April, 1998
by Peggy Caton
Overcoming Resistance in the Treatment Resistant Patient
Case Example and Specific Treatment Techniques: Merrill
Merrill was sitting on a bench in the hallway, day after day, saying nothing, doing nothing, face impenetrable. If I asked him if he would like to come to the art room, he said and did nothing. If I told him to come to the art room, he got up and followed me. Sometimes I saw him standing in the hallway, a strange expression on his face, one arm partially raised, body poised, as if he gotten stuck while walking and just froze in that position. If I said, "Merrill, you can go," he suddenly continued walking down the hallway.
Merrill is a 52-year old Japanese-American, who is being treated for catatonic schizophrenia. He has been considered treatment resistant, particularly due to his history of hypersensitivity to neuroleptic medications. I have had an opportunity to work with Merrill at my post-doctoral internship site at the Anne Sippi Foundation, where I am a psychological assistant to Jack Rosberg, Psychologist.
On occasion, I have observed Jack Rosberg demonstrating echolalia using Merrill as an example. If he said, "Merrill, how are you?" Merrill would say, "Merrill, how are you?" If he said, "Merrill, say ‘fuck’", Merrill would say, "Merrill, say fuck". Jack does this to try and break the taboo that Merrill has against expressing angry thoughts and feelings. With further prompting, Merrill would say the word without the directions. Rarely, Merrill would be in what was called the excited or acute phase and talk continuously, with loose associations mixed with echolalia, repeating snippets from conversations in the room. But that phase wouldn’t last more than a day before he returned to his former inert self. Often interns would try to work with him, talk to him, and sometimes get muttered replies. On a good day he would answer yes or no questions with head or eyebrow movements. On a bad day he would be totally frozen, impervious. But even so, he would usually do what another person told him, as long as it was stated as a command. Thus, he was an easy client to work with in this phase, didn’t make trouble, did what he was told. The funny thing is, when he was in an excited phase, people tried to get him to be quiet or to shut up altogether. I was told he was more shut down after a weekend visit with his mother, who, it was said, attributed his talkative side with eating too much sugar.
Jack Rosberg suggested that if someone would spend four hours a day consistently with Merrill, he might come out of his silence. We watched some taped sessions from several years ago of Jack working with Merrill, when Merrill was somewhat more verbal, and it hardly seemed possible that he answered questions instead of just repeating them. Merrill’s situation seemed like it had deteriorated since then and didn’t show much promise. If he was not assigned to the kitchen to slowly eat his meals, which required multiple prompts when he got stuck, or was brought to a group to sit and watch, he was a constant fixture on the hallway bench. He would go on outings or on walks, but needed someone else to give him directions in the simplest of ways.
Occasionally, I would try to work with Merrill using art, but he was unable to choose a medium, or a color. I would direct him to pick up a marker and to put it on the page. If I asked him to draw, it had to be a specific direction, like, draw a line. He would draw the line over and over until he wore a hole through the paper. I tried to get him to use water colors and just the directions of putting the brush in the water, wiping it on the edge of the water cup and putting it in the paint had to be repeated each time or he would either leave out a part, stop altogether, or continue painting back and forth while the brush ran out of paint and water. Sometimes he couldn’t even get this far, and, in effect, was too frozen to follow any directions without emphatic prompting. We could get him to trace a picture more easily, but he would often just stop while holding the pencil and not continue until he was prompted. With other clients in the room, it was difficult to spend the continuous time that Merrill seemed to require and it all seemed to be going nowhere anyway. Sometimes, I would try to talk to Merrill, but there was no indication that he heard or processed anything I said, and I had pretty much given up, hoping someone else would work with him.
