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Essay Instructions: This is a humanities paper. we are studying The Enlightenment and beyond and are using,The Asheville Reader, and Fiero(The Humanistic Tradition)F4 and F5. My topic is "Declaration of the rights of the Student." ....:As a response to the state budget crisis, Dr Heard (my instructor) has been appointed Uber Chancellor Supreme and made the following changes. All majors are eliminated (you now will graduate with a degree in Humane Letters, having taken a dictated list of classes with no electives .) 62%of the faculty members, 75% of the support staff and one administrator have been fired. Smoking on campus has been banned, and the cafeteria will serve two meals a day of corn hash and gruel ( it is up to you whether you notice the difference).
As an enlightenment student you gather together your fellow students and the few faculty who will talk to you in covert meetings, preparing a "Declaration of the Rights of the Student". Uber Chancellor Supreme will read it if he has the time.

I hope I have supplied enough info, if I could have as much humor in the paper as possible I would appreciate it.

Essay Instructions: Ok, so I've never used one of these sites before.
There've been some uber “fun” family issues and I'm not going to be able to devote time to this paper, so I need a good guide to work with...
This paper needs to be a good overview of Music and its role in the psychological standpoint.
The goal of this paper is to find substantial evidence stating the benefits and impact of music on the human psyche.
I have a rough outline of the basic Ideas of the paper:
A. Over view of music - Why is it so universally important?
What kind of les does it play in our lives?
B. Music and Society - Music's role in our world and cultures. Music as universal munication.
C. Music and the mind - Exploring the affects of music on the human mind. (I would say this should be the most substantial part of the paper.)
D. Music and you - How music can change life for the world and you.

These are really just my original thoughts for the paper and they can be altered here and there as needed.

Now there aren't too many technicalities other than all sources must be hard bound, with the exception of online archived journals, and there should be at least 2 footnotes per source.

Any questions, don't hesitate to contact me!

Thanks so very much!!
Your efforts are so greatly appreciated.

Marie

Essay Instructions: Earlier rather than later would be great! This essay should be mostly a close reading paper which articulates a clear, well-structured argument about the evolution of the idea of autonomy in Western Canon as exemplified through the transformation of the metaphor of men as leaves. It seems to me that something smart may be said about human autonomy in the face of the divine, given the primary texts I've chosen, but anything pertaining to the idea of freedom is appropriate for this paper (the class is about the idea of freedom in the humanities- very vague, I know!)

I will attach a jstor pdf that may be useful (but it may not!) and a word document with the specific passages to be analyzed (you may choose to pick a couple of extra sentences, or lose some, if necessary. For example, I may have noted X.3-5, but you may actually need to look at X.1-10)).

I'm pasting what I wrote on the word document here below just in case! I listed some webpages at the end (for discussions on Leaves of Grass), but they may not be useful. Please use what is natural/makes sense with the overall argument. This is a completely free paper-- I made up the topic myself and am very sad that I don't have time to write most of it-- so you may play around with the topic/sources (I would stick to the primary sources though) as necessary! Just make it good! It's a fun topic, I think.

Since all of these books are uber-well-known I assume you can find cope of them and discuss the specific passages in terms of their textual context, the goals of the work, etc- as well as the historical framework, personal beliefs and/or cultural traits of the authors when necessary to understand their particular view of freedom, autonomy, divine power, etc.

Thank you very much! Please email me if you have ANY questions whatsoever.

Here goes the pasted doc!
-

THE METAPHOR OF LEAVES AS MEN- HUMAN AUTONOMY AND THE DIVINE, or something like this (which will hopefully sound better!)


*I used different translations for some of the works (i.e. The Iliad); you’ll have to choose which versions are available to you. Please connect different sources; point out differences; give context in historical/political terms when relevant, and always in terms of the work itself. Develop an argument in terms of some facet of the idea of freedom. I think that something may be garnered in terms of the notion of individuality and autonomy in the face of “fate,” the gods/God/divinity. I think these uses of the metaphor are different modulations of this problematic in terms of the author’s time, social environment, beliefs, etc.

* Things that I hope you might be able to introduce somehow:
A reference to Emerson when discussing Whitman
The concepts of Negative and Positive liberty (from Isaiah Berlin’s Two Concepts of Liberty)- and more arguments from his work, if necessary
Heroism and autonomy. How does the idea of heroism change and come into play in these uses of the metaphor of men as leaves? How do these authors conceive of the relationship between autonomy and/or liberty and heroism?

THE ILIAD
Thick as autumnal leaves, or driving sand,
The moving squadrons blacken all the strand. II.458-468

As is the generation of leaves, so is that of humanity. The wind scatters the leaves on the ground, but the live timber burgeons with leaves again in the season of spring returning. So one generation of men will grow while another dies.
The generation of men is like that of leaves. The wind scatters one year's leaves on the ground, but the forest burgeons and and puts out others, as the season of spring comes round. So it is with men: on generation grows on, and another is passing away.
VI.146- 150

THE AENEID
Here, waves of them spill and splash to the shore,
Mothers and men and the corpses of great-hearted heroes
without any life in their limbs, boys and unwedded girls,
youths laid on the pyre before their parents’ eyes.
They are countless as leaves that fall in the forest,
loosened by autumn’s first frost, as birds roiled up in a flock
when the season is cold, routed by turbulent skies,
fleeing the sea for lands that are warmed by the sun.
They stand there begging to be first to cross,
they stretch their hands for love of the opposite side.
-Virgil, Aeneid VI.305-314. The dead seek to cross the river Acheron.

DIVINE COMEDY, INFERNO
(106) And demon Charon with eyes like burning coals
(107) Herds them in, and with a whistling oar
(108) Flails on the stragglers to his wake of souls.

