AND THEN also, very importantly, the case-aide worker has to be the adult in the situation. You go to college and you have a moratorium, you live in a protected world whether you like it or not, you're not worried about food or clothing necessarily, your tuition is paid, your big head-aches occur in two sets of three weeks during the year--it's all pretty easy.

And suddenly you come to a situation where what you do or what you say is apparently important to someone else, and you must make the judgments. The rules are not there as to how you should behave or what you can rebel against. You suddenly become the adult instead of the one being taken care of, and you find it's not that easy. This enables you to take another look, to review your relationships with other people. And changes do occur without therapy, without any such thing--as a normal process of growth.

At the end of about six weeks, you begin to get a puzzlement in the group. The case-aide brings the best of intentions. Harvard students -- people in that age bracket, generally--bring a sense of omnipotence to their work: it is as a result of their good intentions that the patient will get well. It is as a result of somebody paying a little attention to him. Sometimes this actually works.

But intentions are not enough, and this is what I've learned, if anything, in case-aide work. Some knowledge is important, but people with psychology or soc rel backgrounds generally do not make the best case-aide workers . . . they're anxious to apply their theories where theoretical knowledge is almost an impediment. Total naivete is worse, however. Some students start working from voyeuristic interest, but that quickly drops out. Adequate supervision stops that. I'm talking about the kind of person who feels that if this patient could only realize it's silly to keep banging his head against the wall, he'd stop. We had had some like that, and they do pose a major problem, but eventually, through group pressure, they are ready to become case-aide workers.

Patients Are People

But the ones who have a smattering of theoretical knowledge get hung up on interpretations instead of listening to the patient and relating to him as a person. Successful case-aides react naturally to a patient and bring things back to the group to find out what they're about. Frequently they are being therapeutic without doing therapy. They try to figure out the patients, but as people, not as cases.

After six weeks, then, the patient isn't getting well. He is still sitting behind a newspaper during the hour. He still says, "Aah, I can't see you because I'm gonna play poker." You go see him after five weeks of visits, after having brought him a little gift, and he's in bed and he just doesn't want to see you. And this has to be understood--as a rejection, or as a fear of closeness, or as an invitation to get into bed too.

You have to come to grips with this, and the case-aide's intentions are no longer the meaningful variable in dealing with the patient's experience of the situation. They are meaningful in terms of keeping the case-aide working with the patient, and they are meaningful to the patient, I guess, in terms of the fact that the case-aide keeps working in spite of the rejection, but in terms of curing someone, the inner conviction, by God, I'm going to help this person, itself is not enough.

So, at the end of six weeks, we begin to hit a puzzlement, a wondering at the loss of omnipotence, and maybe you begin to get a flaking out. Some people begin to drop from the group; they get discouraged. Three weeks in a row the patient hasn't wanted to see them. They decide the case is incurable, this is a lousy deal, and they drop out.

Realizations

This is not necessarily true. Cases may be incurable--in fact I don't think we cure anybody, we get them well enough to manage in the world. Nevertheless, you struggle through that, and the group begins to need support from the advisor and the day leader. Up comes exams about this time or a few weeks later; there is an interruption, and unless the case-aides keep contact with their patients, you find that the patients do reject the case-aides.

At this point the case-aides need to have explained to them that they are important, that the patients have been rejecting them, lying to them, or whatever. And about this time a depressed mood settles over the group. They have discovered that they're not going to fix the patients in 12 or 16 or 18 visits once a week. Here the group really comes to grips with itself. Is it going to be a group? Is it going to survive this realization, this destruction? How meaningful is it? Why did they get into this thing? It's a difficult job, it's hard work, and so forth.

They work this through, and begin to feel better about what they're doing because now they've finally gotten to know their patients and what this stuff means--not analytically, but in terms of interpersonal relationships. And then it's almost time to stop. We have to work through the termination, and we get a genuine depression in each member of the group, as well as in the over-all group. They have to realize that it is up to the patient to retain whatever they've done.

He may keep two per cent or 90 per cent of the good, the growth, the change. The whole year may have been spent just in getting to know the patient. That patient is not going to walk out of the hospital this year. Are they going to volunteer next year? This is the point at which the girls start speaking about "my father" instead of "Daddy." They become more realistic about the difficulties involved.

IN GROUP discussions, they bring up their own feelings, something different from their own problems. I only recall one instance when we got into some individual past history. This one episode related to dealing with feelings about death, and this brought up a piece of personal history which was very useful because it caused the other group members to express their feelings freely. But we got right back on to the patients.