytic techniques that have influenced the development of psychoanalysis during the last half of this century. I will not discuss here how these trends, as well as our ever-increasing knowledge and our increasing distance from Freud's authority, have led to specific theoretical developments (Cooper, 1984, 1985), many of them inferred in the newer transference model. Our current pluralistic theoretical world, in which almost all analysts are working, wittingly or not, with individual amalgams of Freud's drive theory, ego psychology, interpersonal Sullivanian psychoanalysis, object-relations theory, Bowlbyan or Mahlerian attachment theory, and usually smuggled-in versions of self-psychology, lies at the base of the newer ideas and disagreements concerning transference interpretation.
    Although the historical definitions of transference and transference interpretation have the merit of seeming precision and limited scope, they are based on a psychoanalytic theory that no longer stands alone and has lost ground to competing theories. Of necessity, the historical definition is being replaced, or at least subsumed, by modernist conceptions that are more attuned to the theories that abound today.
    In this hodgepodge setting, it might help us both in our thinking about transference interpretations and in our understanding of the theories we hold, if we discuss a few of the sharper alternatives that are now available, indeed, confront the psychoanalyst. I shall present a brief vignette to illustrate some of the issues. It will become apparent that in my conception of the modernist view, we have not abandoned the historical perspective; rather, it has become a component part of a larger, more complex conception.

A woman in the second year of analysis says, "This treatment is all flattened out. It's like everything else in my life. It goes on, but nothing comes of it, certainly nothing good." Suddenly the patient begins sobbing uncontrollably and says, "You never give up on me. You keep thinking there's hope." And then, after a pause, for the first time in her adult life, she vividly and movingly recalls the detailed circumstances of her father's leaving her mother and herself when she was five years old.
    Let me begin by pointing to the obvious. I made no interpretation and yet a long-repressed memory emerged to consciousness with full affective coloring. Why did this happen? The feeling that nothing was happening was frequent during the treatment, often felt by me as well as by the patient, as I was the target of her projections. These complaints were usually accompanied by her insisting that she could not understand why I bothered to treat her when surely I had more worthwhile patients. I had made many interpretations relating these feelings about the two of us to her feelings about a father who had abandoned her, and she had regularly responded with polite boredom.
    There were a number of converging reasons for a new memory to emerge at this point in the analysis: she wanted to be sure that I would remain hopeful and not give up on her; she was giving me a gift for showing an interest in her; furthermore, my interest in her confirmed her self-pitying view that her parents had never been interested; she felt guilty for obstructing my efforts, etc. More than anything else, though, she was responding to mounting anxiety over an impending disruption of our appointments. Whereas in the past such anxiety regularly led to depressive anger, a sense of rejection, and impending panic, this time, in response to a new and growing conviction that I would not abandon her, this new memory allowed her to emphasize the difference between her father and me, thus partially relieving her anxiety. The earlier transference interpretations relating to her disappointing father, combined with the actual safety and reliability of the relationship with me in the analytic setting, had eventually led to a changing perception of me that could no longer be denied by the patient. This created a changing intrapsychic balance.
    Under these new circumstances, inner conscience increasingly became the ally of the analyst, as the patient began to experience the growing discrepancy between her developmentally derived internalized expectations of me and the predictable actuality of that relationship. In effect, the voice of conscience, ever on the attack, found a newly accessible failing and said, "Feel guilty for not letting him help you and for insisting on continuing your masochistic disappointments." The new memory enabled her to make a new compromise: "Even though I admit that my analyst is different from my father, my father was just as bad as I claimed, and I'll now prove it. I also feel safe enough now to revive those old and terrible memories. " Later in the treatment, she will even remember good times with her father.
    In one important aspect, the analytic situation acts as a Proustian madeleine. It awakens sweet resonances of the sense of childhood security and safety, whether actual or fantasied, and thus allows the release of memories, even painful memories. This portion of the transference is usually interpretable only in retrospect.