(109) As leaves in autumn loosen and stream down
(110) Until the branch stands bare above its tatters
(111) Spread on the rustling ground, so one by one

(112) The evil seed of Adam in its Fall
(113) Cast themselves, as his signal, from the shore
(114) And streamed away like birds who hear their call.

(115) So they are gone over that shadowy water,
(116) And always before they reach the other shore
(117) A new noise stirs on this, and new throngs gather.
III.106-117


PARADISE LOST
He walkt with to support uneasie steps [ 295 ]?
Over the burning Marle, not like those steps?
On Heavens Azure, and the torrid Clime?
Smote on him sore besides, vaulted with Fire;?
Nathless he so endur'd, till on the Beach
?Of that inflamed Sea, he stood and call'd [ 300 ]?
His Legions, Angel Forms, who lay intrans't?
Thick as Autumnal Leaves that strow the Brooks
?In Vallombrosa, where th' Etrurian shades?
High overarch't imbowr; or scatterd sedge
?Afloat, when with fierce Winds Orion arm'd [ 305 ]?
Hath vext the Red-Sea Coast, whose waves orethrew
?Busiris and his Memphian Chivalry,
?While with perfidious hatred they pursu'd?
The Sojourners of Goshen, who beheld
?From the safe shore thir floating Carkases [ 310 ]?
And broken Chariot Wheels, so thick bestrown?
Abject and lost lay these, covering the Flood,?
Under amazement of thir hideous change.
I.295-313

LEAVES OF GRASS

Look at relevant poems in Leaves of Grass (“leaves” are used repeatedly??"look at examples below. Not all of the uses may be relevant), and/or focus on the use of the metaphor in “Song of Myself,” where the word is used seven times.

Swiftly arose and spread around me the peace and knowledge that pass ?all the argument of the earth, ?
And I know that the hand of God is the promise of my own, ?
And I know that the spirit of God is the brother of my own, ?
And that all the men ever born are also my brothers, and the women ?my sisters and lovers, ?
And that a kelson of the creation is love, ?
And limitless are leaves stiff or drooping in the fields, ?
And brown ants in the little wells beneath them,
?And mossy scabs of the worm fence, heap'd stones, elder, mullein and ?poke-weed.
“Song of Myself”

others (some may not be relevant to the analogy of men as leaves)
“Here the Frailest Leaves of Me”
“Scented Herbage of My Breast”
“As Toilsome I Wander’d Virginia’s Wood”
“A Song for Occupations” ** (good to explain WW’s theory- see below)

"A Song for Occupations" in later editions, he explains:
We consider the bibles and religions divine . . . .
I do not say they are not divine,
I say they have all grown out of you and may
grow out of you still,
It is not they who give life . . . . it is you who
give the life;
Leaves are not more shed from the trees or
trees from the earth than they are shed
out of you.
Whitman believed that both the human body and consciousness bore the inimitable impress of the Almighty. (http://www.whitmanarchive.org/about/articles/anc.00007.html)

Sites:

“Song of Myself” (Text)
http://www.princeton.edu/~batke/logr/log_026.html

Leaves of Grass, sources:
http://www.sparknotes.com/poetry/whitman/section2.rhtml
http://www.whitmanarchive.org/about/articles/anc.00007.html

