Life has never been easy, and over the last fifteen years or so it has gotten harder for all of us. We work harder and longer for lower real wages, and prospects for the future are probably dimmer now than at any other time since the Great Depression. But life has always been hard for persons who live with severe and chronic mental illness, in part because the public finds these persons so hard to understand and to empathize with. To some extent, the mental health professions have also shunned these persons as being unhelpable, and that is a great loss both for patients and for those professionals who do not have the experience of treating them. I am writing as a practicing clinician about how psychotherapy might help persons struggling with chronic mental illness, and what we all might learn from the process. I will first look at the existential condition of the chronic mental patient, then discuss what psychotherapy is and how it can help. I will then outline the factors that hinder therapeutic work, and finally I will suggest what might be learned from the experience of helping those who carry the heavy burden of chronic illness. Since some readers may have questions about the epistemological status of what is written here, I will confess that this paper is from start to finish anecdotal, and is therefore as strong or as weak as reflection on one's own experience can be; I personally believe there is worthwhile knowledge that cannot be scientifically warranted.

Some people are very unfortunate in that, through no fault of their own, they fall ill with severe forms of mental illness, that is to say, severe forms of schizophrenia, bipolar disorder, paranoia, and personality disorder. Worse yet, these severer forms of mental illness may not respond well to conventional psychiatric treatment, so that the patient's hopes for cure are perpetually dashed. The patient, who may have been a perfectly normal person for the first fifteen to twenty years of life, suddenly finds that he or she is beginning to walk down a very different path from that taken by neighbors, school chums and friends, a path that leads eventually to the state hospital—the last stop on the way to complete social marginality and personal despair. Imagine for a moment that some invisible force leads you to think bizarre and frightening thoughts and to act so oddly that even your best friends are deeply embarrassed by what you do in public. Distracted by mocking voices no one else can hear, thinking thoughts so strange even your own mother cannot accept them, or swept along on enormous currents of emotion, you cannot concentrate on school or work, and all your social relationships deteriorate; no one understands why you behave so oddly, and you yourself may have only a wildly distorted notion of why others pull away from you. The medicine you are given may make you groggy and your tongue heavy, your vision may blur and your hands may begin to shake, and yet the symptoms that trouble you persist. You hope that better doctors and better medicines will cure you, and if your family has a lot of money, you are sent away to famous hospitals and clinics with high hopes.

But nothing works. The symptoms always return: the voices, the thoughts, the overpowering moods, the suicidal impulses, the urges to cut yourself or to set yourself on fire, the odd, often frightening behavior in your home or in public places that makes people call the police. Then comes the ambulance ride to the emergency room, the doctors with their questions, the tranquilizing shot of medicine, and the long ambulance ride to the state hospital. How many times? Ten, twenty, thirty—they all begin to blur together into a long slow-motion nightmare from which there is no waking up. As time passes, friends go on with their lives, family members visit the hospital less often, and more and more of your time is spent with people just like you. It is hard to convey the patient's growing feeling of horror that his or her life is slipping increasingly out of control and farther and farther from the mainstream. Others complete their educations and marry but you do not; others start families and careers but you do not; others earn money and spend it as they please but you get yours from government checks and from guilty relatives; and from everywhere comes the implied message that you are an embarrassment, a burden, and an outcast. Even the professionals that treat you pull away from you using an assortment of excuses since you do not get well; they call you a treatment failure or a refractory patient, and hope for someone more "treatable" who will remind them of their power to cure. Thus, over the years, everything that supports your self-esteem and your value as a person disappears, and you are left alone to struggle with life and why you should bother to cling to it.