    At the risk of further complicating this little vignette, I will try to summarize what I have described. A recovered memory, an important event marking a change in the analytic atmosphere, was the result of a number of interacting factors. (1) There was a background of specific old-fashioned transference interpretations-in effect, "you think I am your father, but I am not." Many of these interpretations related to the missing memories. (2) These interpretations were made in the here-and-now-when the patient felt angry and rejected, I talked about how she was actually making a statement about me -that I am, in her opinion, just like her father, and I encouraged her to talk about how I was like him, or why she was now frightened of me or angry at me. (3) While the analyst was, of course, often the object of projections of representations of the past, I played an equally important role as the necessary background of safety for the patient's experimentation with new self and object representations. Projections onto the analyst may occur during this experimentation, but those experiments are going on everywhere in the patient's life, and the analyst may not always be the center of interest. (4) A change in intrapsychic balance occurred, with the need for new compromises, because of increasing unconscious cognitive dissonance and new alignments of guilty feeling. A mismatch of internal representations and new perceptions is never tolerable, and in neurosis we rearrange our perceptions to suit our rigidly held internal expectations. The persistence, constancy, and facilitating qualities of the analytic environment, including the transference interpretations, provide not only a background of safety, but lead to a new psychic reality of greater tolerance for shameful and frightening unconscious fantasies. Paradoxically, they also create increasing guilt over maintaining old grievances in a new environment. (5) This led to a need for a new adaptation to an old danger-the impending disruption of the sessions-because the old adaptation had become too conflictual. Inner conscience would no longer permit simple enactments of the old fantasy of abandonment. (6) Finally, the outcome of all these ingredients was the need for a new intrapsychic compromise formation. To achieve this, a memory was recaptured (incidentally, confirmed by her mother). The memory, whether created or recaptured, was important in helping the patient to organize a new transference relationship with the analyst, more clearly distinguishing him from the damaging remembered father, and in helping her to restore a more satisfactory arrangement with her altered superego. She could begin to accept her anger at the father of childhood without quite so much need to justify and enact it in the present.
    The historical view of the transference interpretation--the analyst as abandoning father--has played a part in this transference reorganization, but only one part. The modernist version of the transference interpretations urges us toward a richer and more inclusive understanding of the transference events. The patient is changing, indeed, in response to the analyst's transference interpretations; but she is changing in the course of a relationship with the analyst. In this relationship, transference interpretation has played a vital role not only in helping her to gain insight, but also in helping her to regulate her feelings and her relationship with me, as well as mine with her. Her expectations of me have changed. We have attained better empathic contact. It is here that what I referred to earlier as the "romantic" and intersubjective emphasis of the modernist view becomes apparent, in the effort of two people to connect affectively.
    When we speak of transference interpretations, it is probably wise to include also those that are silent-the many interpretations we entertain but never utter to the patient. These silent transference interpretations-hypotheses about what is happening in the analysis-are crucial for the analyst's conduct of the treatment, influencing the way he listens and intervenes, and leading to many subsidiary interpretations. These unspoken interpretations deserve to be considered in any narrative of the analytic process, even though they may achieve utterance only later in the analysis. Their absence is at least one reason why recorded analyses often sound stilted.
    The modernist view also stresses the open-endedness of the analytic situation. The new experiences of the interpretations and the facilitating environment of the analytic setting force significant alterations of internal representations, structures, and conflicts. This changing intrapsychic balance leads not only to alterations in the transference, but, far more important from the patient's point of view, it leads to changes in extratransference relationships as well. These changes outside the analysis may then facilitate new experiences in the analysis. In fact, one of the significant elements in the background of our vignette was the patient's greatly improved relationship with her husband. Psychoanalysis is not a closed system of an intrapsychic world impinging on a single target.

