Treatment of Schizophrenia - The Therapeutic Alliance
The principles of direct confrontation:
Psychotherapy with the schizophrenic patient
JACK ROSBERG, ALASTAIR A. STUNDEN
Rosberg J, Stunden AA. The principles of direct confrontation: Psychotherapy with the
Schizophrenic patient. Nord Psykiatr Tidsskr 1989;43:491-498. Oslo. ISSN 0029-1455.
A new approach to the use of psychotherapy in the treatment of schizophrenia is offered
which challenges many basic assumptions about how best to treat this difficult illness. A
clinical consultation conducted by the senior author in Sweden with a 32-year-old woman
(Stephanie) with a 28-year history of psychosis is used to illustrate the rationale behind the
principles used. Although the consistent character of schizophrenia across cultures is a compelling argument for a biologic basis for the disorder, this should never justify the assumption that the interpersonal behaviors that interfere with the patient's ability to function are so intractable that psychotherapy is useless. The belief that the schizophrenic cannot be helped through psychotherapy is more often tied to the resistance and reluctance of the mental health professional to learn how to use interventions that will be effective in reaching the patient. Most important, the therapist must assume responsibility for change, and, as a result, must do, and endure, whatever is necessary to ensure that change takes place. This principle is crucial when working with schizophrenic patients whose very illness often prevents them from voluntarily entering into a meaningful treatment relationship. The verbatim descriptions of the interventions used by Rosberg in the consultation, accompanied by the analysis of the rationale behind them, illustrates how even the most intractable patient can be successfully influenced by psychotherapy when psychotherapists can overcome their resistance to the treatment process.
Direct confrontation, Psychotherapy, Schizophrenia
Jack Rosberg, M.A., Treatment Director, Anne Sippi Clinic for the Treatment of Schizophrenia, 2457 Endicott Ave., Los Angeles, CA 90032, U.S.A.; Accepted: 13.06.1989.
The illness called schizophrenia transcends the many cultures and languages which traditionally separate one part of the world from another. Without question this commonality of symptoms and the consistent character of the dysfunctions schizophrenia causes, regardless of language, ethnic background, or country of origin, constitute a compelling argument for the biologic basis for the disorder. Regardless of etiology, how-ever, no one is ever justified in assuming that the ultimate consequences of the illness - that is, the maladaptive psychologic and interpersonal behaviors - are intractable and therefore not subject to change or modification. These issues of intractability are seldom related to any biologic reality but, instead, are more often a function of the inability of the treating professional to believe that psychologic treatment can be effective.
The history of the treatment of schizophrenia is both lengthy and frustrating (1-7). Suffice it to say, finding an effective treatment for the disorder has proved so elusive that almost every society which recognizes the existence of schizophrenia has ultimately had no alternative but to isolate those people suffering from it; both as protection for the larger social group and as protection for the individual patient.
With the advent of the phenothiazines in the early fifties, society was led to believe that a pharmacologic cure for schizophrenia was imminent. This fantasy was allowed to become so ingrained and unshakable that the failure of the phenothiazines to cure anything has done little to discourage the public in its pursuit of a medical breakthrough. This attitude has also made it extremely difficult, particularly in the United States, to encourage, develop, and train professionals in the use of psychologic methods that can modify and relieve the patient's maladaptive behavior.
It is with these thoughts in mind that we present the case of Stephanie. Although she displays behaviors that are both typical and atypical of the schizophrenic patient, she illustrates clearly our approach to treatment. Through her interactions with Rosberg, she allows us the opportunity to demonstrate how even the most intractable case can be successfully influenced by psychotherapy when the therapist understands how to intervene and how to overcome the internal resistance that can be expected in treating a case of this type. We hope the problems she presents and the solutions we have offered will provoke other clinicians to explore further the psychologic methods used.
The consultation was conducted and tape recorded by Rosberg in the autumn of 1987. Rosberg later described his experiences with Stephanie in interviews conducted by Stunden. The data from all these sources were then used by the authors in the development of this paper. Thus, in the Treatment sections of this study the reader will note the authors present a narrative in the first person. This narrative was taken directly from the Rosberg interviews with Stunden.
We also remind the reader that our observations in no way are meant to diminish the efforts of those who have worked with her. The extraordinary energy she spent at retaining her psychosis prompted Professor Gaetano Benedetti to describe her as a “window into hell”. It is important to explore cases such as Stephanie, even if we only gain one small grain of wisdom from her 30 years of human tragedy. We also wish to commend the dedicated care given Stephanie by her psychiatric treatment team in Sweden.
