Minorities in the minority

(Who is on the border of psychiatric care?)


PaeDr. Zlata Šramová, October 1998


(Report prepared for the International Conference on Reintegration of Psychosocially Handicapped People, Fall 1998)


An old rabbi lost his sight; he could no longer read or see the faces of the people who came to visit him. A healer offered him: „Entrust yourself to my care and I’ll free you from your blindness. “

„That is not necessary“, refused the rabbi. „I see everything I need“.

(Not all closed eyes sleep and not all open eyes see).

                       Anthony de Mello


As psychiatry has defended its minority position among medicine disciplines, we have continuously transferred a minority point of view on our clients in our own field. Consciously or unconsciously. There’s something like the privileged patient who cooperates and responds to therapist’s expectations, undergoes pharmacotherapy, tries (more or less successfully) to gain insight to the meanings of defense mechanisms, longs (at least we suppose) for change and demonstrates his new attitudes. (American psychologist D. A. Levy writes about it in a nice and witty way.)


Besides those who can’t decide whether or not to start therapy, there’s a group of patients/clients the therapists are trying to avoid. Those are: Chronic schizophrenics, severe obsedant disorders, geronto psychiatric patients, patients with severe addiction problems (particularly hard drugs) and personal disorders (described according to MKCH-10)


I call those the minority in psychiatry. Minority in a medical, social and therapeutic sense. Professionals working with these groups are confronted with many extreme situations while satisfaction is minimal. It’s like being “run down” by very difficult cases, which often lead to symptoms of burn out syndrome. Therefore, many psychiatrists, therapists, psychologists, analytics and social workers try to avoid extreme/ borderline personality disorder patients.


The marginal group, for Mindell (1994) is a group left on the edge of society, usually because it doesn’t fit into the primary identity of the dominating group. (Here dominating means the healthy or psychiatric majority group). According to Tajfel (1978): “Minorities are groups aware of mutual similarity, a certain social handicapping”. “The inner consistence and structure of the minority can be the result of a developing awareness of being considered different”.


The therapist’s privilege is set by his/her professional and social status. We determine (based on social norms and criteria) what is allowed and what is not, what form of behavior is appropriate, what role should we have at a certain age, in what way our development should be directed, the limits of our expectations and requests. If the patient/client is outside these borders we often (and despite professional training) react with dissatisfaction.


Why should a 40 year old chronic schizophrenic behave like a teenager, a 52 year old alcoholic like a sulky child, an 80 year old lady like Miss World? How come a 50 year old lawyer is interested only in cuisine and a 45 year old engineer wants only to repair radios? Why does a chronic invalid talk about studying at college while everyone “knows” it’s a lost cause? None of them fits in the primary identity of majority; on the contrary, they are an obviously secondary (in analytic terminology unconscious) side of our society. Let’s try to have a look at them from the other- positive side.


All of these patients/clients help us to perceive new edges. Those of client and those of therapist. The task of the majority in relation to the  minority is to change its attitude. We as therapists are thus expected to help the patient/client find the meaning of their attitude, find and experience their edges, reflection of relations, the meaning of escapes and maneuvering. All this, while respecting, despite the majority’s norms and rules, their rhythm, excesses, or strangeness.  Or to respect the style which they refuse to give up and accept this in its specificity. This approach also tests our edges, flexibility and willingness to change, since the conflict between the pressure of the minority and the outside obstacles others might temporally bring a new awareness of membership and thus reinforce old alliances and perhaps lead to a strong inner inhibition of leaving the group.


For instance, a chronic invalid schizophrenic living with his elder parents adapts rather quickly in a new therapeutic situation, starts to join ergo therapy and seems to be on a good path to resocializating.  As soon as he joins a social training focused on communication (a higher level of resocializating program- our image of what step should come next) he fails repeatedly and in few days regresses to the original form of behavior- stops taking care of hygiene, hangs around, smokes, reacts in an irritated way, meets old friends. After all, that’s the world he knows and feels relatively okay in. We can’t pull him out of it before we know what it means to him and force him (even if with the best intentions) into a different world.