Does it make any sense to talk of doing psychotherapy with such people? I would like to argue that it does. In fact, those of us who work with chronic and severe mental illness have found four areas in which one can realistically help the so-called refractory patient. First, one can work to help patients live with the illness and make an optimal adaptation to it, much as one would attempt to do in the psychotherapy of patients with cancer or multiple sclerosis; even where cure is not a possibility, the quality of a patient's life is greatly affected by the degree to which the patient can accept the condition and concentrate all of his or her powers on finding new ways to carry out the essential activities of living. Severe and chronic illness constitutes a profound disconfirmation of our assumption that nothing bad will happen to us, that tragedy befalls others but not us. Patients who learn that they are seriously ill are deeply shocked, and the mind recoils in disbelief. At some deep level far beneath consciousness, the mind senses that it must confront a terrible reality and calls into play various mechanisms of defense to ward off knowledge that will bring pain. Thus, patients will argue over diagnosis long after the matter is clear to others, and blame the doctors or the hospital for their incompetence. In doing so, these patients try to maintain the hopeful view that only medical bumbling stands between them and good health, for it would be terribly painful to admit that they are incurably ill. This is not to deny that some patients are in fact incompetently treated, but for many patients the real problem is that their familiar world has been turned upside down in a way too painful to contemplate. It is essential for patients to get beyond this stage of disbelief and massive denial, because any chance they have for recovery or for a better quality of life depends upon coming to grips with a new but terrible reality. My experience treating patients with chronic mental and physical illnesses leads me to believe that supportive psychotherapy can help the patient get beyond shock and disbelief and the sterile dynamics of blaming so that all their energies can be directed towards maximal adaptation to the challenge presented to them.

Second, one can help the patient to function on a higher level. Here one hopes to help the patient towards incremental change, such as improving control over angry impulses so that the patient is able to move from a locked to an open unit. But setting such incremental goals is part of the more general process of helping the patient adapt to a new reality and to limitations that cannot be wished away. Even after years of unsuccessful treatment, many patients do not appreciate that they have chronic conditions; and while often demoralized they still maintain the hope of complete cure. The problem is that from the standpoint of complete cure, important incremental changes can appear worthless. As a result, patients can remain for years in a kind of paralysis, wishing for cure but taking no concrete steps to improve the quality of their lives. Therapy can help these patients see that their reluctance to make little efforts is often motivated by continuing, massive denial of their illness, and by a despair that lives so deeply damaged could ever be made fulfilling.

Third, one can help these patients retain a sense of their own humanity and membership in the human community. As I have suggested above, the life of chronic mental patients is filled with indignities great and small, and downward mobility is the rule. In addition to the delusions which tell these patients that they are no longer human, society seems to turn its back on them so that in the end they may feel more like things than people. Any activity which can put these patients back in touch with the feeling of being human or can remind them that they are more than an illness can be of great help. Saying hello in the morning, or a firm handshake can be therapeutic in this sense, and so can the time spent in helping patients recall their good memories or time in idle conversation; all of these activities help put patients back in touch with their premorbid, healthy selves, and remind them that illness has not taken them over completely. We need to remember that therapy in a hospital for the very sick is virtually anything that helps patients feel more human and function better; talking in an office and the technical aspects of therapy but one way of helping. Thus, on the wards for the very ill there is no such thing as idle talk; every pleasant word can be a link to hope and a renewal of bonds with the larger human community, every moment spent in pleasant company a reminder that one is worth spending time with.

And lastly, psychotherapy can aim at keeping the patient's hope alive. In everyday life as within the hospital, life without hope leads to numb, vegetative existence, to violence as a means of feeling alive, or to suicide. Viktor Frankl, a psychiatrist who survived a Nazi concentration camp, considered the will-to-meaning or a sense of one's agency and purpose in life as essential to maintaining the will to live, while Ernst Bloch, a philosopher who lived through the same period of fascism and Cold War, described hoping as the fundamental and defining human activity. My own experience, personal and professional, tells me that people need hope as much as they need air and water. Perhaps that is why secret police the world over isolate prisoners from all contact with the outside world, deprive them of sleep, and subject them to random beatings, since in this painful isolation the prisoner loses all hope and therefore any reason to resist. The patients I work with live in an isolation imposed by their illness, and at times it seems to them that their torment will never end. Therapy has to address this demoralization by working to bring out their will to survive, their stubbornness, and their fighting spirit and to direct these forces against the daily problems of living with an unrelenting illness. As patients learn to fight their illness, as they fight for their right to have a life, they find that this new, active relation to their condition gives them hope and thus even more reason to carry on. Sometimes group psychotherapy is also crucial in keeping hope alive, since group members can share their common problems and feel the support of others; one should not underestimate the restorative power of human solidarity, the feeling of being bound up with others in a common struggle against adversity. Like the characters in Camus' novel The Plague, chronic patients know that the odds are against them but they feel better when they can experience the camaraderie and fighting spirit of those who share their plight. One may lose a struggle without losing one's dignity.