Several weeks ago, I decided to make a more concerted effort to spend time with Merrill, partly because at that point I was the only intern at the facility and no one else appeared to be really working with him, as he sat mute on the hallway bench most of the day. I began to take Merrill with me outdoors and have him sit with me while I was talking with other clients. I walked him around the grounds, showing him leaves and flowers, having him touch or hold them. We sat in the rose garden and I talked to him about the dandelions and how the wind blows the seeds away. I picked up on and had Merrill blow on it as the seeds floated around us. I took him to the garden and gave him a trowel and demonstrated over and over how to dig up the weeds. Finally I just let him pull the tops or root around with the trowel on his own. He usually continued this for about 20-30 minutes before he stopped. There was one day when another client and I were doing some heavy weeding together, and a few other clients had gathered. We were talking and having fun and joking around. I looked up at Merrill and he was watching us smiling, really smiling. I was amazed to see his face light up.
By that time, I was experimenting with activities in the art room as well. I tried different directions, different mediums. One day I tried what I thought was a silly exercise, the connect-the-dot box game I had played as a child, where several rows of dots are on a page and each player connects one dot to another in order to created boxes that they put their initials in. I connected one dot to another and asked Merrill to do the same. He may have started on a dot but then he began moving his pencil past other dots and down to the bottom of the page, then around, in jagged, strange lines. Often he would stop and I would connect another dot, then prompt him to do the same. I had to hold onto the page while he tensely drew his extended line, which seemed to go over the page according to some internal process that I could not fathom. He would mutter sometimes and sometimes I could understand him: "Don’t do that", "You’re doing it all wrong". The next day I tried the same exercise with a colored marker and he went longer and farther around the page, muttering. The third day, I asked him to choose from two colors and he did choose. Then I decided to use oil pastels, thinking it would move easier across the page. There were 24 pastels. At first, I gave him a choice of two from those and he shook his head. Then I said, "You can choose a different color" and he said in an emphatic frustrated voice, "I don’t know different colors." I said, "What color do you want?" He replied, "I don’t know."
What started coming out slowly, painfully, cryptically in dialogue with me after that was glimmerings of his inner world. He said he was nothing. He didn’t belong anywhere, he was "just a check mark". He didn’t have the right to be anywhere and didn’t have a right to want anything. I asked him if he hoped he would change. He said, no, that he didn’t have the right to hope. He said that he does whatever the staff tell him to do because he feels if he didn’t, they might kill him. I told him he didn’t have to draw if he didn’t want to. He put the pastel that was in his hand back into the box.
The next week, I worked with him on a keyboard I had brought. He sang songs with me if I picked them out and played them. He read the words from the songbook and sag along with me, in tune. I tried to get him to choose a song, choosing being one of his least favorite activities. That’s when I learned to slow down with him. I watched him slowly read every single song title in the index and then somehow got him to put his finger somewhere on the page and we sang the song I said he had chosen. The next week on the keyboard he played four-fingers, up and down the same four keys many, many times until he stopped. I tried simple directions, like playing a short pattern on a few notes. He wouldn’t really repeat the pattern I had played, but played on those two or three notes over and over in different variations until he stopped. He began to say he didn’t know how to play, that he couldn’t do it. That’s when he told me about the voices, the voices that tell him not to play, so he stops. I asked him what would happen if he continued to play or do something even thought the voices told him to stop, or that he was doing it all wrong. He put his hands up over his ears, but then said it didn’t stop them.
Jack Rosberg came in and had Merrill read something from a book. Merrill said the voices were gone, for that moment. Jack suggested that I try distracting him with activities and not to focus on the voices. So the next time Merrill and I met I tried to get him to read out of The Good Earth. Since Merrill is Japanese, I had previously brought in Japanese music for him to listen to, so somehow I thought this book, which was already in the art room, might connect with him on a cultural level. He read a paragraph but had difficulty pronouncing the words. Then I discovered that he didn’t know what some of the words meant, like "cauldron" or "wheat". He seemed not to know what wheat was. I tried to draw it and then tried to show him grain fields from National Geographic. At the end of the reading he told me he didn’t understand anything he had read. It appeared as thought there were holes in his experience, that I had to back up several steps in so many areas to find the place where I could connect with him.
