"No-Therapy": A Method of Helping Persons with Problems Jack Zusman, M.D.
ABSTRACT: Groups, settings, and activities which are not labeled therapeutic but which are devoted to helping persons with problems seem to be quite effective. Persons involved in Alcoholics Anonymous, Synanon, and other similar groups are not therapists but yet attempt to deal with problems. "No-therapy" is proposed as a name for the activity which goes on. The relationship between therapist and patient and between "'no-therapist" and person with a problem are quite different. "No-therapy" is particularly suited to help with problems of behavior and is not suited to help with problems of thought or emotion.
Mental health professionals are accustomed to prescribing and administering therapy to those who come to them for help. In recent years a great variety of therapies have developed---from psychotherapies and group therapies to bibliotherapy, dance therapy, and art therapy. Each therapy should be particularly useful for persons with that particular kind of problem. There are also some persons with problems who do best with no help at all. There are still others who respond best to help which is not called therapy but which is provided in some other way. Alcoholics Anonymous, Synanon, TOPS, Recovery, Inc., and similar groups all provide help for people with problems. These groups usually emphasize very strongly that they are not providing therapy and the members of the groups do not see themselves as being in therapy. Mental health professionals have themselves sponsored or originated groups and activities which are not considered therapy but which are ancillary to therapy or supportive for patients in therapy. These include halfway houses, sheltered workshops, patient employment in hospitals, patient social clubs, and so forth. Such nontherapeutic groups, settings, and activities are a very useful and important way of helping persons with problems. The success claims made for them are as impressive as the claims made for therapy provided by professionals. These activities should not be considered secondary or adjunctive. They deserve careful study and appropriate utilization. This paper is an atDr. Zusman is associate professor, Department of Psychiatry, State University of New York at Buffalo, E. 1. Meyer Memorial Hospital, 462 Grider St., Buffalo, N.Y. Community Mental Health Journal, Vol. 5 (6), 1969
482
Jack Zusman
483
tempt to describe some of the common elements in these activities and to suggest the kinds of persons for which they are indicated or contraindicated. The term "no-therapy" has been coined to label this general class of settings, groups, and activities which are helpful but not therapeutic. (Miss Joan Doniger suggested the term to the author.) No-therapy can best be described in contrast to therapy. THERAPY Therapy is any activity in which a member of a professional group (or someone reporting to a member of a professional group) takes direct responsibility for improving the mental health of a patient or client through personal interaction. A professional is a trained person with a clearly defined relationship and responsibility to the patient, with a code of ethics and with a defined role. Where therapy is carried out by relatively untrained persons, e.g., psychiatric aides, these act under the supervision of professionals, e.g., nurses, and adopt much of the professional's role and code of ethics. There is a clear distinction between the role of the patient and that of the therapist. Practice of psychological therapy gives the therapist privileges with respect to the privacy of the patient which he would not have in normal social interaction. It also places restraints upon him, not permitting him to use this information for personal advantages or to let personal preference interfere with his relationship to the patient. The patient is expected to place himself in the hands of the therapist, follow directions and reveal himself completely. This definition of therapy does not deal with the content of therapist-patient interaction because the content can vary widely and yet the interpersonal transactions remain the same. Therapy is often considered the central activity of mental health agencies and in some institutions every staff member is expected to be part of the therapeutic team. The plumbers, the cooks, and the gardeners may be briefed on how to deal with patients or on individual patients. These staff members go about their work with a responsibility to consider their relationships with patients in addition to carrying out their primary jobs. NO-THERAPY Along a continuum from psychoanalysis to no treatment at all, no-therapy falls somewhere close to the latter end. As it is intentionally practiced in halfway houses, sheltered workshops, and some rehabilitation services and unintentionally practiced in large mental hospitals, Alcoholics Anonymous and other helping groups, it clearly differs from both therapy and ordinary social interaction. Yet the differences are subtle and difficult to describe. No-therapy is interaction between a person who is recognized as having a problem and those around him who are interested in helping but take no responsibility for the outcome. The setting is one rec-
484
Community Mental Health Journal
