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Talk is Not Cheap: A Narrative Approach to the Successful Discharge of a ''Dangerous Male With Schizophrenia'' From a Medium Security Ward
Anja Vaskinn, Peter Sele, Frdric Andr Eftevg Larsen and Asle Dal Clinical Case Studies 2011 10: 247 originally published online 25 April 2011 DOI: 10.1177/1534650111407306 The online version of this article can be found at: http://ccs.sagepub.com/content/10/3/247

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CCSXXX10.1177/1534650111407306Vaskinn et al.Clinical Case Studies

Talk is Not Cheap: A Narrative Approach to the Successful Discharge of a Dangerous Male With Schizophrenia From a Medium Security Ward

Clinical Case Studies 10(3) 247258 The Author(s) 2011 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/1534650111407306 http://ccs.sagepub.com

Anja Vaskinn1, Peter Sele1, Frdric Andr Eftevg Larsen1, and Asle Dal1

Abstract This case presents a man diagnosed with paranoid schizophrenia and persistent violent behavior admitted to a security ward. A treatment deadlock characterized by a defeatist personal narrative and a staff narrative highlighting alleged antisocial traits and unpredictable violence called for a new clinical approach. Assessment confirmed a schizophrenia diagnosis and disconfirmed a diagnosis of antisocial personality disorder.Violence only appeared inside the ward.This enabled an alternative narrative to manifest itself. According to the new staff narrative, he struggled with persistent psychotic symptoms and used violence to deal with negative emotions, such as anxiety arising from perceived interpersonal rejection or potential failure at independent living. The new client narrative included a sense of agency. The case illustrates how oppressing narratives can block treatment progress and how this can be overcome by allowing alternative narratives. Violence was reduced, and he was discharged 3.5 months after the start of the narrative intervention. Keywords dangerousness, narrative therapy, schizophrenia

1 Theoretical and Research Basis for Treatment

In Norway, people with a combination of a psychotic disorder and a persistent history of aggressive and dangerous behavior are usually treated within special units known as security wards. A maximum security ward is characterized by a very high degree of control. These facilities are locked and have a high staff-to-client ratio. The physical environment emphasizes a minimization of furniture and other inventory while maximizing the visibility and overview. Persons admitted to a maximum security ward usually have florid psychotic symptoms in combination
1

Oslo University Hospital HF, Oslo, Norway

Corresponding Author: Anja Vaskinn, TOP/Psychosis Research Unit, Oslo University Hospital HF, Aker Hospital, Building 14 Gaustad, P.O. Box 4959 Nydalen, 0424 Oslo, Norway Email: anja.vaskinn@medisin.uio.no