I would like to stress two of the points that have already been implied in what has been said. The first pertains to the relative roles of intrapsychic and interpersonal perspectives. Since Freud's discovery of psychic reality, it has been part of the historical conception to focus primarily on the intrapsychic life of the patient, the psyche being conceived largely as driven toward objects, rather than formed and constantly reforming in relation to objects. Analysts holding this view (Curtis, 1980) of course acknowledge the interpersonal aspect, but they are likely to see it as a part of the surround rather than a part of the core of analytic work. They believe that the intrapsychic realm is the only one to which analytic expertise applies, and that any emphasis on the interpersonal is liable to lead to dilution of analytic work, excessive intrusion of the analyst into the patient's life, or a shallow corrective emotional experience.
    All these dangers are real, and have occurred in the history of psychoanalysis, but I believe, with Gill and Emde recently and Sullivan long ago, that we cannot fully interpret transference resistances without acknowledging their interpersonal quality. There has been a mistaken tendency to equate psychic reality with the intrapsychic, and to neglect the contribution of interpersonal interaction to the creation of new psychic reality.
    Freud (1905), in the postscript to the Dora case, made this point when he wrote, "I ought to have listened to the warning myself. 'Now,' I ought to have said to her, 'it is from Herr K. that you have made a transference on to me. Have you noticed anything that leads you to suspect me of evil intentions similar (whether openly or in some sublimated form) to Herr K.'s? Or have you been struck by anything about me or got to know anything about me which has caught your fancy, as happened previously with Herr K.?' Her attention would then have been turned to some detail in our relations, or in my person or circumstances, behind which there lay concealed something analogous but immeasurably more important concerning Herr K." (p. 118). While Freud was interested in the hidden motive, he recognized that the route to it was through the interpersonal connection. Although he spoke of the transference from Herr K. onto himself, he implied that it could not have occurred unless the patient had seen something about him that made such a concordance of perception possible. Schwaber (1983) has emphasized this point. Of course, the patient needs to match the interpersonal world to his intrapsychic world, and to achieve this he or she uses all available data, no matter how one-sidedly perceived-the analyst's silences or his talkativeness, attitudes, tastes in art, manner of dress, speech habits, etc. The analyst who cannot tolerate this close scrutiny himself and denies the veracity of his foibles that are included in the patient's transference is unable fully to interpret the transference and is encouraging deceit in the analytic relationship. At the same time, the analyst must be able to discover how his foibles and failures are being used in the service of the patient's neurosis, as well as to distinguish the misperceptions that patients create to suit their needs. Otherwise, indeed, the patient's neurotic defenses are strengthened.
    This touches on the issue of "distortion" in the patient's communications to the analyst. Schwaber (1983) and Gill (1982), from somewhat different perspectives, have both suggested that the analyst is in no better position to know the patient's "truth" or the correctness of his perceptions than is the patient. They maintain that both parties' views of the transference are valid, and it is a failure of logic to think of transference interpretations as "correcting" distortions. Schafer (1985) criticizes Gill's view as removing the gradients of expertise, of need for help, of closeness to conflict, etc., that characterize the different responsibilities of therapist and patient in the analytic situation. I would go further and suggest that the concept of defense, central to the idea of transference resistance, carries with it the clear implication that the patient, in the neurotic areas of his psychic functioning, has to some degree unconsciously constricted, distorted, and rigidified his perceptual, affective, and cognitive capacities. We know that all historians are biased, and we have every reason to be alert to the unconscious sources of bias in the histories constructed by our patients.
    It behooves the analyst to know not only the content of his patient's narrative, but the needs that compel its construction, the elements that must be a part of any human history that are missing in the particular history, and the effect of the shared experience of analyst and patient in creating new histories, often quite different from each of them. When the patient in our vignette said everything is flattened out, it would not be unreasonable for the analyst to suspect that exactly the opposite was the case. The purpose of the analyst's alertness to distortion is not to correct his patient, but to allow him to understand the needs that are dictating the patient's construction.
    I shall give another vignette to illustrate my view of the problem. A woman in her last months of analysis said, "I never wanted to say thank you to my mother. That would have meant to be chained to her. . . . It's terrible, but to feel free I had never to be spontaneous with my mother." I said, "It's been very difficult for you here to feel that you could be entirely spontaneous and trust me not to make you feel guilty or dependent." The patient became silent for a time and went on, "It makes me very angry to hear you say that I didn't trust you. It isn't that I didn't trust you, it was that whatever you said invoked in me a reaction like my mother had said it. As a child I was always uniform, balanced, defended. If I thought I mistrusted you how could I keep coming here? If I kissed my mother goodbye before going to school and at the same time thought that I wanted her to be dead, I'd be terribly guilty. It's hard to accept that you could allow me to have both feelings toward you."
    The patient felt accused over the matter of trust, explaining that it had nothing to do with the analyst, but was a reaction to her mother. She sharply differentiated (some would say split) between the analyst she trusts enough to keep coming, and the analyst-mother whom she mistrusts. One of the aims of interpretation is to develop the capacity to bring these different representations closer together with less anxiety and guilt.
    This dialogue had been preceded by years of work on both her feelings about the analyst and about her mother. Initially, her mother was simply absent from her childhood description, dismissed as a bland, not very intelligent woman, who played no part in her upbringing; in fact, the patient from earliest years recalled that she was the one who took care of her incompetent mother, and she had no memories of ever being cared for. From the analyst's perspective, it is essential both to understand what the patient believes and to hypothesize about how that belief came about. We know that childhood could not have been as the patient recalled it; her mother did care for her as a little girl, even though the patient is also telling us that she felt inadequately cared for. It wounds her narcissism to have to admit that she was not always the independent oedipal victor she later became. Distortions of history have been elaborated, and the analyst will try to understand the psychological circumstances, intrapsychic and interpersonal, that led this woman to erase any evidences of infantile helplessness, to eradicate her mother's essential caretaking, and to adopt her thinly disguised hostile attitude toward a fantasied helpless mother. The analytic aim is not to contradict the patient's view; rather it is to be alert to predictable reactions that will arise in the transference with the patient who holds such beliefs (e.g., her fear of attachment and dependency, her mistrust of the analyst's capacity to tolerate her murderous competitiveness) and to be ready to assist the patient in her struggle to come to grips with internalized versions of her mother and herself that she has not been able to entertain consciously. For example, during years of analysis, this woman insisted that everything I did was guided entirely by my need to obey the rules of my profession, and had nothing to do with her personally. She also maintained she did not in any way know me or anything about me. These beliefs can be clearly regarded as transference distortions by means of which the patient attempted to maintain her original repression of both her attachment to her deeply depressed and disappointing mother, and of her mother's interest in her child, however faulty that interest was. In fact, when she was ready to know what she knew, she knew an enormous amount, both about me and about her mother. Until then, as far as she was concerned, it was an honest statement. The concept of distortion neither demeans the patient nor implies a single correct truth.