How, then, might one advance these treatment goals? I would like to suggest that psychotherapy, broadly defined, can make a major contribution towards helping the chronic patient. For me, psychotherapy is a special, two-person relationship in which one person, the therapist, makes a sustained effort to listen to the other person, the patient, with the object of getting to know that other person's world from the inside out, in as much detail as possible. In this essentially phenomenological task, the therapist tries to empathize with the patient while at the same time looking beyond the patient's phenomenal world to see what might be structuring it. In so doing, the therapist treats the patient as someone whose life and history are important and of intrinsic worth. It would be very misleading simply to call this talk therapy; good therapy is always more than mere words. Psychotherapy uses words to promote and explore a relationship, because it is within this relationship that the patient's troubles manifest themselves and find some measure of resolution. Thus the therapist pays careful attention to the ways in which the patient structures the relationship, for there is a sense in which the patient brings the whole of his or her history along into the treatment room, seeing the therapist both as a person in the present and as an embodiment of important figures from the past. Helping patients see how the past can obscure the present, and they can gradually break free of unconscious mind sets, are important elements of treatment. And intimately bound up in this process is the restoration of the patient's sense of agency, that sense that one can make things happen and not live as a perpetual victim.

But how can such changes come about? At this point it might be useful to review in a little more detail those aspects of therapy which help the patient. These may be divided into two broad groups. First are the existential factors, those which address the patient as a fellow human being who must cope with the basic predicaments of existence: limited knowledge and power, the experience of pain and loneliness, and the sure but unwelcome prospect of death. Patient and therapist alike struggle with these reminders of human finitude, and often they are both overwhelmed by their feelings of insignificance. Thus, the first of the existential helping factors, being taken seriously by the therapist, is of great importance in the sense that, as the therapist listens carefully and intently to the patient's story, the therapist conveys by example that the patient is someone of value whose words and experiences deserve careful and respectful attention. The sad fact is that the chronic patient is seldom listened to carefully; clinicians ask about symptoms or behaviors or reactions to medications, but they can be remarkably indifferent to the patient's life and the patient's need to tell someone about it. Hence, the quality of the therapist's listening, and whether it is patient or rushed, whether it encourages a full narration of the patient's life-drama or settles for the merest sketch—conveys a subtle but powerful message about the patient's worth as a human being quite apart from the content of what the therapist might say.

The second helping factor is the experience of really feeling understood, a factor stressed in the writings of Carl Rogers and Adrian van Kaam (1966) and, within a psychoanalytic context, by Heinz Kohut in his extensive discussions of empathy (1971, 1977). It is not enough that the therapist listen carefully to the patient; the patient needs to see evidence of and to feel that the therapist appreciates what his or her life has been like, that the therapist can look at the world through the patient's eyes. In any therapy, this is a crucial element, but with chronic patients it assumes special importance since few people can bring themselves to enter the chronic patient's world of madness, failure, and despair. These patients begin to believe they are too valueless and too damaged to be worth anyone's attention, even though deep within themselves they, like us, harbor the desire to be understood and valued, to be confirmed in their humanity by another person. That is why so many therapies with chronic patients begin with the simplest kind of talking: a few pleasantries exchanged on the ward, a chat about sports or music, an exchange of humorous remarks. In another context, these words would have no special significance, and one could brush them aside. But in a psychiatric hospital, these brief exchanges are often a patient's tentative and unobtrusive way of reaching out to a potential therapist to see if the gesture will be returned.

