In mid-2003, I was asked by the editors of an Italian psychiatric journal, NOOS: Aggiornamenti In Psichiatria, to write a paper on a Windhorse approach to early intervention for severe mental disorders. The editors had read the first edition of Edward Podvoll’s book then-titled The Seduction of Madness (1990) which in Italian was La Seduzione Della Passia. This request coincided with Dr. Podvoll’s final year with us in Boulder, CO before his death on December 7, 2003. Knowing something of the demanding time and energy that is required to write such a paper, I hesitated. Advice came to mind, “No one has time. We make time.” I decided to go ahead. This seemed a meaningful way for me to acknowledge my gratitude to Dr. Podvoll and the Windhorse community for all I had been given. The topic of early intervention is of critical importance and I hoped to make some small contribution to this worthy cause. I hoped to use this opportunity to give back to one of my ancestral homelands, Italy, where my father’s parents immigrated from in the early 1900’s. A fourth factor was that an intensive Windhorse team had just completed, providing me ample clinical experience to explore the topic of early intervention through a teaching story. At the time, I dedicated this paper to Dr. Podvoll as a parting gift to my heart-companion. With more hope, I encourage you to read this entire paper. Please consider how to intervene in the early life of a young person you may know before s/he enters an enduring realm of madness. Let’s make time.
Jeffrey Fortuna, MA
Co-Director, Windhorse Community Services
This paper is dedicated to my friend and mentor,
Edward M. Podvoll, MD: vibrant in life, vibrant in death.
The intent of this paper is to briefly summarize the Windhorse approach to understanding and treating psychosis; to focus on the development and intervention at the early stages of psychosis; and to present relevant clinical experience that shows the Windhorse approach to early psychosis in action.
I appreciate this opportunity to explore the topic of the early development of psychosis from a point of view that complements modern Western psychiatric theory and practice. This point of view has become known as “Windhorse”, and is practiced in several treatment centers internationally, which collectively are known as “The Windhorse Project”. The Windhorse Project, originally founded in 1981 in Boulder, Colorado, USA, developed to serve the needs of both mental health practitioners wanting a truly compassionate approach that includes their own experience in the recovery equation, and the needs of those persons wanting to recover from extreme states of fear and confusion. The work of writing this paper actually enhances my understanding of psychosis and my work with highly disturbed people. This very process of continual learning renews the enthusiasm of my and my colleagues clinical lives, energizing our paths of life-long learning. This topic of the development of the therapist, and the constant renewal of one’s compassion within the actual process of the clinial work, deserves an in-depth treatment beyond the scope of this article. However, this aspect of the Windhorse approach, which we call “reciprocal” or “mutual recovery”, is woven through this paper.
Over the past 22 years a substantial body of literature has developed to present Windhorse. There are primary clinical papers (Podvoll 1983, 1985; Fortuna 1987, 1995); a “Windhorse Guide for Families” (Packard 1992, a webtext at www.WindhorseAssociates.org); a first-person account (Stark, 2000); and books on psychosis that reference Windhorse (Aurthur, 2002; Neugeboren, 1999). The most comprehensive presentation of Windhorse is the classic text Recovering Sanity: A Compassionate Approach to Understanding and Treating Psychosis (Podvoll, 2003; previously published as The Seduction of Madness, 1990). Dr. Podvoll, the principal co-founder of the Windhorse Project, currently lives and works with Windhorse Community Services in Boulder, Colorado. There is also a reference literature on “contemplative psychotherapy” (Note 1), as developed at The Naropa University, which maps the theoretical background for Windhorse (e.g., Podvoll, 1985; Trungpa, 1983; Wegela 1996; Lief, 2001; Rockwell 2002). There are several excellent books on meditation and Buddhist psychology that provide further background on Windhorse (Mipham, 2003; Trungpa, 1984,1992).
II. The Windhorse Approach
Windhorse is a whole-person process-theory of psychosis, treatment, and recovery, which brings a unique perspective to the stages of psychosis we see and experience daily in our work. We provide home/community-based treatment for persons recovering from major mental disorders, conducted in the person’s natural setting. Adaptations of the original model to other fields of homecare, such as care for elder and dying persons, are rapidly developing. The clinical work is conducted by a team of people who practice “basic attendance” with the client and with each other, to foster a healing environment. Each client lives in his own individual household, rather than a group residence. (Note: for ease of expression in this article, the masculine form of the pronouns “his/him” will be used.) The pattern of each Windhorse program is tailored to the client’s unique needs, circumstances, and resources. A team can range from one staff (who is in close consultation with a senior staff member) working with a client several hours per week, up to a full “therapeutic household” with one or two live-in staff housemates, a team of staff doing basic attendance with the client, a psychotherapist, and psychiatrist. A detailed conceptual framework joining contemplative and western psychologies outlined by Dr. Podvoll in Recovering Sanity guides our work. In particular, we emphasize mediation practices in our staff training and in all aspects of the clinical work. We closely attend to the unfolding process of the client’s recovery as mirrored in the team’s active learning and social dynamics, rather than pursuing clinical outcomes pre-determined by professionals and family members. We believe that people can grow through the process of recovery rather than simply resigning themselves to managing a life-long illness. “Process” is the key term: there is a process of development of psychosis and a process of recovery, with characteristic landmarks and stages that can be skillfully handled in the midst of uncertain change. At the beginning of any process, the patterns are not yet set. For instance, at the beginning of relating with a disturbed person, we consciously avoid introducing heavy medical diagnoses and dire predictions, which can become self-fulfilling prophecies. We orient ourselves to the present experience and adopt a “wait and see” attitude. We try to simplify, rather than complicate.
