A MODEL THERAPY FOR PSYCHOTIC YOUNG PEOPLE

by ,.,

Jay Haley· and Neil P. Schiff, PhD.··

Abstract

The prevailing ideology regarding the origin and treatment of

Schizophrenia is challenged. A three stage model is presented and
illustrated with a detailed case history. Success and failure premises
are also examined.

The prevailing ideology regarding the origin and treatment of schizophrenia

assumes that it is a chronic, long-term disease, probably transmitted genetically,
and that it is evoked by stressful interaction between person and the environment.
Current treatment includes medication to modify the symptoms of schizophrenia
and a psychiatric rehabilitation approach, which includes creating a supportive
environment by engaging the patient's family. The family is educated to think of
schizophrenia as a chronic, long-term illness which is probably incurable and has
episodic acute phases. The family is a<;ked to exhibit patience, limited expectations
since the person is handicapped, and to avoid emotionally charged interactions·
with the patient as well as negative emotional expression. In addition, an effort is
made to slowly introduce limited skill training of various' kinds to the client
(Strachan, 1986).

This point of view is preferred and taught by the most powerful constituencies in
the field. However. there is scant evidence that this approach has led to an increase
in therapeutic success if we defme success as achieving normal behavior. In 1980, a
promising therapeutic approach. particularly successful in cases of first psychotic
episodes. was described in Leayin~ Home by Jay Haley. The outcomes have been
successful enougb that it is unfortunate the "leaving bome" approacb has not
received more attention. interest and application. The approacb will be illustrated
here.

In the past. when therapy with such young people failed. the fault was attributed
to the client. The incompetence of the therapist was not emphasized because the
ideology in the field assumed such clients were essentially incurable. Granting
that therapy with psychotic problems is difficult. therapists must still accept
responsibility for failure. Chronicity and a lifetime on medication are often the

• Jay Haley is the Director of the Family Therapy Institute, 5850 Hubbard Drive,
Rockville MD

•• Neil P. Schiff. Ph.D., is in private practice at 4545 Connecticut Avenue, N.W.,

Washington, DC. 20008. .

This paper presents a model for the strategic therapy of schizophrenia and
describes the successful application of the model in a case previously diagnosed
chronic.

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 A Model Therapy for Psychotic Young People I J. Haley and N. Schiff

fault of therapists who have misunderstood the problem or lacked the therapeutic
skill to solve it. Lack of skill is not surprising since training in how to do therapy
with these young people has been almost unavailable since medication replaced
therapy in the field (Carpenter, 1986).

As a guide for therapists who wish to increase their success with young people
diagnosed schizophrenic, a case will be offered here where the proper steps were
taken and success occurred. Such success is not routine but it is possible when the
problem is properly approacbed. Following this case discussion, the premises
which increase the probability of success with this problem and those which lead
to failure will be presented.

Case Example

A young man began to experience psychological difficulties at the age of 21

during his second semester of college. He attributed his difficulties to the onset
of an overwhelming, immobilizing, diffuse and vaguely located pain of
mysterious origin. While he performed well academically, he had problems
getting along with his friends, took LSD, became increasingly uncommunicative
and withdrawn, ate little and wrote odd, cryptic letters to his parents. When he
returned home for his summer vacation his sophomore year, his parents realized he
was having serious problems. In July of that summer, during a conversation with
his father, the young man, we shall call him B, shattered a triple glazed window,
cutting deeply into his left forearm (the full use of which he needed to play the
guitar). He found himself, after emergency treatment and restorative surgery in a
general hospital, in a psychiatric unit where he remained, with a diagnosis of
paranoid schizophrenia. for nine weeks. B was also hearing voices and experiencing
paranoid ideation.

Wben this therapy began, B had been out of school for well over a year and had
been hospitalized three times with the diagnosis of schizophrenia conf111Iled. He
was living with bis parents, attending a day treatment program several days a
week at a local CMHC1 , participating in individual and family therapy and
taking Moban and Tegretol2 • He showed signs of Tardive Dyskinesia3 , He bad
achieved a precarious stability and functioned marginally, though he was slated,
probably unrealistically, to return to college the following spring semester. His
father contacted us to see if something more could be done to help his son.

