Development and Treatment of Pseudo-Mental Illness N E I L
M O N R O E ,
R O B E R T
A.C.S.W.*
BORGMAN,
PH.D.*
Hickory,
N.C.
This article describes common life-history themes and intervention strategies with 25 patients who seemed over eager to regard themselves as mentally ill and had aggressively sought treatment for more than two years with little improvement. What they seemed to require was an approach that challenged this self-image, and helped them to organize their past experiences around a more constructive and satisfying identity.
Overconcern with one's psychologic fragility and mental ill health has long been recognized as a major hazard in effective treatment of emotional distress and behavioral deviancy (1). For example, F. Scott Fitzgerald (2) wrote of the addiction to interminable psychiatric treatment among the very wealthy. For such people, the joy of being treated is worth the pain of feeling mentally sick. Goffman (3) has poignantly described the trauma of being designated mentally ill. He assumes that most patient recruits fear losing their minds or their self-control. These doubts about one's sanity become socially validated when one is presented to mental health authorities, since such professionals usually presume the presence of illness in those who come before them (4). According to Goffman, the pre-patient often enters the mental health system expecting reassurance and benign treatment; instead he finds that he loses his privacy, autonomy, and self-respect. Thus the mental patient career begins with an experience of abandonment, disloyalty, and embitterment. Goffman further maintains the person then copes with confinement in a mental hospital (or other "total institution") by identifying with his therapeutic captors, that is, the mental health establishment and its definition of him as "sick" (5). The societal reaction view of mental illness, as presented by Goffman and others, focuses upon mental patients as victims of a rejecting society which acts in concert with a mental health delivery system to lock a person into a mental patient role, maybe permanently. We agree with Spitzer and Denzin (6) that this perspective is incomplete in that it overlooks the contribution the patient recruit might be making to the process. We know that at least some people successfully fight the designation of mental patient, •Family Mental Health Services, 346 Third Ave., N.W., Hickory, N.C. 28601.
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some escape from it, and leave feeling better from having had the experience. Thus there is justification for scrutinizing the psychosocial worlds of those who successfully traverse the road from suspected mental illness to full and permanent patienthood. In addition, there is need for intervention strategies designed to restore such career patients to a life of fuller human beingness. Study Design The staff of a small mental health center recently became interested in a group of patients whose self-identity as mentally sick seemed to be their major problem. Such patients were prone to manufacture symbols of their presumed illness for the benefit of their families and therapists. They differed from those suspected of the "Ganser syndrome" in that they regarded themselves as being mentally ill, and ulterior motives for producing psychotic symptoms were not obvious. The professional staff were simply asked to nominate candidates for this study according to the following criteria: 1. A self-identity as mentally ill, as indicated by the presence of at least two of the following characteristics: (a) tenaciously held beliefs about the self as being mentally sick, including use of psychiatric labels in referring to the self; (b) persistent seeking of mental health treatment for at least two years with little change in behavior or attitudes; (c) voluntary association with other persons who were or had been receiving psychiatric care. 2. Presence of stereotyped symbols of mental illness which seem to disappear rapidly when challenged. The symbols would include reports of delusions, auditory or visual hallucinations, or unsuccessful "suicidal" gestures. A total of 25 patients were included in this study, nine men and 16 women. Their histories were reviewed, and conferences held with their therapists to supplement data not present in the record. Characteristics of Sample These career patients initally entered the mental health system between 1952 and 1971 (median entry year was 1965). They had received from two to 20 years of sporadic or continuous treatment (median was eight years). The first contact with a mental health professional had occurred between the ages of thirteen and twenty-eight (median, eighteen). Twentyone had suffered at least one instance of psychiatric hospitalization. This inpatient confinement had occurred on the psychiatric ward of general hospitals for 12 patients; nine had received inpatient care only in a state mental hospital. Four never had been hospitalized. Sixteen of these career patients were natives of the area in which they
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currently resided, and another five were born in the same state. Thus 21 of them had been reared in small manufacturing and trade centers of the Eastern United States. The social class of these career patients was normally distributed. The parental families of seven were judged to occupy social classes I or I I (professionals or business proprietors), according to the Hollingshead scale (7). Eleven were from social class I I I (clerical, skilled tradesmen, or small proprietors) . The remaining seven were from the two lowest social classes. At the time of the study, 16 were single, seven were married, and two were separated or divorced. Median educational attainment was tenth grade, similar to that of the general adult population of the area where they resided. With regard to employment, nine never had held any regular job for a year or more, nor were they students. Seven were enrolled in high school or college at the time of this study. Five were unskilled laborers. Only four worked regularly at skilled or managerial employment. The occupational status of these career patients was considerably lower than that of their parental families, but was due, in part, to their relatively young age and the disruptive effects of repeated hospitalizations. Right to Feel Mentally Sick We are aware that persons have a right to feel mentally ill, and to re* ceive treatment for the illness they believe they have. Nevertheless, we presume that regarding oneself as mentally unbalanced is a destructive form of self-hatred, both for the self and others. Specifically: 1. These patients expressed extreme pain, demoralization, and hopelessness about being mentally ill which they regarded as fact. In addition, some mentioned they had received more than they had wanted when they went around proclaiming being mentally ill before their families and therapists. They were referring to indefinite hospitalization, electroshock therapy (ECT), or chemical control. 2. The families of these patients expressed much anxiety, bewilderment, or guilt about their relative's mental disturbance, and what he or she might do while feeling mentally ill. The relatives were often inconvenienced in arranging hospitalization or other psychiatric care. The financial sacrifices with little return in terms of improved behavior were also a problem in some families. If the patient were married and a parent, family life was often disrupted and the children upset by complaints of mental illness and subsequent hospitalization. 3. As a group, these people were an underproductive lot. Their work records were quite spotty and they usually held jobs much below their educational attainment. Sometimes their sense of inadequacy led them to avoid responsibilties to their spouses, children, or employers.