There are three terms key to our approach: 1. windhorse; 2. basic attendance; 3. islands of clarity.
- Windhorse energy is the active element of our intrinsic health and intelligence that one can become more aware of and bring into daily experience.
“Windhorse refers to a mythic horse, famous throughout central Asia, who rides in the sky and is the symbol of a person’s energy and discipline to uplift himself. Windhorse is literally an energy in the body and mind, which can be aroused in the service of healing an illness or overcoming depression.” (Podvoll, 2003, p. 224).
Our inherent health abides through illness and disorder, and is the guiding survival instinct for our life. This life force can be seen in the healthy radiance of a person’s presence; heard in honest words expressing the poignancy of whole-hearted emotions; known in the curiosity and genuineness that a person brings to his or her world. In central Asian medical systems the “mind” is associated with the element of the “wind” in the body, and mental illness is seen as turbulent consciousness moving unstably in the body, experienced as fear and confusion. A traditional metaphor for healing mental illness is the wind element can be “tamed” like a wild horse. The metaphor of the horse has several meanings for us: to apply our strength in a steady way to support the client as rider client (hence our common slogan “to give aid with the strength of a horse”); to gently tame the wild horse of the mind distracted by compelling thoughts from the path of one’s life; to conduct our teams like mounted cavalry that travels lightly, changes direction easily, and acts with military precision. Windhorse is a model of health rather than from a model of pathology alone, bringing hope and workability to the otherwise fearsome shock of psychosis. We regard a person’s energy that may be wild in psychosis as workable Windhorse energy.
- Basic Attendance is our core healing practice that arouses the discipline and workability of Windhorse energy. Basic attendance is “basic” because it works with the most fundamental situation: to synchronize body, mind, and environment by gathering attention and sharpening perceptions with the ordinary activities of life. It is “attendance” because the therapist’s intention and training is to of compassionate service by tending to the needs of someone during the recovery process. We regard psychosis as a major disruption in the balance of the body-mind-environment system that dislocates the person from the functional reference points of ordinary life. The mindful work of basic attendance brings the therapist’s and the client’s mind “back home” to the body and the immediate environment. This brings natural wakefulness to the nightmare of psychosis. The caring and gentleness of basic attendance promotes therapeutic friendship to emerge among client and team members.
- Islands of Clarity continually interrupt any psychotic turbulence with momentary experiences of insight and freshness that bring the person into more direct contact with his body and environment. This experience is a coming to one’s senses, as if awakening from a dream. One feels a return of confidence in oneself and connection with others, a hallmark of Windhorse energy. Such fragile moments are islands of clarity that must be recognized and protected as the seeds of recovery. Although islands of clarity spontaneously occur, they can be enhanced and stabilized by the practice of basic attendance, which cultivates Windhorse energy.
In summary, Windhorse energy is the stabilizing experience of personal presence. Basic attendance is the discipline of healing relationship. Islands of clarity are spontaneous clearings in psychotic confusion. Taken together, they are the Windhorse way of developing the health of both therapist and client.
III. Clinical Experience
Dr. Podvoll’s Recovering Sanity is based on his presentation of four primary case histories drawn from first-person literary sources. His close reading of the material (over the ten years of writing his book) refocused attention on the personal reality of insanity and the fundamental mental functions that propagate it. The four cases were presented as “parables”, i.e., compelling instructive stories. In the same way, one can view one’s work with a person in psychosis as a “parable”, i.e., as a story replete with hidden meaning. This view is based on one of the key skills of Windhorse therapy: “One needs to learn directly from intimate relationships with people in psychosis about the abysmal struggle taking place within psychotic turmoil itself.” (Podvoll, 2003, p. 4) The real question then becomes: how to learn from the therapeutic relationship itself? The following clinical experience will be presented from this point of view. Careful consideration has been given to protect the confidentiality of the persons described.
Phase I: I first met Marco in December, 2002. He voluntarily traveled to Boulder, escorted by his two parents, for a preliminary “mutual interview” with us. Such an interview, based on reciprocal communication, explores whether there is sufficient practical and interpersonal ground to support the journey of the clinical work. Marco showed qualities of a suitable Windhorse candidate: he was articulate about his experience, albeit in his idiosyncratic way, and interested in interpersonal dialogue; he had several personal disciplines in the area of music and creative arts; he was curious about the spiritual meaning to his life-path; he could safely spend periods of time alone during the day in an open community setting. On the other hand, he thought he was perfectly fine and that his main problem was how the adults in his life (parents and psychiatrists) misunderstood him and kept things that he wanted from him. His parents were open and engaged with us, willing to grow through their involvement with the team, and had sufficient financial resources to support the treatment. It was obvious that we were all “drawn” to each other, and were inspired to proceed. This enthusiastic interest to work together is usually the first experience of Windhorse energy, which we regard as necessary to begin. Marco was a young man of 20 years coming to Windhorse at a life-crossroads: face longterm commitment to a psychiatric hospital or live in a Windhorse household to work with a team of interesting people who would support him in reducing the psychiatric medicines he so intensely disliked. If you were him, which would you choose? He was 2-3 years into his psychosis, having been diagnosed with “schizoaffective disorder”, which we regard as within the early phase of the development of such a potentially lifelong disorder.
