Authors: M.D. William Glasser
This went on for about twenty minutes, when suddenly he ripped the respirator from his mouth and nose and screamed at me, “For Christ’s sake, I’m dying. Won’t you leave me the fuck alone?”
I said, “No, I won’t leave you alone. You need counseling and I’m not going to give up. You seem OK now; let’s go on.”
And he was OK. His face, which had been blue-black from anoxia, had a little color, and he seemed to be breathing easier after the outburst than I had ever seen him breathe. We continued, and his breathing took a sharp turn for the better.
The man stayed in the hospital for another two weeks getting his strength back but then was discharged. His lungs were badly scarred and he had to walk slowly, but he was able to breathe well enough to take care of himself. He came back to see me as an outpatient three or four times and said he thought he could handle things on his own.
The key in this therapy was his trying to push me away and my not letting him do it. When I persisted, it was as if something had happened that he had never dreamed would. As much as he tried, he could not get me to reject him. It was enough to help him get back into some kind of control. His lungs were damaged, but he could breathe and take care of himself. There is tremendous power in good counseling. The medical resident who witnessed that dramatic episode was astonished and, truthfully, so was I. What I learned was never to give up, and I don’t.
I will now go into greater detail so you can see exactly how choice theory applies to what I am trying to explain. Again, I want to state that it is important to know that even if what I suggest does not help, it can do no harm. It is also free or moderate in cost, depending on whether you can apply it yourself or seek several months of counseling, which should be enough, especially if the counseling involves learning choice theory, which explains what the problem may be and what the client can do to cope with it better in the future.
When we face a large frustration in a relationship, as did Norman Cousins, my veteran with asthma, and Francesca, we don’t know what to do to reduce the frustration. We search our memories
for an old behavior that has given us some relief in the past. In almost all instances, we immediately find depressing, a familiar behavior we learned as a child. I am sure Cousins and the asthmatic were depressing strongly, as was Francesca, when their lives spun out of control. But depressing is not an effective behavior; it hurts and immobilizes. Still, it gives us more relief than anything else we know, for three reasons.
First, depressing, and all other symptomatic behaviors, including arthritis, restrain a lot of anger, which, if unleashed, would make things worse. Second, these behaviors include a powerful call for help, and in many instances good counseling is effective. If we have an autoimmune disease we will also look for a doctor who may counsel or recommend counseling, which could be helpful. Third, these behaviors keep us from trying to do something we fear we may fail at. It’s easier to depress or to be sick than to look for a new relationship or a new job, especially if we’ve had some experience with rejection, which most of us have.
Although depressing gives us some control, it does so at a very high price: misery. Even as we depress, our misery and our continued frustration force us to keep looking for better behaviors. Even when we seem resigned to what has happened, we are not. It is not in our genes to accept a major frustration, such as an unsatisfying relationship, without getting our creative systems involved. Our creative system may not come up with anything effective; rather, it may come up with something that is mentally or physically more harmful than depressing. But whatever it does, its purpose is to try to find a new total behavior that will lead to some resolution of the problem.
However, it is not uncommon for people who cannot find a way to regain more effective control over their lives or who, for a variety of good reasons, refuse to give up on an unsatisfying relationship to choose to depress for the rest of their lives. That they may have additional symptoms is common, but often a new symptom like arthritising may give them enough control over their lives so they no longer choose to depress.
Arthritis did so for two women I counseled in my practice. It
gave them something tangible to struggle with that they could try to do something about. Not much, but something. They were not willing to struggle with their unsatisfying marriages. They were not going to leave, and they didn’t want to change the way they dealt with their husbands.
But besides physiological behaviors, it is far more common for us to be offered usually one, but sometimes a whole group of, psychological acting, thinking, and feeling behaviors by our creative systems. Together with depressing, psychiatrists call these total behaviors mental illness. Most of these total behaviors fall under the heading of neurosis; psychosis; or physical pain, such as headaching and backaching, for which there is no evidence of a physical cause.
If they are psychological, we may never, even with counseling, discover the reason we choose them, but it almost always has to do with a relationship problem. The problem does not have to be love; it may be that we want more care or less demanded of us, but whatever it is, an important relationship is not working for us. If you look for the unsatisfying relationship, you are on the right track. This is the usual method in our madness.
But because these behaviors, called mental illness, are offered does not mean we have to accept them. In psychosis, our creative system offers hallucinations and delusions, even physical creativity as in catatonia, and offers them so strongly it is hard for us not to accept them. If our lives are far out of effective control, it may be almost impossible for us to reject them. We need to restrain the anger. We often want help, and we can use the symptoms to avoid having to take care of ourselves or to look for and hold on to a new and necessary relationship. Good counseling can often persuade us to stop accepting the offered psychological creativity. But even with no help, not everyone who chooses to accept craziness stays crazy.
Hundreds of thousands of people who function very well today have had episodes of craziness in their lives. Millions more who have chosen to depress, phobic, obsess, compulse, anxietize, panic, and ache and pain with no physical basis for that pain no
longer do so. Some start to refuse these creative offerings on their own, and many go to counselors. With counseling, they are able to gain enough effective control over their lives that they no longer choose these behaviors. Finally, the creative system may offer the idea of suicide: Get rid of the problem and, with it, the pain once and for all. People who commit suicide make their last creative move. But many of them, if offered counseling, would welcome it and avoid the final step.
The following case that I dealt with in the first month of my psychiatric residency illustrates my contention that craziness is offered and accepted and that the offer can be refused if the person believes it is not working in a particular situation. In 1954, I was a ward doctor in the Brentwood Veterans Hospital in West Los Angeles. The patients had all been diagnosed with schizophrenia, and one man was almost frightening in his delusional behavior. Each morning when I made the rounds, he would curse me and spit on the floor when I approached. He was very threatening and kept yelling at me to get the imaginary monkey off his back who was tearing the flesh off his bones. He acted as if the monkey was there and cried out in pain and cursed me for being such an inadequate doctor that I could do nothing about this small animal who was making his life a living hell.