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Panic
A dramatic panic reaction in adolescence was cited by 20 of these 25 career patients (or their families) as the beginning of the "illness." Panicky behavior took the form of hysterical screaming or crying spells, disorientation and confusion, exaggerated confessions of misconduct, temporary paralysis or physical immobilization, or self-destructive acts such as wrist-slashing or drug-overdosing. The initial panic in 11 of them seemed sexual in nature—anxiety about the first homosexual experience, initial sexual intercourse, or incestuous stimulation. Six of these sexual panics also involved abandonment by the lover. Three others first showed disturbed behavior following the birth of a stillborn or defective baby. The panicky behavior in the remaining six occurred during their first year away from the family home in college, boarding school, or military service. Immediate psychiatric attention was given to 14 of the 20 during the initial panic. The other six seemed to "recover" spontaneously, only to have the panic recur several years later. Those diagnosed and treated by the mental health system at the time of the initial panic began acquiring and using their symbols of mental illness. Their subsequent careers as mental patients provide no justification for the efficacy of early "treatment." Other studies (8) have shown that panic reactions are likely to subside more quickly when the person receives reassurance and emotional support from his family and friends. In fact, this is what most families give when one of their members becomes dramatically upset (9-12). Identity Crisis Doubts about one's sanity occurred during the panic reaction; affirmation that one was indeed going mad may have come from awareness that a blood relative had previously been designated mentally deviant by the community. Nineteen of these 25 career patients had a parent or sibling who had received treatment for mental illness or had been labeled alcoholic, prior to the candidacy for patienthood (nine had two or more relatives so designated). The most usual pattern was for the deviant relative to be of the opposite sex. Four men had mothers who had been treated for mental illness; alcoholism was diagnosed in the mother of another, and in the sister of still another. Among the 16 women, seven had alcoholic fathers and one had an alcoholic older brother. Mental illness was treated in the fathers of two women, and in the brothers of another two. Several of these career patients revealed that they had learned symbols of mental illness from their relatives, along with how to obtain various reactions from mental health professionals. Seven of them had used hallu-
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cinogens or amphetamines, confessing that they had wanted to induce temporary insanity to discover "what it was like." Functionally, the self-identity of being mentally ill seemed to relieve guilt or anxiety about sexually deviant experiences. Five women appeared to have regarded themselves as nymphomaniacs before adopting the psychotic self-concept. Two women had much concern about incestuous conduct with brothers. I t appeared that 12 of these patients preferred to see themselves as mentally ill rather than as sexually perverted, and the mental illness self-concept served to relieve them of responsibility for the sexual choices they made. Betrayal The persons closest to these patient candidates had originally referred them for psychiatric aid. Of the 25, ten were taken directly to psychiatrists by their families. Six were referred by family physicians, and five were responsible for initiating mental health contact themselves. Only four persons were initially referred by community authorities such as the police, schools, or welfare departments. Initial treatment was likely to reaffirm the self-identity of mental illness for these patients. First intervention for 16 of them consisted of being locked up on psychiatric wards. Initial treatment of another was by outpatient electroshock. Such radical intervention was also quite incongruous with the life situations of the persons being treated. While most adolescents look to their parents and physicians for protection, reassurance, and help, as teenagers, 13 of our group found their families and doctors arranging confinement on adult psychiatric wards. Four of them were even under sixteen at the time of the first psychiatric hospitalization. Faced not only with adjustment to a mental hospital ward, seven teenagers had to cope with electroshock treatments as well, including one who was just thirteen and another who was fourteen years old. (Only nine in our group escaped EGT throughout their patient careers.) Several of these teenagers cited loss of memory following shock treatment as having convinced them that they indeed had lost their minds permanently. Inpatient care and EGT are not the most common treatments prescribed for middle and upper class patients, especially as the initial intervention (7). The intervention these patients received was due, in part, to the extreme manipulativeness of the family. We judged 13 families to be highly manipulative of the treatment. These families seemed most frequently to evoke guilt in the practitioner about relieving suffering in order to induce him to do what the family wanted. I f the practitioner resisted, the family would take the patient elsewhere for help.