B was the youngest of three brothers in what everyone regarded as a model family.
His parents were attractive and likeable people in their early 50's, though his
father's characteristic facial expression conveyed an abiding impression of
weariness and unhappiness. B's older brothers, who participated in the first

1 Community Mental Health Center

2 Which were prescribed to control the symptoms of psychosis.
3 The involuntary, spasmodic muscle movements that are a side effect of
antipsychotic medications and can be permanent.
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Journal of Systemic Therapies I Vol. 12 #3, Fall, 1993
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interview, were both thoughtful, articulate and courteous men, each of whom was
well educated, accomplished,. married and living in another part of the country.

B was an artist of considerable talent whose aspiration was to teach art after he
graduated from college. He was also interested in martial arts and a student of
Tae Kwon Do. In contrast to his brothers and parents, B looked like a tormented
Dostoyevsldan character who had escaped from the underground and inexplicably
surfa~d in a nice suburban family to whom he bore only some slight physical
resemblance. He could also have passed for a young Van Gogh.

This therapy went through three successive, overlapping stages which are typical
in such cases. There was a beginning period when everything progressed well, a
crisis and relapse, and a disengagement

In the fltst stage, which lasted for approximately ten sessions, the therapy
generally went smoothly and predictably, according to plan. Fortuitously, the
entire family had assembled for the middle brother's marriage when B's therapy
began so that the fltst session included all the family members, though it was the
only session in which the two older brothers were present. The therapy took place
in a room with a large, one-way mirror with one of the authors behind it
observing the proceedings. His presence, but not his identity, was known to the
family.

The fltSt session involved a review of the situation, a review of previous attempts
to ameliorate it, a discussion of the possible Origin of B's problems, a description
of B's primary symptom and the formulation of a goal.

In regard to the possible origins of B's difficulties, the parents did not feel a sense
of guilt and were not at all defensive about having caused B's problems. Their
view of schizophrenia was "an acute response to environmental stresses", and it
did not cause them to blame themselves or defend themselves for B's difficulties.
This relieved the therapist of the difficult task of dealing with parental guilt and
sensitivity to blame which is common with such cases. The parental definition of
schizophrenia was practical and broad enough to allow the therapist to ask them
to take steps to help B, either by reducing environmental stresses or by helping
him to cope with them more effectively, without inducing or aggravating a sense
of blame. Since it was assumed that B's difficulties were reactive to the
relationship between his parents, it was important to be able to ask them to
behave differently to help him.

The general strategy presented to the parents was to encourage a return to a

normal situation with normal expectations of B as quickly as possible. The
rationale was simply that if you want someone to behave normally, they must be
treated as normal. Both older brothers who, along with the father, bad once
experienced depression. supported such a strategy. each having remarked they they
thought B would improve if be was expected to do more. In addition, the therapist

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 A Model Therapy for Psychotic Young People I J. Haley and N. Schiff

said he would deal with B alone regarding his pain though, at points, he might
involve the parents in a discussion of it and ask their assistance to help resolve it.
In the ftrst session during time spent alone with B, as a beginning step to help him
get over his pain, he was asked to keep a log of when it occurred, how long it
lasted, etc. Thus, the ftrst session concluded with the normal goal of preparing B
to return to college -- after a focus on B's central difficulty -- his pain. His parents
stated that they expected B to do more to take care of himself and help around the
house.

In the second session, which included only the parents and B, the parents asked B
to enroll in two courses at a local college. In addition, there was a preliminary
discussion of B beginning to work part-time. The therapist agreed to speak with
B's doctor at the day treatment program to have him withdrawn so that his days
were free to attend school and to work. Involvement in a day treatment program
occupies time otherwise spent in normal pursuits and, just like antipsychotic
medication, signifies the person is incapable of norma! living. Finally, our
psychiatrist consuItant4 took over the responsibility for B's medication and
began to reduce it immediately.

There are several important reac;ons for the elimination of medication as quickly
as possible. One, even a small dose of medication identifies a person as sick and
therefore he cannot be expected to be fully responsible for himself or capable of
shouldering normal responsibilities. If a person's symptoms stabilize a
dysfunctional family, even a small amount of medication maintains the status
quo. Medication does not solve problems; rather, it deftnes the person as ill and
stabilizes an aberrant situation.