Essay Instructions: Read the article on grief and mourning in schizophrenia.
2)Write a 1,200-1,500-word essay in which you propose a safety plan to address potential depression and suicidality in clients who have just been diagnosed with schizophrenia. Include in your discussion a commentary on the necessity of addressing grief and loss during the treatment process.
3) Use APA format, including an introduction, a conclusion, and a title page. Cite in-text and include a reference page as necessary.
ARTICLE
Psychiatry 70(2) Summer 2007 154
Grief and Mourning in Schizophrenia
Daniela Wittmann and Matcheri Keshavan
Depression and suicidality after first episode of psychosis are well-documented responses
in patients with schizophrenia (Addington, Williams, Young, & Addington,
2004). The understanding of depression and suicidality has been increasingly
refined through careful study. Researchers have identified a number of factors that
may cause depression such as insight into the illness, feelings of loss and inferiority
about the illness as a damaging life event, hopelessness about having a viable future
with the illness and mourning for losses engendered by the illness. The authors argue
that grief and mourning are not just an occasional reaction to the diagnosis of
schizophrenia, but are a necessary part of coming to terms with having the illness.
They offer three case examples, each of which illuminates a distinct in which
psychosis and mourning may be related?psychosis as a loss of former identity,
psychosis as offering meaning and transformation, and psychosis as a of coping
with the inability to mourn. In their view, recovery depends on mourning illness-
related losses, developing personal meaning for the illness, and moving
forward with "usable insight" and new identity (Lewis, 2004) that reflects a new
understanding of one's strengths and limitations with the illness.
DEPRESSION AND SUICIDALITY
IN SCHIZOPHRENIA
Depression and suicidality are
well-documented responses in patients with
schizophrenia (Addington, Williams, Young,
& Addington, 2004). Following a psychotic
episode, patients are considered at risk for
both and are carefully followed by their treatment
providers. While depression was initially
viewed as a component of the psychotic
state, the understanding of depression and
suicidality has been increasingly refined
through careful study.
The research on suicidality in schizophrenia
has demonstrated that only a small
percentage of patients kill themselves in response
to command hallucinations
(Grunebaum et al., 2001; Harkavy-Friedman
et al., 1999; Heila et al., 1997; Power, 2004)
and that depression that follows a psychotic
episode may be related to other factors.
Kimhy and colleagues suggests that the first
few weeks after hospitalization, patients are
at risk because of stresses such as uncertainty
about future hospitalization, employment
concerns, loneliness and relationship problems
(Kimhy, Harkavy-Friedman, & Nelson,
2004). Insight and a coping style that tend towards
integration of the illness rather than
sealing over and disregarding it are critical to
adjustment to illness (Tait, Birchwood, &
Daniela Wittmann, LMS W, is Assistant Professor at Wayne State University Department of Psychiatry
and Behavioral Neurosciences.Mafc/ien Keshavan, MD, is Professor at Wayne State University Department
of Psychiatry and Behavioral Neurosciences.
Special thanks to Rocco Marciano, MSEd, for providing clinical material for this paper.
The work of the authors was supported by the Michigan Department of Community Health and the
Joseph F. Young, Sr., Psychiatric Research and Training Program.
Address correspondence to Daniela Wittmann at University Psychiatric Center, 2751 E. Jefferson,
Detroit, MI 48207; E-mail ne.edu.
Wittmann and Keshavan 155
Trower, 2004). They are also associated with
a greater likelihood of depression, suggesting
that patients are driven to unhappiness, perhaps
despair, by recognizing the effect that the
illness will have on their lives (McGlashan,
1987). When the depression does not lead to
suicide, it may lead to social withdrawal and
disengagement from services (Tait,
Birchwood, & Trower, 2003). Of significance
may be a little explored finding by Kim and
colleagues who studied factors that contribute
to the suicidal behavior in patients with
schizophrenia. Their major finding was that
the hopelessness was by far the greatest contributor
to suicidality, with substance abuse,
insight into illness, and higher cognitive function
following suit. In analyzing their data on
333 patients, they also found, interestingly,
that while patients with high scores on lifetime
suicidality had insight into their illness of
schizophrenia, they did not have insight into
being depressed (Kim, Jayathilake, &
Meltzer, 2003)
THE EXPERIENCE OE LOSS IN
SCHIZOPHRENIA
As the field of study moved from a description
of symptoms and cognitive styles to
investigations of patients' internal experiences,
the meaning of depression emerged as
an important factor. Building on earlier work
by Mayer-Gross (1920) and McGlashan &
Carpenter (1976), Birchwood and his collaborators
were able to develop the concept of
"post psychosis depression" in which an episode
of psychosis is responded to as a "life
event" rather than simply experienced as an
illness (Birchwood et al., 2005). Patients in
Birchwood's study were acutely aware of the
losses experienced as a result of their illness.
More specifically, they saw themselves as having
been rendered socially inferior by the illness.
These patients were not necessarily more
insightful than those who did not develop post
psychotic depression. They were, however,
likely to be more pessimistic than those who
did not develop it. This finding corroborates
Kim and colleagues' notion that hopelessness
is the key factor that predicts whether a
person with schizophrenia will be at risk for
suicide.
In her extensive and comprehensive review
of the literature on depression and suicide
in schizophrenia, Lewis (2004) speaks to
the fact that some schizophrenic patients must
mourn losses engendered by the illness. She
coins the phrase "usable insight," insight
based on an accurate perception of what has
been lost which then determines how one
might go on into the future with a realistic appraisal
of one's situation; according to her,
patients have to accept what was lost (job, education,
social relationships). They must also
give up their psychotic symptoms which may
have been a of coping during the illness
(Lewis, 2004).
The experience of the symptoms and diagnosis
of a chronic mental illness is a serious
crisis. Any chronic illness brings with it limitations
and losses, but schizophrenia is potentially
more damaging because it affects the
psyche itself. Positive symptoms bring about
the loss of usual cognitive functioning and a
capacity to orient oneself to both external and
internal reality. Negative symptoms influence
one's capacity to remain affectively and energetically
engaged with the social and occupational
world. When such altered capacity to
perceive and engage is experienced as a result
of war, torture, or abuse, we call it trauma. In
schizophrenia, the loss of functioning is a
traumatic loss. McGorry and colleagues, who
interviewed 36 patients (who had experienced
acute psychosis in the past 2-3 years) after discharge
