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The Disturbed Caller

Barry Greenwald, Ph.D.

GOALS OF THE SESSION

To present the major symptoms of the disorders classified closer to the psychotic end of the continuum.

To provide some brief theoretical explanation for the behaviors and feelings associated with severe emotional problems.

To provide some strategies for dealing with these callers that take into account the severity of the pathology and the limits of a paraprofessional crisis worker.

ONE PERSPECTIVE

The behavior of the severely disturbed individual is primitive, disorganized, disoriented and disabling. A person can be flamboyantly bizarre, frighteningly and dangerously out of control, simple and childlike, completely speechless and immobile, vividly hallucinatory, or regressed to an infantile, vegetative state. At first blush, these behaviors seem meaningless; a kind of random arrangement of vaguely recognizable human positions. These people are likely to elicit discomfort and anxiety and often outright fear in the observer. The seeming incomprehensible nature of the disturbed person's dealing with the world tend to evoke withdrawal rather than approach reactions. These are strange people. These are different people. These are people who seem wholly unlike ourselves. These are the people we lock away in mental institutions pumping them full of strong drugs that transform mania into docileness.

Perhaps the strange and bizarre behavior is not meaningless. Perhaps its origins are not so different from the origins of our own inordinately logical and comprehensible strategies for living and surviving. Perhaps these awesome symptoms are the product of the developmental process gone awry.

THE SYMPTOMS

Severely Impaired Reality Testing: In order to live in our world we need to continually test our perceptions of what is real against the perceptions of others. Reality is a matter of consensual validation. We essentially agree that a tree is a tree; a chair is a chair; and a lavabo is a lavabo. Our exact internal interpretations of these objects may differ somewhat, but we agree on the generic class enough to communicate meaningfully with each other.

The reality testing of the severely disturbed departs from this accepted consensual validation. Phantasy can be, and often is, as real as the "real world." Reality (as we agree to it) is distorted by strong, conflicted needs. A person who feels overwhelmed by a state of helplessness, believes that he is capable of flying. A person who is consumed with rage believes that he is responsible for some world catastrophe; proof of his grandiose power.

Most of us have experienced "near psychotic-like" symptoms in our dreams. Dreams are governed by a different logic than is our waking life and in dreams "anything can happen" and often does. People who are dead live again. Wishing something can make it come true. Calamities can be undone with a fanciful thought. We can be hero or victim depending on whatever issue we are working on in our dream work.

The loss of reality testing means the loss of the shared world and with it the loss of meaningful communication with others. If a person's perceptions are so different that they become "unreal" to us, we stop being able to understand what is being said. If a person assigns meanings to a word that bear no similarity to the meanings we assign, then the same words may be used but no meaning is exchanged. The disturbed person becomes isolated because he no longer experiences or understands the world in the way that we do.

Thought Disorder: Closely allied to the loss of reality testing are severe thinking problems. Not only is the person's perceptions affected, his internal representation and organization of those perceptions is severely altered. The way the person thinks does not make sense. The kind of logical approach to the world that we take for granted is not present. Two plus two may add up to seven. Dangerous activities may be pursued because the dangerous consequences are ignored or misestimated. Conclusions that bear no relationships to the facts at hand may be drawn while obvious conclusions are completely missed. Thinking becomes idiosyncratic, so unique and personalized that it separates the person from the usual logical system upon which we rely. The disturbed caller can be a citizen in a country inhabited by one.

Inappropriate Affect: A person's emotional responses can be likened to his bodily temperature. When the body is well, the temperature hovers at 98.6. When the body is taken ill, the temperature reflects the disordered state by elevating. Emotions, too, reflect changes in the psychological equilibrium of the individual. When something is bothering us, we may be more irritable or appear depressed. When we are excited about something, we may laugh more easily or even cry more easily. In general, however, our emotional responses reflect accurately the situations that evoke them. If something sad has happened, our response is to feel the sadness. If something joyful has happened, our response is in tune with that joy. The affect (feeling) is appropriate. To laugh about a death or disaster; to cry or moan about a happy event, however, is something else. We are struck by the inappropriateness of the response. The person seems to have missed something or seems out of sync with what is going on around him. There is something inappropriate about the emotional response. Disturbed people often react inappropriately to the emotional climate around them. Their feeling responses appear bizarre and strange and they stimulate a good deal of discomfort in those around them. This is another symptom that can lead others to withdraw from them.