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The family's success in directing the treatment and the impotence of the practitioner to resist thus constituted another form of betrayal for the patient. The kind of treatment the family wanted often seemed designed to expiate their guilt, or helped them reenact their own distressing experiences. For example, one mother insisted that her son be examined by the psychiatrist from whom the mother was receiving treatment, although the son himself was in treatment at a mental health center in another town. The doctor honored the mother's request that her son be hospitalized. Another mother, who herself had received ECT in a state hospital, took her sixteenyear-old son to three different psychiatrists before finding one who would administer similar treatments to the boy. A brother, guilty about incestuous activity with his sister, took her to a mental health center for two years before she finally revealed this activity which the brother then corroborated. It seemed as though presentation of the self as mentally deranged was a protective device, designed to ward off potential Judases. Presenting symptoms of a specific mental disease was found by these career patients to elicit predictable responses from mental health professionals; more genuine reactions were assumed to end in betrayal. The betrayal experience was also used to justify embitterment toward family and community by some of these career patients. Abandonment We have cited the role of abandonment anxiety in the panic reactions of some of our group. Sixteen of these 25 patients already had undergone parental abandonment during childhood. The fathers of six had died (two were murdered and two committed suicide). The mothers of three others had also died. Three had lost a parent through divorce. Four had felt abandoned through placement in boarding schools or by periodic desertions by a parent. Freud (13) has cited incorporation of the lost love object into the ego as a method of coping with abandonment. If the lost parent was also the deviant parent, then the candidate for patienthood might incorporate the parent's identity as a deviant into his self-concept and behavior. To the extent that the person felt responsible for loss of the parent, regarding oneself as mentally ill would be a form of self-flagellation necessary for selfredemption. Another way of coping with loss is through seeking after and binding new love objects. Mental health practitioners or other mental patients seemed to have been chosen by these career patients as the new love objects; the mentally ill self-identity and the symbols of derangement were the binding tools. These patients reasoned quite realistically that the mental health establishment would abandon them if they ceased presenting ex-
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emplars of mental illness. They also knew that they would be guaranteed passage to another therapist should a given helper tire of them. All these career patients had experienced repeated referrals from one therapist to another. Embitterment Our group certainly consisted of embittered human beings. Like any love object, the mental health establishment experienced the full fury of their hatred as well as of their love. Most presented themselves sullenly saying: "I'm mentally disturbed and dare you to do something about it." For example, one young man came to the mental health center proclaiming, "I'm a chronic schizophrenic and only need aftercare maintenance." Fourteen of them were fond of quoting opinions or prescriptions of previous therapists to find fault with the current treatment. These career patients were adept at finding and exploiting territorial and philosophical rivalries among mental health professionals. They would solicit a rival professional to criticize the present therapist. Of course some of their complaints and invidious comparisons were astute and well taken. In short, the raison d'etre of these career patients seemed to be one of taking over the treatment and defeating it. Toward their families, these career patients appeared to adopt a stance of "see how mentally ill you made me." The guilt they induced was used to elicit special attention and to bind their families to them. One young man, jealous of the attention his parents had lavished on his psychiatrically treated sister, exclaimed, " I wanted to show them I could be just as sick as her." Uproars were frequent occurrences among 16 of these career patients and their families. They used symbols of mental illness to evoke help and provoke control from their families. They would then take the help but defy the control, thereby eliciting punishment from the family, followed by mutual guilt and temporary reconciliation. Toward the community, these people used their mental illness as license to express resentments toward others without suffering the consequences. Their families would usually apologize for them, informing those they had hurt of the mental illness. I t is suspected that the family often gained vicarious satisfaction from the hostile frankness of these patients toward others. Implications for Treatment Our study so far suggests that existing anxiety about self-identity and abandonment created in these persons a vulnerability to the initial panic reaction which brought them into the purview of the mental health estab-
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lishment. Both family and practitioner seemed to have been overwhelmed by the seriousness of the panic reaction, leading them to institute radical intervention procedures which intensified the panic in the patient recruit and eventually led to coalescence of the person's identity as mentally sick. These radical intervention plans may also have been seen by the person in ways that intensified feelings of abandonment, betrayal, and embitterment toward the mental health establishment as well as toward the family. Converting misfortune into a bonanza, these persons then utilized their treatment to acquire symbols of psychosis, and began using their identities as "sick" to bind themselves to their families and mental health practitioners. Thus they resolved their anxiety about being abandoned and betrayed. As icing on the cake, the mentally sick role then enabled them to express embitterment and to avoid awareness of concerns about their past or present sexual deviancy. In subsequent dealings with mental health practitioners, these patients presented themselves in states of panic in which they manifested the acquired symbols of mental illness that they believed would guarantee them treatment. Identification of pseudo-mental illness is hindered by the person's use of these symbols of psychosis. Nevertheless, these differ from other psychotic manifestations in that the symbols of mental illness are given up quickly when challenged. Although the symbols themselves may be transient, the underlying self-identity as "sick" is much more resistant to change, and challenges to it generally generate much anxiety and opposition. It takes courage by the practitioner to interpret these panic states to the person and family as expectable responses to the problems and disappointments of their current life situation, rather than as manifestations of recurrent or chronic mental disease. This may be the first crucial step in beginning a regime in which the person can be helped to discover a new, more constructive identity as a contributing, acceptable member of society. How is this done? Phases of Treatment For convenience, we have divided the treatment of these persons into four phases: (1) Challenges to the symbols of psychosis and the self-identity of being mentally sick; (2) exploration of the original panic reaction; (3) discovery of a new self-identity as mentally sound; and (4) termination. 1. I n the first phase, a relationship to the person is established on the basis of concerns other than usages of psychotic symbols and the mentally ill self-identity. The message is clearly conveyed that the practitioner is not interested in discussing sick behavior or diseased states but rather, the focus is upon concern with the joys and challenges of living, or the hurts and disappointments the person is currently experiencing.