from hospital, found that at 4 months,
46% had symptoms of post-traumatic stress
disorder. At 11 months post discharge, 36%
could still be classified to be suffering from
post-traumatic stress disorder according to
DSM-III criteria (McGorry et al., 1991).
Morrison Frame, and Larkin (2003), in their
review and analysis of research on the relationship
between trauma and psychosis, conclude
that "since the findings of high rates of
post-traumatic stress disorder in response to
psychosis have been replicated in many studies
with differing methodologies, it is reasonable
to conclude that some people do develop
156 Grief and Mourning in Schizophrenia
post-traumatic stress disorder as a response
to psychotic experiences" (Morrison et al.,
2003).
We may think of the loss of cognitive
and emotional functioning in schizophrenia
as the primary loss brought ahout hy the illness.
The losses of independent functioning,
such as educational, vocational and social
competencies, and loss of place in a social milieu
can be described as secondary losses. With
both primary and secondary losses can come
the loss of faith in self, others, and in a viable
future. Birchwood's description of a sense of
inferiority or loss of self-esteem is relevant
here.
When Lewis speaks of the need to give
up the symptoms of psychosis, she is speaking
to yet another loss. For some people, the development
of psychosis may be an unconscious
method, a strategy, with which to face
unbearable loss. In their book The Cognitive
Psychotherapy of Schizophrenia, Kingdon
and Turkington propose trauma as one of the
four predispositions that can lead to psychosis
(Kingdon & Turkington, 2005). Morrison
and colleagues (2003) go so far as to suggest
that post-traumatic stress disorder and psychosis
may lie on a spectrum of responses to
trauma. Allen, and Console (1997) in their
study of 266 women who were hospitalized
for a number of conditions related to trauma,
found a relationship between dissociation and
psychosis. While cautioning against
misdiagnosing psychotic decompensation in
traumatized individuals as a primary psychotic
disorder, they hypothesized that individuals
who use dissociation as a of coping
are sufficiently out of touch with internal
and external reality to be susceptible to psychosis
(Allen et al., 1997). Read, Mosher, and
Bentall (2004) reviewed studies that examined
the relationship between childhood
trauma, loss and stress, and psychosis (Read
et al., 2004). In most of the studies, they found
a strong relationship between early physical
and sexual abuse and hallucinations and delusions,
while no relationship or a weak relationship
was found between trauma and negative
symptoms and thought disorder. A yet
stronger relationship between trauma and
hallucinations and delusions was found when
a person who had been abused as a child was
re-traumatized as an adult. They suggest, similarly
to the above authors, that in some cases,
psychosis may be a of integrating trauma.
If psychosis is a method of coping with trauma
or a defense against loss, it must be given up so
that ordinary grief and mourning can
proceed.
The issue of psychosis as a defense
against loss touches on a debate about the
cause of the development of schizophrenia
since it was first described by Kraepelin and
Bleuler (Bleuler, 1911; Kraepelin, 1913). Current
views are based in research and present a
rich picture that spans the gamut of non-biological
to biological causes of schizophrenia.
Read and colleagues, in their review of the history
of schizophrenia in a scientific and
sociopolitical context, question the methodology
in genetic and biological research and
point to the influence of social engineering
that affected the theory and treatment of people
with severe mental illness in the early
twentieth century. They suggest that these
flawed approaches are still present in the
bio-psycho-social model of schizophrenia.
They propose that societal as well as familial
dysfunction, abuse, and trauma may be by far
the most important precursors of a psychotic
disorder (Read et al., 2004). The influence of
the environment is also examined by other authors.
Spauwen and colleagues studied 2524
adolescents between ages 14 and 24 through
self-reports of trauma and psychosis proneness.
They found that approximately 42
months later, a larger proportion of adolescents
who were severely traumatized and were
prone towards psychosis (had schizotypal features)
were more likely to develop psychotic
symptoms (Spauwen et al., 2006). Cannon
and Clarke reviewed the hterature that looked
at the perinatal environment, developmental
issues, and genetic and societal influences.
They concluded that these issues have to be
taken into account when defining vulnerability
for schizophrenia and that early intervention
aimed at prevention is indicated (Cannon
& Clarke, 2005). The precise interplay of the
paths to psychosis is far from being fully
Wittmann and Keshavan 157
understood. It is necessary to consider biological,
psychological, social, and cultural factors
in order to do full justice to understanding
schizophrenia and psychosis. This paper can
only touch on these issues, but appreciation of
all aspects of this complex disorder underlies
our thinking about loss, grief, and mourning
in schizophrenia.
In the following discussion, the authors
will propose that developing the capacity to
grieve and mourn losses related to the illness is
not just a by-product of the adjustment to the
illness for some patients; it is a necessary process
aimed at psychological integration of the
illness for all patients diagnosed with schizophrenia.
It is a process that is complex and can
take many forms.
GRIEF AND MOURNING
IN SCHIZOPHRENIA
Grief is a necessary response to loss and
is defined as "the process of experiencing the
psychological, behavioral, social and physical
reactions to the perception of loss" (Rando,
1993, p. 24). Mourning is "the cultural or
public display of grief through one's behaviors."
To paraphrase, it is a conscious and unconscious
process which serves to untie attachment
to the past, to adapt to the loss and
develop a new identity without what is lost
(Rando, 1994, p. 23). There is a need for the
person experiencing the loss to suspend defensive
responses long enough to experience the
powerlessness that comes from not being able
to restore the past.
After an episode of psychosis, a person
needs to find meaning for what happened so
as to integrate it into a sense of self that has
been irrevocably changed. Larsen, in his paper
on the meaning in first episode psychosis, uses
an anthropological prism through which to
describe this process (Larsen, 2004). According
to him, people who experience psychosis
use "a cultural repertoire," at least initially, to
label what has happened to them. They may
shift between various explanatory models sequentially
or in a complementary fashion,
such as the medical model, the stress-vulnerability
model, the stigma model, or the spiritual
model, to make the experience of psychosis
meaningful and acceptable. He suggests that
while using already existing models, persons
with psychosis take an active role in constructing
the integration of their experience.
He borrows the term "bricolage" (used by anthropologist
Levi-Straus in his book The Savage
Mind which deals with societal development)