Poor Impulse Control: The abilities to size up a situation, to plan the most advantageous strategy to reach a goal, to delay action until the most auspicious moment, and to act carefully, planfully, and deliberately in order to achieve the desired end represent critically important adaptive skills. Severely disturbed people often loose this complex ability and their behaviors and actions take on an impulsive quality that indicate severely impaired judgement. Poor impulse control can lead to behaviors that are dangerous to the person or to people around him.

Delusions and Hallucinations: Delusions are beliefs, often highly systematized, that are severe distortions of reality. ("I am Jesus Christ." "The FBI is after me." "I am being poisoned by aliens from outer space.") The person believes and clings tenaciously to these distortions and arranges his/her life to accommodate them. Often, the delusional system is quite transparent to the observer. It may represent a wish for grandiosity to compensate for feelings of worthlessness. It may represent a terrible, inexpressible rage turned against the self. In general, delusions are a way of dealing with internal conflicts by reshaping the external reality to afford greater comfort. The usual sequence is from delusions of persecution to delusions of grandiosity although there is no guarantee that this pattern will always be followed. Persons feeling persecuted are more prone to impulsive behavior designed to protect themselves from their imagined persecutors. Persons who become grandiose are less likely to pose management problems although their behavior is no less bizarre.

Hallucinations may effect any of the senses although the most common are visual or auditory. People see or hear things that are not there although they are totally convinced that their perceptions are absolutely real. Hallucinations may be thought of as parts of the self that are experienced as unacceptable being split off (thrown out). Forbidden feelings and impulses are disowned and take the form of an hallucination with a seeming life and force of its own. "It is not I that wants to kill you. Its the voices who tell me that I should."

As bizarre as hallucinations and delusions may seem, they are the attempts of a beleaguered personality to survive, to stay alive. Often the original hallucinations or delusions are of a kinder, more accepting reality than the one in which the person lives. They seem to represent an escape from a harsh and brutal reality that resists amelioration. All too often, however, the sanctuary afforded by the original delusions and hallucinations is transformed by the unresolved conflicts and become even more cruel than the reality they sought to soften.

WHERE DOES IT ALL BEGIN?

There are those who believe that the psychosis is biochemically based and there are those who believe that the psychosis has its origins in the severe mishaps of the developmental process. Perhaps the safest conclusion is that we do not yet know which "explanation" accounts for the profoundly bizarre behaviors that constitute the psychoses. Psychology, as a field, is still in its infancy and it will probably be some time before the origins of psychosis are explained definitively. At best, we are still only putting out pieces of the puzzle, experimenting with how they are put together. The total picture is not yet comprehensible. Very likely, the answers we seek will be in some complex interaction between the physical and the psychological.

For our purposes, we are going to look at psychological explanations that are rooted in the developmental process. There seems an inherent logic in viewing the psychotic symptoms as failures to negotiate certain developmental tasks that form the building blocks for later, more sophisticated personality development. Psychological and physiological development moves from the dependent, primitive, undifferentiated, need-driven to the autonomous, stable, multi-functioning, reality oriented functioning associated with the mature organism. Physiological development is a process of unfolding guided by an internal, genetically set biological clock. Nerves become myelinated, fontanel close, hormones are released, muscles become capable of control, bones grow, secondary sex characteristics emerge. If all goes well, the newborn grows from infancy to adulthood along a predetermined path. Psychologically, however, there can be great developmental variation. No precise genetic clock governs this growth. While there is an important interaction between a growing organism's physiological readiness and his/her psychological environment, the effects of this environment are impressively influential in the outcome of the maturing process. A psychologically damaging environment can undo the best genetic stock leading to a disturbed, non-functional personality residing within a sound body.