ognized as devoted to people with problems. No-therapy is person-to-person interaction (as distinguished from therapist to patient interaction) in an atmosphere of helping. No-therapists may be patients or staff, that is, they may be present to get help with their own problems, or they may be paid to be present. There is no role distinction at all. No-therapists do not usually follow any theory. Their training comes from life and their code of ethics and feelings of responsibility are personal. In their interactions they are as concerned with their own welfare and pleasure as with that of the people around them. No-therapists respond to others spontaneously without concern for consistency or therapeutic role. They deliberately avoid the kind of concern, responsibility, and gratifications (or lack of them) which therapists must have. Some examples of no-therapy may be of help in clarifying the concept. Patients and therapists as an almost absolute rule do not borrow money from each other, no matter how well they know one another. Where an exception is made to this rule, it is likely to be justified by elaborate theoretical considerations. A no-therapist is free to borrow or lend money as he wishes. In deciding whether to do so, consideration may be given to credit rating but not to theory. In a halfway house, a resident was a collector of junk. Each day he accumulated a large volume of material which soon overflowed his room. In a therapeutic milieu, consideration woudd be given to the origin and meaning of the behavior in deciding how to deal with it. With no-therapy, the junk is thrown out as soon as it becomes a nuisance. Quite likely the collector himself will be thrown out eventually as a nuisance. In a hospital, if a patient comes up to a carpenter and begins interfering in his work, the "therapeutic" carpenter would probably consult a nurse, might attempt to involve the patient in the work, or might firmly ask the patient to leave because of the briefing he has had about this particular patient. The no-therapy carpenter will spontaneously say, "Get the beck out of here," and consider the patient a nuisance. The carpenter will not consider his responsibility to a treatment program or the possibly damaging effects of his rude behavior upon the patient. He will not be guided by theory nor by any professional role model. Obviously, no-therapy has been going on for centuries in mental hospitals and asylums, often with terrible results. Why is no-therapy an innovation and why does it seem to be effective now, when 3 ~ years ago in mental hospitals it was not? The answer is that, in past years, no-therapy took place in institutions but it was not the dominant form of interaction. There was a good deal of mutual helpfulness and normal social intercourse among patients and among patients and some staff, but the philosophy and overall approach might be called "custodial therapy." This was therapy in that the professionals did take responsibility for the lives and mental health of those in theiz care. The
Jack Zusman
485
therapy was to keep them in custody since this was the best that could be done. Patients were thus placed in a role very different from that of staff. A staff person annoyed by the symptoms of a patient did not use the means employed in usual social circumstances to express annoyance. He used far stronger methods and in doing so reinforced both his own and the patient's different roles. Even now, many interactions in both therapy and no-therapy settings are actually "custodial therapy" oriented. Some of the differences between therapy and no-therapy can be seen in Table 2. Therapy and no-therapy both may be looked upon as forms of treatmentmattempts to help someone get better. However, in therapy there is a therapist taking direct professional responsibility for the process. In notherapy the patient takes responsibility for himself and the no-therapist takes responsibility for himself. They both take responsibility for getting along together, with neither one in permanent charge. While no-therapy often goes on under the jurisdiction of a professional, e.g., in a mental hospital, who has in a sense prescribed it as a treatment, the professional has to establish the situation by giving up all special authority over and all responsibility for the behavior of the patients. TABLE
Comparison of therapy and no-therapy Therapy Therapist's aim Long-range goal
Responsibility of staff Role model of staff Response to symptoms Group discipline Theoretical foundation Selection of patients Selection of staff
Ethics of staff Therapist's gratification Actions of therapist
Carry out prescribed treatment plan Alter course of mental illness To professional To patient Professional Tolerant, controlled, modifying Flexible, carried out with therapy in mind Essential Therapeutic mixture 2. Training 2. Experience 3. Personal qualities Professional Long delayed Strictly regulated Regulated by ethics, tradition, theory
No-Therapy Comfortable interaction Prevent secondary disability; end immediate problem To self To social group Parent, sibling Unaccepting, spontaneous, suppressing Spontaneous, personal, response of group important Minimal Personal compatibility 2. Personal qualities 2. Experience 3. Training Personal Mainly immediate, personal Mainly natural, unregulated
486