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Should the person bring up his psychotic symbols or bemoan his fate of incurable disease, he is diverted into other areas of concern or is asked to reflect upon past accomplishments of which he is proud. Interestingly, these methods are quite effective in quickly eliminating suicidal gestures and threats often made by these persons early in treatment. The suggestibility of these patients usually is so great that they quickly suppress deviant communication and anxiety and embitterment diminish. Because of this, these persons may leave treatment, only to turn up later at someone else's door complaining that their identity had been challenged. 2. I f they remain in treatment, or return, exploration is undertaken to help them discover the beginnings of the self-identity as "sick." This involves discussion of the original panic reaction and feelings about the mental health intervention experienced. The person's concerns about mental illness or alcoholism in the family may also be discussed, and what these facts might mean for the person's own present and future life. The person may also bring up feelings about past or present sexual deviancy and what these mean for the future. 3. About this time the patient may show increasing interest in developing a less deviant life style. Most desire to return to school, work, and active recreation which is explored and encouraged. A new identity, which is more goal directed, begins to emerge, but "retesting" of the therapist occurs, and the treatment relationship undergoes numerous challenges. I t is as though the patient tried to make a last effort to test the "sick" identity against the emerging "healthy" one to see which would indeed survive. During this stage the relationship becomes truly interactional in that as many challenges come from the patient as from the therapist. The major work of this phase is exploration of the new identity and its freedoms and dangers. Emergence of the new identity is facilitated through encouragement of an external projection of the internal struggle. Two therapists work with the same individual, but at different sessions. One plays a "good" role and the other a "bad" role. The bad therapist, who is initially confrontive and rigid, begins to assume a "softer," more flexible role. The "good" therapist, who was initially supportive and understanding, begins to assume a more rigid, demanding role. During this phase, we have often used the patient's vocational rehabilitation counselor as the other therapist in this way. The patient then learns to integrate the good and the bad identities as both belonging to the self. 4. In the fourth phase, the patient begins showing a drive to achieve distance from the therapist and to establish relationships to other people. Frequency of interviews are decreased, but this phase is essentially supportive and often marked by exchange of gifts between therapist and patient.
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PSYCHOTHERAPY
Of these 25 patients, nine have reached termination and are functioning independently and productively in school or employment without mental health assistance. Nine dropped out, mostly during phases two or three. They seemed unable to establish autonomy away from their families which maintained a need for them to continue the course of pseudo-mental illness. The remaining seven are at various points in the treatment process. I t does appear that the "flight into health" and the re testing which occurs in phases two and three are prerequisites for the establishment of the ego control necessary for the individual to become autonomous and remain free of pseudo-mental illness. SUMMARY
This article has focused upon treatment of 25 patients whose major problem seemed to be their belief of having a chronic mental disease. They thus acted out the role of mental patient in their lives by aggressively seeking treatment, referring to themselves by psychiatric labels, and reporting psychotic symptoms or suicidal threats. They undoubtedly had suffered much demoralization resulting from destructive life experiences, both within their families and with the mental health establishment. Common life history themes were parental loss in childhood and presence of another family member who had been treated psychiatrically or was regarded as alcoholic. Intervention strategy involved challenging their self-image of having a chronic mental disease, and helping them to recognize other more positive aspects of their experiences and existence around which they could organize a more constructive and satisfying self-identity. REFERENCES
1. Erikson, K. T . Patient Role and Social Uncertainty—A Dilemma of the Mentally 111. Psychiatry, 20:263, 1957. 2. Fitzgerald, F . S. Tender Is the Night. Scribner, New York, 1933. 3. Goffman, E . The Moral Career of the Mental Patient. Psychiatry, 22:125, 1959. 4. Scheff, T . J . The Societal Reaction to Deviance: Ascriptive Elements in the Psychiatric Screening of Mental Patients in a Midwestern State. Soc. Problems, 11:401, 1964. 5. Goffman, E . Characteristics of Total Institutions. Symposium on Preventive and Social Psychiatry, U . S. Government Printing Office, Washington, D. C , 1958. 6. Spitzer, S. P. and Denzin, N. K.
of Deviance.
The Mental
Patient:
Studies in the
Sociology
McGraw-Hill, New York, 1968, pp. 461-463.
7. Hollingshead, A. B. and Redlich, F . C.
Social Class and Mental Illness.
New York, 1958. 8. Glass, A. J . Psychotherapy in the Combat Zone. Symposium on Stress. Army Medical Service Graduate §chool Washington, D, C. 1953, ?
?
Wiley,
U . S.