The transference and its interpretation are at the center of all considerations of analytic theory and technique. Freud, throughout his life, seemed astonished by the power of transference, and we are no less so. The concept was relatively simple when we understood persons as in the grip of their drives, and the purpose of the analysis was the expansion of consciousness. Today, the idea of transference has become so complex that we are no longer sure what in the analysis is not transference, and if it is not, what it is. Our loss of innocence is part of a large change in world view concerning history and truth. Major philosophical, scientific, and cultural movements, as well as our own researches, have led to a new and desirable situation of theoretical pluralism in psychoanalysis, although at the price of the loss of a great overarching theory. As a result, our once straightforward historical understanding of transference interpretation has yielded to a more polymorphous and confusing, but more interesting modemist view. This modernist view has raised our awareness of elements of the transference that were previously neglected, and it has opened the way for experimentation and reconsideration of many old problems.

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Twelve Aspects of Coping for Persons with Serious and Persistent Mental Illness
Frederick J. Frese- Innovations and Research, 1993, 2(3). 39-46

As with the acquisition of most skills, learning to cope with a disability is a function of experience and guidance from others. The author, diagnosed with schizophrenia at age 25, is now a psychologist who works with persons hospitalized with mental illness. He has frequently delivered presentations about coping with schizophrenia during the past 3 years. His ideas are based on his personal experience of living with the disorder, his experience with his patients, and that which "rings true" to his thoughts on twelve aspects of learning to live with this serious mental disorder.
    When people lie, sparks are set off in the brain, thus melting brain chemicals which may be the conscience and pride. "I was 2 years old when I got my doctorate, an M.D. from Harvard. I got a Ph.D. in comparative literature and a law degree at the same time, as well as a phi beta kappa in care-giving from Sunny Acres." The above is a paraphrased sample of speech from one of my actively psychotic schizophrenic friends. She is really a very nice person and has a lot of good ideas, but obviously something is not quite right with the way she is thinking.
    I, too, am a person with schizophrenia. I am not currently psychotic but I have been in the state of psychosis frequently enough to have become somewhat familiar with the trips there and back. After years of keeping my experiences with schizophrenia a secret, a few years ago I decided to become open about my condition. Initially I revealed my background during talks I was giving locally. Later, at the invitation of various groups of professionals, consumer/survivors and family members, I began giving talks around the country. At first I gave a talk calling for partnership between consumer/survivors, professionals, and family members. The speech was fairly well received. But at the annual convention of the South Dakota Alliance for the Mentally III, I was asked to give two different speeches to the same audience. I decided to give the second speech on coping skills. In doing so I learned consumers and family members would far more like to hear about how to go about living with schizophrenia than about more theoretical or political aspects of caring for the mentally ill.
    My first speech in South Dakota was given almost 3 years ago. Since then I have given the same basic talk several dozen times in about half the states. The speech has evolved considerably since it was first delivered, as audience members contributed comments that I felt were particularly valuable. My talk addresses twelve aspects of coping with schizophrenia. I have organized it a little differently for this article, but I still keep the basic twelve aspects as the organizational framework for the presentation. What follows is the essence of the basic speech, adapted for publication.

1.) Denial, Acceptance and One's Belief Structure
I cannot tell you how difficult it is for a person to accept the fact that he or she is schizophrenic. Since the time when we were very young we have all been conditioned to accept that if something is crazy or insane, its worth to us is automatically dismissed. We live in a world that is held together by rational connections. That which is logical or reasonable is acceptable. That which is not reasonable is not acceptable. The nature of this disorder is that it effects the chemistry that controls your cognitive processes. It affects your belief system. It fools you into believing that what you are thinking or what you believe is true and correct, when others can usually tell that your thinking processes are not functioning well.
    I had been hospitalized five times before I was willing to consider the possibility that there might be something wrong with me. We are all conditioned from birth not to accept that which is crazy or insane. That which is insane is beyond the pale of that which those in our human family will accept. We accept that which is logical, that which is rational and reasonable. That which is crazy is dismissed. Therefore it is very difficult for us to accept that what we are thinking is in fact crazy. Psychosis is a "catch 22." If you understand that you are insane then you are thinking properly and are therefore not insane. You can only be psychotic if in fact you believe that you are not. Therefore almost everyone with this disorder initially denies that they have it. Some deny it all their lives. Most of the 300 patients I have in the hospital where I work will tell you that they are not mentally ill. Denial of the disorder comes as part of the territory for most of us who have it. Some of those who have the disorder not only deny that they have it but also deny that it exists. It is exceedingly difficult for you to admit to yourself that your mind does not function properly. It fools you. With this disorder you develop an epistemological structure that is not consonant with that of the vast majority of those in the larger, majority population.
    But if one does not acknowledge that they have the disorder, how can it be helped? Why would anyone want to be cured of a disorder that they do not believe they have? I find that a good approach for persons in such denial is to point out that, even though they may not have the disorder, it is true that they have been treated by others as though they do have mental illness. They will usually agree with this thesis, especially if they have been hospitalized. Often these folks will accept being referred to with a term like, "survivor." Once they have accepted the fact that others may view them as mentally ill, they then have some motivation to learn more about the disorder.   It is generally best not to try to make a "frontal assault" against denial. Try to establish a trusting relationship and gradually chip away or "defreeze" the rigid cognitive defensive structure that constitutes the denial.

2.) Knowledge of the Disorder
In this, the "Decade of the Brain," evidence continues to mount that viewed from an objective, or, scientific perspective, schizophrenia is a brain-based disorder. It can be best conceptualized as an imbalance in the biochemistry of the brain's neurotransmitting systems (Gershon & Rieder, 1992; Wong et al., 1986). Studies are published with great frequency now, further establishing the neurophysiological correlates and consequences of serious mental illness. As articulated by one prominent psychiatrist, "Patients have to be taught to accept the fact that they are ill, that this is not a mystical experience but a disease--an illness that needs treatment." (Cancro, 1992).
    From the viewpoint of the person with the disorder, however, the phenomenon can be very much like a mystical experience. The young psychiatrist, Carol North (1987), describes herself as being in a parallel reality or at a cosmic juncture. I (Frese, 1993a) have referred to one of my breakdowns as "cruising the cosmos." David Zelt (1981) describes himself as being "constantly in touch with the infinite and the eternal." The nature of the disorder is that it affects the brain's thought and belief systems, it affects a person's confidence in what is truthful. Therefore, to the person who is experiencing the disorder it very much can be a mystical journey where poetic relationships and metaphorical associations dictate truth. To the person who is experiencing the disorder, these subjective experiences are very real indeed.   Therefore, while one should try to understand as much as possible about how the disorder is accompanied by biochemical irregularities, one should also understand that for the person who has the schizophrenia, it indeed can be a mystical or even a religious experience.  Often these mystical experiences can be most seductive. One has the feeling that he is having special insights and even special powers. One is no longer restricted by the rigid control of rationality. One begins engaging in what experts have called paleologic (Arieti & Brody, 1974) or parataxic thinking (Sullivan, 1953). Many consumer/ survivors prefer the term, "poetic" logic.