A second reason for eliminating medication as quickly as possible is that it can

produce permanent damage to the nervous system in the form of Tardive
Dyskinsia. B already exhibited signs of this malady at the time his therapy with us
began. In addition, the side effects of medication can be an impediment to behaving
normally. Depending upon dosage, medication can make people sleepy, unable,
under law, to operate a motor vehicle, amotivational, unable to express
themselves clearly, and sexually dysfunctional which makes normal social
relations difficult.

A much more extensive discussion of B's pain took place during his second
session. B said the pain was in his whole body, concentrated around his head and
came in stages and waves. He related that its effects were mitigated by time spent
with his girlfriend and the massages his father gave him, often late at night when
his suffering was particularly acute. Aside from having caused him serious
difficulties at school, B's pain caused him to lose a good job, isolated him socially,
and introduced a pervasive pessimism into his thinking about himself. Essentially,

4 Loren Mosher. M.D., who was the psychiatric consultant to the Family Therapy
Institute, interviewed the patient and his family regarding medication. handled
all aspects of the patient's withdrawal from medication and regularly followed
the progress of the therapy.
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the pain made him a failure in his life. B did not have any idea about the origins of
his pain but did agree keeping track of it might help identify its antecedents so
they, and thus his pain, could be altered.

We assumed B's pain was a problem in and of itself but also a metaphorical way of
talking about other problems. Such "irrational" statements can be understood as
disordered tbinking or they can be thought of as metaphorical communication. The
interaction around bis pain -- wbat it caused him and others to do and not to do,
wbicb cbanged as tbe case progressed -- led to ideas about its function and
therefore how to resolve it

Talking to B about his pain was a way of talking about other problems in tbe
family and prescribing modes of behavior to solve them. For example, the family
agreed that keeping busy by going to school and working would mitigate the pain
or at least distract B from it Time spent with someone special, like his girlfriend,
also helped, as well as time spent with other people. Arranging situations so that
they were gratifying belped. As is evident, these directives not only belped B but
could also have been applied to the parents. Similarly, talking to B about his
girlfriend was a way of talking about his parents' relationship. For instance, B
would complain of boredom and awkwardness in the relationsbip, of a desire to
see someone else, etc. It could be assumed there was some relationship between
wbat B was saying and wbat was transpiring between his parents.

In response to the therapist's request, B brougbt some of his drawings to the

second meeting. According to bis parents, B had become obsessed with tbe
Crucifixion and most of his drawings were grotesque and morbid renderings of it
Rather than criticize or interpret bis interest in tbe Crucifixion, the therapist
took it at face value as simply an interest, joining B in it In fact, B mentioned that
to bis knowledge no one bad really done a study of the way the Crucifixion was
depicted in different places from one historical time period to anotber. B
mentioned that he migbt consider sucb a study for an academic thesis. Joining B in
bis current interests was treating bim as normal, rather than explaining bis ideas
as pathological and thus freed him to shift his artistic focus, whicb be later did.

Since it is assumed that something in the family relationships engenders the

extreme bebavior on the part of the identified patient, it is important to become
involved and knowledgeable about the parental and other relationships quickly in
order to seek out possible cbanges. In this case. the parents bad special problems.
In other cases that migbt not be so.

The parents were asked whether B had any reason to be concerned about them. Mrs.
C volunteered tbat she was overweigbt and had bigb blood pressure (later she
mentioned a drinking problem). Mr. C said be generally busied himself with the
details of running the house (wbicb be never completed,) to tbe exclusion of
everything else. including. by implication, his wife. .

As an example to B and to assuage B's concerns about them. the parents were asked
to do certain tasks to help eacb of tbem over their own difficulties and to

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 A Model Therapy for Psychotic Young People I J. Haley and N. Schiff

consolidate their relationship, though they were also told it would help B. These
tasks also indicated to B and to the parents that the therapist knew there were
other problems, probably related to B's difficulties in the family. It was also a
way of talking about their relationships while keeping the focus on B, without
becoming blaming or accusatory about what the parents might have done earlier
that contributed to B's difficulties.