I will present Marco here with the method of “body-speech-mind” description, which is the way we conduct clinical supervision in contemplative psychotherapy generally and Windhorse in particular (Rabin and Walker, 1987). This is the disciplined attempt to present the whole-person in detail, emphasizing description over theory and diagnosis. This facilitates the listeners’ empathy with the person, both dilemmas and strengths, and minimizes the professional tendency to focus on presenting problems, diagnoses, and standard interventions. The intent is to bring the person alive as a palpable presence in the supervision relationship. We find it especially important to meet the person with an open state of mind at the beginning, which applies to the supervision discussion or the healing relationship itself. This allows the person to introduce himself and speak for himself. This is the way we respect the early stage of any situation: to open communication at the beginning rather than close down emerging possibilities. How else can one truly meet another and have an understanding of the situation he is in? To begin, the attendant regathers his presence through the ongoing practice of synchronizing one’s body, mind, and environment. This allows one to ‘tune into’ or resonate with the other person and the dynamics of his immediate situation, which then informs one on how to respond with accurately with the right action at the right time. As I often say to my Windhorse students: “once the connection is formed, then timing is everything”. The following description is a lightly edited transcript of an actual supervision group presentation by the author, to allow the reader to “tune in” to Marco the person.
Body: Marco is 21 years old. He once told me that he is 6 ft. tall. He is lanky; he is very boyish in his presentation, in his appearance, and in his movements. And very fluid as if he had been massaged too much…his joints move easily. This is partly so because he has identified himself as a musician, and he is into music – he plays music, he thinks music, he sings music, he feels music, so his body has this feeling of moving into the next rhythm or tune. He has dark blue eyes that move a lot which characterizes his energy, which is restless and moving, flitting about. He has dark brown hair, which is always a mess, from my point of view. From his point of view, it is probably in stylish disarray. I have never seen him with anything remotely like combed or brushed or arranged hair. It usually looks like he has been sleeping on it, or has had his hat on, or has been resting his head on something…very messy. At one point he was thinking about growing dreadlocks [matted braids], which I think is based on this disarray and it just grows. He has a long face, with a thickening of the neck, a fleshiness that may be related to the clozaril he takes. It looks like a medication-puffiness. He has a long face, very pleasant-looking face. [Question: Clozaril?] It is one of the new atypical medications, of the new generation of anti-psychotics. Acne…he has significant acne. He is an attractive-looking young man with this boyish quality. His clothes tend to be hippy-style. This one day I saw him he had on a knit cap of rainbow colors, jauntily stretched over his brow and disheveled hair, with torn jeans with drawings all over. He always seems to be drawing on things in a creative spirit. For example, he had “One Love” written across the backside of his pants and the words of “fire, water, earth” written on the legs area, all in black ink marker, and abstract designs on the front. He wears socks with hiking shoes, loose shirts, and a dark blue military-surplus sweater. He lives in a nice 2-bedroom apartment. He has a guitar, which he plays quite a bit…he has it and it has him, with decorative decals all over it.
Speech: The music is mostly his expression. His voice is pleasant and soft and has a quality of singing, as if he were singing or appreciating the sounds that are coming out of his mouth. He makes up words, often in the middle of a sentence, and one of his favorite words that I hear often is “HAJ” which is usually a word of affirmation or assent. I think this is also the name of god in his pantheon of spirits. He enjoys talking but it is not so much his mode of expression. It is more like playing music which he will do at every opportunity…singing, making up songs, listening to music, listening to Jamie play [the team leader], which is a great way of interchange. He also draws quite a bit. He also has a book that he is writing in. There is this flow of creativity that he is constantly in. The quality of it is one-way and I often feel like an audience. My experience of him, and being in relation to him is that he is very self-absorbed. He has a lot of pride in who he is and how he is, and in his potential for being a great musician, which is his career aspiration. His emotional life is oriented towards the positive, putting a positive spin on things, which may be somewhat related to his perceived role in his family which is to bring positive light and love energy to his family, who are otherwise, in his view, caught up in anger and rage most of the time…that is his concept, and one of his missions is to bring happiness to his family, for everyone to get out of their ruts. People comment, and I have felt with him, when there are lapses in this flood of positive creative energy that comes from him, there are dark feelings and these don’t really have a name…my sense of these dark feelings is that they are related to entrapment, being buried alive, dark claustrophobia. He has been hospitalized [psychiatric] a few times and he has spoken of these with a very furrowed brow and a sense of him as damaged fragile flower, a
damaged soul…that this has done damage to him. These dark feelings…I am always interested in them. I am as interest in them as he isn’t. These have no interest to him, it seems. I have this sense that he is fleeing from them.
Mind: His mind has this quality of absorption. One of his words that he uses quite a bit is “trance”, that he enjoys “trance, being entranced.” When I hear this word from him I realize that I have a quietly judgmental attitude towards the word “trance. I think, “That is not what one should be cultivating, if one had half a brain,” which is my hostility emerging toward him, when I see his boyish naiveté about spiritual matters. He is very somehow caught up in and schooled in spiritual matters. He has traveled about, studied a lot, made up a lot of stuff, all of which he is very certain about. And in our meetings and with other people, he will rhapsodize about spiritual experiences he has had and will talk about his “path”, his “path unfolds”, with themes like “the interdependence of all of us”, or “path of love” or “getting close to god”. He can go on like this and it can feel very syrupy, overly sweet, and very difficult to digest when I hear him do this kind of rhapsody. It seems so abstract to me, almost maddeningly so. I can barely stand it. Even though from his point of view we are sharing that which is most precious to him.
[Question: What about that part of his health growing up?]
He studied piano when he was younger. He is quite good on the piano. There was some discipline and study there. He used to teach piano, he was a tutor, and he also taught guitar to people.