3.) Medication, Chemicals
Persons with serious mental illness are disabled, just like people who are blind, deaf or crippled. Like others who are disabled we can be helped by artificial support. Where the blind may have a cane or a seeing eye dog, the deaf may be helped with a hearing aid, and the crippled may be helped with a wheelchair or a crutch, we, too, can be helped by artificial means. Because our disability is one of a biochemical imbalance, it is reasonable that our "crutch" is chemical. For us, our crutch is the neuroleptic medications that we take. In order to keep our brain's neurochemical processes properly balanced, we need the assistance of helpful chemicals, prescribed medications. Certainly without having such medications available, I would not be able to function as I do today. True, there are side effects of these drugs: akathisia, akinesia, dyskinesia, dystonia, et cetera, and these can be quite problematic, even disabling. But the medications are becoming better. Around the country I have met dozens of persons who have been helped by clozapine, which has only been widely available in this country for a relatively short time. The drugs Risperidone, Roxiam, and Olanzapine, which may be widely available during the next few years hold out further hope for those of us who are disabled with mental illness. Those of us who are dependent on these drugs should attempt to learn all we can about them and their side effects, both short term and long term. These medications hold such hope for us. But just as some chemicals function to assist us, others are harmful to us. Such "street drugs" as PCP and amphetamines are much more likely to cause a recovered schizophrenic to relapse into psychosis than they are to have a similar effect on a "normal" individual. Likewise, marijuana and alcohol also increase the likelihood that persons with these vulnerabilities are going to experience mental breakdowns. Those of us with these vulnerabilities to breakdowns in our biochemical systems need to learn as much as possible about the effects of drugs so that we can utilize and avoid them in a judicious manner.

4.) 'Paleologic' or Delusional Thinking
When a healthy individual functions in a normal manner, encountering moderate degrees of stress and pressure, his or her physiological systems operate in a healthy manner. But when stress increases and is sustained, physiological systems begin to wear and weaken. Eventually they malfunction. They break.
    Different individuals react in different ways. Some people react more with blood pressure increases, others more readily react with sweaty palms. Still others react with increased gastro-motility, their stomachs "churn.' Psychophysiologists refer to this as "response specificity," and point out that people tend to develop symptoms in the physiological systems in which they are most reactive (Sternbach, 1966). Blood pressure reactors develop hypertension, skin reactors develop hives, stomach reactors develop ulcers.
    From this perspective it is not unreasonable to view some of us as neurotransmitter reactors. When we are functioning in a normal manner, we are rational, but we tend to overreact to stress with our emotions and our cognitions. Ordinarily we reason as others do. Our mechanisms for processing information in a logical, rational manner are intact. We are said to use linear logic and Aristotelian reasoning. When our systems encounter pressures, our physiological/mental processes react as a defense. Our mental processes react in such a manner as to defend against the stressors. We may become more vigilant, more suspicious. Our thinking may speed up, our minds may begin to race. We may start developing new, more original ways of thinking about things. Our coping mechanisms begin to strain. At some point our minds begin to break. At first they just crack a little. They craze. Then we begin to "go crazy." We lose our ability to remain rational. Instead our minds revert to an evolutionally earlier way of functioning.
    Beneath our centers for rational processing in the brain resides the paleocortex, the limbic cortex, the reptilian brain. Here are the centers of emotions, of anger, of fear, of humor and of love. Ordinarily from this paleocortex, emotional activity affects us as when we are moved to tears by a story or to laughter by a joke. But we rapidly recover control and are guided by rationality. We remain confident that that which is reasonable or logical is true. We can believe that which strikes us as rational.   But when our rational processes break, our cognitions become dominated by the activities of the paleocortex. Our mental processes begin to become dominated by paleologic (Arieti & Brody, 1974) activity. We begin to lose our confidence in rational processing and begin to see truth in nonlinear relationships.