I had no experience with this kind of problem, and I was a little frightened of him. He was a World War II veteran, and the symptoms started soon after he was discharged from the military. I dreaded going up to him, and I could never get any conversation going no matter how hard I tried. This went on for three months, when one day, instead of being threatening, he asked me politely (not even mentioning the monkey) if I could see him in my office after rounds. I was uneasy, but the attendant said it would be OK; he would stand by. I was baffled by this total change, but curious. After rounds I beckoned for him to come to my office, which was right off the ward, forty feet from where he usually sat.
He told me in a perfectly normal way that he thought he was sick and asked me to examine him physically. He said he was feverish and was having trouble breathing. When I felt his head, it
was hot. I then tried to listen to his lungs, and it was like listening to a brick wall; he had lobar pneumococcal pneumonia. I told him that he had to go to the medical ward; we could not treat him in the psychiatric unit. Because of antibiotics, this disease was becoming rare and I had never before seen a case.
I walked him over to the medical ward in a nearby building, and during the walk there was no sign of any psychosis. He kept thanking me for being so nice to him. I introduced him to the internists, who confirmed my diagnosis and were glad to take care of him. This was a disease that some of them had never seen either. During the two weeks he was in the medical ward, I visited him every day as I had promised, and he never showed any signs of craziness. The hard part was to convince the medical residents that he was crazy, actually the craziest patient I had ever seen and that he did need to be on the psychiatric ward. I never convinced them, and I took a lot of ribbing for keeping a sane man in the hospital.
If I knew then what I know now, I think I could have helped this patient when I saw that he had the capability of choosing to stop being crazy. But I didn’t know what to do, nor did anyone else. Gradually, the monkey reappeared, and all his symptoms returned, but he was always polite to me when I made my rounds. He kept telling me how well he had been treated on the medical ward. He still told me about the monkey, but he never accused me of being incompetent or blamed me for not relieving his suffering. I tried to work with him, but I didn’t know what to do. I think that he had put me into his quality world, and today I could use that fact to try to work more intensively with him.
I believe he was talking and acting right out of his creative system, as do most severely psychotic people, but he was able to choose to turn off his creative system for the few weeks he spent on the medical ward. My guess is that staying alive took precedence over whatever problem he was choosing to psychose about. After he was cured of the pneumonia, he chose to go back to the craziness, rather than try to deal with the problem. But with me, he was able to choose some sanity; he was never as crazy as he
had been in the past. This was in the days before psychiatric drugs, some of which might have helped him. In the course of my residency, I learned how to deal with people like him, and a year later, during my last four months on service, using the beginnings of reality therapy, I was able to discharge thirty-two of the thirty-six patients I was assigned. Many had been crazy for years, and all but four chose to be sane enough to leave.
One of my techniques was to spend time with my patients, get close to them, and then ask them, “Please pretend to be sane with me. I have no interest in your craziness.” I reasoned that even the craziest people do a lot of sane things every day. They eat, sleep, smoke, watch television, go to the bathroom, clean up around the ward, and go to various therapies like arts and crafts where many do fine work. When I asked them to be sane with me, someone they liked, I wasn’t asking for much more sanity than what they were demonstrating in much of what they did in the hospital. In my experience, it is not difficult to help people stop listening to their creative systems in the safe confines of a good hospital. What is hard is to guide them in the direction of the better relationships they need to stop being crazy when they leave. The main purpose of a hospital is to take care of their physical needs, provide them with the good relationships they need, and prepare them to stay close and try to get along with people when they leave.
Let me now return to Francesca and use her huge frustration to explain some of the other ways our creative systems can get destructively involved with our lives and what we can do about it. I use Francesca because there is hardly a married woman who hasn’t occasionally thought, My life would be a lot better with someone else. It is the acting on that simple thought that is so tragically portrayed in thousands of books, plays, and movies.
In Francesca’s case, her husband, Richard, as a lover and her life on the farm had not been in her quality world for years. But she was able to accept the status quo because she had no pressing picture in her quality world of a better life than what she had. What sustained her was a picture of her children doing well and needing her and a picture of herself as a loyal, if not loving, wife.
She handled her dissatisfaction with Richard and farm life by mild, long-term depressing. Her choice to depress satisfied the first of the three reasons we depress—it restrained her anger—and that was enough for her. Angry outbursts would have made the situation worse. The other two reasons did not apply. She didn’t want help, and she wasn’t thinking of doing anything else but keeping the life she had. The level of depressing she chose was high enough to give her enough control of her life so that her creative system did not get involved physiologically. She was healthy; she was not crazy; and before Robert came, she had chosen to do nothing that anyone would have labeled a mental illness or even abnormal.
The four days with Robert upset the fragile equilibrium that Francesca had maintained for years. Afterward, to keep the anger in check and to maintain the status quo, she had to depress much more intensely. She felt terrible. She could do little or nothing around the farm, and she was worried that she would not be able to keep the bargain with Richard that she had kept for years. Now she had the picture of a satisfying life with Robert in her quality world, a picture so discordant with the take-care-of-my-children and loyal-wife pictures that had sustained her for years.
Francesca was in a conflict, by far the most serious frustration we can suffer because there is no good solution. Either way, Richard or Robert, there is misery. She was trying to depress so strongly that she would not even think of making the choice. She recognized that life with Robert was an impossible picture. She said she couldn’t leave her family under these circumstances, and she didn’t.