[Question: Other relationships?] He has his parents, nuclear family. Father is a business manager. Mom is a householder. They are very committed to Windhorse. Marco says dad has an angry side. They are very likeable and gentle somehow. There are two sisters. He says he has all these various friends in his hometown who he says he misses desperately. His parents say that these people have drifted off or are useless people according to his parents who are into drugs, who have no career aspirations, and are not really doing very much. He says he has a music band, which he is trying to pull together called “Pizzaz”. I have this sense that things are drifting apart for him, and his relationship predicament is something like, “you can’t go home again.” His parents do not want him home again. He has been living at home in a basement apartment in their big house where he has this vagrant musician lifestyle, smoking pot and doing nothing useful from their point of view. Leading an aimless scattered life. They do not want him home again although they have not quite said that, and are not sure if they are ready to say to him “you are out of the nest.” There is also a sense of letting go of his boyhood buddies, and he is in transition to something. So it is like this: you can’t go home again but the future does not have a form and that is probably scary, as one could often experience at age 20. He plays at the local coffeehouse at their open microphone night. His poetry comes through as lyrics for songs, which he can make up spontaneously. He is quite a lyricist although he does write some poetry and he has shared some of it during some of our sessions. I am sometimes impressed by his poetry. I have this sense that he is sitting on some gifts, and I can sometimes see them, although I am not sure what they are. But sometimes I have the feeling that he has experienced a “calling”, like he has been “called to the higher life” [presenter laughs uncomfortably]. I’m not sure. He has done a lot of psychedelic drugs in very unusual places with a lot of unusual people, and he has felt himself in the presence of god. I have this familiar kind of experience of working with someone where you have this combination of psychosis, self-absorption, and genius, knotty and tangled up and I find myself there with him wondering about his gifts and sometimes I am impressed by them. Most of the time he seems like a real “upstart”: a young person who presumes, who self-assumes that he is very privileged, entitled, has many talents, and that older people just don’t get it, that we are all old dead wood. At one point he called Jamie and I “old geezers.” “Geezer” means an old person who wheezes…a geezer is a wheezer, which would be typical for 14 year-old boys to say. So we seem to be talking about a 14-year old boy who is 20.
[Question: Do you think his perception of his family as a “hellish container” is justified?] I would not say that…he is exaggerating.
[Question: Any genuine discipline going on? or a partial mindfulness discipline.] He does now have a meditation practice that we have been gradually introducing him to, based on his own self-styled meditation practices. I have been occasionally giving him some simple instruction in mindfulness meditation and he is spontaneously doing some meditation on shifts, and he does go with Gretchen [a team member doing basic attendance] to the Naropa University meditation hall, which is down the street from his apartment, and they might meditate for 15 minutes. I have talked with him about this in our meetings and we have occasionally done some of this in our meetings, which is mindfulness of breathing and body. So there has been some of that going on, gently edging into that, and it also characterizes the entire team environment.
[Question: Genuine discipline?] One would have to really look into his music, his dedication to music. Music is both his transformative vehicle and his greatest discipline, and at this earliest stage of the work it is hard to tell. This is the fourth month of the work. I think our meetings are taking on more of a sense of discipline themselves, that our meetings themselves could carry the spirit of discipline and we could learn about discipline.
[End of supervision presentation transcription.]
Marco’s parents provided the following story. Marco grew up in a traditional Western upper-middle class family setting, with both parents and two sisters present. From an early age, he was observed “to be in his own little world about half the time.” He learned best on his own and did not like to take instruction from others. In grade 2 (age 7) he became “disruptive”, although he was often the “teacher’s pet”. In school, he was very bright and academically successful, always volunteering, and able to “make speeches publicly”. He had many sustained friendships, was popular and well-liked by his peers, and was elected to student offices. Generally, he was well-spoken and likeable. At age 14, with the onset of adolescence, everything changed. He became obstinate and withdrawn and became involved with street drugs, which appeared to slow, if not throw off track, his maturational process. His parents felt “he remained a kid” with the narcissistic attitude that “it’s all about me.” He behaved as if he were unaware of the effect of his needs and communications on other people. In my experience, with early-age drug use, such ego-centricity can be an overcompensation for the drug experiences that can be shattering to the emerging self-concept. That is, fragile self-boundaries can become solidified as defense against overwhelming personal disorganization, at the expense of an awareness of other people and one’s surroundings. For many years, he was well-trained in music arts, learning to sing, play the guitar and piano, and music composition. He also became skilled in visual arts, poetics, and lyric writing. At age 18, upon graduating from high school he traveled alone to Australia for several months, attended a meditation retreat, hitchhiked extensively, lived in a tent, experimented with hallucinogenic drugs, and studied esoteric philosophy. He felt he “saw god” and developed a “direct relationship with him.” He felt his “third eye” (the so-called “mystic” or “spiritual eye”) was opening in spasms. Returning home to parents, he became increasingly withdrawn. Within one year, he developed his first psychotic episode which to him was life-changing spiritual crisis. He spent long periods screaming in pain and hitting his head against the wall. For the next two years he was in and out of psychiatric hospitals and their medication treatments, all of which he found traumatic to his “spirit”. He continued using street drugs, intermittently living at home, hitchhiking around the countryside, and being committed to hospitals from which he was constantly trying to escape. He continued his music interests but was unable/unwilling to engage in any productive young-adult activities. His speech, thinking, and behavior became increasingly idiosyncratic and scattered and he acquired the label of “schizoaffective disorder.” In this condition, he came to Windhorse.