The case of Stephanie
Who is Stephanie? At the time of the consultation Stephanie was 32 years old. She is Caucasian, has no children, and was never married. Unable to attend regular school, she was taught to read and write while in the hospital. She now writes many letters, chiefly to her parents and the attending staff.
Stephanie currently receives no medication for her illness. In the past she was treated with phenothiazines without noticeable effect. She is seen regularly by her two therapists and also by ancillary staff, including educational and occupational therapists. At night, she receives a sleeping medication.
When Stephanie was born her father literally took over all the duties usually associated with the mothering process, including feeding. He ex-tended his control so that not even the maternal grandmother was allowed to assume any responsibility for the growing Stephanie.
Stephanie entered psychotherapy at age 4 years. Her therapist described her as terrified of people. “She was so frightened I couldn’t get her to sit on my lap”. When Stephanie was 9 years old, her second brother was born. By this time, her parents felt she was so dangerous to herself and her sibling that she could not be allowed to remain at home even with supervision. At age 9, because Stephanie was acting out, she was beaten severely by her father. Shortly afterwards her psychologic illness exacerbated, and she was hospitalized. Her psychologic condition did not improve and she was placed in an institution. Her experience at her first placement is described as “terribly bad”. For example, as a form of punishment, her feces were rubbed in her face.
From the age of 13 years she was hospitalized at a Swedish psychiatric hospital in Stockholm. From time to time she would be discharged as improved and sent to other, less restrictive institutions. Eventually she would become unmanageable and be sent back. At one point Professor Ludwig Binswanger was invited to consult on her case and she was also treated in several different countries over the time of her illness.
While in Stockholm, Stephanie was seen by a woman psychiatrist whose work was supervised by Professor Gaetano Benedetti. It was his position that treatment should focus on reestablishing a good symbiosis with a healthy mother figure, to counteract the bad symbiosis that had been generated by the father. To promote this, Benedetti had Stephanie’s mother live with her 24 h per day and denied the father any access to his daughter. Benedetti’s attempts to help Stephanie by manipulating the family system did not prove effective.
Stephanie at the time of consultation
When Stephanie was seen by Rosberg in 1987, it was obvious she was not a happy person. On first impression she appeared thin and debilitated, but not from deprivation. She seemed as if she was literally being consumed by her illness and that these energies were so powerful that people were afraid to test her psychosis. Everyone had intuitively retreated from her because she appeared so awesome and overwhelming.
She was in a setting where she had everything at her disposal. Everything was directed to her well-being. She had convinced everyone that this was the only way she could be treated. And. furthermore, she knew it. She had taught everyone that she needed protection from herself and that others had to be protected from her, too. There were no other patients on her ward. She had two therapists and a team of specialists plus a battalion of aides to shield her from her impulses. She was bathed by aides and fed by aides. She was dressed in special clothes made out of sail cloth so that she could not easily tear them from her body. She had a helmet to protect her head if she tried to injure it.
Stephanie had created a psychotic equilibrium between herself and the real world. No doubt she had done this as soon as she could in every treatment setting in which she had ever been placed. She had learned how to force everyone to compromise with her. She would not unleash her destructive power if they would respect her right to be psychotic. Thus, she demanded that others forget that her fear of annihilation was the sole motivating force furiously driving her to forge a safe world in which to live.
Stephanie had learned through painful experience that her only security lay in the protective armour of her psychosis and that life itself depended on her skill in maintaining it. How could she willingly participate in some process that would take her psychosis away from her? And, more importantly, what therapist would be willing to undertake such a hazardous mission? She encouraged everyone to believe in the unalterable character of her illness and hoped to convince them she was beyond help. She tried to make the risk too great for treatment to be possible.
Stephanie had created her own kingdom – a kingdom she protected by coercing everyone to defend it. In this context she had made probing her interpersonal dynamics or analyzing her character structure unimportant. If she could shield herself from intrusion by terrorizing others as she herself had been terrorized, why would she even need to develop a normal psychotic process with first-rank symptoms? In our view, this 32-year-old woman had taught herself to survive in a horror-ridden internal world controlled by a malignant primary process too powerful to conform to the puny intellectual demands of a trivial delusional system and too arrogant to relinquish center stage to the gaudy distractions of second-rate hallucinations.