Some years ago I was seeing a patient in psychotherapy on a chronic ward. One day as I walked into the large day room, a woman I hadn't noticed before got up and greeted me very pointedly, looking me in the eye and saying clearly, "Good morning, Dr. Ortega. How are you?" I was struck by her forthrightness, and then I remembered that some three years before she had resided on a ward where I worked, a special locked ward for very difficult patients. In those days she had been withdrawn and suspicious, so aloof and angry she was unapproachable. Her remembering my name after three years and the directness of her greeting were so striking I was almost without words. Later as I thought about the encounter, I was struck by the fact that after more than three years of no contact with me, and with only minimal contact before that, she had remembered my name exactly and greeted me as though we knew each other well and had met only last week. Even though she had confined herself to saying hello and did not want to carry on a conversation, it was hard not to take her behavior as a remarkable sign and an implicit request for human contact. In fact, this woman was later assigned to individual therapy, first with a psychology extern I supervised and then with a clinical nurse specialist, and made such progress over two years that she was released from the hospital. For the great improvement we must certainly credit something within her, some drive towards health that led her to reach out to those who could help her; her therapists then served as catalysts who elicited the latent health within her, using the therapy relationship to strengthen what was already there. Perhaps my coming to the ward regularly to see a difficult patient, and the sight of this other patient's progress awakened in her the long-dormant hope that she might regain her sense of aliveness.

There are other, more specific factors that help in psychotherapy, and I would like to touch on these briefly. Catharsis, first mentioned by Aristotle in his discussion of tragedy, is a powerful healing element, for it is a relief to tell a painful secret to someone else and so give it a measure of concrete and finite reality; to some degree one is then freed from the oppressive limitlessness of subjective fantasy. It is also very gratifying to continue to be accepted by the therapist after having revealed something troubling and painful. Patients have unfortunately had a great deal of experience with not being accepted, so that the therapist's patient listening and facilitating questions convey a new and benign attitude of acceptance which the patient can then take in and make a part of the self. We need to remember that patients are fighting not only the symptoms of their illnesses but also their own attitudes, which often reflect the disapproval and the incomprehension with which others have viewed them. The therapist's implied acceptance of the person of the patient—as opposed to any specific, objectionable behaviors—can provide a model for imitation and internalization, which is to say, for the gradual taking in of a more benign and productive attitude towards the self.

This brings us to the second specific factor, therapy as a generator of new perspectives on the self and its problems. There is certainly a sense in which patient know their own world of lived experience (Lebenswelt) far better than the therapist. But patients are also stuck in that familiar world and cannot find a way out of their problems. In order to help, the therapist must first of all become immersed in that world as completely as possible, but having done that, the job is to see if there are dynamics which structure that personal world, the understanding of which would give the patient new tools for getting on with the business of life. Thus the therapist restates what the patient says, clarifies it, or juxtaposes material so that the patient can look on what he or she has said in a new light. I want to emphasize that this work the aim is to suggest connections; one presents the patient with things to notice and lets the patient make sense of the juxtaposition. To a schizophrenic patient who claims that another person's thoughts are making his face feel hot, the therapist might observe that the patient has this hallucinatory experience when other patients are being discharged. The comment implies that the patient's experience is not random or incomprehensible but arises in response to what psychoanalysts call danger situations, circumstances in which the patient feels threatened by an impulse and fears annihilation or loss. After all, part of living with psychosis is learning to recognize how one's illness has affected one's mental processes, so that while a normal person might feel sadness when a close friend died, a person with schizophrenia might have the delusional belief that the friend was still alive and experience his own voice as sounding like the dead friend's. At this point a therapist might observe that some people might feel sad that a friend had died, leaving it to the patient to make some link between the death and his experience of his own voice.