The Clinical Work
For the next 6 months we worked with Marco in a Windhorse therapeutic household and clinical team. I served as the principle psychotherapist and met with Marco twice per week in intensive individual psychotherapy sessions (one-hour) in my office setting. My role was to provide therapy to Marco, and to supervise the process and direction of the treatment team. My partner in the work was an experienced Windhorse team leader who organized the team members’ activities and schedule with Marco, and supervised the household. Together we co-led the team. In addition, there were 3 counselors providing basic attendance with Marco, and a staff housemate living with Marco, who was a graduate student in contemplative psychotherapy at Naropa University. These four staff generally served as peer-mentors for Marco, and were well-suited to his interests, age, and temperament. Marco and I met with the team psychiatrist twice per month to monitor his medications and general health concerns. One of Marco’s main goals for being at Windhorse was to reduce, if not eliminate, the medication he was taking which he actively resisted due to stated side-effects of lethargy and inhibition of his creativity. We agreed to this pursue this goal as long as Marco could continue to live well and safely in the community. We soon discovered how disorganized Marco’s lifestyle, thinking, and communication patterns were, and we began to gently introduce some order and predictability into his daily rhythms of activity, rest, sleeping, eating, being alone and being with others. Overall, this was a gradual process of Marco and the team getting to know each other which takes much time and effort. We discovered towards the end of the first 6-month phase, that Marco was secretly using marijuana and occasionally more powerful hallucinogenic street drugs, which in our experience always undermines the recovery process. The integrated treatment of persons with so-called “dual-diagnosis” is one of the greatest challenges facing modern psycho-social rehabilitation practitioners. There is an excellent resource published by the Center for Psychiatric Rehabilitation of Boston University: A Comprehensive Guide for Integrated Treatment of People with Co-Occurring Disorders (Spaniol and Pita, editors, 2002). This is especially important in the work with persons in the early phases of psychosis who are statistically more than 50% likely to have a co-occurring substance abuse problem.
Marco was also receiving regular homeopathy and acupuncture treatment. The accupuncurist saw Marco’s situation as; “His constitutional style is associated with the earth and the stomach. He can immediately leave [in his mind] the earth straight into the stratosphere, with all kinds of New Age spiritual reasons for not being on the planet. He has lost his integration and suffers much anxiety and broken-heartedness. His situation is so severe yet he presents so sweetly. Through acupuncture, I am trying to promote his grounding and integration. It is about nourishment and support, and to show him the fact that there is a place for him on this earth and that he can nourish himself.” She also emphasized how important it would be for Marco to have a balanced diet and to reduce his excessive intake of sugar. We later discovered that Marco had a serious and deteriorating dental condition caused by excessive sugar intake, poor hygiene, and anxiety-based resistance to dental treatment. As a team, we found this “alternative” diagnosis very useful, giving us more insight into who Marco was and how to work with him. In Windhorse we often find adjunctive health practitioners especially helpful with the process of medication reduction and for support of general wellness.
Marco and the team worked together for the first 6-month phase with this staffing pattern. Marco was an independent person with strong ideas of what he was willing to do and when. We provided a stimulating environment with real opportunities for him to grow and learn, and to simply be with and enjoy the team members. The complete story of that treatment period is too extensive to report here. However, one aspect is of singular importance. Over the months, I became more insistent with him that he face what I regarded as his serious street-drug dependency. He resisted my efforts at every turn, arguing that the hallucinogens were sacred substances put on this earth by god for the spiritual enhancement of human beings and that they were an integral part of his spiritual path. I argued that his drug use was associated with each of his hospitalizations that were becoming more extended and conflictual with each admission. I insisted that the street drugs were causing him to lose his mind rather than find it, as he insisted. I told Marco that until he understood the process of his disorder (“how it works”), which he did not even agree that he had, that it was bound to recycle. I explained the logic of the “cocktail” and its five elements (explained later in this paper), which is the way in Windhorse to understand the evolution of psychotic process, and the onset of a particular psychotic episode. He refused to acknowledge the message from me and the team. We were at an impasse yet he and I continued to communicate openly about this, which is a key point: the therapeutic relationship can contain conflict as long as there is honesty. Eventually, he left treatment to return home after 6 months against our and his parents’ advice.
Interim Phase: I stayed in long-distant contact with Marco and his parents for the next 3 months while Marco was living at home or traveling alone, usually by bus or hitchhiking and rarely with a destination. Once his parents bought him a car, which he soon abandoned as broken down on one excursion. His parents were very concerned for his welfare, as he continued to use drugs, and live an aimless and increasingly vagrant lifestyle. He attempted to stay with a close cousin but was soon asked to leave. He then returned home, increasingly alone, agitated, and verbally and physically assaultive to his parents. He refused all professional help and especially their medications, which he loathed. His psychosis appeared to be returning, to his family’s extreme distress. The mother had vowed to not have Marco taken forcibly to a hospital by the police as these had previously been scenes of extreme violence and anguish for all involved. His parents finally gave Marco an ultimatum: he either had to leave their home with no support from them or return to Windhorse. He chose to drive to Boulder with his father and they left immediately. Marco was assaultive to his father on the car trip and after many mishaps, they arrived.