The history of Stephanie’s treatment and illness
The history of Stephanie’s treatment and illness is crucial in two ways. Most obviously, it helps us gain some understanding about the interpersonal relationships in her life and their contribution to the effectiveness of her interpersonal coping mechanisms. The role of parents, teachers, and other significant figures must be examined with care if we are to do more than guess at the nature of her basic beliefs about the world in which she lives.
It is equally important to understand the reality of the historical events responsible for some of her resistance of treatment. This idea, developed by Grotstein (8), suggests that a patient’s repeated failure in treatment makes it difficult for a new therapist to help a patient who has had a great deal of unsuccessful prior treatment. Because these patients have experienced so much failure, it is reasonable and appropriate for them to believe that change is not possible and that further treatment will not be effective. This false - that is, delusional - belief must be removed by the new therapists before real treatment can begin. Until steps are taken to counteract the impact of this delusional transference, the patient’s feelings of hopelessness, rage, and disbelief about the effectiveness of treatment will overwhelm even the most skilled therapist. Stephanie’s long experience with treatment proved to be no exception.
Although it is important to take note of the special role of family and parent dynamics and history in the development of each patient’s illness, it is also important to explore and expose the unique contributions each patient makes to their own dysfunctional condition.
Rosberg’s observations during the consultation suggest that Stephanie may have grown up with significant lacunae in her perceptual and cognitive functions and that these prevented her from processing accurately the information contained in the world around her. If true, this would have made it impossible for her to cooperate with the people trying to parent and treat her. Further, it suggests that Stephanie’s illness may be similar to that of other patients whose distorted perceptions reinforce the internalization of world destruction fantasies. These annihilation fantasies frequently produce an unremitting terror which makes the patient’s life a never ending hell. For Stephanie we may infer that she was terrorized because she was unable to convert the energy her fear produced into something that could come under the control of her intellectual/cognitive process, and, furthermore, that the absence of classical (first-rank) symptoms in Stephanie may have occurred because she was unable to choose any alternative in her flight from terror other than total retreat into an atavistic, animal-like state.
In this sense, it made no difference what Stephanie’s family did or did not do. If she were unable to cope in an appropriate way with the information coming into her, the efforts of her parents, even if they had been helpful to her growth, would have made no difference. For some of us there are people who can help our fears and teach us to relieve them. Others of us survive anyway because we don’t have to succumb. But for Stephanie, there was no one.
The importance of Stephanie’s character structure
Professor Gaetano Benedetti, who supervised Stephanie’s treatment, had this to say about her: “When we try to get our needs fulfilled, we hurt her”. In this one statement, he describes the counter-transference issues that are crucial in understanding the treatment approach offered in this paper. To attack well-defended character armour to release the patient from their self-made bonds is a struggle that can wound and exhaust the self-esteem of even the most experienced therapist. On the other hand, while glossing over the patient’s character defects may protect the narcissistic needs of the therapist, it can only harm the patient.
Because schizophrenia cannot be diagnosed by any reliable set of symptoms, the true hallmarks of the disorder must be found in what the patient does behaviorally in response to the genuine perceptual and cognitive disruptions caused by their illness. When these behaviors form an identifiable pattern or character, they provide important guideposts for the therapist in developing a treatment plan. Understanding, therefore, how a patient creates and uses this defensive armour is vital if the therapist or patient is ever to gain access to the humanity that lies beneath.
Any time a patient denies, rejects, or turns away from their humanity, it should create an emptiness inside the therapist. Without this emptiness the therapist does not have a chance to gain a legitimate sense of professional or personal fulfillment. Thus, when beginning treatment, the therapist should always expect that the work itself will help restore the humanness of the patient. As Rosberg describes his own experience with Stephanie: It became a challenge to make contact with her in order to redefine how I perpetuate my own existence; my own effort to overcome the absolute absurdity of life. As a result, I made an effort to join with her. I said “Hello”. I told her who I was and that I was going to try to help her. Before I could even finish that statement her apparent fear of me drove her to turn on me in a sadistic, vicious, and inappropriate way. Her attack was obviously intended to have me discontinue any attempt at making contact with her but this only aroused me to the point where I understood I would have to make her respond. I quickly concluded that the only way I could deal with her was the way she was dealing with me: “To fight fire with fire”.