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with a high risk of committing violent acts. A medium security ward is also a locked facility but is usually reserved for people with attenuated psychotic symptoms and a lower risk of violent behavior. The staff-to-client ratio is somewhat lower than in maximum security wards but still higher than in a regular ward. The biomedical model with its focus on the psychopharmacological treatment of psychosis is dominant in inpatient settings in the Norwegian mental health system and also in security wards. Although psychotherapeutic and psychosocial interventions are usually added to the treatment, the bulk of treatment optimism among mental health personnel in hospital settings is often reserved for antipsychotic compounds expected to tackle the most striking features of schizophreniathe hallucinations and delusions. When these symptoms persist in the face of adequate antipsychotic treatment, frustration can start to spread among personnel. Nonmedication-based interventions for schizophrenia or other psychoses are numerous. Historically, the psychotherapy of schizophrenia has not fared well, as little scientific evidence of its efficacy could be provided, especially for psychoanalytically oriented interventions (Drake & Sederer, 1986). However, recently, it has seen a renewed interest (Lysaker & Silverstein, 2009). A systematic search of Cochrane Reviews (Jung & Newton, 2009), that is reviews of randomized controlled trials, found strong support for four interventions (assertive community treatment, crisis intervention, music therapy, and psychoeducation). The only individual psychotherapeutic intervention judged to have some support (moderate) was cognitive behavior therapy. Still, this does not indicate that other individual psychotherapies will not be effective, as randomized controlled trials are not always feasible. Indeed, case studies have shown that interventions as diverse as metacognitive (Buck & Lysaker, 2009) or social learningbased procedures (Springer et al., 2010) can be useful in the treatment of schizophrenia. Although their use cannot be considered evidence-based, this does not mean that other psychotherapeutic interventions will not be efficient or cannot be recommended. Probably, the ideal treatment of schizophrenia contains individual psychotherapy in combination with psychosocial and psychopharmacological interventions (Bradshaw, 2000). Mental health personnel tell stories about the people receiving their help. These narratives are influential because they impact on treatment progress. Narratives have such power because they, whether they are told in a hospital context or not, will shape our view of ourselves and define what we notice and remember. Narratives also have the power to determine the future. If mental health personnel are frustrated, it will influence their hopes for the person receiving their help and the manner in which they talk about him or her. Indeed, among the key problems in the mental health system, according to their consumers, are hopelessness (people lose focus on development and growth due to an exaggerated focus on symptoms), depersonalization (persons behavior is explained by diagnosis; person is defined as illness), and the theme of loss (personal identity is replaced by identity of illness; Bassmann, 2000). It is easy to see how a negative dominating narrative among helpers can be responsible for such experiences. Also, stereotypes depicting people with mental illness as incompetent or dangerous can impact on the personal narrative leading to self-stigma (Lysaker, Glynn, Wilkniss, & Silverstein, 2010). Changing a negative and defeatist narrative into a positive empowering narrative can change the course of treatment. Thus, the narratives told in a medium security ward by the people working there are of importance for clinical improvement. Narrative therapy (White & Epston, 1990) is a psychotherapeutic approach that works directly with the stories told. It is not commonly used for psychotic disorders (France & Uhlin, 2006), in spite of the fact that it was early pointed out that psychiatric diagnoses and labels can function as repressive narratives that pathologize people and limit the prospects for recovery (White, 1987). The stories people tell about their own problems are often negative. Such subjugating stories block off alternative stories (Holma & Aaltonen, 1997). Narrative therapy addresses this head

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on. Inherent in the narrative treatment approach is the effort to seek out and highlight alternative, more positive stories and self-perception. In fact, the goal of narrative therapy can be said to be to change a clients personal narrativefrom a negative, unproductive one into a more productive one. Generation of alternative narratives can in turn lead to empowerment and diminish the negative effect of psychological symptoms. One type of narrative therapy, open dialogue approach, has been used for the treatment of psychotic disorders in Finland (Seikkula, Alakare, & Aaltonen, 2001). In this approach, it is suggested that successful narratives include a sense of agency as well as choices for the mental health service consumer. Anderson and Goolishian (1992) have defined sense of agency as a personal perception of freedom or competency to make sense and to act (p. 31). Similarly, it has been suggested that a change in therapy can clear the way so that a new sense of agency can emerge with the construction of a new narrative (Holma & Aaltonen, 1997). In other words, the goal of narrative therapy can be said to be to increase a persons sense of agency. This case study illustrates how a treatment deadlock was overcome by switching from a biomedical stance to a psychotherapeutic narrative stance in the clinical approach to an aggressive young man diagnosed with schizophrenia and admitted to a medium security ward. Paramount in the treatment was the reintroduction of a sense of agency in his life. This article shows how a narrative approach can facilitate the discharge of an impossible case.

2 Case Introduction
The current case presents Martin, a man in his late 20s diagnosed with paranoid schizophrenia who had been admitted to a medium security ward for 2 years. There had been several failed attempts at discharge, and numerous violent assaults on staff members had taken place. The presentation identifies how a subjugating story overwhelmed both Martin and his helpers and describes how a new therapeutic perspective changed interactions, installed hope, and made discharge possible. Postdischarge outcomes are briefly presented. All identifying information except that which is necessary for the demonstration of interventions and outcomes has been changed to ensure Martins anonymity. Martin is not his real name.