So far I given four factors that heal in psychotherapy: taking the patient seriously by listening, helping the patient feel really understood, facilitating catharsis, and providing implicit new perspectives on the patient's experience. There are many other factors one might list depending on one's theoretical allegiances and practical experience. What has impressed me most in my own ten years of working with very ill mental patients is that these people are very strong and very persevering; in spite of living an often hellish existence, they have often preserved areas of vitality that are just beneath the surface, if only we are not too shocked by that outer layer of psychosis to see them. The therapist can do a great deal of good simply by being a decent human being who listens and sometimes points out connections in a low-key way. Often beginning student therapists do wonderfully with patients because their youthful vitality and optimism give the patient hope, and their enthusiasm implies an acceptance and even a liking of the patient that is vivifying. We must remember that the chronic mental patient lives at one of the extremities of the human condition where every energy must be used to endure and survive. Like all persons in extreme situations, patients are not overly fussy over who helps them survive; fussiness is often the luxury of those whose basic survival is not in doubt. Thus the patient is often prepared to forgive the novice therapist any lapses in technique because these lapses seem, for the most part, rather insignificant when compared with the interest, energy, and hopefulness that student therapists typically radiate. I do not wish to minimize the role of technique in the psychotherapy of severe mental illness but rather to put it into existential perspective; these patients are in a raging sea trying to stay afloat, and they do not care if it is a life jacket, a raft, or a piece of wreckage which keeps them above the perilous waters.

Having said that, however, I must add that patients can be very discriminating in the matter of who cares for them, for with great discernment they can tell those who respect them from those who do not. You may have heard that chronic patients can be very aloof and difficult to form relationships with, but they often have good reasons for their reserve. In the course of ten or twenty years, chronic patients have had their hopes dashed many times, and few experiences are more painful than having one's hopes raised by the promise of something good, only to have them crushed by disappointment. Think of your own adolescent years and the pain of dating, and then imagine the still greater pain of these chronic patients when their hopes of finding someone who really appreciates them come to naught again and again. After a time, they cannot stand the pain and withdraw into themselves, secretly hoping they will meet someone but ever on guard against disappointment. They let down their guard only when they see that the therapist can appreciate their plight and can see something of value in them; once this bona fides can be established, treatment can go on.

In practice, this means that every therapy begins with what amounts to a trial period, which in the case of the most suspicious and disappointed patients can go on for months. The withdrawn woman I spoke about earlier initially would not even speak to her therapist when she was assigned one as the result of her dramatic greeting. Her student therapist correctly intuited that the patient was so suspicious and fearful of rejection that even the slightest appearance of going along with the therapist's requests might expose her to unbearable humiliation and the feeling of being coercively controlled. Thus the therapist began by sitting in a chair next to the patient as she watched television in the large day hall, saying nothing but letting the patient feel her regular and undemanding presence. After several weeks of sitting quietly twice a week, the patient unobtrusively began to make small talk, and the therapist joined in casually, making no attempt to ask questions or talk therapy. Some two or three weeks went by in this fashion, towards the end of which the therapist could note a more earnest tone in the patient's voice as though she was looking forward to the therapist's twice-weekly visits to the ward. Gradually, the patient felt comfortable enough to set a regular hour for the meetings and then to ask for meetings in a private office off the day hall. My experience is that many chronic patients are willing to enter into some kind of psychotherapy if only the therapist can meet them where they are; arrangements such as talking about oneself for a fixed period of time several times a week, meeting in an office, and turning thoughts and feelings into words can seem quite strange and forbidding to a patient, so that one must start with something the patient likes to do and join in the activity. Even quite regressed patients can sense that the therapist is more than just a companion, but until the therapist is trusted as a person, the patient is too fearful to make use of the therapist's special function.

But the time does come when the patient's curiosity and inner drive towards health impels the patient towards therapy in the more technical sense, and talk turns increasingly towards the patient's life. Can the therapist really listen to what the patient is saying? So far I have spoken as though the patient and therapist were both well-intentioned and free from hateful fantasies and impulses. This is the naive view that we all on some level maintain, since the more complicated and dialectical view, while truer to the facts of real therapeutic work, is also much harder to face. In fact, therapists must confront their own fear and hatred of the patient. The therapist is, after all, a layperson underneath, and like the layperson has a visceral fear of the patient's illness and the stigma which flows from it. Unconsciously, therapists fear that the patient's condition is in some magical way contagious, and that they will be polluted as a result of prolonged contact. At the same level of unconscious fantasy, the line between self and other can blur so that therapists may consciously experience the patient's confusion and despair as their own in a quite literal and frightening way. For all these reasons, therapists have powerful motives to pull away from the patient using a variety of excuses, sometimes explaining to themselves that the patient is untreatable, sometimes feeling hate for the patient as a way of maintaining psychic distance between the two of them. And in spite of their own moral values, therapists can feel ashamed for treating someone so thoroughly devalued by the larger society, and so to avoid the shame experience and to protect their own vulnerable self-esteem, they may refer these patients to others or treat chronic patients only in high-status settings whose prestige compensates for the patient's stigma.