5.) Social Deficits
Miller and Flack (1990) presented an interesting paper recently. In observing schizophrenics in social interaction and comparing us with normals, they found that we tend not to look at the person to whom we are talking. From our perspective there is good reason for this, of course. We are more easily distracted and if we look at others while we are talking we will see their facial reactions, making it more difficult to focus on what we are saying. This naturally can be most disconcerting to the person with whom we are conversing. Normals expect signs of interaction when they are speaking with others. Since we often fall to respond in the expected manner, we throw them off.
    Miller and Flack also point out that compared to normals we schizophrenics are much less likely than normals to nod in agreement or move our hands in rhythm with our partner's speech. Often when we do nod appropriately it will be later in the course of talking than is usually expected. The reason for such delaying is that we spend a longer time processing information than normals. Such delays of course tend to throw off the rhythms of a conversation. Normals find this disconcerting. They often do not realize that our failure to send and receive the expected cues during conversation is part of our disability.
    Normals send other signals in conversational encounters. They use short statements at the beginning and end "How are you?" or "See you Wednesday" and longer statements in the middle. They also lower the pitch of their voice to indicate they are finished. Schizophrenics tend not to do this. We seem to have a defect in our cue signaling mechanisms. As a result we often have difficulty in knowing when we should be ending a conversation or how to do it. Miller and Flack feel we are defective in our capacity to engage in shared (conversational) activities. I would agree but I feel if we know the nature of these defects and those with whom we come in frequent contact know about these deficits, we can better work together to overcome them.
    Others (Lysaker, Bell, Milstein, Goulet, & Bryson, 1993) have reported that schizophrenics' deficits in social communication skills interfere with their functioning in vocational settings. They point out that schizophrenics may perceive a joke as a threat, or otherwise misinterpret communications by coworkers and employers. Often persons with schizophrenia can perform the work as well as normals, but due to their deficits in social and communication skills they have more difficulty in the work setting, often to the point of even losing the employment. Clearly, those of us with schizophrenia need to know more about our deficits and those who frequently interact with us need to know about our deficits in social interaction. Together we can work to better compensate for them.

6.) Replaying/Rehearsing
   Often when you visit a psychiatric hospital you will see patients who seem to be talking to people who are not there. In their one-sided conversations they will often become quite animated. Because they are talking to people who are not there, it is usually assumed that they must be hearing voices and talking back to them. Although this may sometimes be the case, often something quite different is at play.
    Those of us with schizophrenia are very sensitive to having our feelings hurt. Insults, hostile criticism, and other forms of psychological assault wound us deeply, and we bear scars from these attacks to a much greater degree than do our normal friends. Because we have this hypersensitivity, naturally enough we try to protect ourselves and prepare ourselves from possible future attacks. By way of this, one of the things we do is replay in our minds situations where we have been hurt, trying to develop strategies of response so that if we find ourselves in similar situations again we will not be so damaged again. What we are doing in our minds is saying to ourselves, "What I should have said was..." or "I should have told that guy that I am just as good as he is." We rehearse or replay situations over and over in our minds, and we often find ourselves speaking in an audible fashion when we are doing this. We have a definite compulsion to engage in this sort of behavior.
    Many years ago my wife became so bothered by my tendency to do this, that we worked out an agreement that I would try to engage in this behavior only when I was in the shower in the morning and while I was mowing the lawn. The lawn mower motor tended to drown out the sound of my mumbling.
    Persons with schizophrenia need to know that we have this tendency to talk to ourselves and that this behavior tends to upset normals. I recommend that whenever we have a need to do this that we do the same thing that we do when we have other physiologically based needs to function in a manner not welcome in polite social circumstances. We should excuse ourselves, withdraw to a restroom, or other area where we can be in private and rehearse/ replay until we get the urge to do so out of our system.
    Despite this advice, I frequently find myself in social situations where I am talking to myself, usually in a soft tone. It is at times like these that I am most gratified that others know that I am disabled with schizophrenia. Because of this I think others expect me to be a little different. So when they see me talking to myself they do not seem to be quite so perplexed.

7.) Expressed Emotion
The Expressed Emotion (EE) concept was developed by George Brown and his associates in the Institute of Psychiatry in London in the 1950s (Brown, Carstairs, & Topping, 1958). Brown's studies focused on the relation between family variables and the likelihood of relapse on the part of persons with schizophrenia who had recently been released from the hospital. Those investigators found that patients who went to live with family members who were highly emotionally involved were much more likely to relapse than those patients who went to families who were less "hostile," or who exhibited less "expressed emotion." Furthermore, the relationship between emotional involvement and relapse was not related to the severity of symptoms at the time of discharge.
    High EE was defined as involving three factors. These are from the Camberwell Family Interview (Brown & Rutter, 1966):

1.) Statements of resentment, disapproval, or dislike, and any comments expressed with critical intonation that is, a critical tone, pitch, rhythm, or intensity in their voice.
2.) Hostile remarks indicating personal criticism.
3.) Emotional overinvolvement, constant worrying about minor matters, overprotective attitudes, intrusive behavior.