Some theorists propose that the origins of the psychosis are found in the first year of life. Something goes profoundly wrong in the relationship between the parenting figure and the newborn child. The theory suggests that the damage is so critical that future developmental steps will suffer a distorted outcome or not be taken at all. There is also the conviction that the earlier the trauma occurs in an individual's life, the more difficult it is to overcome. Some believe that early emotional trauma--the kind that leads to psychosis--is actually irreversible. Needless to say, there is controversy not only on the origins of the psychosis but also about methods of treatment and ultimate prognosis.

The cornerstones of development are important to understand because they provide a way of viewing psychotic symptoms.

Body Boundaries: Knowing where we "begin and end" is not knowledge genetically installed. Gaining a sense of our body, its front and its back, its limits, and its responsiveness to our dictates requires an incredible expenditure of energy to master. The random activity of an infant in its crib is really "data collection." He or she is involved in the elaborate, albeit unspoken and unplanned, process of learning about his/her body. It is the process of discerning the "me" from the "not-me." Successful completion of this task which brings an understanding of the body's boundaries makes it possible for the eventual development of the more psychological sense of self, the "I."

Failures in this task lead people to fear that they are very vulnerable; that their body walls will not protect them. They fear closeness will bring merger and merger will mean loss of identity. They will no longer know who they are because they can no longer tell where they begin an end. They fear fusion with the other person. As a result, these people fight to maintain distance from others in order to sustain some sense of integrity. Closeness is not comforting; it is terrifying.

Basic Trust: This deceptively simple concept can wreak havoc if not mastered early in life. Through experience, the growing infant learns that when his caretakers leave, they will, indeed, return. People go away and come back. Being left is not abandonment. Basic trust represents the internal belief that people come back. This awareness is learned; it is not a part of the genetic equipment. Repeated exposures to the "leavings" and "returns" of parental figures help the child develop this trust. Incorporating basic trust is not accomplished painlessly as any observation of infants will immediately disclose. Beginning at around nine months, infants react with fear to new people and express real signs of distress when they are left with strangers. These phenomenon known as "stranger anxiety" and "separation anxiety" are landmarks in the developmental process and indicate that maturational progress is being made. Eventually, the anxiety which is actually a primitive, wordless fear of abandonment is replaced by the certainty of the return of the caring parent figure. Basic trust is in place.

The establishment of basic trust is dependent upon several precursors. The infant must be able to differentiate between himself and others (me/not-me). If there is no one else but me, there can be no loss because there are no others. Others must be recognizable as unique and special entities. If there is just "me" and all others are interchangeable, then no one is a stranger. Stranger anxiety indicates that an infant can tell the difference between significant people who have met needs and others who have not. Basic trust is dependent on parents who behave consistently and predictably with regard to their child, particularly in matters of separation. The infant exists without a concept of time. A minute can seem like a year, an hour an incomprehensible amount of time. Parents need to dose their time away from the very young child, gradually building up the time as the child's tolerance increases. Insensitivity to this developmental process or circumstances beyond the parents' control that take them away for inordinately (from a child's point of view) can have a profound effect on the resulting internalization of basic trust.

Disturbances in basic trust are reflected in difficulties with separation, desperate clinging, a point of view that no one can be trusted, the conviction that "out of sight always means out of mind," a refusal to attach because any separation invokes the primitive fear of inevitable abandonment. In the severely disturbed, paranoid symptoms and inordinate dependency often indicate that basic trust has been profoundly disturbed.

Object Constancy: A game that provides endless hours of delight for the young child is "peek-a-boo." The child squeals with pleasure every time he or she opens his/her eyes and discovers that the temporarily unseen object or person is still there. What seems a simple game, often boring to adults, is really a child at work mastering a concept that adults take for granted. Objects still exist even if you can't see them. Out of sight does not mean out of existence. Mastering this developmental task means that the child is able to maintain in memory, an internal representation of a person or object, when the person or object is not physically present. The ability to evoke a memory, to bring a person back in one's mind's eye can be very soothing and comforting. To know with certainty that even though "I can't see you, you still exist" is reassuring and stabilizing.