But therapists can also find the chronic patient hard to face because such patients remind them of parts of themselves they have disowned and forgotten. Like everyone else, therapists want to think of themselves as basically good, and tend to repress their awareness of what is hateful and destructive within them. But the patient's violence, frank sexuality, and mental confusion can be painful external reminders of what lies within, reminders that the therapist too is a flawed human being and thus potentially an outcast like the patient. For therapists who have spent many years working to become acceptable and possibly prosperous members of society, even the fantasied prospect of becoming an outcast is enormously threatening and reawakens childhood fears of abandonment and shame. Add to this the reality that the state hospitals and the public clinics which treat the vast bulk of chronic mental patients are generally held in low esteem, and one finds a powerful confluence of inner and outer forces pushing therapists away from patients who desperately need human contact. Only when therapists have learned to derive pleasure from their difficult work, and only when they have incorporated a value system which sees their work as good and important—only then can they experience the patient as a fellow human being and a source of interest and inspiration.

Helping those who live with serious and chronic mental illness is not glamorous or remunerative work. The public does not like to be reminded of how bad life can get, and mental health professionals do not like to be reminded that their skills do not always bring about a cure. Families of the chronically ill find that, despite their best intentions, caring for a sick relative can be a great burden, and politicians find that helping the chronic patient does little to get them votes. Beset by guilt and shame, demoralized by the tenacity of the patient's illness, almost everyone sooner or later comes to wish the chronic patient out of sight and out of mind; and just as the individual represses painful experience, so society collectively represses awareness of chronic mental patients, dumping them into remote rural hospitals or into poor parts of town where they, like the poor, can be invisible. Please remember that I am not ascribing conscious malice to anyone, because the repression of painful psychic experience is automatic and involuntary, a self-protective reflex of the mind. I am simply saying that all of us, the public and the professional community alike, have powerful motives for forgetting about these very ill patients.

But I would also like to argue that there are equally powerful reasons for helping these patients. In the first place, we have learned from psychoanalysis and we can see in history that the repressed will return to haunt us however much psychic energy we invest in the act of forgetting; despite their power, defense mechanisms are imperfect and only put off to some future time the confrontation with painful reality. By working with chronic patients and being open to their experience, we are forced to confront what we have disowned in ourselves and (in the best of circumstances) to reintegrate it. In other words, there is a sense in which working with the chronic patient is therapeutic for the therapist.

There is also a sense in which working with the chronic mental patient is philosophically and ethically therapeutic as well. As a society, we cannot pretend that tragedy is somehow foreign to the human condition; all of us, by virtue of being human, are destined to endure our share of pain and tragedy. But relatively little in contemporary American life prepares us to endure tragedy, much less to use it as a force for growth. We learn that we have only to strive, to get to the head of the class, and to greet the world with a smile, a shoeshine, and a killer resume in order to have a life of success and unending affluence. And that, surely, is a collective delusion masking the realities of falling standards of living and diminished prospects for all but the members of a small elite. By working with the very ill, we can rid ourselves of the bad habit of ignoring what is unpleasant or frightening, for in the faces of the chronically ill we can see not only their suffering but also our own. And if we have the courage to keep our gaze fixed on them, we will also see their perseverance in the face of adversity; living in their corner of earthly Purgatory, they have learned to tap some deep well of strength and vitality even though stripped of family, friends, career, money, and the good will of others. Could we survive when stripped of so much? If we look to the literature on survival under extreme conditions such as Terrence Des Pres's The Survivor (1976), we see that human beings in extremis can draw on inner, ultimately biological sources of strength, and this insight can be curiously reassuring. One thinks that if these patients can preserve important aspects of their humanity while in the depths of psychosis, then it must also be possible for us to get through difficult times because we, like they, share that deep will to persist.