I continued with him on the dot game that week. This time, after I started with my first connection, he connected one dot to the next. Somehow we got to where he had made a box and I tried to get him to put his initial in it. After much difficulty with that, he did. Then he more or less played the box game with me though sometimes when there were only two sides completed, he would connect the other two and then put in his initial. Sometimes he would make boxes within boxes until he ran out of space.
The next time we sat I asked him to start the connections. He drew a line that went in a jagged fashion up to the top of the page and then drew a large box around the periphery of the paper and then more boxes inside. After he stopped, there was still space left, so I asked him to draw something else. When he did not respond, I drew a circle next to the interior box. He said he could not draw anything. I said he didn’t have to draw, let his hand draw for him. He drew another circle on the other side and put his initial in both circles. I have since used, "let your hand choose: or "let your hand do it" with success when he seems unable to make decisions or to act.
Last week, when I came in, Merrill was standing in the hallway complaining that he hadn’t been shaved. He was really beginning to talk now. When he got to the art group, a new intern gave him some animal stencils to trace and he completed all of them on the page, complaining that he did it all wrong. In the afternoon we got him to play a simple soccer game with us, but we had to tell him where to stand and to kick the ball each time. Someone would kick the ball right at him and he would neither stand aside nor go after it. By the next day, he was starting to talk continuously. I brought him to the day patient room, which was a little out of the way of the regular traffic, to play the keyboard. He said right away that he didn’t know how to play, so I let him talk. Other clients occasionally came in and played on the keyboard or watched, and interacted with Merrill and me. Two women clients came up to him and kissed him on the mouth. Another began talking to him in a made-up sound language that she refers to as Russian, and Merrill told her, "Estelle, I don’t know ‘Indian’".
Merrill started to pout out whole dialogues and conversations he had heard, endless variations of questions he had been asked. "How old are you?" "Are you Spanish, are you Indian, are you Russian, are you Chinese?" Things people said to him, said about him in front of him, things his voices told him. Characters on TV, Bert and Ernie from Sesame Street. "Do you want to see Titanic? No don’t take him" "Do you want to go to Disneyland?" "They leave him on the bench to rot." He said he was an icicle, he was a rock, he had arthritic, he was dead.
There was a hand-done painting on the wall with a tiny little rabbit peering out from behind a tree root. He said he was that rabbit. He wasn’t a turtle, but a rabbit. That he was frightened, afraid of everything, afraid of his own shadow. "Who’s afraid of the Big Bad Wolf?" He was nothing, he was nobody, he was a one year old baby, he couldn’t even say the letter "m". He couldn’t do anything; he had to be shaved, he had to be dressed. People talk all around him as if he weren’t there, ask him endless questions that make no sense to him, and talk about him as if he were a baby, a pet, or a toy. "Has he had his pill? Has he gone to the bathroom?"
"I am a robot", he said. "I am Howdy Doody", "I am Gilligan on Gilligan’s Island."
I spent six hours with him that day. He talked nonstop. We took him to Home Depot when we went to buy plants. He talked. He sat near the garden when we planted the seedlings. He talked. He talked loudly, imitating and repeating what we said, repeating other conversations, talking in riddles.
The next day it was raining and when I came down the hallway, I heard the sound of Merrill’s voice above the other voices in the clinic. He was sitting with another client in the recreation room and that client was having fun with him, getting him to give the "finger" to other clients and the doctors, getting him to call another client "fat boy", getting him to call the doctor "baldy", just because he was freely repeating anything anyone told him to. We would sit in the art room and clients would come by the window making faces at him, waving at him. Other clients came in and he would greet them loudly and enthusiastically: "Hi, Carol! Hi, Anna!" And he would repeatedly say Carol’s name with comments and questions. "Carol, am I a toothpick?" Carol tried to get him to be quiet, but he would or could not. Other clients would come in and try to play therapist with him, or make comments on his condition. "What pill did you give him?" or, "I think he is masking contempt, making fools of you", etc.