as a term that best describes the accrual
of ever-developing explanations for reworking
a new identity. Bricolage, which means a
"do-it-yourself" job in French (Collins Gem,
2000) is described by Levi-Straus as an "attribute
of human creativity in life and a proof
of individual analytic and theory- generating
capabilities (Levi-Straus, 1966, p. 462). This
approach assumes an agency on the part of the
person with psychosis and echoes descriptions
offered by people who have described this experience
from within. As Patricia Deegan,
Program Director of the Northeast Independent
Living Program and a person in recovery
from schizophrenia, suggests: "We are fully
human subjects who can act and in acting,
change our situation" (Deegan, 1997).
In the grief and mourning literature, a
sense of agency is similarly assumed. In his
generally accepted theory, Worden, in his
study of children's grief, proposes four tasks
rather than stages of grief and mourning to accentuate
the dynamic nature of the mourner's
work (Worden, 1996). The tasks are: 1) To
accept the reality of the loss, 2) to experience
the pain or emotional aspects of the loss, 3) to
adjust to an environment in which the deceased
is missing, and 4) to relocate the dead
person within one's life and find s to memorialize
the person. Although the person recovering
from psychosis is not grieving the
loss of another person, he/she is grieving the
loss of the person he/she used to be and in that
sense must complete these tasks in order to
cope with the loss of the past self and achieve a
new identity.
It must be noted that a person with a
chronic illness may experience temporary
re-?mergence of intense grief and mourning at
significant milestones or anniversaries and
that such "short upsurges of grief" (STUGs)
158 Grief and Mourning in Schizophrenia
can be expected (Rando, 1993, p.64). Johnson
and Rosenblatt describe this as
"maturationai grief" in order to distinguish it
from complicated mourning (Johnson &
Rosenblatt, 1981).
COMPLICATED MOURNING
IN SCHIZOPHRENIA
"Comphcated mourning means that,
given the amount of time since the [loss], there
is some compromise, distortion or failure of..
. processes of mourning" (Rando, 1993, p.
149). Complicated mourning can develop in
individuals newly diagnosed with severe mental
illness who have insight into their illness,
but have been unable to cope with the losses
and changed identity inherent in the acquisition
of the illness. It becomes chronic, and
Bowlby describes this as a state in which "the
individual becomes and remains sadly disorganized"
(Bowlby, p.lO9, in Rando, 1993).
There is an extensive literature on complicated
mourning, but complicated mourning in
schizophrenia is an uncharted sea that
beckons exploration.
First, we must distinguish between
complicated mourning and depression since it
is depression that is typically described as a reaction
to psychosis. Efforts have been made to
elucidate the distinction. Horowitz and colleagues
developed criteria for complicated
grief disorder which relate primarily to the
loss of a person, but could be adapted to the
experience of complicated grief due to losses
engendered by psychosis (Horowitz et al.,
1997). Ogrodniczuk and colleagues, in a
study of bereaved individuals, were able to
isolate three dimensions of complicated grief:
1) grief (intrusive thoughts, feelings about the
lost person, searching for the lost person), 2)
grief experience (persistent emotional distress
related to death/loss, propensity to ruminate
about the lost person, painful feelings associated
with the death), and 3) grief avoidance
(active avoidance of thoughts and feelings associated
with the lost person) (Ogrodniczuk et
al., 2003). Coming to terms with psychotic illness
involves many of the above-mentioned
experiences: intrusive thoughts, search for
past identity, persistent emotional distress related
to the the illness affected the person's
life, possible avoidance of any thoughts
or feelings about it, or using psychosis as a defense
against loss. It would not be a stretch to
consider examining and adapting
Ogrodniczuk's concepts to an emotional
response to the experience of psychosis.
CASE STUDIES
We herein describe three patients, each
of whom illustrates the key issues pertaining
to the relationship between mourning and
psychosis. All patients have verbally consented
to parts of their story being incorporated
in this manuscript. We have avoided
providing, and modified where necessary, any
aspects of their history that might identify
them.
1. Grief and Mourning of
a Former Self
Latoya is a 26-year-old African American
woman who was a third-year college student
at the time of her first episode of psychosis.
Social withdrawal and increasingly poor
hygiene as well as increasing paranoia for
nearly 4 years led her family to seek psychiatric
care for Latoya. Latoya believed that there
was a family secret and that her parents were
planning to kill her. She was finally hospitalized
after she physically attacked her father.
Latoya cooperated with medical treatment
(Olanzapine, later Aripiprazol and finally
Risperidone Consta), but was reluctant
to engage in psychotherapy: "I didn't trust my
doctor and my therapist." Her attendance in
groups was also half hearted. She participated,
but with little enthusiasm. By her own
admission, she was having difficulty accepting
that she had a mental illness.
Although she tried to return to academic
and work projects, Latoya was not successful
initially because her field is fairly rare.
She was not interested in other activities. Her
motivation flagged. Her activities centered on
Wittmann and Keshavan 159
her home where she lived with her parents.
She was not socially involved. After a year of
enrolment in a treatment program, Latoya
was asked to participate in a research study
that involved the description of losses engendered
by the experience of psychosis. Latoya
was eager to speak about what had happened
to her and how she felt about it.
Latoya was aware that she had experienced
a number of losses. She named "time,
school, job, friends, apartment" as the concrete
things that she no longer had in her life.
But the loss that meant the most to her was the
loss of confidence, the loss of personal identity:
"I am more nervous and shy now, I didn't
used to be like that." Latoya said that she had
experienced fears that her parents would have
to take care of her for the rest of her life and
that she had felt depressed to see that everything
that she wanted to do in her life had to
take a back seat to her illness.
When asked, Latoya was able identify
periods of depression since diagnosis. She was
relieved to hear that some of those feelings
might be grief and that grief is a normal part of
adjustment to a chronic illness. She thought
that she had not grieved her losses. She had
not cried and she had not felt angry. Instead,
she said, "I overthink". She was curious about
grief and had many questions about the process
and when and how she might see some
changes in herself.
During the following six months,
Latoya continued to work with her therapist
on recovery. She gradually came to accept that
she had a mental illness which she had to manage
while she tried to return to building a life
for herself. She has steadily increased her activities,
but has done so in a carefully calibrated
manner. She has moved into the social