By way of closing, I would like to speak about a remarkable patient. Several years ago, I spent nine months helping a deeply psychotic woman face her death from cancer. Years before the treatment started, I had known her when she had been on a special ward for very difficult patients. At that time, she had been very suspicious and fearful, frequently raging at staff for all sorts of imagined insults and crimes—such as taking away her babies or poisoning her. Because she was very large and often looked at one with a wild, angry expression, she frightened the staff who, in spite of her fearsome appearance and raving, found her strangely likable. Although I was too inexperienced and too frightened of her to see her in therapy, we did speak in passing, and she impressed me as an intelligent, kind person who had lived a hard life and who was now locked away in a deep intractable paranoid psychosis. Two years later she was living on an open cottage, but now she was dying from a cancer she had refused to let her doctors treat. The cottage staff felt badly that someone who had suffered so much was now dying slowly and painfully. Her attending psychiatrist asked if I might work with her in some way to ease her last months. Wondering if I could do anything at all for her, I began to see her twice a week with the initial goal of helping her understand that she was dying. On some level she had already grasped this sad fact, even though her conscious mind, dominated by paranoid delusions, worked to reject it.

She was not an easy person to work with. Often she would complain that God was punishing her or that the nurses were lying about her medical condition in order to torment her. She related experiences in which she heard the voices of dead loved ones or saw ghosts, and she pressed me to accept her experiences as objectively real. She wanted very much for me to validate her experience and remove her torment and I, in response, felt quite paralyzed by the weight of her need. But intertwined with her demand that I see things her way was a much more amiable request that I simply spend time with her. I tried in my way to relate her bizarre perceptions to her overall situation and to express the emotional distress implicit in what she was saying, but I am not sure that any of this was helpful. But she did not let me lapse into discouragement. As patients had so many times before, she led me in a new direction that was useful for her, although I was slow to realize it. One afternoon as I struggled to find something we could talk about, I wondered if she recalled TV shows she had seen as a kid. I am not sure why this notion popped into my head, but I remember feeling that talking about the present was very difficult. I immediately discovered that she loved to talk about such shows, and she recalled them with such accuracy and vividness that I was both startled and heartened. She seemed genuinely happy to recall the hours spent in front of the TV on Saturday mornings, and she took pleasure in seeing how impressed I was with her memory. My own efforts at recall were considerably inferior to hers, but she was more than happy to fill out my sketchy recall, and together we shared a time when things had gone right. These sessions seemed to give her the key to unlock the good memories within, and to provide a way of prying loose the grip of delusion. I think she wondered if her life had been worthwhile; here with her memories and her ability to give pleasure to both of us, she had an answer of sorts. I know she gloated a little at being able to recall the whole of the theme from "Mighty Mouse." One can easily imagine how, locked in the grip of psychosis and terminal illness, this patient might have fallen into the profoundest despair and then apathy. But her desire to survive psychologically and her formidable ability to reach out to those around her enabled her to use me as a Winnicottian object, as means of accessing what was vital and meaningful within her. She could also see that I, too, had been watching the same shows in my childhood, and I think she found the image of the two of us as children happily watching our favorite TV shows very comforting, for within it our two different worlds were linked in pleasurable companionship.

Was her death a tragedy? In the sense that her life was cut short and filled with pain, then surely it was. But in her dying she showed great strength and inventiveness; she succumbed to a harsh fate but did not surrender her spirit. Even on the last morning of her life, she argued with the nurses about taking her off the medical ward for a cigarette. So lively did she seem in argument that the nurse who went back to the office for a lighter was shocked to find the patient a few moments later slumped over in her wheel chair, quite dead. Right up to the end she did not want pity, and I think she sensed a good fight would get everyone's mind off the end which was so near. Her gift to us was that by her inventiveness and warmth she kept all of us from falling into despair; she kept us going so we could keep her going. She showed us that adversity did not have the last word, that there is grit within us even if we do not know it. She showed us that, as Hemingway said, we can be strong in all the broken places. And for that we must remember her.

