CLINICAL HANDBOOK OF SCHIZOPHRENIA

55. Recovery 571associated with her psychiatric condition. Thus, the case manager focused on tryingto get Celeste to take her medication as prescribed and to attend a skills group forpeople who were interested in employment, hoping to address the sources of her difficultiesbefore pursuing seriously Celeste’s stated desires to work. If Celeste’s disabilityhad been related to her mobility or vision, it is obvious that she would not haveacquired a job until she no longer needed to use a wheelchair or regained her vision.As it was, Celeste was soon discharged from case management due to her failure toattend scheduled meetings and her refusal to be evaluated by the agency psychiatrist.From her perspective, the case manager was indifferent to her needs and wants, andsaw no change in her condition. Celeste began to feel that the agency was simply tryingto drug her into a state of passivity and hopelessness; evidence for which she unfortunatelyfound in the agency’s waiting room among some of the older, more“chronic” clients. She did not want to become one of them.After refusing these services but showing up repeatedly in hospital emergencyrooms due to persistent, harassing voices, Celeste was then approached by an outreachworker from the same agency, who suggested that she could in fact work despiteher disability. This clinician encouraged Celeste’s desire to work, offering herseveral options of treatments and supports from which to choose in pursuing hergoal most effectively. With frequent support and assistance with transportation,Celeste chose to get a job working at a fabrics store. She then found, however, thathearing voices and feeling paranoid made it difficult to be comfortable at work, andshe asked whether the clinician could do anything to help. The clinician describedboth pharmacological and psychosocial approaches to symptom management, andsuggested that Celeste discuss these concerns with her family and with a psychiatristor nurse practitioner at the agency, who might be able to suggest medications thatcould help with these difficulties.After some reluctance, Celeste eventually chose to describe her situation to a nurse,who, based on Celeste’s concerns about being “drugged,” initially suggested a low doseof an antipsychotic medication, explaining to Celeste that this would not make her tootired to work. With the medication Celeste found some relief and, less harassed by thevoices, began to feel more comfortable at the store. As she began to bring in some of hersewing projects and to make friends with a few of her coworkers, Celeste’s paranoia significantlydecreased. In her case, work served several functions, giving her a reason toutilize treatment and helping to offset and/or reduce her symptoms.Celeste’s second clinician did an important thing that the first had failed to do: shelistened. Now it certainly is not a revolutionary idea that clinicians need to listen, or thatthey should be trained to listen in a disciplined and respectful way. The practice of psychotherapygrew out of a conviction that listening should be valued. But in psychoanalyticand psychodynamic psychotherapies, listening has an additional purpose, to cultivateinsight and understanding that might eventually lead to behavioral change. Celesteneither wanted to change nor was she asked by the second clinician to do so. She neitherwas seen as lacking, nor was she offered, insight. In fact, the problem to be addressed wasnot situated within Celeste at all, but in the poor fit between her disability and her environment.When Celeste wanted to work, the clinician helped Celeste to get a job that shewould like and that was consistent with her interests. When Celeste was bothered by thevoices brought on by the schizophrenia, the clinician suggested a few options that mightmake the voices less bothersome. When Celeste was concerned that her coworkers andemployer would not like her, her clinician encouraged her to find out by actually trying tosocialize and to share with them her interests and skills.Against the historical backdrop of stigma, discrimination, and society’s demand thatpeople be restored to “normality,” what appears to be revolutionary is that this approach