arena very slowly, too. She is aware that her
friends have moved on in their lives at a faster
pace. Her social experiment now involves
co-workers. Friendly banter is comfortable
for her now, but she is not ready for more.
While her parents support her and she appreciates
it, she does not confide. Her therapist
appears to be a valuable sounding board, but
Latoya remains reserved. She can share humor
and discuss concerns, but not vulnerable
feelings. This may be due to pre-illness personality
development or to a wish not to be
overwhelmed with unbearable feelings. As
she is no longer denying her illness and is
moving forward, this seems to be a reasonable
pace for Latoya.
Analysis. Latoya's reaction is an example
of Birchwood's post-psychosis depression.
Psychosis was a life event which altered her irretrievably.
She has identified her losses and
her feehngs about them and she has used individual
psychotherapy and the research project
to attempt to integrate them. Early on, she
was able to name several secondary losses and
fearfulness about the future. As is typical in
grief, she ruminated about how she got ill,
what happened to her and how she could get
her life back. The slow and deliberate rate at
which she is now recovering may in part reflect
a desire not to jeopardize her progress. In
order to reconstruct her life more fully, she
may need to allow herself to feel the feelings of
grief and come to terms with her new identity
more deeply as a woman with a serious mental
illness. Then she can build the future with
greater confidence, and pursue goals that are
relevant and attainable.
2. Transformation of Identity
through Psychosis
Jeffrey is a 28-year-old Caucasian single
man. He was 23 at the time of his first episode
of psychosis. According to him, he had
suffered mild depression and lack of focus for
many years, but his condition escalated over
several months into an acute episode of psychosis,
depression, and suicidality. He describes
himself as having lost a sense of meaning
and purpose in life and could not find his
place in the world which he saw as competitive,
individualistic, materialistic, and violent.
He was hospitalized for several weeks. Jeffrey
describes his symptoms during his hospitahzation
as "hallucinations, paranoid delusions
and illusions, being catatonic and obsessed
with trivial aspects of my physical features."
He thought he had gone to hell because he had
caused world destruction. When family mem160
Grief and Mourning in Schizophrenia
bers called or visited, he was rendered mute by
the disbelief that they had survived. When his
sister caringly tried to suggest that he might be
going through a formative experience and
could see this as a blessing, he saw this as being
mocked by God through her.
Initially, Jeffrey saw himself as not ill at
all, but as receiving messages from God
through the Internet and the walls of the hospital,
telling him that he was being punished.
He felt responsible for his own misdeeds and
for the suffering of others. His discussions
with his psychiatrist who gently challenged his
thinking led to his recognition that he was experiencing
hallucinations and delusions that
were related to a biological illness, but that the
content of his delusions and hallucinations
might be an avenue to a deeper understanding
of his own spiritual beliefs. In a sense, he could
use the insight into his nature brought about
by the psychosis to pursue his search for
meaning as he was recovering from the illness.
Jeffrey was not resistant to this thinking. Having
had caring and supportive family relationships
predisposed him to an ability to develop
a solid therapeutic alliance with his doctor. He
reasoned that through psychosis, God had
given him a sense of direction to be helpful to
others and to be good.
After hospitalization, with unwavering
family support, Jeffrey resumed his work and
academic life, and gradually increased his social
activities. He experienced the usual anxiety
about re-entry?was he different or the
same, how would he be accepted? He was welcomed
positively, and this boosted his
self-confidence. Following up on a
long-standing interest, he turned to reading
spiritual literature, to prayer, and to music in
order to ease his residual anxiety and apprehension
about the future. In these activities, he
found solace. He was treated initially with
Risperidone which was eventually phased
out. He is maintained on a small dose of
Fluoxetine.
Jeffrey wrote a paper about his experience
of psychosis and its outcome. He described
his prayer life as having changed from
one of "requesting, pleading or bargaining for
favors or personal satisfaction to one of praying
for the well-being and blessings of others,
praying that I might improve as a person in
kindness, love, unselfishness and generosity."
He used his experience with depression as a
lesson that negative thoughts, words, and feelings
were not worthwhile, but promoted the
very experiences they were supposed to help
with. As a result of having mental illness,
Jeffrey found himself feeling "a much stronger
sense of empathy and compassion... for those
who are experiencing pain and suffering . . .
and a desire to alleviate it." Having been ill
taught Jeffrey that he and others were vulnerable
and interdependent which gave him a
sense of community with fellow human beings.
At the same time, unlike before, he felt a
clear sense of responsibility for himself as a being
"created in the image and hkeness of God"
with "the gift of free will." Jeffrey felt that he
had found the "best known psychological
remedy for worry, stress and anxiety," in
entrusting himself to God and Jesus's
teachings.
Today, he may superficially look the
same. But inside, Jeffrey is transformed. With
clear insight into the illness and without denying
the need for treatment, he has developed a
new meaning for his experience. As he described
it, "the true miracle isn't that our own
or others' suffering, physical or psychological,
has been completely eliminated, but rather
that we change (with God's help) the real root
of the suffering and pain: how we view it, how
we respond to it. It can become . . . the 'mystery'
and 'challenge' of suffering rather than
merely the 'problem' of suffering. We can
come to realize that it has been a 'blessing in
disguise.'" Jeffrey looks on his experience
with psychosis as an opportunity to find his
spirituality, his true nature, his compassion
for others, and an inner peace: he sees himself
as having benefited from it in the long run.
It appears to have been so for Jeffrey.
According to him, he was mildly depressed
and unfocused prior to his psychosis. Now, he
sees himself as able to think as more positively,
more compassionate about others' suffering,
more able to accept help, and as able to
assume personal responsibility for himself. He
is in graduate school, working, and active in
Wittmann and Keshavan 161
the community as a volunteer. He was able to
care for his dying father and has come to terms
with his death without exacerbation of
symptoms.
Analysis. Jeffrey appears to have engaged
with his illness by seeking a spiritual answer
to his suffering. As Larsen (2004)
indicates, people struck with psychosis search
for an explanatory model which would enable
them to integrate the illness into their identity.
Jeffrey's recovery appears to have been very