Object constancy and basic trust are the foundations for the development of all future relationships. The successful internalization of these psychological constructs will effect the way the individual expresses and experiences trust of others, manages closeness and intimacy, deals with separations, masters self-soothing behaviors. and ultimately forms an integrated concept of "self."

Disturbances in object constancy and basic trust lead to profound and enduring psychological disturbances. All future personality development is rooted in these primary building blocks. Thus, if the foundation is weak, all subsequent structures are subject to collapse when the individual experiences high internal or external stress.

The human infant, for all his/her seeming fragility, can be an amazingly resilient creature. If this were not so, the number of people expressing high degrees of psychological disturbance would be even greater than it is. It is ofttimes quite amazing what the human is capable of enduring and still turning out within normal limits. Our skill in understanding psychopathology is, unfortunately, better postdictively than it is predictively. Looking back on an individual's history, it is often quite easy to point out the events that had a traumatic effect on personality. It is much more difficult to estimate the impact of an event while its happening. Psychology is an imprecise science, but we have begun to cast a systematic eye at the process of human development and the events that affect it both positively and negatively.

SIMPLE POINT OF REFERENCE

Human development is the result of the complex interaction between "nature and nurture," between the biological givens and the offerings of the environment. Child rearing experts abound and theories of what constitutes good rearing practices change with the prevailing psychological winds. Inexperienced parents (that includes or will include all who elect to raise a child) have sought answers from the "experts" as they face the difficult, challenging, frightening, and formidable task of guiding a child from infancy to maturity. Concerned parents wish to raise their children as free from physical and psychological disturbance as possible.

The first year of life is critically important in the genesis of psychosis. The developmental tasks of establishing body boundaries, basic trust, and object constancy must be begun. The interactions between parent and child must foster and nurture a healthy completion of these tasks in the months and years to come. Successful parenting involves the ability of the caretaker to suspend his/her needs in favor of the infant's needs. While it is difficult to imagine or comprehend the infant's internal experience of the world, it is nevertheless important to make some inferences about what it could be like. Unfettered by reality or its limitations, it is possible to imagine that an infant is a mixture of grandiosity and helplessness. The hungry infant who cries to signal his internal discomfort may well imagine in the most primitive and wordless way that his cries brings the satisfying breast or bottle into existence to meet his/her hunger. The parent who responds predictably and consistently to the child's needs initially fosters this mistaken belief of grandiosity. The child creates his world on the basis of his/her limited experience; s/he simply knows no better. At some very basic, primitive level, good parenting conveys to the child that his efforts, limited as they may be, make some difference in the world. Consistent caring from parents who can put the child's needs first communicate that the world is nurturing, comforting, trustable, and non-abandoning. These are powerful messages encoded in the memory of the child prior to the existence of words. During the first year of life, the infant needs to believe that "the world is his/her oyster." Socialization can wait. Civilization will have its turn, but first, needs must be met with little frustration. During the first year of life, there is little need to be concerned with "spoiling the child."

As the child matures physiologically and psychologically, reality will impinge. The Nirvana like existence of the first year is replaced, appropriately so, with the requirement to master other developmental tasks. For the growing child, there is a never ending series of jobs to do, skills to master in order to fit into the society in which s/he lives. Mastery is accompanied by hard work, delays, substitute gratifications, failures and frustration. The well-indulged infant is at no risk of becoming the self-indulgent adult if the developmental process moves along its normal course. While the successful negotiations of infancy will most likely preclude the development of a psychosis, it should be remembered that it is not an insurance policy against all forms of emotional disturbances that may find their origins in later periods of development.

