Bob Green (
Thu, 3 Jul 1997 08:38:36 +1000

I will try and read the latest responses from Bill, Estaban and Lindsay
before I leave for a long weekend. In the meantime here is my response to
an earlier post by Lindsay.


The easy ones first, do you have more specific references for the following

>There are several recent interesting texts from the cognitive therapy
>literature including: Haddock & Slade, Chadwick, Birchood & ?, and another
>with Kuipers. The focus is on beliefs ofcourse- but at times the emphasis on
>personal meaning parallels the personal construct approach.

Perhaps worse than a diagnosis of schizophrenia is the term PD, at least
someone diagnosed as schizphrenia is told this is what they have diagnosed
with and that there is some hope of change .... but I digress.

Like anything else denial is not a monolithic construct. I suspect the
fundamental issue is denying "madness" as it is popularly understood. I can
recall a person who killed their parent while actively disturbed. This
person periodically struggles with the idea that he/she is a sane and
reasonable person BUT one who committed a horrific and senseless act. This
person readily, perhaps too readily accepts the diagnosis of schizophrenia
(in itself this may not be insight) and a need for treatment, however this
insight can be tenuous and affected by circumstances and substances. How
does one adequately reconcile such extremes? I don't really expect an
answer on this one.

Non-compliance can also be a result of concern about side effects, and even
doctors will tell you they rarely finish a course of antibiotics. Insight
and denial can also be processes.

>Issues of denial and insight are interesting. Do clients deny suffering or do
>they deny the label of schizophrenia because of the images and associations it
>conjures? I heard an interesting use of the word denial lately in a different
>context- men who have sex with men when married but who don't want to identify
>as gay- labelled as men in denial. Denial of what exactly? The question of
>schizophrenia remains. Is denial being used here in the same way as the phrase
>"without insight"? Is the term also linked to the phrase "non compliant"? My
>guess from the way the terms are used on the ward is that the answer is yes to
>both. Interesting personal construct questions may look something like:

Valid questions and an interesting way to elicit difference/constructs.

>"How do you describe what's happening for you at the moment?"
>"What do you understand by the term schizophrenia?"
>A comparison of these responses would then be of interest.

In terms of meaning, this probably varies enormously and perhaps the best
people to answer this are those who experience 'symptoms'. Meaning can also
be understood in several senses. Believing I am a prophet may give my life
a sense of meaning/direction and my utterances may be related to this
purpose, however whether all my experiences can be
understood/interpreted/meaning be detected I don't know. Sometimes the
theme is more understandable than the content.

Some people simply dismiss their more unusual experiences at a later date,
when treated. There is also the issues of double book-keeping where a
person can hold the view that they are a US president but also someone else
and not be troubled by this major difference in status and role, let alone
the unlikelihood and inconsistenceies involved. Then there are people who
will tell you that a relative is really a person purporting to be their
relative and that their family is dead, while relaying this in the most
matter of fact/untroubled manner.
I suspect some of these experiences are unfathomable.

Perhaps the point is that the choice isn't between "meaning" and "meaningless
epiphenomena of a damaged biology", as there always remains a person who has
these experiences, regardless of whether the experiences are understandable
or meaning can be detected. I would suggest a more general goal of trying
to understand how a person makes sense of their world and how they
experience it is an important goal. Not the only one but a necessary one.

>Currently I am trying to understand a man who used to work at the steel works.
>He has an elaborate "delusional system" who nobody I think has ever really
>listened to. Some may consider him thought disordered- he certainly doesn't
>meet the neater requirements of the cog behavioural ABC approach to delusions.
>Interestingly though he does use terms consistently- he has meanings for terms
>such as "pardon", "perfection", "one", "first born creature of the universe",
>"clear thoughts". These all relate in some way. "Perfection" is related to a
>steel process. He had difficulties towards the end of his apprenticeship. He
>talks of the steel works being at war, not receiving a pardon, and the
>psychiatric patients getting side effects because of what the steel works did.
>I am sure there is meaning in there, and it can't just be meaningless
>epiphenomena of a damaged biology. Currently we have a big white board and are
>trying to clarify meanings of these terms- as I mentioned they seem to be used
>consistently but sometimes bear little resemblance to common usage.

Now for the really tough one. In terms of whether voices are construing or
the construed, it depends. Firstly, voices may not be experienced as wanted
or even as belonging to the person. Secondly, the content may be active or
Thirdly, where the voices are commenting on the person they are both
construing and the construed. Voices can also be induced in people who are
starving. These are more considerations than any form of answer. There is
also the issue of who construes and the role of the self.

>The narrative therapy approach (which can be considered constructivist) is
>alos interesting. Narrative therapists (including my partner) work on
>"revising the relationship with the problem"- where the problem in this case
>is the voice. This has some similarites to reconstruing voices or changing
>beliefs about voices. I wonder sometimes though whether the voices are the
>construing or the construed?

A not unrelated consideration concerns, what does it mean for someone who
has been disturbed by voices and other phenomena to be well? I suspect no
one really knows what is going on in the minds (of anyone) of people who
respond to treatment. Do symptoms vanish, are they background experiences
no longer dominating, do people simply stop talking about them? Where are
they and do they go anywhere?

For a final consideration there is the issue of how does a PCP based
approach toward working with people diagnosed as mentally ill differ from
other approaches.

A few thoughts on a challenging subject, especially for people who work in
the area.