quick and rather successful. It appears that the
major loss he experienced was the frightening
intrusion of the psychosis with its attendant
distortion of cognitive and emotional functioning.
However, the loss of functioning was
quickly reversed by medication and
psychosocial treatment. He was able to read
and think. He began to practice his own version
of cognitive therapy?engaging in positive
thinking with which to face life
experience. Recovery from psychosis gave
him an opportunity to seek long-desired spiritual
guidance. In the Judeo-Christian tradition,
suffering is often seen as a test of faith. In
the Eastern traditions, worldly suffering is a
lesson in compassion and selflessness. Jeffrey
adopted the teachings of both traditions and
actively transformed the meaning of his illness
from loss into a gift. In that sense, he is not
grieving. He is transcending the illness
experience and incorporating it into his
identity as God's plan to make him a better
person.
3. Psychosis as a Defense against Loss
Brent is a 29 year old single white man.
He is college educated and until 2 years ago
worked as an administrator in a technical
field. He came to the outpatient treatment
program after 6 years of uncertain diagnosis
and unsuccessful treatment with mood stabilizers
and antipsychotic agents. Brent had suffered
from paranoid delusions, mood swings
and overpowering ideas of reference which led
to obsessive/compulsive activity. He had also
made 2 major suicide attempts as a result of
feeling utterly worthless. Immediately prior to
her arrival in the program, he was placed on
Aripiprazol. He gained crystal clear insight
and wished to engage in treatment that would
lead to his recovery. His primary motive was
the care of his young daughter whose custody
he wished to retain and whose well being he
had guarded surprisingly well even while quite
psychotic.
Brent had returned to his city of origin
in order to be cared for and supported by his
mother while he was recovering from his illness.
His father who had a volatile temper had
died during his adolescence and his mother, a
woman who appeared to have a severe personality
disorder was remarried. It became
immediately obvious that the relationship
with his mother had been very disturbed since
childhood, including ongoing criticism, demeaning
attitude and sexual abuse. At the
time of admission. Brent's mother was allegedly
denying his illness, refused to become educated
about it and maintained a highly controlling
and critical stance with him. When
Brent asserted himself in the slightest manner,
his mother severed contact. She also controlled
all of Brent's relationships with the extended
family. Brent internalized some of the
criticisms, particularly vis-a-vis his weight and
overly high expectations about achievement.
When the Brent was ill, he was highly
dependent on his mother, not trusting his own
judgment in anything.
Within 3 months of clear insight. Brent
began to use more independent judgment in
all areas of his life. This included his relationship
with his mother and incurred his
mother's wrath and criticism. Eventually,
Brent decided that maintaining a relationship
with his mother would be too destructive to
himself and his daughter. He decreased contact
which led to his mother abandoning
contact altogether.
Brent became tearful and depressed in
response to these events. He felt alone and
frightened, uncertain of his ability to go on.
He recalled the many years of psychotic functioning
which robbed him of his career and his
confidence to support himself and his daughter.
He became unreasonably fearful of his
ex-wife's power to control time with their
162 Grief and Mourning in Schizophrenia
child (he had full custody), felt much
self-doubt in general and began obsessing
about his weight. He was sleeping excessively,
had difficulty getting out of bed and only
tended to his daughter's needs. He became
frightened of his depression and began losing
hope.
When his therapist interpreted his reactions
as grief, described the typical symptoms
and suggested that the Brent's feelings v^^ere
normal and justified, Brent appeared greatly
relieved. Since he tended to absorb rather
than repel hostility and then internalized it as
self-criticism, the therapist encouraged him to
nurture his feelings of anger and outrage at his
mother's behavior and named for him the fact
that he had experienced the loss of nurturing
by a parent a long time ago. The permission to
experience anger led to some guilt, but mostly
empowered Brent to feel some entitlement to
his own feelings and point of view. His emotional
reaction suddenly had a purpose instead
of signifying that he was getting ill
again. He experienced much sadness about
having missed many formative years due to
his illness per se and due to the in which
the illness made him dependent on his mother
who had been controlling and destructive. He
began to look at himself with more compassion
and began to attach to his therapist as the
source of his reality testing which he knew was
impaired within himself. With this new reliance
came also significant transference, the
content of which was projected self-criticism,
dependency and sexual attraction to the therapist.
Since Brent understood the transference
relationship (from previous treatment), he
was able to work with transference
interpretations by the therapist.
As Brent gained increasing sense of
himself as separate from his mother, he began
to think hopefully about his future. He applied
and was accepted to a graduate program.
He was taking a risk not only academically,
but also emotionally because the
program was structured in such a as to be
stressful during time limited periods. As his
anticipatory anxiety grew, he was asked to review
his past behavior when he coped with
work-related stress by stopping his medication
and relying on delusions of grandeur and
self-referential interpretations of the environment
rather than on working through his feelings.
He acknowledged the temptation and
re-committed himself to taking his medication
as prescribed and to coping with the challenges
of school with the help of his ordinary,
non-psychotic personality. He exercised regularly,
ate more simply and considered giving
up smoking and caffeine. Self-regulation and
self-care were in fact the condition under
which his therapist agreed to support his plan
to attend school. He used this success to continue
his griefwork - as a testimony to the fact
that he had value even when disowned by his
mother. He would say vengefuUy: "I want my
mother to see me when I graduate without her
assistance!". He would feel guilty about this
feeling, but was easily reassured when told
that his feelings were just feelings and did not
hurt anyone.
Two months after his acceptance to
graduate school. Brent's hairstylist who was
also his mother's hair stylist cut his hair so
short so as to make it impossible for Brent to
make his hair stylish. For Brent, who was continuing
to struggle with his weight, his thick
and fashionably styled auburn hair was a narcissistic
refuge from his more typical
self-loathing. He interpreted his ugly haircut
as an attack by his mother by proxy and had
difficulty dislodging this belief. Given this latest
blow, he was unable to cope by using his
own defenses and psychotherapeutic interventions.
He became increasingly depressed