B improved rapidly. Over the course of less than ten sessions, he registered and
began two college courses, obtained a part-time job as a painter, was withdrawn
from medication, improved his relationship with a girlfriend. became much more
animated and forthcoming. and he experienced considerably less frequent episodes
of his pain. He also evidenced a droll sense of humor. From the third session on,
the better B looked, the more depressed and lifeless his parents appeared.
particularly his father. Therefore, a relapse was anticipated.

During the initial ten sessions, there were increasing indications of an

estrangement between B's parents. Mr. C never smiled at his wife. nor held her
hand, nor touched her affectionately nor ever evidenced any interest in what she
did or said. When asked in the second session to do two exceptionally nice things
for his wife, Mr. C responded by washing ber car.

As more information about the C's relationship accumulated. the distance

between them became more evident In an interview alone, Mrs. C reported that
the marriage had been on the rocks five years earlier. She said that neither she nor
her husband shared many interests. Mr. C was not staying the same room as his
wife. They did not agree philosophically on bow to handle B. and Mrs. C thougbt
her husband coddled him. In a meeting with Mr. C alone. he related that some
years earlier he had decided to leave his wife, had told B, wbo was then in high
school. and then changed his mind, never explaining that to B. Apparently, Mr. C
bad barbored the hope that he would move in with a woman friend but she rejected
him and so be returned home. Mr. C related that just wben be bad begun to tbink
of leaving his wife again, B began having problems in college, wbich put the
matter on hold, and even out of his mind. Mr. C also related that his wife
regularly drank too much and had been doing so for a long time.

As B continued to improve, a contract was negotiated with Mr. and Mrs. C to

help them "improve their communication". independent of B. The eleventh session
was the fltSt in which they were seen alone as a couple with the focus exclusively
on themselves. At the beginning of this session, Mrs. C looked apprehensive and
mildly depressed. The issue of separation emerged in their discussion. Mr. C
stated that he did not intend to leave but he said so without conviction so that his
real wisbes remained ambiguous. However. taking bim at his word, an effort was
made during this session with the couple alone to get each spouse to do more to
improve their lives with one another.

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The Second Stage

Two days after this session discussing separation, the second stage of therapy
began. The second stage typically begins with a relapse on the part of the youtb
when instability in family relationships develops. One evening Mr. C heard his
son become upset and smash a door. He and his wife were preparing to go out for
the evening and called the therapist immediately. The therapist encouraged them
to follow through with their plans, which they did. After they left, B called his
girlfriend who arrived and spent several hours quietly with him. The C's returned .
home some time after B's girlfriend had gone, and B was asleep. At about 10:00
p.m. they heard B awaken and scream. Mr. C entered his son's room. B told him to
leave saying he would kill him if he didn't leave immediately. Mr. C promptly
called the police. He told B 'that he could either commit himself to a hospital
voluntarily or he would seek involuntary commitment. B agreed to go
voluntarily and did so.

After a night on the psychiatric unit, where he had previously been hospitalized
several times and was well known. B stated to the charge nurse his intention to
leave since be was there voluntarily. His presentation of himself and statement of
his wisb were perfectly normal. He made eye contact, spoke clearly, related his
understanding of tbe situation correctly and generally bebaved in an entirely
normal way. However, he was told that the attending psychiatrist wbo was now
in charge of him would seek a court order if he tried to leave. B made a dash for the
elevator in order to escape tbe unit. It eventually took eigbt people to detain him,
three of whom had to be treated in the emergency room because of injuries
received in tbe scuffle. B ended up in restraints, strapped to a bed and injected with
a two week dose of Prolixin.

Thus. the expected stages occurred. B improved, his parents threatened separation
and B relapsed in sucb an extreme fashion that bis parents bad to join one another
to cope witb him. In addition, his depressed father was mobilized, bis depression
mitigated by his taking action.

The primary question at band was wbat to do about Band bis threats of violence.
It was crucial for the parents to agree on wbat to do. The division between them as
spouses that led to a wish by Mr. C to separate. and probably engendered B's
threat, bad to be set aside. They bad to be jointly in charge because B's difficulties
were apparently reactive to their division.