Community Menta| Health Journal
USES OF NO-THERAPY No-therapy is essentially a method of suppressing symptoms and encouraging conformity. It does not deal directly with "inner life" --the thoughts and feelings of an individual. It is useful where the character or severity of symptoms is such that there is a great risk of social disability if symptoms continue, and where a disturbed "inner life" is either a comparatively minor problem or is not a problem at all. A patient who is so bizarre that he cannot function in normal society and requires removal is then in danger of being disabled from institutionalization. Treatment is urgently indicated to get him to the point where he can be released. Patients who are already disabled--whose symptoms are fixed---also can be helped by no-therapy. Even for those who cannot be helped, those who are permanently disabled and will require lifetime institutionalization, it seems preferable to use a no-therapy approach rather than a therapeutic one because no-therapy is simpler, less expensive, and probably more comfortable for the patient. No-therapy is also indicated where the major or only symptom is a deviant style of life, e.g., alcoholism or juvenile delinquency. In some cases it is possible to combine "no-therapy" with psychotherapy. In other cases "notherapy" alone is best. CONTRAINDICATIONS No-therapy should not be used where the major problem is one of disordered thoughts or feeling with no overt, uncontrolled symptoms. No-therapy should not be used for persons who either are overcontrolled and need some experience in being deviant or whose success depends upon being creative through being deviant. No-therapy should not be used for persons who require no therapy at all or for those who require only psychotherapy or drug treatment and otherwise can function independently in society. For example, an adolescent who lives in a destructive home and who requires both removal from home and psychotherapy, need not be admitted to a halfway house or a ward for no-therapy. He may be able to function perfectly well in a boarding-house or a dormitory, while receiving psychotherapy. LOGISTICAL ADVANTAGES OF NO-THERAPY No-therapy is much less expensive than therapy. Personnel do not require extensive training and volunteers are easily used. The institutional settings need not be elaborate but can be a rented house or other rented space. In a no-therapy setting it is essential to keep a low staff-to-patient ratio. When the patient lives in the setting, he is charged for room and board as soon as it is possible for him to pay this. Thus an incidental but important benefit of no-therapy is the low cost of establishing and operating new settings.
ABSTRACT: Groups, settings, and activities which are not labeled therapeutic but which are devoted to helping persons with problems seem to be quite effective. Persons involved in Alcoholics Anonymous, Synanon, and other similar groups are not therapists but yet attempt to deal with problems. "No-therapy" is proposed as a name for the activity which goes on. The relationship between therapist and patient and between "'no-therapist" and person with a problem are quite different. "No-therapy" is particularly suited to help with problems of behavior and is not suited to help with problems of thought or emotion.
Mental health professionals are accustomed to prescribing and administering therapy to those who come to them for help. In recent years a great variety of therapies have developed---from psychotherapies and group therapies to bibliotherapy, dance therapy, and art therapy. Each therapy should be particularly useful for persons with that particular kind of problem. There are also some persons with problems who do best with no help at all. There are still others who respond best to help which is not called therapy but which is provided in some other way. Alcoholics Anonymous, Synanon, TOPS, Recovery, Inc., and similar groups all provide help for people with problems. These groups usually emphasize very strongly that they are not providing therapy and the members of the groups do not see themselves as being in therapy. Mental health professionals have themselves sponsored or originated groups and activities which are not considered therapy but which are ancillary to therapy or supportive for patients in therapy. These include halfway houses, sheltered workshops, patient employment in hospitals, patient social clubs, and so forth. Such nontherapeutic groups, settings, and activities are a very useful and important way of helping persons with problems. The success claims made for them are as impressive as the claims made for therapy provided by professionals. These activities should not be considered secondary or adjunctive. They deserve careful study and appropriate utilization. This paper is an atDr. Zusman is associate professor, Department of Psychiatry, State University of New York at Buffalo, E. 1. Meyer Memorial Hospital, 462 Grider St., Buffalo, N.Y. Community Mental Health Journal, Vol. 5 (6), 1969
482
Jack Zusman
483