For Rosberg, the patient had made the decision to deny her humanity by staying in her psychotic world. She was not going to give up her world and join Rosberg in his. Rosberg would have been willing to enter Stephanie’s world, but she had rejected that option also. At this point, we see Rosberg’s first use of his own feelings to arouse Stephanie to respond to another human being. He continues: She had rejected me and I don’t like that. It’s not fair, it’s not human and it‘s disrespectful and rude. I can only say these things because she had given me an invitation to enter her world in the sense that she encouraged me to act towards her as she had been acting towards me. She told me to kill her, to spit on her, to hit her, to cut her head off, to pull her hair out; all the things she would have done to me if she had been released from her restraints. Her violence towards me tempted me to be violent in return. But reason told me this was exactly what she wanted me to do so she could perpetuate her condition. As a child, her rage had resulted in cruelty at the hands of her father and she had come to believe that therapists would respond to her rage with sympathy and understanding because they could not allow themselves the reality of their own anger. When I realized this, I told her repeatedly and forcefully that I was not her father. I added that although I would not treat her cruelly or revengefully as her father had, I would do whatever I could to make her realize that her acting out would not drive me away but would make me even more insistent that she treat me with respect.
The approach to treatment
To understand the approach to Stephanie, you must first understand what we think about treatment. Treatment is a set of direct, interpersonal confrontations leading to a common goal: to force the patient to choose between staying sick and getting better. In every case we treat we have to make new decisions as to what we are going to do and how we are going to do it. This process is often unconscious and instinctive, and it is only when we look back that we can see what we have done and understand what it means. Nevertheless, we approach each case with certain basic principles in mind: First; patients deserve our help and we will do everything we can to see that they get it. Second; there is nothing fair about schizophrenia. It does not let people do what they want to do with their lives. It interferes with their humanity. It robs them of their dignity, and it deprives them of their happiness. Third; we cannot help our patients if we allow ourselves to believe they have a right to be sick. We must press them, over and over again, to join us in our world, no matter how long it takes or what we have to do to get them there. The only tools we have are our human feelings and our understanding of their illness. In the right combination, these are all we need.
In our view there is no such treatment as non-intrusive treatment. Anything that presumes to treat schizophrenia successfully will be an intrusion in the life of the patient. With few exceptions, most therapists do not view treatment in this manner at all. The problem they have is a real one. To accept responsibility for the treatment of psychotic patients is a concept many do not even understand. It is always easier to blame the patient for not getting better than to look at yourself. Nobody likes to look inside and see their own pathology mirrored by the patient’s psychosis. Nobody likes to experience the feelings of failure and fatigue as the patient appears to win battle after battle. And, most important, nobody wants to expose the incompetence they feel when they are asked to take on the well-rehearsed illness of the veteran schizophrenic*.
The problem of effective treatment for the schizophrenic patient is made worse because few clinicians understand enough about the psychology of the disorder to do little more than flail about randomly. In part, this occurs because the nature of the condition lends itself to creating distance between therapist and patient, which is often not grasped by the therapist. This, in turn, prevents the kind of positive, intimate relationship that is needed to help the patient get better. In addition, most therapists have been trained not to intrude in the life of the patient unless the patient gives permission to do so. In treating the schizophrenic patient, this frequently results in a long, if not total, postponement of the treatment process, with the therapist waiting endlessly for permission that may never arrive.
The gulf between therapist and patient is often widened by the false belief that the perceptions and needs of the schizophrenic patient are truly different from our own. To believe otherwise would threaten our own psychologic integrity and force us to acknowledge the fact that schizophrenia is a human condition and one to which we are all susceptible. Why else, for example, do we continue to insist that the perceptual process of the acute patient is so shattered that we have no means of establishing human contact with that person? Or, for what other reason do we presume a veteran patient to be beyond hope when we find out his life is being controlled by unspeakable confusion and terror instead of the basic physiologic drive of hunger? What else but our own fear would allow us to give such forces free rein in our patients’ lives and only permit us to attack them when we receive permission to do so?
Making therapeutic contact with Stephanie
When Rosberg first arrived at the hospital, Stephanie was standing in a huge, cavernous room with an aide sitting next to her. Her arms and legs were in restraints and she was talking to herself. She was at the end of the room and could see what was going on from every angle.
* The authors wish to acknowledge Dr. Loren Mosher, who coined the expression ‘Veteran Schizophrenic”.