Both parents were afraid of B and thought their lives would be in jeopardy if he
returned home to live. Tbey even considered moving elsewhere and not telling
him their. new address. It is generally an error to bave parents eject a problem
young person from the borne wben be is in bad sbape. It is best to keep bim borne
until be bas recovered and is functioning well. However, parents, too, have rigbts
and they need not keep a grown son in the bouse wben be threatens violence, Witb
therapeutic assistance, the parents decided B should live on bis own. Tbey would
continue to assist bim by giving bim a car to use and money towards room and

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 A Model Therapy for Psychotic Young People I J. Haley and N. Schiff

board until he departed for college. Mr. C said he would inform B in the hospital
of their changed position.

The hospital psychiatrist thought B was a chronic schizophrenic and should be

hospitalized a long time and permanently kept on medication. He did not see the
episode as situational but as diagnostic in that it could be expected the young man
would do this again and again. Yet, despite this belief, he was persuaded to release
the young man. This persuasion was done with some skill. Our psychiatrist spoke
to the hospital psychiatrist and complimented him on his courage. When asked
how he was being courageous, our psychiatrist said that he was giving anti-
psychotic medication despite the evidence that the young man already had Tardive
Dyskinesia from such drugs. He was risking a lawsuit by the parents. The hospital
psychiatrist thought it over and asked if our psychiatrist would like to have the
case back. Our psychiatrist accepted the proposal and the young man was promptly
discharged which solved a problem which is typical among colleagues when
dealing with schizophrenia.

B was released and returned to his parents' house until he located a room. It was
assumed that the young man's threats of violence were provoked by a situation,
which was now cbanged, rather than something inherent in his personality.

Initially, Mr. C was vague about when his son was to move out. This vagueness
could have been construed by the son as indicating that his father was still
terribly depressed and B would have to behave in an extreme fashion again to pull
father together. Therefore, the therapist insisted that his father define a position
by setting a date. At the therapist's request, the parents made arrangements to
have people in the home over the weekend to keep B company, help him move and
prevent the possibility of violence. They arranged for B's middle brother to be
there one day and his cousins the next. Mrs. C arranged for the parents to be away
at a jazz festival. Before the day arrived, B leased a room. He moved out to a group
house several miles from his parents' home. He was actually pleased with this
arrangement since he had a girlfriend he wished to visit him and that had been
awkward at home.

B was seen in therapy with bis parents and alone. His therapy continued to focus
on eliminating his pain, which worsened immediately after he moved out, and on
preparing him to go off to college. In addition, work with the C's, as a couple, also
resumed. The issues between the couple were Mr. C's depression and Mrs. C's
drinking, which sbe had endeavored to stop on ber own but bad not succeeded

Getting B off to college required disengaging him from his covert involvement in
the parental relationship. It was clear that when B functioned normally, his
father was faced with his unhappiness in the marriage and with his uncertainty
about what he wanted to do. In fact, given his previously aborted separation, Mr.
C may have been uncertain about whether he could separate, even if be wisbed to.
B's difficulties pulled the couple together and required them to focus on him.
Another issue, that did not require the sacrifice of B's well-being and future, was
required. The logical issue to pursue was to stop Mrs. C's drinking. One month

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after B's brief hospitalization, Mrs. C stopped drinking to save her husband from
a therapeutic ordeal which he had agreed to undergo with her if she drank. Mr. C
agreed to stop drinking as well and they had an alcohol free house.

After Mrs. C stopped drinking, B's departure for school grew more imminent. He
was very concerned about obtaining a room in a dormitory so that he had
opportunities to meet people and make friends, yet be bad not made the phone call
necessary to secure a room. His father, assigned the task of reminding him, bad not
done so. We construed B's failure to make this call as bis uncertainty about
whether his parents still needed him in their relationship. A boundary needed to
be drawn to separate B's life from bis parents'. The failure to make the telephone
call could be used therapeutically to force the issue.