tempt to describe some of the common elements in these activities and to suggest the kinds of persons for which they are indicated or contraindicated. The term "no-therapy" has been coined to label this general class of settings, groups, and activities which are helpful but not therapeutic. (Miss Joan Doniger suggested the term to the author.) No-therapy can best be described in contrast to therapy. THERAPY Therapy is any activity in which a member of a professional group (or someone reporting to a member of a professional group) takes direct responsibility for improving the mental health of a patient or client through personal interaction. A professional is a trained person with a clearly defined relationship and responsibility to the patient, with a code of ethics and with a defined role. Where therapy is carried out by relatively untrained persons, e.g., psychiatric aides, these act under the supervision of professionals, e.g., nurses, and adopt much of the professional's role and code of ethics. There is a clear distinction between the role of the patient and that of the therapist. Practice of psychological therapy gives the therapist privileges with respect to the privacy of the patient which he would not have in normal social interaction. It also places restraints upon him, not permitting him to use this information for personal advantages or to let personal preference interfere with his relationship to the patient. The patient is expected to place himself in the hands of the therapist, follow directions and reveal himself completely. This definition of therapy does not deal with the content of therapist-patient interaction because the content can vary widely and yet the interpersonal transactions remain the same. Therapy is often considered the central activity of mental health agencies and in some institutions every staff member is expected to be part of the therapeutic team. The plumbers, the cooks, and the gardeners may be briefed on how to deal with patients or on individual patients. These staff members go about their work with a responsibility to consider their relationships with patients in addition to carrying out their primary jobs. NO-THERAPY Along a continuum from psychoanalysis to no treatment at all, no-therapy falls somewhere close to the latter end. As it is intentionally practiced in halfway houses, sheltered workshops, and some rehabilitation services and unintentionally practiced in large mental hospitals, Alcoholics Anonymous and other helping groups, it clearly differs from both therapy and ordinary social interaction. Yet the differences are subtle and difficult to describe. No-therapy is interaction between a person who is recognized as having a problem and those around him who are interested in helping but take no responsibility for the outcome. The setting is one rec-
484
Community Mental Health Journal
ognized as devoted to people with problems. No-therapy is person-to-person interaction (as distinguished from therapist to patient interaction) in an atmosphere of helping. No-therapists may be patients or staff, that is, they may be present to get help with their own problems, or they may be paid to be present. There is no role distinction at all. No-therapists do not usually follow any theory. Their training comes from life and their code of ethics and feelings of responsibility are personal. In their interactions they are as concerned with their own welfare and pleasure as with that of the people around them. No-therapists respond to others spontaneously without concern for consistency or therapeutic role. They deliberately avoid the kind of concern, responsibility, and gratifications (or lack of them) which therapists must have. Some examples of no-therapy may be of help in clarifying the concept. Patients and therapists as an almost absolute rule do not borrow money from each other, no matter how well they know one another. Where an exception is made to this rule, it is likely to be justified by elaborate theoretical considerations. A no-therapist is free to borrow or lend money as he wishes. In deciding whether to do so, consideration may be given to credit rating but not to theory. In a halfway house, a resident was a collector of junk. Each day he accumulated a large volume of material which soon overflowed his room. In a therapeutic milieu, consideration woudd be given to the origin and meaning of the behavior in deciding how to deal with it. With no-therapy, the junk is thrown out as soon as it becomes a nuisance. Quite likely the collector himself will be thrown out eventually as a nuisance. In a hospital, if a patient comes up to a carpenter and begins interfering in his work, the "therapeutic" carpenter would probably consult a nurse, might attempt to involve the patient in the work, or might firmly ask the patient to leave because of the briefing he has had about this particular patient. The no-therapy carpenter will spontaneously say, "Get the beck out of here," and consider the patient a nuisance. The carpenter will not consider his responsibility to a treatment program or the possibly damaging effects of his rude behavior upon the patient. He will not be guided by theory nor by any professional role model. Obviously, no-therapy has been going on for centuries in mental hospitals and asylums, often with terrible results. Why is no-therapy an innovation and why does it seem to be effective now, when 3 ~ years ago in mental hospitals it was not? The answer is that, in past years, no-therapy took place in institutions but it was not the dominant form of interaction. There was a good deal of mutual helpfulness and normal social intercourse among patients and among patients and some staff, but the philosophy and overall approach might be called "custodial therapy." This was therapy in that the professionals did take responsibility for the lives and mental health of those in theiz care. The