3 Presenting Complaints
Martin had been hospitalized a number of times. He received a diagnosis of paranoid schizophrenia during his first hospitalization at the age of 20. Symptoms included auditory hallucinations and somatic and paranoid delusions as well as social withdrawal, apathy, emotional blunting, and alogia. During the current hospitalization, he was transferred to our medium security ward after physical attacks on staff members on the ward where he was initially admitted. At the time we were introduced to the case, Martin had been admitted for 31 months (the last 23 months at the medium security ward) and treatment progress had come to a halt. Martins response to available antipsychotic medication and milieu therapy was only partly successful as he still suffered from devaluating auditory hallucinations, paranoid delusions, and negative symptoms. Auditory hallucinations caused substantial distress and limited his level of functioning. He heard devaluating voices that he largely attributed to family members or staff. He described the emotional tone of the voices as vicious. The voices depicted him as useless and mocked his every attempt at improving his own situation. Statements included ones like Just forget about it, you wont make it anyway and Shut up! We said, shut up. Furthermore, Martin displayed a range of maladaptive interpersonal behaviors such as verbal threats or physical assaults toward staff with reference to them talking negatively about him or projecting bad vibes. Martin also caused substantial material damage in the ward by kicking in doors

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and smashing windows. His violent behavior often resulted in him being mechanically restrained with belts or separated from the other clients admitted to the ward (open-area seclusion). Violence occurred without clear prior warning signals. Due to an apparently unpredictable violence pattern, staff members felt insecure and visibly apprehensive when Martin was nearby. He always initially justified his aggressive outbursts by claiming that the staff had started it, with reference to hearing them making demeaning comments. However, after a time delay of some days, he expressed nonviolent attitudes and regret at the incident, and he acknowledged having acted in anger on the false belief that a psychotic voice he heard was real. It was difficult to engage Martin in any structured milieu therapeutic activities over time. Repeatedly, he expressed initial enthusiasm when efforts were made to initiate activities based on his interest in music, electronics, or sports. However, he soon lost interest and refused further participation, without any evident reason. There had been several attempts at discharge to outpatient treatment and independent living in his apartment, but they had all faltered. Because of such failures and his persistent violent behavior, the discourse on Martin at the security ward saw through the passing of time an increasing focus on individual pathology with questioning of his schizophrenia diagnosis and the gradual appearance of the term antisocial personality. Clinicians and staff started to lose hope that Martin could live a life outside hospital. Speculations arose that a discharge might represent a hazard to other people and therefore could not be justified. When a new treating clinician was allocated, the treatment plan included transfer to a maximum security ward as well as electroconvulsive therapy, based on a hypothesis that an underlying depression could be causing Martins violent behavior.

4 History
Martin lived with his parents and an older sister till the age of 10, at which point his parents divorced. He went to live with his father while his sister lived with the mother. He played basketball and soccer. Through adolescence, he had some close friends but no romantic relationships. The description of his function and behavior was unremarkable until his mid-teens, which marked the start of a prodromal phase with social withdrawal, cannabis use, and delusional ideas. At the age of 17, he expressed clear persecutory delusions that his drinking water had been contaminated by his classmates. After his first hospital admittance at age 20, he received outpatient treatment for several years. He lived alone in his own apartment and held a part-time job. However, there were two intermittent hospital admittances at age 22 and 25 due to changes in the medication regimen. Unfortunately, Martin does not tolerate the one antipsychotic treatment that has shown superior effect on his psychotic symptoms (clozapine) due to somatic side effects. Other antipsychotics have proved less efficient in treating his positive symptoms. He was admitted to hospital again at age 27 and transferred to our medium security ward after displaying violent behavior.

5 Assessment Diagnostic Considerations

Uncertainty regarding Martins true diagnosis had arisen. Staff found it puzzling that his (selfreported) hallucinations and unpredictable violent assaults persisted, despite adequate antipsychotic treatment and the fact that he did not appear to be psychoticthere were no signs of disorganized thought or hallucinatory behavior. Questions such as Is he really psychotic? or

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Maybe he hits because he has an antisocial personality and not really schizophrenia? were posed ever more frequently. Such speculations called for a thorough diagnostic reexamination. Medical charts were reviewed and new interviews with family members undertaken. The diagnosis of paranoid schizophrenia was confirmedhe suffered from auditory hallucinations and paranoid delusions. However, no support for existence of a diagnosis of personality disorder was found. Specifically, antisocial behavior was exclusive to institutional contexts. Thus, the general Criterion B according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) of a personality disorderthat the pattern of inner experience and behavior is present across a broad range of personal and social situationswas not fulfilled. Furthermore, Criterion Dthat the pattern should be of stable and long durationwas not fulfilled, as there had been no reports of antisocial behavior in childhood or adolescence. Finally, as there was no evidence of antisocial behavior taking place during nonpsychotic phases, Criterion Ethat the pattern is not better accounted for as a manifestation or consequence of another mental disorderwas not fulfilled. Clearly, Martin did not have an antisocial personality disorder. Thus, his violent behavior had to be framed differently. Formal violence risk assessment using Historical-Clinical-Risk Management-20 (Webster, Douglas, Eaves, & Hart, 1997) revealed that violent acts toward other human beings only took place within institutions and indicated that the risk of violent acts were higher with continued hospitalization as opposed to a life outside the hospital. Also, it became clear that violent acts invariably took place as the planned discharge date came closer. This had repeatedly resulted in the postponing of discharge, as it was interpreted as evidence that he was not yet ready for life outside the security ward.