Phase II: Father and son took up residence at a local motel and my team leader partner and I began to try to re-establish contact with Marco. Marco was very guarded and distant when he and I first met. He said vaguely, “Things are sometimes hard.” He seemed to be struggling with his composure. Strained and awkward gaps filled our conversation and he had long delays in responding to my questions. We did not share eye contact. He asked to take a car-ride and when we returned he prematurely opened the car door and almost fell out. Overall, his body and mind and environment were desynchronized and he was caught in compelling private experiences. We again organized a Windhorse staffed household and clinical team. Four days after arriving, Marco moved into a spacious rented home with two male staff housemates who were kind and steady. One was the same young man he had lived with during the previous phase of treatment. I again saw Marco twice per week for psychotherapy, now only at his home, since he rarely left the house. The team leader did 3 basic attendance shifts per week, along with two other young team members doing basic attendance. Marco remained very silent and withdrawn with the team. He spent his days resting in bed, doing small brush paintings, and just staring and thinking. He vaguely spoke of his “extreme pain”, “fears”, and that were “forces at play.” Occasionally he would fix my gaze and stare as if he were reaching out to me over a vast distance. He seemed deeply lonely. He spoke of committing suicide and ending his pain. To us, he was a different Marco from before. His music, rhythm, and seemingly boundless youthful creativity had given way to a morose, brooding, withdrawn mood. He seemed driven by fear and a hopeless loneliness to a suicidal preoccupation. We felt anxious and helpless. One day he abruptly packed his backpack and disappeared. We feared for his safety and waited, “shifting the household” during the five days of his absence (see Podvoll, 1990, p. 292 “the patient is missing”). He returned saying he just had “had to hit the open road”, and broke off further communication.
During this period Marco wrote poetry from his lonely place:
- If we listen and learn
our instinct will provide
will seek the moment
will heal will heal.
- If you had a moment for every memory…could you piece together the sapphire and the perplexing or even fathom the dream you are dreaming?
3. The only eye sees you
grey elephant sees near
grey owl talks to violet
purrs flute of blue lagoon
and candling eye
a Rich fire fall hard
upon this crumbling path
and the only eyes see you
a Rich fire fall hard
upon crumbling path.
He then began damaging the household, repeatedly punching holes in doors. This developed into menacing staff if they did not get as far away from him as possible. The situation continued to escalate and no one in the household could sleep, relax, or feel safe. The sense of tension and danger in the household was palpable. One morning he suddenly packed up again and left in an angry and disorganized state. After consulting with the parents, we wrote a court order to have him taken to a secure psychiatric hospital for being suicidal and gravely disabled. Fortunately, he returned to the house later that morning and was peacefully escorted to the hospital by the police. A week later, he was transferred to a hospital near his parents in his home town. I visited him the morning he left and later wrote in my notes:
“Marco left today, north on a chartered plane with mother. I saw him briefly this morning…he was startled and dismayed to see me at the door and said he ‘felt terrible’…and requested, ‘pray for me’. He dozed off as I stood in the doorway of the desolate room…his breathing settled down as did he…I sat quietly and did tonglen [a Buddhist meditation on compassion] for him as he had asked. I feel sad and discouraged beyond measure. The bitter lesson of accepting my/our limitations…his bitter lesson? Humbling to all of us. I saw mother this morning…she asked the mother’s plaintiff question, ‘Why is he so stubborn?’”
He has remained there now for several weeks in a continuing state of angry withdrawal although he is consenting to taking prescribed medication. He has made several attempts to escape the hospital, and has been returned by friends or by the police. His mother states,”I am glad he is in a safe place. We now know he cannot make it on his own for now. Until he can face his illness and situation he is stuck where he is. All we can do is continue to support and visit him. It is now up to him. What else can a mother do?” I have continued to contact Marco and consult with his parents, long distance. I have written Marco two brief letters, presented here. They are composed in the style, tempo, and content consistent with our previous communications, so they are unique to him and me:
Hello Marco, Jeff Fortuna here…I have been thinking of you since the last time we spoke by phone, last week. You asked me to pray for you, and I have been in my Buddhist way. First praying for you to have some mental relief and relaxation. Second, praying that you will come to some deepening understanding of your current situation and how to best act in it. I sense there are cycles here. It was just about a year ago that we spoke first by phone. You were in the hospital, facing an extended 6-month commitment. So, we spoke about Windhorse and a change of direction for you. Now you are back, full circle…cycles like the seasons? Autumn again. I would enjoy speaking directly with you – of course, when you are ready. As for now, quiet prayers are happening.
All the best, warmly, Jeff”.
Hi Marco, Jeff Fortuna here…writing to you and thinking of you. I tried to phone you yesterday and the person said you were not taking phone calls. I then got a bit of a glimpse of your situation from your parents and it sounds like a struggle…you against the hospital people? A kind of stalemate I guess. And I hear that you are taking meds again which I hope are not too unpleasant for you. I am always sending you positive energy and well-wishes from afar.
I wanted to offer to be a friend and partner of some kind during this difficult period. I am imagining that you are alone, with no one to talk with or explore things. You and I have had a good feeling that we have shared in the past, one of trust and honesty and warmth and openness, which I value and that is still available to us, over the phone even. So I am writing to offer to speak with you whenever you like to try to sort through this impasse. I really don’t have an agenda or a point of view about your situation…just well-wishing and an open ear to you. Feel free to write or call…I will probably call you again soon on the chance that you are in the mood to connect.
Be well…kindness to oneself always applies, Jeff.”
As we say in Windhorse,”It is the quality of long term relationships that can make all the difference.” That still continues.