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9. Kaplan, B., Reed, R., and Richardson, W. A Comparison of the Incidence of Hospitalized and Non-hospitalized Cases of Psychosis in Two Communities. Am. Sociol. Rev., 21:472, 1956. 10. Sampson, H . , Messinger, S., and Towne, C. Family Processes and Becoming a Mental Patient. Am. J. Sociol, 68:88, 1962. 11. Whitmer, C. and Conover, G. A Study of Critical Incidents in the Hospitalization of the Mentally 111. Soc. Work, 4:89, 1959. 12. Yarrow, M., Schwartz, C , Murphy, H . , and Deasy, L . The Psychological Meaning of Mental Illness in the Family. /. Soc. Iss., 11:12, 1955. 13. Freud, S. Mourning and Melancholia. In Collected Papers, Vol. 4, Hogarth, London, 1925.
M O N R O E ,
R O B E R T
A.C.S.W.*
BORGMAN,
PH.D.*
Hickory,
N.C.
This article describes common life-history themes and intervention strategies with 25 patients who seemed over eager to regard themselves as mentally ill and had aggressively sought treatment for more than two years with little improvement. What they seemed to require was an approach that challenged this self-image, and helped them to organize their past experiences around a more constructive and satisfying identity.
Overconcern with one's psychologic fragility and mental ill health has long been recognized as a major hazard in effective treatment of emotional distress and behavioral deviancy (1). For example, F. Scott Fitzgerald (2) wrote of the addiction to interminable psychiatric treatment among the very wealthy. For such people, the joy of being treated is worth the pain of feeling mentally sick. Goffman (3) has poignantly described the trauma of being designated mentally ill. He assumes that most patient recruits fear losing their minds or their self-control. These doubts about one's sanity become socially validated when one is presented to mental health authorities, since such professionals usually presume the presence of illness in those who come before them (4). According to Goffman, the pre-patient often enters the mental health system expecting reassurance and benign treatment; instead he finds that he loses his privacy, autonomy, and self-respect. Thus the mental patient career begins with an experience of abandonment, disloyalty, and embitterment. Goffman further maintains the person then copes with confinement in a mental hospital (or other "total institution") by identifying with his therapeutic captors, that is, the mental health establishment and its definition of him as "sick" (5). The societal reaction view of mental illness, as presented by Goffman and others, focuses upon mental patients as victims of a rejecting society which acts in concert with a mental health delivery system to lock a person into a mental patient role, maybe permanently. We agree with Spitzer and Denzin (6) that this perspective is incomplete in that it overlooks the contribution the patient recruit might be making to the process. We know that at least some people successfully fight the designation of mental patient, •Family Mental Health Services, 346 Third Ave., N.W., Hickory, N.C. 28601.
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some escape from it, and leave feeling better from having had the experience. Thus there is justification for scrutinizing the psychosocial worlds of those who successfully traverse the road from suspected mental illness to full and permanent patienthood. In addition, there is need for intervention strategies designed to restore such career patients to a life of fuller human beingness. Study Design The staff of a small mental health center recently became interested in a group of patients whose self-identity as mentally sick seemed to be their major problem. Such patients were prone to manufacture symbols of their presumed illness for the benefit of their families and therapists. They differed from those suspected of the "Ganser syndrome" in that they regarded themselves as being mentally ill, and ulterior motives for producing psychotic symptoms were not obvious. The professional staff were simply asked to nominate candidates for this study according to the following criteria: 1. A self-identity as mentally ill, as indicated by the presence of at least two of the following characteristics: (a) tenaciously held beliefs about the self as being mentally sick, including use of psychiatric labels in referring to the self; (b) persistent seeking of mental health treatment for at least two years with little change in behavior or attitudes; (c) voluntary association with other persons who were or had been receiving psychiatric care. 2. Presence of stereotyped symbols of mental illness which seem to disappear rapidly when challenged. The symbols would include reports of delusions, auditory or visual hallucinations, or unsuccessful "suicidal" gestures. A total of 25 patients were included in this study, nine men and 16 women. Their histories were reviewed, and conferences held with their therapists to supplement data not present in the record. Characteristics of Sample These career patients initally entered the mental health system between 1952 and 1971 (median entry year was 1965). They had received from two to 20 years of sporadic or continuous treatment (median was eight years). The first contact with a mental health professional had occurred between the ages of thirteen and twenty-eight (median, eighteen). Twentyone had suffered at least one instance of psychiatric hospitalization. This inpatient confinement had occurred on the psychiatric ward of general hospitals for 12 patients; nine had received inpatient care only in a state mental hospital. Four never had been hospitalized. Sixteen of these career patients were natives of the area in which they
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currently resided, and another five were born in the same state. Thus 21 of them had been reared in small manufacturing and trade centers of the Eastern United States. The social class of these career patients was normally distributed. The parental families of seven were judged to occupy social classes I or I I (professionals or business proprietors), according to the Hollingshead scale (7). Eleven were from social class I I I (clerical, skilled tradesmen, or small proprietors) . The remaining seven were from the two lowest social classes. At the time of the study, 16 were single, seven were married, and two were separated or divorced. Median educational attainment was tenth grade, similar to that of the general adult population of the area where they resided. With regard to employment, nine never had held any regular job for a year or more, nor were they students. Seven were enrolled in high school or college at the time of this study. Five were unskilled laborers. Only four worked regularly at skilled or managerial employment. The occupational status of these career patients was considerably lower than that of their parental families, but was due, in part, to their relatively young age and the disruptive effects of repeated hospitalizations. Right to Feel Mentally Sick We are aware that persons have a right to feel mentally ill, and to re* ceive treatment for the illness they believe they have. Nevertheless, we presume that regarding oneself as mentally unbalanced is a destructive form of self-hatred, both for the self and others. Specifically: 1. These patients expressed extreme pain, demoralization, and hopelessness about being mentally ill which they regarded as fact. In addition, some mentioned they had received more than they had wanted when they went around proclaiming being mentally ill before their families and therapists. They were referring to indefinite hospitalization, electroshock therapy (ECT), or chemical control. 2. The families of these patients expressed much anxiety, bewilderment, or guilt about their relative's mental disturbance, and what he or she might do while feeling mentally ill. The relatives were often inconvenienced in arranging hospitalization or other psychiatric care. The financial sacrifices with little return in terms of improved behavior were also a problem in some families. If the patient were married and a parent, family life was often disrupted and the children upset by complaints of mental illness and subsequent hospitalization. 3. As a group, these people were an underproductive lot. Their work records were quite spotty and they usually held jobs much below their educational attainment. Sometimes their sense of inadequacy led them to avoid responsibilties to their spouses, children, or employers.