Additionally, warmth, expressed in terms of positive comments and voice tone, appear to be added protection for persons discharged to low-EE environments and dissatisfaction, even when not expressed in a critical or hostile manner, appeared to increase relapse risk in high-EE households.
    It is my experience that those of us with schizophrenia are indeed very sensitive to hostile criticism and other forms of expressed emotion. But it is not only in the family context. Whenever persons with schizophrenia encounter criticism, insults, or other forms of psychological oppression, we tend to be damaged in a manner that increases the likelihood of our relapsing into psychosis. This vulnerability tends to be part of the disorder. Those who have this disorder need to know that they are vulnerable in this manner. Other persons who come into frequent contact with the mentally ill also need to know that we are particularly sensitive in this regard.
    As with those in the AA organization, those of us with schizophrenia need to avoid the persons, places, and things where we are likely to encounter expressed emotion. But of course, we will not always be able to avoid such circumstances. For those times when we are going to encounter hostile criticism, etc., I recommend that we be prepared to protect ourselves by developing a mechanism for communicating to others something about the nature of our disability. Some years ago I developed a card which I carry in my wallet. When I find myself being faced with unfair criticism I will present the person doing the criticizing with my card, which has these words written on it:

Excuse me. I need to tell you that I am a person suffering from a mental disorder. When I am berated, belittled, insulted, or otherwise treated in an oppressive manner I tend to become emotionally ill. Could I ask that you restate your concern in a manner that does not tend to disable me? Thank you for your consideration.

While I don't use this card frequently, I do find it gives me assurance to have it with me.

8.) Stress and Excitement
Not long ago three former patients at our hospital were the focus of a local TV news program on mental illness. All three performed very well for the program but unfortunately within 3 weeks each of them had relapsed and were back in the hospital. My own breakdowns frequently occur while I am attending conferences or shortly thereafter. I often find that visits to a shopping mall where there is much stimulation causes me too much stress.
    Persons with schizophrenia should realize that they can become overstimulated by exciting circumstances as well as by stressful circumstances. We need to develop techniques to limit the effects that overstimulation may have on our systems. I find that when I begin to become overstimulated it is often helpful to politely excuse myself and withdraw from the situation. If I am at a conference I can withdraw to my room or if I am at a mall I can withdraw to a less stimulating environment.
    I find that if I know ahead of time that I am going to be in a stressful or exciting situation for an extended period of time it is helpful to increase the dosage of my medication prior to involving myself in such events. At meetings where there are often sharp exchanges between the participants, I find that it is helpful to withdraw from the circle of participants and sit at a distance from the verbal exchanges. It is less taxing to be out of the line of verbal fire that often occurs during meetings where important issues are being discussed.

9.) Music and Hobbies/ Woodshedding
Because the nature of our disorder is such that our ability to sustain our rational processes is damaged, it is often helpful if we engage in activities that do not tax our logical abilities. Music, art, and poetic type endeavors are often easier for us to handle. For this reason I encourage persons disabled with schizophrenia to engage in these forms of expressions as a way of communicating.
    As Tim Woodman (1987) relates in describing his disorder: "What really helped was art therapy. I got a lot of satisfaction out of painting, and it seemed to me to go some way toward answering my unspoken desire for personal harmony" (p. 330).  In my own case I find that dancing for extended periods of time can be very therapeutic. There is something about being able to express yourself in a nonrational manner that helps release pressures that have built up from stresses that have been encountered. Often these musical or artistic expressions come forth in a manner that is not readily appreciated by others. Nevertheless, the fact that we are expressing ourselves can be most therapeutic. A term that has been adopted for such activity is "woodshedding." (J. S. Strauss, personal communication, December 171, 1990.) This term is taken from jazz, where a musician will go out away from others to a woodshed and experiment with various sounds until the sounds begin to form patterns that can be appreciated by others. For those of us with schizophrenia, engaging in woodshedding activities, whether they be in art, music, or poetry, can be a viable method for building a bridge back to the world of normality.
    Not long ago a patient of mine who engages frequently in writing poetry wrote a poem that I feel carried a particularly insightful message to mental health workers. She wrote:

Be my teacher
Not a preacher,
And as I learn,
Give me a turn.

10.) Stigma/ Discrimination
Traditionally those of us who were struck with mental illness were ejected from society and placed in isolated asylums. The words "crazy," "insane," and "nuts" have come to mean those things that can be immediately dismissed as unimportant by the members of the normal population. Until about 30 years ago those of us who were determined to be insane were removed and not expected to return to society. When we did start returning we were not generally welcomed. As I pointed out in a recent article (Frese, 1993b), the movies have a tradition of portraying the mentally ill as monsters. The news media also primarily addresses mental illness when one of us has killed or has committed some other form of bizarre crime.
    While normals can speak openly and even casually about cancer or heart disease, the topic of schizophrenia elicits primarily emotional reactions like fear or derisive humor. Normals are not comfortable with the thought of a seriously mentally ill person living in their neighborhood, being in school with them, or being in their workplace. We still frighten them. They do not know what to expect from us.
    Recently the National Mental Health Consumer's Association adopted a six-part national agenda. One of that organization's six designated issues is discrimination, for which the following is stated, "Discrimination, abuse, ostracism, stigmatization and other forms of social prejudice must be identified and vigorously opposed at every opportunity." Likewise there has been established a National Stigma Clearinghouse (275 Seventh Ave., 16th Floor, New York, NY 10001) which monitors and challenges media stereotypes of the mentally ill.
    For those of us who have returned and have found that we are not as welcome as we would like to be, we have a challenge. We must work together to change the image we have with those in what I sometimes refer to as the "chronically normal community." As more and more of us are becoming open about the nature of our disability, we have an obligation to share with others as much as we can about mental illness so that there is less fear and greater understanding and acceptance. To help counter the negative images, it is of course helpful to have positive images of the mentally ill to put forth. Mike Jaffe (1993) and his family have done us all an outstanding service by producing and widely distributing posters highlighting "people with mental illness (who) enrich our lives." They point out that such persons as Robert Schumann, the composer, Vaslov Nijinski, the dancer, Eugene O'Neill, the playwright and many other accomplished individuals, suffered from serious mental illness.
    Of course I cannot leave the topic of discrimination without mentioning the Americans with Disabilities Act (ADA). This recent legislation is seen as a significant step forward for us in the area of employment opportunities, building on legislation that has been evolving during the past two decades. Numerous consumer/survivor activists have stated that the stigma that accompanies serious mental illness in many ways is worse than the illness itself.