The Working Model
In general, it is our frame of reference that allows us to make sense of our experience, and to then explain events to ourselves and others. Our actions are then guided by our point of view that frames the situation. In particular, in working with psychosis, strong elements come into play since there is often extreme chaos, uncertainty, and even mortal danger. For most people, losing mind is akin to losing life itself. Fear is a common reaction to the emergence of psychosis both in the person and in those around, which can immediately trigger the urge to control on the part of family and caregivers, i.e. to exert some power over the unsettling chaos. This process is described in detail by Dr. Podvoll as the birth of “asylum mentality” (Recovering Sanity, 2003). It is core to the Windhorse approach to resist this tendency to control out of fear, and to practice simply being present with the person and the situation. We term this the “practice of asylum awareness.” This is not a theoretical frame of reference, rather a practical and relationship-based entering of a situation that is pacifying and reassuring. In the field of mental health treatment, there are all manner of theories about psychosis: what it is and its various sub-types (diagnosis), how it develops (etiology), and its future potential (prognosis). The medical theory of psychosis is the predominant modern paradigm, which asserts that psychosis is a biologically-based pathological condition best treated with medical means such as hospitals, medical personnel, and medications. There are less well-known process theories of psychosis and its therapeutic treatment that have been developed by R. D. Laing, Loren Mosher, John Perry, Stan Grof, Frieda Fromm-Reichman, and others, that emphasize the personal meaning and journey-quality of psychotic experience unique to each person. These “alternative” paradigms rely more on therapeutic relationships and healing environments to promote recovery, than on somatic treatments such as medications and electroshock, which tend to promote an adjustment to a life-long medical condition. Sometimes the theories of psychosis are as elaborate and obscure as the delusional systems of the person in psychosis. In every case, they provide frames of reference that can be applied with heavier or lighter interpersonal force, depending on the style, experience, and training of the particular mental health practitioner, and the agency context in which he operates.
In Windhorse we emphasize applying a theoretical view with a light hand, allowing for reciprocal communication, shared decision-making, and honoring the directness of immediate experience. “Theory” is a real factor in the context for the contact and relationship between the person and the attendant and should be applied sparingly. In Windhorse training, we rely on contemplative practice to show us how to relax with the personal shock of meeting directly our experience, unmediated by theory and the constant stream of internal dialogue we take for granted. This is fundamental to being able to directly contact another person, especially one in madness. In Windhorse we call this “sympathetic resonance”, meaning empathy motivated by kindness. From this, we find that “sympathetic insight” naturally develops as an understanding of the nature of the total situation at hand, and how to skillfully act within that (see Podvoll, 2003, pp. 319-353, “Psychotherapy”). This is not so much a theoretical frame of reference as a way to practice compassion action in challenging situations. In Windhorse, the interpersonal clinical practice of compassion is based on personal contemplative practice, and fosters the openness of interpersonal learning rather than the closing down and attempted control of the other. This is especially relevant when encountering a person in the early stages of psychosis, as well as to the early stage of any particular interpersonal contact. The beginning is the formative stage, a transition with still-open possibilities. The patterns are not yet set, and can develop in any number of directions. In our work with Marco, we worked to bring in such a patient approach to meet him on his personal ground, and to provide a spacious and kind environment (both physical and social) for him to express himself and relax. This process requires time and sustained effort.
Edward Podvoll, in Recovering Sanity, presents a working model of psychosis (pp. 171-190):
“This model can be worked with in a practical way, that has ‘clinical implications’, and that can be used in designs for treatment. Briefly, the model has these stages: The ‘Cocktail’ is the mixture of causes and conditions necessary for ‘Imbalance’ to occur, consisting of a wounding rearrangement between the body, neurotransmitters, and the mind, giving access to the ‘Second State’ of mental functioning – including the microperations – which differentiates into ‘multiple zones of conciousness,” one of which is ‘manic consciousness. Thus a functional psychosis evolves.” (Recovering Sanity, 2003, p. 172)
Dr. Podvoll’s working model of psychosis clearly explains the set of causes and conditions that lead to psychosis:
“The ‘Cocktail’ consists of a Predicament, an Intention, Exertion, a Substance, and Mindlessness. Usually, all of these ingredients can be found to one degree or another in the production of a psychosis.” (Podvoll, 2003, p. 173)
This is a useful way to understand the process of early psychosis, and to actually assess whether someone is in danger of psychosis. Predicament refers to the crush of external circumstances that undermine the stable sense of self, leading to a “switchout” as a self-transformation to realms of magic and power as the only and best solution to such an impasse. Marco, mired in an identity crisis as a “spiritual seeker”, loses control of his mind, and surrenders to “god-consciousness” attaining temporary experiences of insight and power. Intention refers to the deep ambition to transform to a state of freedom from the constraints and responsibilities of mundane life. For Marco, such an intention to transform is an exaggeration of the adolescent molting to the new adult life (the so-called “identity crisis”). Exertion refers to the effort or work required to being this transformative intention about. These are actual practices that unbalance and desynchronize the body and mind. Marco engaged in constant traveling, trance-inducing music, sleep-cycle disruption, and self-styled meditations that drove his mind to distraction. Substance refers to the literal fuels that drive the coming transformation. Alcohol and marijuana are the most common, although hallucinogenic drugs are the most powerful. These accelerate the imagination, blurring the line boundary between dream and reality. Marco’s dependence on the mind-altering states of chronic drug use became an addictive trap. Mindlessness refers to the absence of direct contact with oneself and surroundings. One forfeits the sense of presence by an inversion and perversion of the conscious attention, to a state of numb blankness or being lost in fixation on hallucinated states. Marco’s attention became absorbed in his “spiritual” reality, withdrawn and uncommunicative into his own little world. The logic of the Cocktail makes sense of common figures of speech, such as: “his unrealistic self expectations only bring humiliation”; “he suffered a blow of disappointment”; “he is alone in a bad situation with no way out”; “he cannot bear who or where he is”; “he is absorbed in private tasks and works hard at it”; “drugs and alcohol give him false daring and fake spiritualtiy”; “he is really out of it, spaced out”; etc. These can be the obvious danger signs of an impending psychosis.