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Panic
A dramatic panic reaction in adolescence was cited by 20 of these 25 career patients (or their families) as the beginning of the "illness." Panicky behavior took the form of hysterical screaming or crying spells, disorientation and confusion, exaggerated confessions of misconduct, temporary paralysis or physical immobilization, or self-destructive acts such as wrist-slashing or drug-overdosing. The initial panic in 11 of them seemed sexual in nature—anxiety about the first homosexual experience, initial sexual intercourse, or incestuous stimulation. Six of these sexual panics also involved abandonment by the lover. Three others first showed disturbed behavior following the birth of a stillborn or defective baby. The panicky behavior in the remaining six occurred during their first year away from the family home in college, boarding school, or military service. Immediate psychiatric attention was given to 14 of the 20 during the initial panic. The other six seemed to "recover" spontaneously, only to have the panic recur several years later. Those diagnosed and treated by the mental health system at the time of the initial panic began acquiring and using their symbols of mental illness. Their subsequent careers as mental patients provide no justification for the efficacy of early "treatment." Other studies (8) have shown that panic reactions are likely to subside more quickly when the person receives reassurance and emotional support from his family and friends. In fact, this is what most families give when one of their members becomes dramatically upset (9-12). Identity Crisis Doubts about one's sanity occurred during the panic reaction; affirmation that one was indeed going mad may have come from awareness that a blood relative had previously been designated mentally deviant by the community. Nineteen of these 25 career patients had a parent or sibling who had received treatment for mental illness or had been labeled alcoholic, prior to the candidacy for patienthood (nine had two or more relatives so designated). The most usual pattern was for the deviant relative to be of the opposite sex. Four men had mothers who had been treated for mental illness; alcoholism was diagnosed in the mother of another, and in the sister of still another. Among the 16 women, seven had alcoholic fathers and one had an alcoholic older brother. Mental illness was treated in the fathers of two women, and in the brothers of another two. Several of these career patients revealed that they had learned symbols of mental illness from their relatives, along with how to obtain various reactions from mental health professionals. Seven of them had used hallu-
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cinogens or amphetamines, confessing that they had wanted to induce temporary insanity to discover "what it was like." Functionally, the self-identity of being mentally ill seemed to relieve guilt or anxiety about sexually deviant experiences. Five women appeared to have regarded themselves as nymphomaniacs before adopting the psychotic self-concept. Two women had much concern about incestuous conduct with brothers. I t appeared that 12 of these patients preferred to see themselves as mentally ill rather than as sexually perverted, and the mental illness self-concept served to relieve them of responsibility for the sexual choices they made. Betrayal The persons closest to these patient candidates had originally referred them for psychiatric aid. Of the 25, ten were taken directly to psychiatrists by their families. Six were referred by family physicians, and five were responsible for initiating mental health contact themselves. Only four persons were initially referred by community authorities such as the police, schools, or welfare departments. Initial treatment was likely to reaffirm the self-identity of mental illness for these patients. First intervention for 16 of them consisted of being locked up on psychiatric wards. Initial treatment of another was by outpatient electroshock. Such radical intervention was also quite incongruous with the life situations of the persons being treated. While most adolescents look to their parents and physicians for protection, reassurance, and help, as teenagers, 13 of our group found their families and doctors arranging confinement on adult psychiatric wards. Four of them were even under sixteen at the time of the first psychiatric hospitalization. Faced not only with adjustment to a mental hospital ward, seven teenagers had to cope with electroshock treatments as well, including one who was just thirteen and another who was fourteen years old. (Only nine in our group escaped EGT throughout their patient careers.) Several of these teenagers cited loss of memory following shock treatment as having convinced them that they indeed had lost their minds permanently. Inpatient care and EGT are not the most common treatments prescribed for middle and upper class patients, especially as the initial intervention (7). The intervention these patients received was due, in part, to the extreme manipulativeness of the family. We judged 13 families to be highly manipulative of the treatment. These families seemed most frequently to evoke guilt in the practitioner about relieving suffering in order to induce him to do what the family wanted. I f the practitioner resisted, the family would take the patient elsewhere for help.