The therapeutic task is to contemplate how he could be a “bum” or live a part of this quality in his life. Sometimes we even start with finding out what the quality is like.


In practice, a therapist meets the expectations of family members, employers or society to cut out the „ pus-filled ulcer“ and make everything like it was before.

There are programs (therapeutically effective and working for a majority of diagnostic psychiatric disorders) and even specific offers for individual diagnostic groups- OCD, depressions, chronic groups of schizophrenics, etc.

Despite our proclamation of individual approach (but how much do we really respect it?), there’s always a group of patients/clients left who are not able to/can’t respect or fit into existing programs.

If we tried to increase the pressure, they could pull even farther out in their minority group.

And we might feel that the therapeutic program is not effective or that the patient/client is not therapeutically suggestible, or (let’s admit it’s seldom) we might feel, we failed in the role of therapist.

Only rarely do we consider giving up our generally accepted criteria. From a more positive point of view, these are the patients/clients who help us become more creative and perceptive to man’s needs.


Questions we should ask in relation to our images (if we recall examples from the beginning of our report) might be following:

- Are our expectations those of the patient/client?

- What might be good for a 40 year old schizophrenic about adolescence? How might we assist it?

- How might we support a sulky child in a 52 year old alcoholic? What doesn’t want to mature?

- What keeps us from appreciating and acknowledging the beauty of an 80 year old lady? Or what wants to be appreciated?

- Why not support a longing for education (while it’s generally accepted criteria) and why not appreciate our patient/client for something else?


The main emphasis is on understanding and supporting what was observed –that is, what the patient/client agrees with. This is easier if we can appreciate it in the context of what’s happening, the way patient/client speaks, the structure of their language, the type of their physical symptoms, relations and synchronic associations. That is the attitude and the philosophy of process oriented psychotherapy.

For example, when a patient/client complains about absence of relationships, the therapist can work on their feelings in that moment and look for the support. If someone behaves under the influence of medicaments, the best thing is to use their “medicaments language” to communicate with them. If someone’s closed off, to communicate with their vegetative reactions. If restless, try to approach them through the movement channel.


An inconvenience of different approaches to mental disorders is that their competing takes away the patient’s energy from the treatment (and therapist’s as well) and can hinder in cooperation and team work necessary for creation and a more functional approach to individual suffering. Keep in mind we don’t have the right to set rules and to not respect the individual meaning of challenges, messages and needs we meet through our patients/clients.  That will help us not to abuse our privilege as therapists, not to consider ourselves unerring and behave that way, but we’ll accept the minority in our psychiatric clientele as a gift and as a challenge to our whole psychiatric and social community.



POP approach:


 A man came to see a psychiatrist and complained about a three-headed, twelve-legged dragon he’s seen every night. He’s just a bundle of nerves, can’t sleep at night and is going to have a break down. He’s even been thinking of suicide. “I think I can help you”, the psychiatrist consoled him “but I have to warn you that is going to take one or two years and cost you three thousand dollars”

“Three thousand?” shouted the man, “No way, I’d rather go home and try to make friends with it!”


 Anthony de Mello


Translation: Lenka Abrahamova, Andrej Jelenik

September 2006




Mindell, A.: Sitting in the fire. Lao Tse Press,  Portland, OR. 1994

Mindell, A.: The Year I. Global process work. Viking - Penguin- Arnana. New York and London.1989

Tajfel, H.: The social psychology of minorities. London. In MGRG.1978

D.A.Levy: edited Dr. Ivan Sarmány, CSc. Journal of Polymorphous Perversity, 1991


PaeDr. Zlatka Šramová: Author is currently working in Geriatric center, has a private psychotherapic  practice with mostly psychiatric clientele. She is an extern teacher of Pedagogic Faculty UK Bratislava