From the point of the Cocktail, “psychosis may be the natural consequence of the way anyone has lived.” (Podvoll, 2003, p.2) Modern scientific thought and the medical model in particular, view the person developing a psychosis as a helpless victim caught in the cross-fire of pathological forces, rather than an active participant in the development of the disorder. We view the person as an active agent in the overall set of causes and conditions that lead to the development of psychosis, and therefore he is also an active agent in the process of recovery. Likewise, the family is a crucial element in the process of recovery, not because they “share the blame” but rather that they are active participants in the evolving life process of their child. The attribution of cause and responsibility tends to imply blame and guilt. This highlights a ubiquitous dilemma: Is the client a victim of an illness with no responsibility, therefore we should only give him pity and sympathy? Or is this the behavior problem of a young rebellious adolescent, therefore one can be justifiably angry and hold the client responsible. In Windhorse, we allow for such ambiguity knowing both sides of the dilemma can be true at different times. However, we are always gently working to create a healing environment that: avoids situational predicaments for everyone involved; sets an intention that balances freedom and responsibility; exerts effort to balance mind and body; dismantles the addictive cycle of substance abuse; and cultivates mindful presence in ordinary daily life. The Cocktail ingredients become the reference points for creating a sane environment of health and recovery.
Whatever the stage of development the person is in at the time when psychosis emerges, that stage provides the critical context and experiential content of the disorder. There are many theories of the stages of development from the simple to the complex that map the human journey from birth to death. The syndrome of schizophrenia begins most often in the late teens. Adolescence, even under the best of circumstances is an extended period of turbulent change, of transition from childhood to adulthood, involving the transformation of self and of coming into one’s “power” as an independent and effective adult. Personal character is changing and forming; the body changes shape and size; the emotions go to excess, driven by floods of new hormones; peer relations become paramount as parental influence fades; the mind is expanding and questioning the very fabric of conventional reality resulting in a variety of existential crises. The young adult is exposed to myriad influences outside of the home, and especially to the street drugs which bring compelling experiences of altered perception, meaning, transcendence of the mundane, and new rhythms of interpersonal and erotic intimacy. Such dramatic alteration in the rhythms of the body, brain, neurotransmitter systems is also the biology and the felt-texture of psychotic imbalance (Podvoll, 2003, pp. 177-186). Adolescence as a naturally dramatic transformation also sets the stage for the evolution of a functional psychosis. We should certainly do everything we can to protect the young person undergoing adolescent transformation.
Everyone agrees that the earlier the recognition of and intervention in a developing disorder of any kind then the more likely there will be a positive outcome. The psychoses are known to be especially difficult to see coming, to predict and anticipate. One problem with the modern medical-model focus on medications as treatment is that professionals and families only react after the full appearance of the syndrome. Robert Whitacre in his brilliant work Mad In America (2002) explores the effects of psychiatric medications on the long term course of the psychoses as potentially deleterious. So we must continue to ask: what are the non-invasive treatments of the psychoses, that see psychosis as a process of development with signs and stages, that could bring early recognition and help? In light of this question, this paper has presented a Windhorse consideration of early psychosis and recovery. The author wishes to express his gratitude to Marco for the opportunity to work together, and he wishes Marco well…very well.
It is important to understand that psychosis is a total body-speech-mind process that constantly recycles in the course of a person’s life. Therefore, there is always a return to the early stages of the disorder, a return to the beginning. In this sense, early intervention is always a possibility no matter how “late”, which is a continual basis for recovery. There are always opportunities to arouse Windhorse energy, to engage in the discipline of basic attendance, and especially to recognize and respect islands of clarity. There is always time to intervene with compassion. Harold Searles, MD, a venerable figure in the history of the compassionate care of persons in psychosis, sagely offers this advice:
“We shall be encouraged to enter into such work, for example, in proportion as we become convinced that even a single moment of deeply-felt intrapersonal and interpersonal relatedness is subjectively timeless, eternal, and ‘makes up for’ several decades of living as a less-than-whole person.” (Note 2) (Searles, 1965, p.512)
- “’Contemplative psychotherapy’ refers to the quality of treatment that results from joining the interpersonal discipline of psychotherapy with the personal discipline of working with oneself through the practice of meditation…[as] the application of mindfulness-awareness practice to clinical situations.
One of the earliest Western psychologists who pointed to the joining of personal and interpersonal practices was William James. He said,
‘The faculty of voluntarily bringing back a wandering attention, over and over again, is the root of judgement, character, and will. No one is compos sui if he have it not. An education which would improve on this faculty would be the education [or therapy] par excellence. But it is easier to define this ideal than to give practical direction for bringing it about (Psychology: Brief Course. New York: Dover, 1961, p.424).
The unification of these practices reveals the central tole of ego processes in the formation of neurosis and psychosis. This understanding of ego, so different from the prevailing notion of ego in conventional psychology, has led to many resourceful means of treatment. Though such clinical ventures are characteristic of Buddhist psychology, they are also developing in other contemplative traditions, both religious (including Chrisitian, Judaic, and Hindu) and secular.” (Podvoll, Edward. “Preface”. Journal of Contemplative Psychotherapy, 1987, vol. IV.)
- Harold Searles, MD, is a notable practitioner of the discipline of intensive psychotherapy, and has presented his life’s-work in three classic volumes, one of which is quoted from here. He was the primary therapist-teacher of Edward Podvoll, MD, the key co-founder of Windhorse The author continues to practice within this line of work.
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Fortuna, Jeffrey. “Therapeutic Households,”, Journal of Contemplative Psychotherapy, 1987, vol. IV. (Republished in Barker, Phil and Stevenson, Chris (eds.). The Construction of Power and Authority in Psychiatry, Oxford: Butterworth-Heinemann, 2000.)
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