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The family's success in directing the treatment and the impotence of the practitioner to resist thus constituted another form of betrayal for the patient. The kind of treatment the family wanted often seemed designed to expiate their guilt, or helped them reenact their own distressing experiences. For example, one mother insisted that her son be examined by the psychiatrist from whom the mother was receiving treatment, although the son himself was in treatment at a mental health center in another town. The doctor honored the mother's request that her son be hospitalized. Another mother, who herself had received ECT in a state hospital, took her sixteenyear-old son to three different psychiatrists before finding one who would administer similar treatments to the boy. A brother, guilty about incestuous activity with his sister, took her to a mental health center for two years before she finally revealed this activity which the brother then corroborated. It seemed as though presentation of the self as mentally deranged was a protective device, designed to ward off potential Judases. Presenting symptoms of a specific mental disease was found by these career patients to elicit predictable responses from mental health professionals; more genuine reactions were assumed to end in betrayal. The betrayal experience was also used to justify embitterment toward family and community by some of these career patients. Abandonment We have cited the role of abandonment anxiety in the panic reactions of some of our group. Sixteen of these 25 patients already had undergone parental abandonment during childhood. The fathers of six had died (two were murdered and two committed suicide). The mothers of three others had also died. Three had lost a parent through divorce. Four had felt abandoned through placement in boarding schools or by periodic desertions by a parent. Freud (13) has cited incorporation of the lost love object into the ego as a method of coping with abandonment. If the lost parent was also the deviant parent, then the candidate for patienthood might incorporate the parent's identity as a deviant into his self-concept and behavior. To the extent that the person felt responsible for loss of the parent, regarding oneself as mentally ill would be a form of self-flagellation necessary for selfredemption. Another way of coping with loss is through seeking after and binding new love objects. Mental health practitioners or other mental patients seemed to have been chosen by these career patients as the new love objects; the mentally ill self-identity and the symbols of derangement were the binding tools. These patients reasoned quite realistically that the mental health establishment would abandon them if they ceased presenting ex-
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emplars of mental illness. They also knew that they would be guaranteed passage to another therapist should a given helper tire of them. All these career patients had experienced repeated referrals from one therapist to another. Embitterment Our group certainly consisted of embittered human beings. Like any love object, the mental health establishment experienced the full fury of their hatred as well as of their love. Most presented themselves sullenly saying: "I'm mentally disturbed and dare you to do something about it." For example, one young man came to the mental health center proclaiming, "I'm a chronic schizophrenic and only need aftercare maintenance." Fourteen of them were fond of quoting opinions or prescriptions of previous therapists to find fault with the current treatment. These career patients were adept at finding and exploiting territorial and philosophical rivalries among mental health professionals. They would solicit a rival professional to criticize the present therapist. Of course some of their complaints and invidious comparisons were astute and well taken. In short, the raison d'etre of these career patients seemed to be one of taking over the treatment and defeating it. Toward their families, these career patients appeared to adopt a stance of "see how mentally ill you made me." The guilt they induced was used to elicit special attention and to bind their families to them. One young man, jealous of the attention his parents had lavished on his psychiatrically treated sister, exclaimed, " I wanted to show them I could be just as sick as her." Uproars were frequent occurrences among 16 of these career patients and their families. They used symbols of mental illness to evoke help and provoke control from their families. They would then take the help but defy the control, thereby eliciting punishment from the family, followed by mutual guilt and temporary reconciliation. Toward the community, these people used their mental illness as license to express resentments toward others without suffering the consequences. Their families would usually apologize for them, informing those they had hurt of the mental illness. I t is suspected that the family often gained vicarious satisfaction from the hostile frankness of these patients toward others. Implications for Treatment Our study so far suggests that existing anxiety about self-identity and abandonment created in these persons a vulnerability to the initial panic reaction which brought them into the purview of the mental health estab-
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lishment. Both family and practitioner seemed to have been overwhelmed by the seriousness of the panic reaction, leading them to institute radical intervention procedures which intensified the panic in the patient recruit and eventually led to coalescence of the person's identity as mentally sick. These radical intervention plans may also have been seen by the person in ways that intensified feelings of abandonment, betrayal, and embitterment toward the mental health establishment as well as toward the family. Converting misfortune into a bonanza, these persons then utilized their treatment to acquire symbols of psychosis, and began using their identities as "sick" to bind themselves to their families and mental health practitioners. Thus they resolved their anxiety about being abandoned and betrayed. As icing on the cake, the mentally sick role then enabled them to express embitterment and to avoid awareness of concerns about their past or present sexual deviancy. In subsequent dealings with mental health practitioners, these patients presented themselves in states of panic in which they manifested the acquired symbols of mental illness that they believed would guarantee them treatment. Identification of pseudo-mental illness is hindered by the person's use of these symbols of psychosis. Nevertheless, these differ from other psychotic manifestations in that the symbols of mental illness are given up quickly when challenged. Although the symbols themselves may be transient, the underlying self-identity as "sick" is much more resistant to change, and challenges to it generally generate much anxiety and opposition. It takes courage by the practitioner to interpret these panic states to the person and family as expectable responses to the problems and disappointments of their current life situation, rather than as manifestations of recurrent or chronic mental disease. This may be the first crucial step in beginning a regime in which the person can be helped to discover a new, more constructive identity as a contributing, acceptable member of society. How is this done? Phases of Treatment For convenience, we have divided the treatment of these persons into four phases: (1) Challenges to the symbols of psychosis and the self-identity of being mentally sick; (2) exploration of the original panic reaction; (3) discovery of a new self-identity as mentally sound; and (4) termination. 1. I n the first phase, a relationship to the person is established on the basis of concerns other than usages of psychotic symbols and the mentally ill self-identity. The message is clearly conveyed that the practitioner is not interested in discussing sick behavior or diseased states but rather, the focus is upon concern with the joys and challenges of living, or the hurts and disappointments the person is currently experiencing.