THE BORDERLINE STATE

Originally the Borderline Personality was conceived of as a last ditch position for people on their way to becoming psychotic. The personality was conceived of as an army under siege in the process of retreating from a more mature level of functioning to a more primitive one. In its retreat, the army left small groups of forces at "developmental outposts" which would hopefully hold off the assault until the main force had a chance to regroup or to flee fully into a psychotic position. Borderline people might look "hysteric" or "obsessive" or "hypochondriacal" but if these defensive syndromes were challenged, the underlying psychotic process would become evident. Essentially, this conception of the borderline personality was of a "holding position," a transitional state between higher level functioning and psychotic functioning.

Recent theoretical thinking has deemphasized the transitional view of the borderline. Instead, the borderline personality is thought to occupy a place on the pathology continuum, less disturbed than the psychosis but closer to that level of disturbance than to other emotional disorders. It presumes some mastery, although not altogether successful, of the developmental tasks previously outlined. The primary emotional conflict seems centered on primitive rage and the failure to form a core identity. The rage seems the response to excessively frustrating, depriving interactions with the primary caretakers very early in life. While the environmental deprivations were severe, they were not sufficient to evoke a psychotic orientation. In reviewing the history of a borderline, it is not surprising to discover that there was one parent or a grandparent or some surrogate who tempered and mitigated the otherwise traumatic parenting experienced by the child.

Borderlines often present themselves as depressed, feeling dead or lifeless inside, empty, energyless, goaless. They are not dysfunctional in the sense of being unable to hold down a job or even enter into a stable, long term relationship. It is the lack of zest, the lifelessness of these people that suggest the severity of their disturbance. They appear marginal; peripheral to life. While not psychotic, they may often have periods when they behave, think, and experience the world psychotically. They are often highly suicidal and, in the course of psychotherapy, it is not unusual for them to become actively suicidal and require hospitalization. People who work therapeutically with borderline patients often report feeling anxious and uneasy with these people. It is as if the borderline nonverbally communicates the severity of the underlying disturbance before it becomes overtly apparent. The experience of this anxiety in the professional helper remains one of the best clinical indicators that there is more going on than meets the eye.

Psychological health requires a consolidation and an integration of disparate, often contradictory aspects of who we are. The "I" that we take for granted is the result of an Herculean effort to bring together a relatively consistent picture of our "self." The opposite of integration is "splitting," a disowning of parts of the self that do not fit into a coherent picture. The borderline has particular difficulty dealing with these inherent contradictions and is prone to split off pieces of the self rather than attempt to integrate them. Often, it is the primitive rage that is disowned. It is feared that its eruption will be overwhelmingly destructive or be so unacceptable that it will eventuate in the loss of all relationships. It may be repressed or it may be projected onto the others or the environment. In the process of therapy, the borderline patient must own this rage, confront his fears surrounding its power, develop structures for managing it, and, inevitably, fit it into his conception of "self." In the most simple, reductionistic terms: "Even nice guys get angry."

The treatment of the borderline is difficult, time consuming, and uncertain. There will be periods in treatment when the borderline functioning is replaced by psychotic behavior and thinking due to the stress involved in integrating various aspects of the self. It is during these psychotic periods that the hotline may be called.

SOME STRATEGIES FOR DEALING WITH PEOPLE WHO ARE PSYCHOTIC OR BORDERLINE

While in calls with less disturbed people we strive to uncover feelings that are beneath the surface, that is not always the best strategy with severely disturbed people. In general, they are being flooded or overwhelmed by too many feelings and need to find a way to put the lid on the torrent of feelings they are experiencing.

If it seems to you the feelings are at fever pitch, do not ask the caller to tell you more about them. Instead, use calming interventions. Use a calm but firm voice that indicates both caring and certainty as you speak.

"I know you are very upset. Lets take a few moments for you to calm down so we can talk. Try taking a couple of slow, deep breaths."

"I want you to tell me about this in detail." Ask questions designed to organize the person's story and deal with only small bits of it at a time. "How did it begin? " "What were you doing at the time?" "What happened next?" "And then..." Your technique is designed to slow the person down and to break experience into manageable chunks. Feelings are acknowledged but are not made the main focus of the conversation.