Jack Zusman
485
therapy was to keep them in custody since this was the best that could be done. Patients were thus placed in a role very different from that of staff. A staff person annoyed by the symptoms of a patient did not use the means employed in usual social circumstances to express annoyance. He used far stronger methods and in doing so reinforced both his own and the patient's different roles. Even now, many interactions in both therapy and no-therapy settings are actually "custodial therapy" oriented. Some of the differences between therapy and no-therapy can be seen in Table 2. Therapy and no-therapy both may be looked upon as forms of treatmentmattempts to help someone get better. However, in therapy there is a therapist taking direct professional responsibility for the process. In notherapy the patient takes responsibility for himself and the no-therapist takes responsibility for himself. They both take responsibility for getting along together, with neither one in permanent charge. While no-therapy often goes on under the jurisdiction of a professional, e.g., in a mental hospital, who has in a sense prescribed it as a treatment, the professional has to establish the situation by giving up all special authority over and all responsibility for the behavior of the patients. TABLE
Comparison of therapy and no-therapy Therapy Therapist's aim Long-range goal
Responsibility of staff Role model of staff Response to symptoms Group discipline Theoretical foundation Selection of patients Selection of staff
Ethics of staff Therapist's gratification Actions of therapist
Carry out prescribed treatment plan Alter course of mental illness To professional To patient Professional Tolerant, controlled, modifying Flexible, carried out with therapy in mind Essential Therapeutic mixture 2. Training 2. Experience 3. Personal qualities Professional Long delayed Strictly regulated Regulated by ethics, tradition, theory
No-Therapy Comfortable interaction Prevent secondary disability; end immediate problem To self To social group Parent, sibling Unaccepting, spontaneous, suppressing Spontaneous, personal, response of group important Minimal Personal compatibility 2. Personal qualities 2. Experience 3. Training Personal Mainly immediate, personal Mainly natural, unregulated
486
Community Menta| Health Journal
USES OF NO-THERAPY No-therapy is essentially a method of suppressing symptoms and encouraging conformity. It does not deal directly with "inner life" --the thoughts and feelings of an individual. It is useful where the character or severity of symptoms is such that there is a great risk of social disability if symptoms continue, and where a disturbed "inner life" is either a comparatively minor problem or is not a problem at all. A patient who is so bizarre that he cannot function in normal society and requires removal is then in danger of being disabled from institutionalization. Treatment is urgently indicated to get him to the point where he can be released. Patients who are already disabled--whose symptoms are fixed---also can be helped by no-therapy. Even for those who cannot be helped, those who are permanently disabled and will require lifetime institutionalization, it seems preferable to use a no-therapy approach rather than a therapeutic one because no-therapy is simpler, less expensive, and probably more comfortable for the patient. No-therapy is also indicated where the major or only symptom is a deviant style of life, e.g., alcoholism or juvenile delinquency. In some cases it is possible to combine "no-therapy" with psychotherapy. In other cases "notherapy" alone is best. CONTRAINDICATIONS No-therapy should not be used where the major problem is one of disordered thoughts or feeling with no overt, uncontrolled symptoms. No-therapy should not be used for persons who either are overcontrolled and need some experience in being deviant or whose success depends upon being creative through being deviant. No-therapy should not be used for persons who require no therapy at all or for those who require only psychotherapy or drug treatment and otherwise can function independently in society. For example, an adolescent who lives in a destructive home and who requires both removal from home and psychotherapy, need not be admitted to a halfway house or a ward for no-therapy. He may be able to function perfectly well in a boarding-house or a dormitory, while receiving psychotherapy. LOGISTICAL ADVANTAGES OF NO-THERAPY No-therapy is much less expensive than therapy. Personnel do not require extensive training and volunteers are easily used. The institutional settings need not be elaborate but can be a rented house or other rented space. In a no-therapy setting it is essential to keep a low staff-to-patient ratio. When the patient lives in the setting, he is charged for room and board as soon as it is possible for him to pay this. Thus an incidental but important benefit of no-therapy is the low cost of establishing and operating new settings.