Stage Three

In an extended, explosive and pivotal session focused on B's failure to make tbe
call to secure a room, his father finally set a limit insisting that the son treat both
parents with respect. This limit, in effect, differentiated B's concerns from those
of his parents, thereby expelling B from the parents' relationship. Mr. C took his
son on, insisting that B speak politely, mind bis own business and take care of his
own responsibilities. B raged apoplectically at his mother and father, cursing
them and insisting he had every rigbt to tell his fatber what to do if bis father
told bim what to do. He defended himself as a peer of his parents. Despite his
profound love for his son, Mr. C threatened to cut B off completely if B did not
comport himself in a more civilized manner. Mr. C had never been so fmn.

As is typical, when the parents become fmn the problem young person begins to
act normal. It is important to note that parents become ftrm with a cbild only if
they assume be is normal and capable of proper behavior. They would not chastise
a young person tbey defined as sick. Therefore, the therapist must support the
view that the son is normal ~ misbehaving, not a psycbiatric case.
.
B began to treat his parents with respect and pleaded for understanding, saying
that he did not wish to be tbougbt of as a monster and suggesting that his
outrageous behavior was derivative of a generational difference and related to
being a punk rocker. This session marked the inception oC the third stage of this
therapy in whicb B became increasingly disengaged from bis parents difficulties
with one another. This session established a new order and though it would be
tested repeatedly, it was never again transgressed. Mr. C never again backed down
from the authoritative position be bad taken with his son.

At the therapist's urging, as a way of helping her remain abstinent from alcohol
and lose weight, Mrs. C spent the next two weeks at a spa in Florida with her
sister. Mr. C remained alone at bome. B completed bis courses in tbe local college
and continued bis preparations for the university, cooperating in a reasonable
manner with his parents.

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 A Model Therapy for Psychotic Young People I J. Haley and N. Schiff

Shortly after Christmas, during a phone call in which B and the therapist were
arranging to have lunch before he went off to school, B complained that while his
mother was in Florida his father had been drinking, contrary to the parent's
agreement with one another. B added that his mother began drinking again and had
the appearance of "really needing it". B said he was looking forward to being away
from his parents and the pathos of what he described as his mother's addiction to
alcohol.

As B had improved again, the conflict between his parents arose again, but this
time there was no relapse and the problem of alcohol supplanted a focus on B.
After the C's acknowledged the reality that B was genuinely concerned about
them, Mr. C observed that B became even more amenable to his father's advice to
relinquish his "punk" attire to make a fresh start at the new school. B's account of
this constructive encounter added an interesting note to what Mr. C had already
told the therapist. B said his parents asked him if he felt abused because of their
alcohol use. Absolutely not, B replied, he thought they had been very good
parents. This was the climate in the family when B left for school.

At school B performed well academically. Until his spring break, he complained,

at times, of difficulties concentrating, of his pain and of his social difficulties.
The therapist spoke to him regularly by phone, though the arrangement was that
he would ask his father for help fust, which he did. The therapist also saw his
parents and was in regular touch with them by telephone, too. By spring break, B
was doing quite well, as were his parents, though Mr. C, in a session alone, said he
still had not made up his mind about his marriage.

At the conclusion of the school year, B returned home to attend summer school
and work. Though the therapist had expressed misgivings about B living at home
instead of on his own, the C's agreed to it. During B's fust day at home, there was a
crisis. Mr. C was out of the area at a meeting. B became upset and frightened his
mother. The therapist encouraged her to leave the house and called Mr. C to
request that he call and speak to his son. While the old pattern had briefly
recurred, the C's managed to weather it adequately and B calmed down after
speaking to his father.

A month or so after the crisis, B decided he wanted to go to California to

complete his schooling. In contrast to his departure for school in January, B
responsibly made most of his own arrangements, soliciting his parents' assistance
only when he needed it. His parents supported his plan, which involved leaving
for California half way througb tbe summer and working until scbool began. A
week or so prior to bis departure, B and bis parents came in for a meeting,
ostensibly because B had experienced a short lived but severe recurrence of bis
pain.