Neuropsychological Assessment
As part of his admittance to the medium security ward, Martin underwent neuropsychological assessment. Results were in line with what is often seen in people diagnosed with schizophrenia: reduced psychomotor speed, memory problems, and trouble with executive functions. However, his intact intellectual skills indicated that progress was possible and that he possessed the resources required to lead a life outside hospital.

6 Case Conceptualization
During casual small talk, Martin presented himself as competent in several fields. However, people who knew him well judged this apparent self-confidence to be superficial and fragile and a compensation for massive unrecognized uncertainty regarding himself as a competent and likeable person. Several authors (Baumeister, 1997; Salmivalli, 2001) have proposed an association between aggression and a self-view where underlying self-doubt is masked by apparent confidence. A lack of intrinsic self-worth is thought to make some individuals especially prone to experience overwhelming self-threat in face of criticism, rejection, or failureand to respond with violence to restore their self-view. Martins display of violence probably served similar self-preserving psychological functions. It has also been suggested (Bjrkly, 2002) that there may be an association between emotional distress, certain psychotic symptoms, and violence, which also seems relevant to understand Martins behavior. Martins aggression was often directed at female staff toward whom he had previously shown covert signs of affection. Shortly after aggressive acts, Martin claimed to have heard the voices of these women mocking him. Furthermore, he reported hearing devaluating auditory hallucinations that consistently mocked his fragile, but nevertheless present, desires for a life

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outside of hospital. His psychotic symptoms seemed to be linked to significant personal issues. Romantic feelings or desires for an independent life both held great emotional value but simultaneously evoked profound uncertainty regarding his competence. Having been admitted to hospital for a long time, the association between violence and its consequences (such as postponement of the discharge date) was highly predictable to Martin. Violence was how Martin managed to ward off overwhelming anxiety facing potential change and fear of interpersonal rejection. In fact, his violence can be understood as a mode of communicating his lack of selfesteem and want of hope for his own future. Martin used violence to avoid exposing himself for possible losswhich could be a reality if he did not master an independent life outside hospital, living in his own apartment. Although use of violence was a successful way to avoid living outside the hospital, it also alienated Martin from his helpers. Their ability and willingness to respond empathically declined with recurrent violent episodes. Martin on his side felt more and more pessimistic about his future. The project of assisting Martin in overcoming the halt in his treatment process was complex. It was necessary to fight two battles, albeit similar, at once. In one battle, Martins own story was combated, in the other, the story of the staff. A new story was neededa story that would open for change and a different future. Martins view of the future was pessimistic. At the start of treatment, when asked where he saw himself 5 years from now, he responded that he pictured himself as admitted to the security ward as an inpatient. Paramount to the treatment was to increase Martins sense of agency. He had to regain ownership to his own behavior (a sense of agency), and his physical mode of communication (violence) had to be replaced by a more adaptive one even when facing troublesome emotions or psychotic ideas (Angus, Lewin, Bouffard, & Rotondi-Trevisan, 2004). The fact that Martin had only hurt people physically inside a hospital setting pointed in the direction of letting him lead a life outside hospital. This was assumed to both save mental health personnel from serious injury and to avoid fuelling the subjugating story of Martin as a dangerous person who would never master a life outside hospital. To install a sense of agency, Martin needed to be in charge of the treatment process leading out of the hospital. It was deemed to be important that he was given the feeling that he could take the time he needed. Martin represented a threat to the stability in the working environment at the ward, as his physical assaults on staff had caused several serious injuries. His violent behavior often came without externally visible warning signs and was consequently hard to predict. As a result, the staffs interaction with Martin was characterized by fear as well as resignation due to the rising uncertainty surrounding his diagnosis and which treatment to offer. The discourse surrounding Martin in clinical meetings at the ward became more and more infected with frustration. Resignation among staff members was evident. The stories they told about Martin put the spotlight on his alleged antisocial traits as well as his unpredictable violent behavior. These stories left any positive perspective on Martin in the dark. In other words, Martins pessimism regarding any possible progress was clearly shared by the staff. Both stories reinforced a treatment deadlock. The staff members were in need of a fixed progression plan with a clear discharge date.