If a caller is hallucinatory or delusional and asks if you "hear" or "see" what he/she is experiencing, respond directly with a "no." Little is ever served by entering the delusional world. It can be very difficult to extricate yourself at a later point.

When appropriate, find out about the medications the caller is using. Find out if he/she has been taking them on the schedule recommended by the physician. If the caller has discontinued use of his/her medications without consulting his/her physician, encourage the caller to contact the prescribing physician to discuss the management of the medication.

DO NOT ALLOW YOURSELF TO GIVE MEDICAL ADVICE OR MEDICAL INFORMATION.

We are not physicians and questions or concerns of a medical nature should be referred to the appropriate professional. Acknowledge the importance of the questions and the importance of getting the right answers from a qualified professional. Become familiar with the Physicians Desk Reference (PDR) and the major tranquilizers and anti-depressants that are prescribed as anti-psychotic medications. Check out the side effects so that you recognize them when your hear them. Knowing them, will help you to know when to actively refer the caller back to his/her prescribing physician.

Keep your expectations about what you're going to accomplish in this call realistic. You are not going to cure a psychosis in 20 minutes. Essentially, you are going to try to help someone through a period of high anxiety. You are buying time with the caller. Your interventions should be concrete, pragmatic, problem solving. A person overwhelmed by anxiety and terror is not likely to have the resources to do his/her own problem solving. You will need to lend your skills and resourcefulness to the caller during this period of time. Thus, you may make direct suggestions, offer plans for dealing with the crisis of the moment, caution or urge a person to not do something, and, at times, actively encourage the person to seek hospitalization.

Do not be surprised if these calls make you feel confused and very often helpless. You are attempting to enter the world of a person whose frame of reference is quite different from your own. Your own ego prevents you from understanding the disturbed world of the psychotic individual as a protection and a safeguard. Working with people who are very disturbed is an incredibly exhausting and draining process. It is not meant for everyone and knowing about your own limits regarding these kinds of disturbances is very important.

Maintaining professional distance is important. The anxiety of the psychotic or borderline can be contagious and disabling. Their stories are tragic, their pain palpable, and their anxiety intolerable. The very disturbed caller can create a vortex about him/herself that seemingly sucks everything into its chaotic midst. If you begin to feel as confused, overwhelmed, and helpless as the caller, something has happened to your distance; you have been engulfed by the caller's world and can feel temporarily as unable to cope as he or she does. While this certainly represents a high degree of empathy, it is not helpful to the caller or yourself. No one is exempt from this happening. Experience provides a safeguard but it is not an absolute guarantee that you will never be contaged by the disturbed caller's intense emotional aura. Constant self-monitoring is required. Supervision is an excellent means for maintaining or restoring perspective.

It cannot be overemphasized that working with highly disturbed individuals is fertile ground for intense personal reactions on the part of the helper. It is as if the highly disturbed have a special sensitivity to the vulnerabilities of others and can effortlessly plug into those vulnerabilities. Strong reactions to or about these callers (positive or negative) should alert a crisis worker to the need to explore these reactions with a supervisor.

Dealing with people who are psychotic or borderline is amongst the most difficult and challenging tasks a clinician performs. While it is gratifying to imagine remarkable cures and the return to full functioning, we also need to learn to be satisfied knowing that we may have kept a person from another hospitalization or helped in a way that allowed the person to go to his/her job the next day. There are seldom "heroic rescues" in this particular aspect of crisis work. The disturbances are profound and only a select few who are able to avail themselves of costly, intense treatment facilities will experience a recovery that places them within the normal range. The severely disturbed often live a marginal life. Medications have made it possible for people who would have heretofore spent the majority of their lives institutionalized, to live, work, and maintain a family in the outside world. As we continue to learn more about the infant science of psychology, the hope is that our methods of helping will provide the potential for markedly improved functioning for all who seek our services.

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