Mental health articles

The following case studies illustrate the human experience that is schizophrenia. Case one: Bridget’s story History and experience

At the time of meeting and working with Bridget she was a middle-aged widow and mother who had lived with psychotic symptoms for nearly thirty years. Bridget was experiencing a relapse of her psychotic symptoms following the death of her husband, Cyril, the year before. Cyril died of cancer and was described by Bridget as a loving husband and father. Bridget’s two adult children described their parents as loving and caring. Bridget first experienced symptoms following the death of her mother and the birth of her second child. At the time her experiences took the form of a hallucinatory voice which called her a whore and a ‘sex pig’. The voice accused her of being too sexual and yet suggested she perform various sex acts with various people. Bridget had a strong religious belief and found particularly distressing the voice’s suggestion to seduce her priest. Gradually she gained control of her hallucinations through medication and what she termed ‘the love of my family and my God’. Although Bridget gained control the voice stayed with her and her control fluctuated over the years. Accordingly, she needed admissions to hospital, which were always accompanied by a secondary guilt about not being a good mother. On analysis these admissions coincided with various stresses and life events. As a consequence Bridget, on assessment, felt that the voice had ‘robbed her of years’. In addition to the voice, Bridget also experienced various thought disorders, particularly passivity phenomena. At these times she experienced thought insertion and thought broadcast. The content of the insertion and broadcast would be predominantly anti-God. These experiences, in her account, were always the precursors to admission and, on two occasions had led to serious suicide attempts, one of which had left permanent organ damage.

Between highly florid episodes of positive symptoms, Bridget would also experience lowering of mood, energy and the ability to enjoy her children. It was unclear if these experiences were the result of depression or negative symptoms. The death of her husband Cyril had, predictably, led to a crisis and an increase of all positive symptoms. What was particularly distressing her was the fact that she experienced the voice as Cyril abusing her ‘from the grave’ and saying he didn’t love her, as she was a ‘whore with a dirty mind’. At the time of referral there were serious concerns regarding Bridget’s ability to keep herself safe. An increase in medication had not had the desired affect of reducing the positive symptoms. Bridget, as can be seen from the above, was a remarkable woman who was very burdened by her symptoms, and was viewed as an amazing survivor in the face of extreme difficulties. Her schizophrenia was only one aspect of her life, an aspect which gained dominance over her abilities as a wife, mother and individual at times, but was not her defining feature.

Keeping Bridget safe

The first priority of work with Bridget was to keep her alive. This necessitated some clear and open discussions with Bridget as to whether she should receive care in her home or in an inpatient unit. She was adamant that she wanted to stay at home with her children. An open analysis of the risk that this posed had to be undertaken with the family. It was decided that Bridget could continue to receive care in her home, but under tight supervision and that admission (against her will) would not be ruled out should it become necessary.

Medication

A review was undertaken. Although the medication for positive symptoms was not changed, an anti-depressant was added. Bridget and her family were informed of the fact that the medication would take some weeks to start taking effect.

Dealing with the ‘voice’

Two psychosocial techniques were used as indicated by the work of Romme and Esher. A system of distraction using a recording of the Pope saying the rosary (a sequence of prayers with relevance to the Catholic faith) was utilized where Bridget would listen to the recording when the voices became particularly bad. Distraction is a technique true to its name where the mind is ‘distracted’ from the voice experience by various alternative activities. If successful, distraction is really a short-term relief from the voice experience and teaches the individual that they can begin to control the voice experience themselves.

In addition to distraction, set sessions focused on the incongruity of Bridget’s lived experience with her husband and the content of the hallucinatory voice. This technique is a direct challenge to the voice experience and is designed to show that the voice is not as powerful as it seems to the person. Bridget was encouraged to reread old letters from her husband and to consider the possibility that the voice was not, in fact, his. Bridget was encouraged to ask the voice why she should believe it, as her real husband would not say these things. In these sessions it soon became evident that Bridget was frightened that if the voices stopped, even though it was negative and cruel, she would truly lose Cyril. This was felt to be a reasonable concern and in keeping with the process of grief. Eventually Bridget regained control of her experiences and the voice became less frequent and, sometimes, reverted to its old form.

The distraction was extremely effective in enabling her to gain control and she found herself getting so involved in prayer that she was able to block out the voice completely. Despite this, the thought insertion remained and Bridget came to the belief that ‘God did not love me.’ For Bridget this was a major concern, increasing the risk of suicide. As the belief was examined, Bridget stated that the only way she could prove to herself that God loved her was if a certain priest were to tell her. Bridget was encouraged to write to this priest explaining her situation. She did this and the priest duly responded with a letter and a set of rosary beads. The priest stated that the beads had been blessed and were to be used in ‘times of hardship as an indication of God’s love for you’. Bridget took great comfort in this letter and the beads and was able to use them to challenge her negative thoughts. Although it took more than 12 months for Bridget to regain her normal level of mental experience, and even then she did have to continue in her grief, she was deemed as no longer presenting a suicide risk.

More importantly, Bridget felt able to control her symptoms and experience pleasure in her family. Bridget’s story shows how a detailed knowledge of the lived experience can both help to understand and support a person with psychotic symptoms. Bridget’s greatest asset in the process of care was her ability to use positive mental experiences (her memory of Cyril and the reality of their marriage), beliefs (her religious faith) and relationships (her children) to combat negative false perceptions (her psychotic symptoms).

Tags: case study, schizophrenia