7 Course of Treatment and Assessment of Progress

Immediately after the assessment, a discharge date was set. This was considered necessary to initiate the two separate, although connected, parts of the treatment: to change the story Martin told about himself as well as the story staff was telling. To reframe the story of Martin, it was necessary to convey hopehope that discharge to a life outside hospital was possible. Thus, the treatment consisted of letting two new narratives develop.

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Martins Narrative
Martin and the treating psychologist agreed on two regular sessions per week. In the beginning, Martins sense of self was entangled with delusions and hallucinations. He was convinced that his voices were real and that he could not escape them. Thus, he experienced himself largely as living at the mercy of the voices, with them being in control of his actions. Initially, he had no perception of who he was outside the psychosis or that such a separate nonpsychotic self even could exist. Regaining a sense of agency could only be achieved with the psychotic material at a distance. This separation process was identified as a central therapeutic task as it also was a premise for the development of a working alliance (Bordin, 1979; Orlinsky, Rnnestad, & Willutski, 2004). Externalizing techniques aimed at separating Martin as a person from the psychotic symptoms were utilized. As Holma and Aaltonen (1997) have pointed out, externalization helps individuals to separate themselves from subjugating stories, making it possible to experience a sense of agency. Specifically, externalizing language was used where psychosis was conceptualized as a problem that existed outside of Martin and that had a negative effect on his life. Martin was invited to see the problem from a distance through the treating psychologists conscious choice of questions and phrases that underlined the division between person and illness. These techniques soon proved fruitful. Increasingly, Martin saw himself as separate from his symptoms, no longer identifying himself as a schizophrenic but referring to himself as a person suffering from schizophrenia. Psychosis became a problem he had, not who he was. Gradually, an alternative and more adaptive personal narrative emerged where violence and psychotic symptoms no longer were interpreted as fixed personality traits. Instead, they were separated from the client and redefined as external problems that could be observed from a distance and dealt with incollaboration with his helpers. Thus, Martin could admit to being anxious about his ability to cope with life outside the hospital while longing for independent living. Violence was deconstructed and reframed as the way he managed unbearable feelings, especially shame triggered by perceived rejection from others. It was important to validate such negative feelings as well as his need for self-protection. Still, paramount to the individual psychotherapy was the empowering of the client by developing and strengthening his sense of agency. The main approach to accomplish this goal was the joint planning of specific interventions. This gave the client the main responsibility for how emerging problems should be dealt with. Moreover, he was able to participate in the development of a progression plan toward discharge by increasingly longer stays in his apartment. His ownership to the plan was achieved by allowing him to define the pace and by decreasing the control aspect on behalf of the hospital. Questions that were worked with continuously in the therapeutic sessions centered on whether he felt ready for the next step in this progression plan or whether it should be postponed until the next week. The qualitative shift in the therapeutic sessions was substantial. Overall, Martin became more tranquil. In addition, his facial affect expressions were more vivid and congruent to the conversational topic. This sparked a good spiral of therapistclient interactions. The client gradually became more understandable to the therapist, enabling more appropriate therapist responses and subsequently probably making the client feel better understood. Martin more often expressed a belief in his ability to cope with psychotic symptoms without turning to violence as well as his ability to master the demands of a life outside hospital. A solid working alliance between Martin and his therapist developed. The verbal repertoire expanded, and there was a decline in aggressive episodes (see Figure 1). The baseline assessment undertaken the month before the intervention started yielded six episodes, including one episode with a serious physical assault toward staff. No aggressive episodes took place during the 4th month, when he was discharged from the hospital.

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4 Number of episodes 3 2 1 0 Baseline Month 1 Level 1 Month 2 Level 2 Month 3 Level 3 Month 4

Figure 1. Display of violence during the course of treatment

Note: Baseline: number of incidents of violence during 1 month prior to the start of the intervention; Month 4: discharge took place; display of violence: Level 1 = material damage, Level 2 = verbal threats directed toward another person, and Level 3 = physical assault toward another person.