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Should the person bring up his psychotic symbols or bemoan his fate of incurable disease, he is diverted into other areas of concern or is asked to reflect upon past accomplishments of which he is proud. Interestingly, these methods are quite effective in quickly eliminating suicidal gestures and threats often made by these persons early in treatment. The suggestibility of these patients usually is so great that they quickly suppress deviant communication and anxiety and embitterment diminish. Because of this, these persons may leave treatment, only to turn up later at someone else's door complaining that their identity had been challenged. 2. I f they remain in treatment, or return, exploration is undertaken to help them discover the beginnings of the self-identity as "sick." This involves discussion of the original panic reaction and feelings about the mental health intervention experienced. The person's concerns about mental illness or alcoholism in the family may also be discussed, and what these facts might mean for the person's own present and future life. The person may also bring up feelings about past or present sexual deviancy and what these mean for the future. 3. About this time the patient may show increasing interest in developing a less deviant life style. Most desire to return to school, work, and active recreation which is explored and encouraged. A new identity, which is more goal directed, begins to emerge, but "retesting" of the therapist occurs, and the treatment relationship undergoes numerous challenges. I t is as though the patient tried to make a last effort to test the "sick" identity against the emerging "healthy" one to see which would indeed survive. During this stage the relationship becomes truly interactional in that as many challenges come from the patient as from the therapist. The major work of this phase is exploration of the new identity and its freedoms and dangers. Emergence of the new identity is facilitated through encouragement of an external projection of the internal struggle. Two therapists work with the same individual, but at different sessions. One plays a "good" role and the other a "bad" role. The bad therapist, who is initially confrontive and rigid, begins to assume a "softer," more flexible role. The "good" therapist, who was initially supportive and understanding, begins to assume a more rigid, demanding role. During this phase, we have often used the patient's vocational rehabilitation counselor as the other therapist in this way. The patient then learns to integrate the good and the bad identities as both belonging to the self. 4. In the fourth phase, the patient begins showing a drive to achieve distance from the therapist and to establish relationships to other people. Frequency of interviews are decreased, but this phase is essentially supportive and often marked by exchange of gifts between therapist and patient.
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Of these 25 patients, nine have reached termination and are functioning independently and productively in school or employment without mental health assistance. Nine dropped out, mostly during phases two or three. They seemed unable to establish autonomy away from their families which maintained a need for them to continue the course of pseudo-mental illness. The remaining seven are at various points in the treatment process. I t does appear that the "flight into health" and the re testing which occurs in phases two and three are prerequisites for the establishment of the ego control necessary for the individual to become autonomous and remain free of pseudo-mental illness. SUMMARY
This article has focused upon treatment of 25 patients whose major problem seemed to be their belief of having a chronic mental disease. They thus acted out the role of mental patient in their lives by aggressively seeking treatment, referring to themselves by psychiatric labels, and reporting psychotic symptoms or suicidal threats. They undoubtedly had suffered much demoralization resulting from destructive life experiences, both within their families and with the mental health establishment. Common life history themes were parental loss in childhood and presence of another family member who had been treated psychiatrically or was regarded as alcoholic. Intervention strategy involved challenging their self-image of having a chronic mental disease, and helping them to recognize other more positive aspects of their experiences and existence around which they could organize a more constructive and satisfying self-identity. REFERENCES
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9. Kaplan, B., Reed, R., and Richardson, W. A Comparison of the Incidence of Hospitalized and Non-hospitalized Cases of Psychosis in Two Communities. Am. Sociol. Rev., 21:472, 1956. 10. Sampson, H . , Messinger, S., and Towne, C. Family Processes and Becoming a Mental Patient. Am. J. Sociol, 68:88, 1962. 11. Whitmer, C. and Conover, G. A Study of Critical Incidents in the Hospitalization of the Mentally 111. Soc. Work, 4:89, 1959. 12. Yarrow, M., Schwartz, C , Murphy, H . , and Deasy, L . The Psychological Meaning of Mental Illness in the Family. /. Soc. Iss., 11:12, 1955. 13. Freud, S. Mourning and Melancholia. In Collected Papers, Vol. 4, Hogarth, London, 1925.