In the transcription of the post-consultation interview Rosberg continues:
When I came into her view she immediately became aware of me and looked at me. She was a little restless but did not seem particularly threatened. When I went into another room with the treatment team, I had no idea where I would work with her. The team had decided to take Stephanie out of the large room and put her to bed in five point restraints in her own bedroom. Although I was not told this I became aware that something was happening to Stephanie because I could hear her talking louder and louder and with more and more anxiety as she was being led back to her bedroom.
Stephanie now knew who was going to see her. I had glanced through the doorway at her and she had seen me. When next I saw her she was tied to her own bed. I looked at her and she looked at me for a long time. A feeling came over me that she knew she had someone to deal with unlike anyone she had dealt with before. She began to mutter in Swedish and Italian. I said, “There’s going to be some changes made today”. At this point she said fearfully, “He has too deep a voice”. This was the transference reaction I had been hoping for. This reaction directed my approach to her because I recognized it was probably connected to her pathological relationship with her father.
I told her who I was and that I wanted to help her if I could. She quickly revealed that she was bright and clever (Stephanie speaks and understands English, Swedish, and Italian) and that she was vividly aware of her surroundings. I found she was able to identify the individuals on the treatment team by their specific traits and habits. The world and the people in it did not melt into each other as it does with many patients. Every part of her environment had special and distinct meaning for her.
I knew from experience that Stephanie had probably learned that anyone she did not know might be a threat to her, particularly if this person was a psychotherapist. And, unless something unusual occurred, she would try to interact with me until she discovered enough of my weaknesses to destroy me or drive me away, learning all the while how better to prepare her the next time the threat appeared. What I am saying to you is that she had seen people like me before. And, she had learned how to deal with us so we would no longer bother her. I cannot tell you how bitterly disappointed she was when she discovered she could neither destroy me nor drive me away.
She began to engage me using the destructive, angry behavior that had always been so frightening to people around her. She screamed, cried, and banged her head on her bed not hard enough to hurt herself, but hard enough to frighten an inexperienced therapist. And, she assaulted me in the only way permitted by her restraints. She spat on me until I was drenched with spittle. Then, she raged at me to leave her alone, not realizing that, in her frustration and terror, she had revealed yet another pathway into her psychosis.
Up to this point, it has been necessary to emphasize the importance of understanding the character armour of the patient. Now, we must reflect on the importance of understanding the character armour of the therapist and how to use it as a vehicle for imposing reality on the patient. Stephanie’s ostensible desire to be left alone did not make Rosberg feel rejected. Instead, he felt outraged at the arrogance of a psychosis that could remove any semblance of humanity from another human being. He continues: I want you to understand that I was angry. More than angry. I was furious that this bright, creative human being was controlled by murderous impulses which made her nothing more than an animal. At one point I raged at her that she was a dictator, and a miserable beast. She responded by screaming at me to kill her. I told her frankly that it was against the law to kill her, but that if the law permitted me to do it I would be happy to do so. This was not an expression of counter-transference but a reality. In the condition I found her, she was a dangerous, murderous human being who would stop at nothing to kill, maim and destroy anything she felt threatened the integrity of her psychosis. I believe it is patently absurd for any therapist to pretend that this kind of behavior does not generate genuine and appropriate feelings of outrage, fury or even hatred. That the patient never hears about these feelings is part of the inadequacy and incompetence of psychotherapy as we know it today. We must learn how to disclose our feelings appropriately to our patients so that they are not cut off from the opportunity to explore and test the reality of their own. The charade that is passed off as therapy must stop denying our patients the opportunity to grow in areas where emotional development has been prevented.
Throughout this period, Stephanie continued to spit at me and try to kick me. I continued to ask her why she was so crazy and why she wouldn’t let me help her. I reminded her, again and again, that she could do nothing to drive me away. In this one respect she was absolutely helpless. Because her physical restraints prevented her from attacking me more viciously, she was literally constrained to interact with me. She had no other choice but silence. And that stratagem she re- fused to even try. I feel strongly that my desire to outlast her no matter how hard she tried to drive me away finally convinced her to listen to me and to pay attention to this crazy man who might really be more powerful than she was.