The Staff Narrative

An alternative story about Martin was enabled by conveying to staff and clinicians at the ward that his use of violence was not an indicator of antisocial traits. It was clearly stated that Martin did not have an antisocial personality disorder but that he used violence to protect himself from difficult emotions and potential loss. It was also stressed that he suffered from delusions and hallucinations and met the criteria for a DSM-IV diagnosis of schizophrenia. Introduction of a discharge date is thought to have been of great importance to the staff. In addition to the apprehensiveness many felt when around Martin, several of them also experienced feelings of burnout. The discharge date, set 3.5 months ahead in time, became a clear anchor point for the staff. They knew that Martins treatment would no longer be their responsibility after this date, as it was decided that on this date he would be transferred either to outpatient treatment or to the maximum security ward. It is assumed that this made it easier for the staff to tolerate another 3.5 months in spite of their apprehensiveness. Another intervention was considered to be of importance to facilitate the construction of a more empowering story. A group of six designated staff members was recruited among persons judged to be less at risk of burnout and given the assignment of working exclusively with Martin. These two steps represented a relief for all members of staff. Also, they embodied a motivational element for the designated staff group. One can assume that being responsible for a successful discharge in what previously had been deemed an impossible case would involve feelings of accomplishment and success. New and specific interventions were implemented when Martin displayed signs of aggression, or it was suspected that he was being tormented by hallucinations or delusions. These were not only known to the client but also Martin had participated actively in the development of these milieu therapeutic strategies that were to be applied in such instances. Similarly, it was specified what he could do himself. In this manner, it was worked toward increasing his sense of agency by ensuring him the power to influence on his surroundings at the security ward but without using violent strategies. The client himself could request the following: (a) A conversation

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with the designated staff member focusing on his emotions and inner experiences, (b) a timeout in the wards open seclusion area, or (c) medication (clonazepam or levomepromazine to reduce irritability). In the case of displays of aggression or the suspicion of psychotic symptoms, the designated staff person was to (a) describe his or her subjective experience of the clients behavior to the client and (b) remind the client of the three above-mentioned interventions and offer them to him. Over time staff reported a change in the communication between Martin and themselves. The implementation of the interventions mentioned above revealed to the staff that there might be other causal explanations for Martins behavior besides alleged antisocial personality traits. By asking him how he felt, they could see and understand his subjective experiences. Consequently, staff now interpreted Martins signs of aggression differently. This in turn changed the tolerance they had toward Martins displays of anger. A sense of mutual trust had been established by allowing the presence of a different narrative.

Transfer to Outpatient Treatment

During his 23-month-long stay at the security ward, several attempts had been made to establish Martin in activities outside the hospital. All proved futile as he soon reframed the encouragement from the staff to build a life outside as a wish to get rid of him. This had often resulted in aggressive behavior, ruptures in the therapeutic alliance, and the subsequent refusal of any further participation in the activity. When this pattern of easily triggered feelings of rejection was recognized, the idea of introducing a helper who was not specifically affiliated with the security ward emerged. This helper is a discharge coordinator whose responsibility is to ensure collaboration between different treatment departments at Oslo University Hospital and community health centers. In this specific case, he was the only helper assigned to work exclusively with the discharge process. He reintroduced Martin to the outpatient clinic and community mental health service that were to be his helpers after discharge, visited the apartment together with Martin, and accompanied him to Ikea to buy furniture. Meanwhile, the security ward was a place where Martin was always welcome. The results were soon encouraging. Martin could switch between strong expressions of hopelessness to the staff and consecutively accepting to follow the schedule and appointments made together with the discharge coordinator. Using the discharge coordinator in a position often filled by staff persons enabled a smoother transition to outpatient treatment. A structured plan of meetings was scheduled for the 3.5month period leading up to the discharge date. Martin, the discharge coordinator, and representatives for the security ward, the outpatient clinic, and the community mental health service participated. The agenda for these meetings was to define responsibility for any action to be taken as well as working on the discharge plan. As the discharge date came closer, Martin gradually regained the responsibility for his own life. A crisis intervention plan was made specifying responsibility and actions to be taken by Martin and his professional helpers during a given crisis. He was encouraged to ask for voluntary short-term admittances at the acute psychiatric ward, postdischarge, if needed. In summary, hope for the future was installed in the client and designated staff members. By trusting the client and offering support within the institution, he was allowed to excel outside the hospital. This was accomplished by giving space to an alternative narrativea narrative where he had the power to succeed in a life outside of hospital; a narrative that highlighted that he had never hit anyone outside of a psychiatric hospital and that he had been able to hold a part-time job. Three and a half months after the new perspective started to grow, Martin was successfully discharged to a life outside of hospital where he attends the outpatient clinic, lives independently