That day as well as the day before, Merrill answered questions about his mother, that she was strict with him, didn’t let him do things, criticized him. He said he was furious with her. That day he began to say "ouch" to comments he or other people would make to or about him. He complained he was a baby. His face twisted up several times and he looked like he was going to cry, but didn’t.
Jack Rosberg came in at noon for lunch and demonstrated how he would focus Merrill, get him to look at him, to answer his questions, and to follow a subject. Merrill kept saying that his food was poisoned and Jack assured him that it was safe to eat. Merrill was referring to Jack as Santa Clause, and the other clients in the room were laughing and still other clients were going by the doorway sticking their tongue out and making gestures and Merrill would look up at them and respond to them while Jack was trying to get him to focus. It became a circus with Merrill as the star attraction.
After lunch, I spent some time in the art room with Merrill. His roommate came in and Merrill commanded him in an angry voice I hadn’t heard before: "Ronald, sit down". I told him that talking like that to Ronald wasn’t nice and he said, "I’m sorry". His roommate left. I asked Merrill if he talked to him like that because he wanted him to leave and he said, "Yes." The remaining client in the room asked Merrill if he wanted him also to leave and Merrill nodded, "yes". So I asked Merrill if he wanted to be alone with me, and he nodded "yes". One thing I am discovering with Merrill, however, is that his need to be compliant and please people cannot be underestimated and that answers he gives to questions may or may not truly reflect what he is feeling. He has said many times to me that he doesn’t know what he feels, doesn’t know what he wants, that he doesn’t have the right to want.
It was difficult to have a conversation with Merrill because he kept looking away. Jack had asked me to have Merrill look at me to keep him in contact with me. I didn’t want to force him, however. He kept looking toward the door, so I sat in that direction. He looked the other way. I asked him if he was afraid to look at me and he said, "yes". I told him he didn’t have to look at my eyes, just in my general direction and he said that was worse. I tried to tell Merrill that it was the last day of my work week there and I would be back on Monday. He said, "Ouch". I asked him if it hurt. He said, "It hurts all over".
So I left Merrill in the hallway, on the bench. I can see how silence and robotic compliance was Merrill’s defense and how in some ways it served to protect him. When he is "out", he is totally at the mercy of anyone who wants to use him as an object of fun and derision. Hopefully he won’t have to retreat back into his rabbit hole to protect himself. But the question remains: Can he learn how to maneuver in this world and to defend himself from would-be predators without having to resort to catatonia?"
Some of the clients and staff don’t seem to understand what Merrill is trying to communicate. He talks in cryptic messages, in mocking sarcasm in the form of impersonated dialogues, with references to television and popular culture. "I am Mickey Mouse." "Am I a dog?" "Come here, Mischa (the neighborhood car)". People laugh at him because he often smiles when he talks this way and seems to say funny things. To some, what he says appears to be nonsense, acting out, or a flare-up of illness needing a PRN (additional as-needed medication).
But he says he is bitter, all dried up. He complains about how people treat him like he is a baby or a pet and describes the absurdity and surrealistic nature of their statements and questions and his situation in general, and how others have no apparent understanding or insight into how he feels, and make demeaning comments. He has told Jack Rosberg how he doesn’t like being made fun of, how it hurts: "Ouch". He talks about how much of an outsider he feels, how alien, like Batman, a "stranger in paradise", a star in the sky. "Can he fly?" Where is he going? What is he doing?" Can he kick the ball?"
After the weekend, Merrill was quiet again in the morning, but not immobile. He indicated that the voices had been telling him to be quiet, and also the staff. I worked with him on taking more risks, taking more responsibility for his actions, teaching him to make small choices, choices that we take for granted in automatic reactions, like sitting in a chair. Merrill is starting to express some hope that his situation will change, though he is still reciting past hurts, making negative self-statements, and complaining about how people talk to him.
Now comes the work of helping Merrill integrate his two sides, of bringing him into contact with other people’s social reality and helping him make decisions and take action on his own behalf. And above all, helping him to learn how to communicate with people so that he can break out of his isolation and alienation and make real contact with the world around him.