1. Copyright © 1994 Richard James Ortega, PhD.  The opinions expressed are those of the author and do not necessarily reflect the policies and opinions of the Maryland Department of Health and Mental Hygiene.
2. I will use the term “patient” for the person living with chronic mental illness, but it should be understood that the patient is first and foremost a human being and not simply the passive medium in which an illness dwells. Treatment seeks to preserve and enhance the patient's humanity, even when it cannot cure.  Polite or euphemistic terminology cannot obscure from our view the unpleasant reality that it is illness which primarily causes suffering, not our choice of words to describe the sufferer. At best, terms like “client” are mild anodynes, and their use can encourage us to think that painful realities disappear when we change the names we use to describe them. Nor does calling the very ill person a “client” fundamentally alter our reaction to the person's existential plight, for that reaction comes from deep within us.
3. Some readers have suggested that not all patients are deeply upset by their illness, and that what is seen as their despair might instead be a projection of the therapist's (or writer's) own feelings of futility with such a difficult enterprise. My experience with inpatients and outpatients has been that almost all people find serious mental problems deeply distressing, so much so that they often use massive denial to block awareness; and where denial as an intrapsychic defense mechanism fails, patients may retreat into numbness and apathy as a way of not feeling psychic pain. That some patients may be exceptionally resilient and especially fortunate in their adaptation to illness is true, but it is the exception that proves the rule. One might add that people who have long lived with severe and chronic mental illness do not easily or readily reveal the full extent of their pain, for they have often been disappointed by helpers who could not bear the weight of their revelations.
4. I am deeply indebted to my colleague Clarence G. Schulz, MD and to his many writings on work with chronic schizophrenia for stimulating and clarifying my own thinking about the treatment of chronic mental illness. His 1975 paper on comprehensive, individualized treatment still has no equal in the literature as a practical guide to helping the patient who is very ill with schizophrenia. I must also mention the papers of Harold F. Searles, MD (1965), whose frankness and originality set them apart and make them a wonderful inspiration for anyone who is struggling with the complexities of helping another person.
5. Michele Ritterman and others have called torture a counter-therapy, a perverse use of knowledge to break human beings rather than to heal them. This terrifying art has sunk to new depths based on an increasingly sophisticated understanding that humiliation, absence of social support, and sleep deprivation can be combined with severe and unpredictable pain in an antitherapeutic regimen which undermines psychic life, and with it any hope. For the torturer, hope is not a theological abstraction but a palpable mortal enemy, against which every destructive technique must be employed.
6. I am not arguing here for psychotherapy as the sole or exclusive treatment modality; the patients of which I write need all the help they can get from every discipline. But especially when the results of pharmacotherapy are meager, psychological and psychosocial treatments may be decisive in raising the patient's functional level and in improving the quality of life.
7. These structuring factors include the psychodynamics of traditional psychoanalysis, the dynamics of neurochemistry and neural structures, and sociopolitical factors like race, class, gender, and religious belief. Good therapy is not squeamish about looking at the world as it is and as it affects the patient, and it could be argued that therapy which is oblivious to the full measure of the patient's life-world is doomed to triviality.
8. To the extent that therapists are members of conventional society, they have learned to value the very things the patient lacks.  Yet in order to help chronic patients, therapists must undergo a process of reeducation in order to find some value context within which the patient is valuable and fully human.  Some secular and religious ideologies may help in this task, but in spite of the support these ideas may give to patient and therapist alike, therapists must constantly come to grips with their tendency to devalue and fear the patient even as they consciously try to help.
9. This is not to minimize the healthy role of repression, denial, and illusion in confronting the intimidating realities of life. Can anyone really sustain awareness of the full extent of human misery for more than a few moments? Much in human culture can be seen as the product of a contest between the need to know for the sheer delight of knowing and the need not to know but rather to enjoy comforting illusions. We need our illusions so as not to be crushed by the weight of suffering and disappointment but we also need true knowledge of the world so that we do not run afoul of objective reality. In the end, history is impersonal and unforgiving in its judgments; every person and every society can go the way of Shelley's Ozymandias.

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