In a last, frantic effort at defeating me, but one which revealed only too clearly the power and control was beginning to wield over her, Stephanie began talking to me entirely in English. “Kill me. Kill me. Do it today”. At this point, she was trying to pull for one of two things. First, she really may have felt like dying instead of trying to protect herself from her own fears of annihilation. She is a terrified person with very little in life other than her psychosis. And that was certainly being upset significantly by me. Secondly, she was asking me to violate her. This long standing tactic was one she had learned to depend on. It had worked, over and over. Just make the other person angry enough and they will violate you. She could not afford to believe it would not work with me. To maintain the integrity of her psychosis, it was vital that she do to me as her father had done to her, and, as she had done to all the others who had tried to help her. She knew from long experience, that if she could get me to do that, then she would defeat me. If she could reverse our positions of power, she could make me ineffective and reduce the threat to her system of survival.
With these thoughts in mind I began yelling at her.“You crazy woman; you don’t have to be this way. Who the hell do you think you are, God? How dare you do this to all these people. You think you have the whole world at your side (referring to the treatment team) but you are not going to control my life!”
In response to my confrontation she broke out in a renewed burst of spitting and kicking, trying all the while to get me to act in a violent way towards her. I started to realize and to literally feel how she had experienced this kind of violence before. 1 said to her, over and over again, “No, No, No, No, No, No, No, No”. Had I responded to her provocations; had I even touched her in the slightest way , or even suggested to her that I might, she would have seized it as an assault on her. For this reason, I even stopped trying to put a barrier between her spitting at me and my face. It was important that I be close to her and still not respond to her provocations in a revengeful way. Even so. She made me angry. I felt anger, and I expressed it in a verbal way and at the same time expressed, on a repeated basis, that I wasn’t going to let her drive me away from her. I knew she was spitting at me out of her rage and frustration. I couldn’t stop her and I felt if I had tried to do so, it would have ended any chance I had to reach her.
It is important to understand that I was not acting permissively. That is, I was not encouraging her to express herself by spitting at me. And, I was not telling her that I was willing to tolerate her gratifying whatever impulses she happened to feel by spitting at me. I told her to stop doing it. And, I also told her that even if she continued, she could not push me out of her life.
What Rosberg describes in the preceding narrative is the essence of Direct Confrontation Therapy. His genuine concern for Stephanie and his ability to express the emotions her condition aroused in him became the keys to gain therapeutic access to her. He was in Stephanie’s life, and she did not want him there and could not do anything about it. He had begun to make her grapple in a controlled, therapeutic way with another human being, and she did not like it. As time went on, she became increasingly eager to yield to his demands in the hope that he would go away and she could return to the safety of her psychosis. Unlike all those other times, the necessity of compromise was being forced on her and she found that it was in her best interests to do it. Her patent eagerness to yield made it possible for Rosberg to consider other opportunities for negotiation and compromise so that he could continue to use what she might give away for further advantage.
Concluding thoughts on the case of Stephanie
In Direct Confrontation Therapy, language carves out the road both the patient and therapist must travel. The emotion of the therapist becomes the fuel to ignite the patient to action. If, however, the therapist’s unconscious contains materials that are too frightening or if the therapist has not yet developed the freedom to express in words or feelings the intuitions that arise from these unconscious forces, the patient will be lost to treatment and another brick will be added to the delusional wall that separates the patient from health.
Stephanie was not allowed to escape into her primary process. Rosberg’s therapeutic encounter with her forced her to deal with the perceptual reality we all share - the reality of language connected to appropriate emotion. When done successfully and consistently, these encounters foster the introjection of realistic values and beliefs. This insertion of reality into the patient’s life makes his/her feel a sense of safety as the therapist takes on more and more of the burden of the patient’s illness. The process of creating change by forcing Stephanie to incorporate appropriate introjects had begun. In this way an alliance can be formed in which the efforts of both therapist and patient can be joined in a common struggle against the illness.
If you believe, as we do, that a patient’s dysfunctional interpersonal behaviors are created when his/her legitimate needs are denied or frustrated, then the healing that occurs in therapy comes about when the therapist responds to the patient’s needs and not to his own. What became important for Stephanie was that Rosberg consistently demonstrated that he was not afraid of her violence; that he would not violate her; that he was not afraid of her psychosis; and that he was prepared to continue waging a battle on her behalf which would help her get better. Rosberg was able to convince her that he was only concerned about her and was not concerned about meeting his own needs. He was not interested in exploiting or manipulating her, but in trying to help her gain access to something she had lost: her right to be human and to be treated with dignity and respect. Hope had been held out to her and she had responded. Perhaps for the first time in her life, someone had not been afraid of her fear. The basis for a genuine therapeutic alliance had been created, and, as a result, Stephanie had been influenced to change her behavior to accommodate another human being.
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