11.) Revealing/Covering
Since deciding to become open, and even public, about my condition, I have received quite a bit of media coverage. One consequence of this is that recovered mentally ill persons, including many professionals, who have not been open about their condition, contact me and ask if it is wise to share such information with others, particularly their employers. Some time ago I developed a strategy for approaching others such as employers.
    The consumer/employee takes an article about myself or another recovered person and shows it to the boss. If the boss's reaction is positive, saying something like, "That person must be very brave and is probably making a real contribution," then you know it may be safe to share with him or her about your own background. If, on the other hand, the boss's reaction is more along the lines of, "I'm sure glad we don't have a 'nut case' like that working here," then you might want to be a little more cautious. Interestingly enough, those who have tried this strategy in mental health settings have received both types of reaction. Those who receive a positive reaction generally follow up and reveal that they, too, are recovered persons. Usually this is a therapeutic relief for them. It is very difficult to carry a "shameful" secret with you. When we consumers meet at conventions and elsewhere I often hear statements like, "I am so tired of hiding," from those who are not open to others about their condition.
    However, as a practical matter, many persons probably should not be too open about their past. The ADA affords some protection and even advantage to officially stating that you have a disability but there is still much discrimination. If you decide not to reveal to others, how do you cover for the time you were in the hospital? If you are unemployed how do you answer when asked what you do for a living? Many consumers find these very difficult questions to handle. I advise that you respond by saying you are a writer, an artist, a (mental health) consultant, or perhaps that you "free lance," depending on how you have been spending your time. None of these responses are lies, per se, but they leave considerable latitude for interpretation and they do not require that you have a specific employer or work location.
    Whether you decide to reveal or not is a serious personal decision. If you are older, established in a career, particularly in the mental health field, it is probably safer to become open about your condition. Obviously, the closer you are to retirement age the better. But if you are younger, just starting out, you might want to be very careful about becoming too open about being a person with serious mental illness. One important thing to remember is that once you tell others about yourself, you cannot untell them. Once you become open, there will be insults, subtle and otherwise. If you decide to reveal, be prepared to do a lot of educating of our "chronically normal" friends.

12.) Networking/Consumer Groups/Self-help
Whenever I was released after being hospitalized, I always knew that there were others who were like me, those who had received psychiatric inpatient treatment and were now in the community. But I had no way of knowing who these people were. Everything was clouded in secrecy. There was no practical way for one to meet others who had similar experiences. As a result, being a recovering mentally ill person was a very lonely experience. As I did, too many discharged persons spend too much time alone in a room watching television or just looking at walls.
    Fortunately this situation is changing. Fourteen years ago the National Alliance for the Mentally Ill (NAMI) was founded and regular meetings of family members now occur in virtually all of the states and larger cities in the country and in many smaller ones. Many of these groups encourage involvement of recovering persons themselves as well as family members. Indeed, NAMI has a national network of recovered persons called the Consumer Council. Recently members of this network have been gaining more influence within NAMI and as of this writing they occupy three positions on the NAMI Board of Directors.
    In addition to the consumers active with the NAMI organization there are two independent national consumer organizations which are active in networking and advocating for recovered persons. The National Association of Psychiatric Survivors (NAPS) is active in advocating for the rights of consumers, but takes a position in opposition to any form of forced treatment, a stance that some recovered persons are not comfortable with. The third nationally active organization for recovered persons which has been regularly recognized in discussions of public policy involving the mentally ill is the National Mental Health Consumers' Association (NMHCA).' This organization is also independent and it has traditionally taken no formal position concerning the forced treatment issue.
    All three organizations have been active in articulating news of persons who have received treatment for serious mental illness. Depending on one's degree of comfort with the family movement and feelings about the forced treatment issue, the activities of one or more of these groups could be of interest to recovered persons wanting to become more active in advocating for bettering conditions for persons with mental illness. In addition to these national groups, most cities and states have consumer organizations with which one can affiliate. It has been my experience that recovering persons benefit greatly from associating with others with similar disabilities.
    In some areas consumers have taken the initiative to establish facilities for recovering persons that are operated by themselves. They may or may not work in concert with traditional mental health providers, but control of these operations remains in the hands of recovered persons themselves. These are usually referred to as self-help efforts and are generally found to be cost effective and much appreciated by the consumers who are involved with them. Indeed, recently when the board members of the NMHCA organization were asked to identify their highest priority in restructuring the delivery of mental health care in this country, they unanimously identified self-help as their major issue. With this kind of enthusiastic support, it is likely that self-help consumer-run drop-in centers, social clubs, and crisis facilities will become more widely available.

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