and immobilized. He was placed on an antidepressant
(Sertraline) which gradually returned
him to his ability to function and continue his
griefwork. At the time of writing, he was reviewing
his dating history and the chances he
missed for good relationships because he was
ill, had no self-esteem and could not use good
judgment in choosing his partners.
Brent continues to move forward in his
life. He is engaged to a woman who has been a
long term family friend and who provides an
alternative and positive primary relationship.
He is working through anxiety about his academic
work and can navigate through his program
successfully. He has advocated on beWittmann
and Keshavan 163
half of his daughter and has been able to secure
a private parochial school scholarship for
her. He continues to attend all aspects of the
outpatient program in order to maintain its
therapeutic effects and he is openly facing
challenges in his environment and within himself.
The loss of his mother is a recurrent
theme in his work. He is aware that he is 'rising
from the ashes' and that he has significant
strengths and talents. He is also aware that he
has vulnerabilities that are related both to his
illness and to his traumatic upbringing. He
has, at times, recognized that when stressed,
he is tempted to return to his delusional and
grandiose symptoms as a to provide himself
with energy and relief from the responsibility
he feels as a normally thinking and feeling
adult. He is seeing that paradoxically,
giving up his symptoms is also a loss: he is giving
up magicai thinking. It is his ability to use
his own personality, values, and his ordinary
emotional responses in the face of existential
loneliness that makes him be the autonomous,
integrated adult that inspires his self-respect.
Analysis, li we look at Brent in the context
of the vulnerability-stress model, the history
of mental disorder in his parents and the
early abuse by his mother may have predisposed
him towards a psychiatric illness. As
mentioned above, there is a body of research
which gives evidence to the possibility that
early abuse, particularly sexual abuse may
lead to psychosis (Read, et al. 1997, Read et
al., 2004, Ross et al., 1994). The stress of adolescence
and young adulthood may have
pushed Brent further towards psychosis. In
the early phases of his adult life, psychosis was
a to have energy and push through challenges
and difficult feelings. With insight, this
patient struggles with the years lost by unsuccessful
search for effective treatment and dependence
on a destructive mother. He is
painfully aware that having the illness postponed
his achievement of adult maturity and
he can ruefully admit that at this point, it is
also a loss to give up the wish to use symptoms
as a misguided strategy towards mastery.
The core of this case is the patient's capacity
to identify and work through the many
losses which may have led to his illness and
complicated his development. Having given
up psychosis as a method of deahng with
them, he is using more mature defenses to
cope. He is continually constructing new
meanings and goals for himself based on his
history, hmitations due to the illness and incomplete
personality development, and newly
acquired capacities. Like a bricoleur, he is
working with what he has, forging a non-traditional
path for himself with elan and creativity.
As he struggles to reach each new level
of functioning, he faces painful memories and
limitations with grief and mourning
(maturational grief).
DISCUSSION
We know that regardless of how much
or little insight they have, patients with schizophrenia
are quite able to recognize that their
lives have changed as a result of the illness. Insight
and style of coping are not static and
evolve over time. We can observe clinically
that those patients who can grieve and mourn
their illness with some success are able to
move forward in their lives more successfully.
The work of grief and mourning has a purpose
and purposeful activity is hopeful and
affirming.
Our clinical examples demonstrate that
grief and mourning in schizophrenia can take
a variety of forms. We present three: 1. some
patients mourn the illness as an event that interrupted
and 'stole' the lives they had envisioned
for themselves (Latoya); 2. others, in
the process of mourning the intrusion of the
illness into their lives search for meaning and
may ultimately find the experience
transformational and positive (Jeffrey); 3. for
others still, the illness itself has been a of
coping with losses - as they move to mourn
those losses without the help of psychosis,
they also mourn the loss of those symptoms
that had served them as a defense against loss
(Brent).
Much research is necessary before anything
definitive can be said about the role of
complicated mourning in psychosis. We are
164 Grief and Mourning in Schizophrenia
hearing from some of our patients that they
are distressed by the in which psychosis
changed their lives. Others are stoic, seemingly
unreflective and opaque in their emotional
response. To complicate the picture, we
are also trying to understand how
neurocognitive changes in schizophrenia affect
insight and the capacity to experience
emotions. Barch, in her review of research on
the relationship between cognition, motivation,
and emotion in schizophrenia, suggests
that cognitive deficits, particularly impaired
working memory, may make it difficult for
patients with schizophrenia to retain the image
of the goal for which to remain motivated
(Barch, 2005). She also proposes that a disturbance
in the dopamine system evidenced by
patients with schizophrenia may be implicated
in anhedonia and thus interfere with
motivation. Motivation to cope with loss and
to move into the future is an important aspect
of mourning. Kapur, in attempting to link biological
changes in the brain to positive symptoms
in schizophrenia, identifies the dysfunction
in the dopamine system as a factor that
may influence patients' focus on inappropriate
stimuli, thus creating unusual, aberrant salience
in thinking (Kapur, 2003). This, too, is
a potential interference with the patient's ability
to appraise and experience loss, grief, and
mourning. In advancing these theories, the
authors call for more research that would help
link the capacity for emotional and cognitive
functioning with cortical changes in
schizophrenia.
As clinicians, we do a good job in many
areas: we search for and provide correct medication,
teach social skills, and offer psycho-
education; we help our patients establish
links back into the community and expect that
they will build satisfying lives in spite of the illness.
But this may not be enough when we are
dealing with people whose sense of self has
been invaded by a serious mental illness and
whose past typical expectations of a future
have been blown to smithereens. In order to
intervene sensitively and accurately, we need
to continue to improve our understanding of
the in which people afflicted with psychosis
cope with the losses engendered by the illness.
We need to continue to study the
neuro-cognitive deficits in schizophrenia that
might interfere with the emotional processing
of grief and mourning. We need to examine
empirically the process of grief and mourning
in schizophrenia as a necessary aspect of
recovery.
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