This session marked the end of B's symptomatic involvement in bis parents'
relationship. With all three of the C's together, it was suggested that B's pain was
related to his concern about his mother's drinking, which she was doing again. In
fact, some weeks earlier, Mr. C found his wife unconscious in tbe bathroom, after

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she had been drinking. She had to be taken by ambulance to a local hospital. B also
expressed concern about his parents evident lack of happiness with one another. B
was told that while the alcohol problem could be solved, his parents might very
well never be happy with one another and, most importantly, there was nothing
that he nor anyone else could do about it. All efforts to help them had not
worked. B was told emphatically that bis own life should not be compromised by
his parents' unhappiness with each other. Mr. C said bis wife was drinking heavily,
while she intimated that be was baving sexual problems. When asked to come in
for a meeting, they demurred.

B went to California alone, found a place to live, registered for school, and was
doing very well when his father called the therapist in mid-September for an
appointment for he and bis wife. During this meeting. Mr. C expressed his wish to
separate. This dismayed his wife who, however, thought it was coming and,
ultimately, inevitable. Several more meetings took place to plan the separation
and each of the COs were seen alone. B continued to do well. He wrote a letter to
each of his parents telling them he loved them, wishing them well, extending his
sympathies and expressing his hope that each would do the best they could during
the separation.

A year after B's departure for California, three years after be smashed tbe
window, severely injuring himself and beginning the first of several
hospitalizations, B returned from California. He had done very well in school and
was living happily. He returned to visit and help bis parents move. The COs bad
sold the family bome and were eacb moving tbeir things to separate living
quarters. B laboured many hours helping both of them, calmly and effectively.
Eacb of his parents was moved and deeply grateful. As his father wrote in a letter
to the therapist, n He was a tower of strength during our moves. He canceled dates,
worked 20 bour days, and displayed sound, COllUDon sense wben mine bad deserted
me. He was a great emotional support to both of us in a very trying situation." B's
mother was so appreciative tbat sbe paid bis girlfriend's way to California as an
expression of tbanks.

One year later B graduated from college, one of the best and most accomplished
artists in bis class and scbool. His father was happily living alone, had lost a good
deal of weight, and bad begun a relationship with another woman, His mother
lost 30 pounds and was also living alone. Both parents bad been present at B's
graduation and bad been quite cordial with another sucb that all of the C's had had
a very enjoyable time and celebration.

Four years migbt not be sufficient time to be sure that tbis young man is
permanently normal, but all the indications are tbat be is past the psychotic pbase
of bis life. Therapy witb others has been equally successful when tbis model is
used. Therapy was based upon systematic steps wbich, if followed successfully,
take future relapses into account.

Certain premises and actions by a therapist faced with this type of problem
increase the possibility of success and decrease tbe possibility of failure.

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 A Model Therapy for Psychotic Young People I J. Haley and N. Schiff

Obviously, success cannot be guaranteed when so many factors are involved in

these difficult problems, but failure can be guaranteed if the wrong premises are
acted upon. The premises that lead to failure in the therapy can be outlined.

Failure Premise 1: To assume the young person has an incurable disease and must
stay on medication for life and be institutionalized regularly.

Failure Premise 2: To ignore the family and attempt to do therapy with the young
person alone. Failure obviously occurs when attempts are made to do therapy
with the young person in custody in the hospital.

Failure Premise 3: To confuse social control and therapy. To think of medication

as therapy rather than chemical restraint, and hospitalization as treatment rather
than custody, confuses the field.

Failure Premise 4: To consider the metaphors of the patient as an indication of

disordered thinking rather than as communicating to another person. This leads to
treating patients like defective humans and not accepting their guidance in
understanding the social situation.

Failure Premise S: To allow therapy to be done by therapists untrained in dealing

with these special problems and guided by teachers who bave never succeeded in
returning such clients to nonnal.

As one might expect, the premises that lead to success with this therapy problem
are the opposite of those which lead to failure. They are listed here:

Premise 1: If an individual reports hallucinations or delusions, a therapist should

assume the person is more interpersonally skillful than the therapist. Dealing
with an expert in communication, the therapist should plan an approach that takes
this into account. It helps to have an experienced supervisor or colleague behind a
one-way mirror for guidance. In the therapy described here, there was
collaboration between the colleagues, with careful strategies planned during the
therapy.

