Personal Accounts: Strengths Versus Deficits, or Musician Versus Schizophrenic

My 44-year-old son David has had a particularly virulent form of schizophrenia since late childhood, and I do not believe the illness itself has abated over the decades. The newer medications cause fewer side affects, but in David's case, they do not otherwise seem to be more helpful than the old ones. Nonetheless, there is a dramatic difference between the David of 20 to 30 years ago and the David of today.

In the old days, David's life consisted of sitting and staring into space, chain-smoking, walking a lot, listening to his beloved folk music, and coming home once a week for dinner. Today he still smokes and walks a lot, but he also works at a restaurant an hour a day, gets himself to a clubhouse for lunch every day, and has learned to ride the buses so that he can get to his music and pottery lessons every week. On his weekly visits home, he often helps me prepare dinner, cracks a few jokes, and plays some live music with the rest of us.

I do not believe that these changes came about because of the possible tendency for schizophrenia to improve over the years. Nor do I believe that the newer medications played a role, since he had been taking them for many years before these positive changes occurred.

David's changes came about rather quickly when professionals and family members began to focus on his considerable strengths instead of his illness. Don't get me wrong—his doctor has always paid careful attention to getting the best possible medications and dosages for him, and I know that this aspect of treatment is important. But David received the same high-quality treatment 30 years ago with no notable improvements in his functioning, and again, even the switch to the newer drugs did not do wonders for him.

In the old days the emphasis in his treatment, aside from medication, was put on his illness and on helping him with his abysmal "daily living skills"—helping him learn to ride the bus, to take a shower, to make eye contact with people, and so on. But where should he go on the bus? For whom should he shower? With whom should he make eye contact—with those fearful strangers on the street who he knows want no contact with him whatsoever? This approach got nowhere.

A few years ago, at a regular semiannual treatment meeting, one of the social workers was reporting on David's considerable deficits. The psychiatrist said, "I don't want to hear all that again. That's his illness, and we have not been able to change that for years. Tell me about his strengths; we would do better to work with those."

I remembered hearing David pick out parts of a Bach fugue on his guitar, which is pretty good for a guy who had never had a music lesson. And his thoughtful foster mother had suggested pottery lessons because of an interest he seemed to have in a neighborhood pottery studio. My other children were artistic and musical; maybe David had talents, too?

With David's timid consent, pottery and guitar lessons became the focus of the treatment plan, and "daily living skills" were no longer emphasized. Guitar and pottery teachers were found, and after I explained the manifestations of schizophrenia and how they might affect David's learning, both teachers were more than willing to take on this new pupil.

After the first guitar lesson, the teacher said, "Hey, this man is talented!" Now that was worth taking a shower for. Maybe the music teacher would say that again. Either way, these lessons would bring the continuing joy of learning to read music and of being able to produce some of those great tunes on the guitar and the harmonica. Learn to ride the bus to get to the pottery studio? You bet. Even make a little eye contact with the friendly pottery teacher, who laughed with pleasure at David's newly created ceramic bear sitting in a canoe. The $215 he made in a pottery sale a year later produced even more eye contact.

Now that David understood the bus system, and now that he had the experience of pleasant interactions with a few people other than family and professionals, he dared to take on a job at a restaurant. He has had his job for two years now, and has never missed a day. They gave him a certificate for his perfect attendance, and now he talks about adding a few more hours of work a day.

Writing about a focus on strengths to improve functioning among people with severe mental illness seems so obvious that I almost feel foolish doing it. The readers of Psychiatric Services know all this. But because the history of treatment for people with severe mental illnesses is replete with cases of missing the obvious, it seems well worth trumpeting David's success with this approach.

How can I be so sure that other factors did not play a role in my son's great improvement? I cannot be completely certain, of course. He does get better care now than he did 20 years ago, and David himself gets enormous credit for his willingness to keep on trying. Not having the awful side effects of the older medications helps. And he is older, so perhaps his schizophrenia has naturally diminished a bit. Maybe all these factors contribute. But the fact remains that he showed very little improvement over the 25 years or so before the music and pottery lessons were started. Once a conscious effort was put into his strengths, the turnabout was dramatic, so I am inclined to think that that was the most important variable.

I am not knocking the importance of daily living skills, the success rates of short-term behavioral therapies, or any other useful treatment approach. Most of us feel more comfortable around people who are clean, do not smell bad, and behave in socially appropriate ways. But it may be that in many treatment plans we have been putting the cart before the horse. I think we need to start with what has meaning for the person struggling with a mental illness.

For David, one result of the emphasis on his strengths is that his life now has some meaning for him. His day has some structure to it, he has a job, and he can produce lovely pottery and music. Playing music also provides a way for him to join his family members on equal footing.

I think David's case can serve as a reminder that a focus on strengths rather than on deficits is a strategy that can be useful for all people, with or without mental illness. For most of us, starting from a platform of whatever strengths we might have can provide a powerful, underlying motive to work on all aspects of life.

In May 2000, my department threw me a splendid retirement party. My sister, children, and son-in-law sang the marvelously appropriate Victorian song "You're Old and Gray, and Only in the Way." Years ago poor David would have been sitting miserably in the corner of the room, head bowed, out of it. This time he was up there in the front row, playing his harmonica with the rest of my motley crew, and we all cried with joy.

Ms. Wasow is clinical professor emeritus in the School of Social Work, University of Wisconsin, 1350 University Avenue, Madison, Wisconsin 53706-1510. Jeffrey L. Geller, M.D., M.P.H., is editor of this column.