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in his apartment, and exerts control over his own life by asking for help, including short admittances to the acute ward when the psychotic symptom load increases.

8 Complicating Factors
The introduction of designated staff represented a relief for all members of staff. However, it also generated separate arenas where different stories could be told about Martin. Indeed, there was a discrepancy between designated staff and other staff in terms of viewpoints on treatment and the potential for successful discharge. A negative narrative clearly persisted in some staff members. This was dealt with through several ward meetings where staff was encouraged to refrain from all discussions concerning Martin and his progress outside of meetings where this was specifically part of the agenda. Loyalty toward the work of the designated staff was explicitly expected.

9 Access and Barriers to Care

Inpatient treatment, especially in a security ward, is expensive. In the case presented here, the utilization of narrative therapy helped accomplish an unexpected discharge to less costly outpatient treatment.

10 Follow-Up
After discharge from the medium security ward, a close collaboration between Martin, the discharge coordinator, the community mental health service, and the outpatient clinic has continued. The principal element in this collaboration has been to maintain Martins autonomy and responsibility for his own life, consistently working toward strengthening his sense of agency. The crisis intervention plan developed predischarge has been utilized, and Martin has been admitted for several short stays to the acute ward postdischarge. As intended, the initiative for these admittances has been his own and demonstrates a positive change in his sense of agency. The reason for the admissions has been an increase in the psychotic symptom load. However, due to the close collaboration, adjustments of Martins treatment have rapidly taken place to seek out appropriate solutions to problems that have arisen. Sixteen months after his discharge from the security ward, Martin has maintained his improved functioning outside of the hospital.

11 Treatment Implications of the Case

This case study demonstrates that a different perspective and an alternative narrative can change the clinical course of schizophrenia. It highlights that clinicians and people diagnosed with schizophrenia should always have the courage to believe in improvement and that progress is possible. Indeed, several studies have shown that full recovery from schizophrenia is possible, even for people with severe psychotic symptoms and low level of functioning (Harding, Zubin, & Strauss, 1987; Torgalsben & Rund, 2010). There is always hope.

12 Recommendations to Clinicians and Students

This case study shows how checking the history and carefully disseminating information from medical charts can introduce a new perspective. Martin had never been violent outside of the hospital. This opened up for the development of a new narrative about Martin. In this narrative,

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Martin could be trusted as a person who was not in the habit of using violence outside hospital. Clinicians and students should be aware that myths can persist in the face of contradictory information. They are encouraged to always verify the basis for the narrative told about their clients. In addition, an explicit focus on the narrative surrounding a person can in fact break an old and limiting pattern. Acknowledgments
The authors wish to thank Martin for his permission to publish his narratives, and Geir Hstmark Nielsen and Brita Elvevg for useful comments during the preparation of this manuscript.

Authors Note
This material is based on the clinical work of the four authors.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Bios
Anja Vaskinn, PhD, is a clinical psychologist and postdoctoral fellow at the Psychosis Research Unit at Oslo University Hospital. Her current research activities include social cognition as a determinant of social functioning in schizophrenia and the clinical implementation of social cognitive training in the treatment of severe mental disorders. Peter Sele, PsyD, is a clinical psychologist at the Specialized Inpatient Department at Oslo University Hospital. His main interest is psychotherapy in the fields of trauma and psychosis and the integration of cultural perspectives in the treatment process. Frdric Andr Eftevg Larsen is a psychiatric nurse and ward manager at the Specialized Inpatient Department at Oslo University Hospital. His main interests are risk assessment, treatment, and rehabilitation within forensic psychiatry. Asle Dal is a discharge coordinator at Oslo University Hospital. His primary interest is the implementation of collaborative strategies across sites in the treatment of double diagnosis such as the concurrent presence of personality disorder or psychosis and substance abuse.

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