Premise 2: The therapist must have power in the case by controlling medication
and hospitalization so that colleagues are cooperative rather than oppositional. If
the therapist is not a physician, he or she must have a collaborating psychiatrist
who will eliminate medication appropriately. In this case, a psychiatrist took
responsibility for the needs of the young man, not for a theory of schizophrenia.

Premise 3: The therapist must properly involve the family of the client. This
means including them in the therapy from the beginning is such a way that they do
not feel blamed for causing the problem. It should be assumed that the parents are
extremely sensitive to blame about their offspring.

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All of the nuclear family, the parents and three sons, were included in the first
interview in the case presented here. The parents and client were the unit of the
therapy throughout (the two brothers lived elsewhere). The therapy was helped
by the fact that these parents did not express a sensitivity to blame for having
caused their son's difflculties.

Premise 4: The therapist should assume the young person is protecting and
stabilizing the family. even when misbehaving or attacking the parents. In this
case, the violence of the youth stabilized the parents' relationship.

Premise S: The therapist must remove from the client the stigma of being ill and
a medical problem. For the parents to take action and be responsible in therapy,
they must consider the problem to be one in their domain. such as a behavior
problem. If it is defined as a medical problem, for example. by continuing
medication, or it is considered a deep psychological problem, the parents will back
off and leave it the experts rather than take charge and expect normality from
their offspring.

Premise 6: The therapist must assume there is nothing wrong with the client that
is not socially determined. The premise is that anyone else in the same situation
would behave the same way.

In this case, that was the premise of the therapy even though the young man had
been bospitalized three times and bad a severe diagnosis each time.

Premise 7: The therapist should assume that he is changing a cycle. When the
young person becomes more normal, the family goes unstable with the parents. or
some two adults if two parents are not involved, threatening separation. The
young man relapses, the family stabilizes, and when the young person becomes
more normal again. It should be emphasized that this does not mean the parents
want their offspring to be abnormal, or that they need that. It only means that is
an adjustment to improvement in the young person. One can observe this same
behavior in hospital staff when a patient improves unpredictably. Because of this
response to improvement, it is important that the parents turn to the therapist for
belp when instability develops and not to their offspring. If the therapist aids the
parents in this difficult time, the offspring is free to continue to be normal.

In this case. the youth became more normal and prepared to go back to college, the
parents threatened separation and tbe young person became violent and was
hospitalized.

Premise 8: The therapist should anticipate a relapse, even though occasionally it

might not happen. Dealing witb the relapse effectively means preventing
medication and hospitalization. If the client is hospitalized, the therapy
essentially starts over unless it is brief and achieves some end.

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 A Model Therapy for Psychotic Young People I J. Haley and N. Schiff

In this case, the hospitalization was only for a few days, and the anti-psychotic
drugs given in the hospital were immediately terminated so the parents could deal
with their son as a misbehaving youth rather than as a medical problem.

Premise 9: If the young person is coming out of a hospital, there is no period of

convalescence. A day hospital or other similar arrangements such as volunteer
work, should be avoided. The young person should immediately go back to work
or school, whatever the he was doing when the hospitalization occurred.

In this case, there had to be a delay until the college semester began, but plans for
college were immediately made and the young man went back to work and took
classes in a local college while waiting.

Premise 10: The therapist must extend himself and be personally involved with
the family and available in crises. The therapist is not a neutral observer in these
difficult cases.

In this case, the family reported being pleased that the therapist was so personally
concerned

Premise 11: It should be assumed that the basic problem is an organizational

malfunction. The hierarchy is in confusion. The difficult young person, or an
outside medical authority, is in charge of the family and the parents are unable to
exert authority over their offspring. When the parents jointly take charge over
the problem young person, he or she becomes normal.

In this case, the father and mother jointly drew a generation line and insisted the
young person behave properly and treat them with respect. From that point, on he
was on the path to normality.

References

Carpenter, W.T., Jr. (1986). Thoughts on the Treatment of Schizophrenia.

SchizOllhrenia Bulletin. 12. 527-539.

Haley, J. (1980). Leayina Home. New York: McGraw Hill.

Strachan, A.M. (1986). Family Intervention for the Rehabilitation of

Schizophrenia: Toward Protection and Coping. Schizophrenia Bulletin, J2.
678-698.

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