Excerpt from From Deep Within (Lewis): Blackjack

 

Blackjack

 

My first clinical experience was working in a state psychiatric hospital with a group of individuals who were diagnosed with schizophrenia. I was a new, inexperienced therapist. I had no idea what I was supposed to be doing. On the afternoon of our first group meeting, I came to the waiting area and figured a welcome to the new patients was a good start. When in doubt, be polite! I never even finished the first sentence of my greeting. As soon as I opened my mouth they stood up in unison and walked away from me toward the meeting room. I was surprised. I ran to the front of the parade and led them to the end of the hallway. No one looked at me or said anything. They shuffled, single file, into the room we had been assigned and plopped themselves down around a circular table. The space was small and cramped. We were so close together that the body odor of some people whiffed through the room. 

I hoped it might be easier to get everyone’s attention now that we were sitting. The group was made up of four men and two women, and I started by asking them to introduce themselves. Immediately, each person started talking over the next, but they weren’t introducing themselves. Three of the men were talking to voices they heard in their heads. An elderly woman was explaining to the others, who were not listening, that the television was sending rays into her head, and another woman stared at the ceiling, waving at no one, at least no one I could see. The only one who remained silent was the fourth man in the group, he just stared at the table. 

The fundamental goal of the group was to help the members learn everyday skills such as greetings and light conversation. After years in the hospital interacting only with staff, their social skills had deteriorated. Most wandered the grounds alone, only socializing when they wanted a cigarette. Smoking was still permitted on hospital grounds at that point, and the patients would come up close to strangers, violate their personal space and ask for cigarettes. Whether they received one or not, the patients would usually end the conversation with a grunt and walk away.

I had been a clinician for all of two months at this point, and I thought my task was straightforward – have the group members interact and learn the cadence of conversation. I planned to model how to engage in an ongoing conversation by simply talking with them and encouraging them to talk amongst themselves.

Toward this end, we met weekly – rain, snow, hail or blazing summer. On rainy days,  I could hear group members walking down the hallway by the squishing of the water in the soles of their shoes. When I suggested they take them off and place them on the radiator to dry, no one ever responded.  Each meeting was the same; the group members walked in, sat in their usual seats and stared at each other. 

The silent patient never even smiled or indicated that he heard anything that was said. When I asked my supervisor about him, she told me that he had been silent since she met him six years ago. It was her idea to try and engage the group in activities.

The next session, I brought in the game Monopoly, still freshly sealed in its wrapper. I thought Monopoly was a good idea. The ability to use money was a skill the group would need if they re-entered the world, and at least it would urge a sentence or two.

“The goal is to try to become the wealthiest person by buying, renting and selling property on the board,” I told the group. “Each of you gets $1500 to start.”

I asked one of the women to open the game and then I passed the money out to each person. The silent patient didn’t reach out to take his, so I placed it on the table in front of him. 

“Does everyone understand the instructions?” 

Everyone but the silent patient nodded. I took out the dice and asked each person to throw them in unison to determine the order of their turns. I asked someone else in the group to keep a list of the numbers each person tossed.

“I’ll be the banker,” one of the men piped up. I was feeling pretty pleased with myself, someone had responded.

“Let’s go,” I said.

One of the women, who was wearing three layers of clothing, I assumed to protect her from the cold, threw the dice towards the ceiling and they scattered across the floor. I asked her to throw the dice once more, but this time across the table. She did so with such force they went flying into the people seated across from her. What a beginning. For the next six weeks, I attempted to teach the group to play the game, but to no avail. At most they finally figured out how to throw the dice on the table. Frustrated, I tried to think of something simpler. 

I thought Pick-up sticks was a clever idea, so I brought them in one afternoon. I slowly explained the guidelines. I felt like my words were molasses. “The dealer holds the bundle of sticks loosely then releases them on the tabletop. One by one, each player must remove a stick from the pile without disturbing the remaining sticks. If a stick moves, the player’s turn ends and the next person tries. Any player who successfully picks up a stick can take another turn and keep removing sticks until one moves and then their turn is lost. The winner is the player who, at the end of the game, has the most sticks.” 

The game started out well, and the patients seemed to enjoy themselves. They seemed to be paying less attention to their inner stimuli and more to each other. They weren’t looking around the room as much, and they even made eye contact. I was ecstatic. We played without incident for several weeks, although the silent man sat staring at the table and didn’t participate, even with enthusiastic requests for him to join the group.  

Meanwhile, the group’s therapy advanced with glacial speed. Amid the games, six months into our meetings, I couldn’t detect any improvement in the group members’ interpersonal skills. Everyone periodically continued to talk to himself, herself or the air, and the silent patient still hadn’t uttered a peep. “Change happens in small increments,” my supervisor said when I turned to her for advice. I was so disenchanted; maybe the thing to do was for all of us to stare at the ceiling together. What was the point? 

I tried to comfort myself with the reminder of the new and exciting clinical experience I was getting. This, however, had little impact.

Each group meeting lasted an hour and a half, and since the games ended quickly, we often played six games or more. One afternoon, a loud argument broke out among three members about whether someone had moved a stick during their turn or not. The argument became a screaming match, as the session was about to end. 

“We’ll talk this over and figure out how to solve the problem at the beginning of group next week,” I said. “Maybe over the week people can think about what might be a fair compromise to each person.” My efforts had bombed, and I so desperately wanted to succeed.

I was frustrated with the results for both Monopoly and Pick-up Sticks. Leaving on a Thursday evening I traveled to Las Vegas for a weekend and my struggles with the group flew out of my consciousness. Each day while in Vegas I took $20 to the casinos and, without fail, lost the money on the slot machines. On my last day, I decided to change things up, and I took a $100 bill to the Blackjack table. The croupier smiled and invited me to sit down. It felt like a group activity. I laughed and talked with the other participants, each of us trying to help the others to beat the house. I had fun with the rowdy group, and even more fun when I won $300.

At our next group meeting, I brought in four decks of cards and a Las Vegas style deck holder. I wore a bright green hat, laid a sheet over the table, and then asked everyone to sit across from me. I gave each person twenty-five pennies, explained the rules, and started dealing the cards. 

The group immediately figured out how to play. I added up the cards for each person and then they decided if they wanted another hit. Since math isn’t my strong point, there was always a delay while I added up the cards for each person. To my amazement, while I was counting, members started talking to each other, asking whether they should or shouldn’t take a hit. They split aces and eights. They doubled down on some cards. I was amazed. Even the silent patient began to play. 

As the months passed, I got quicker at adding the cards without errors. Whenever our group met, I asked what game they wanted to play. The answer was always a resounding, “Blackjack!”

Occasionally, however, my addition was still wrong. One day, when I dealt a hand to the silent patient, without realizing it, I added up the numbers incorrectly. That day, he stood up, looked at me and said, “You gave me the wrong total. Are you cheating or was it an honest mistake?”

I was dumbfounded. From that time forward, he spoke in every group. He asked to be the croupier, and I handed over my hat. He dealt the cards with lightning speed and added them up for the other members. Whenever anyone had difficultly choosing what to do, he slowly and clearly explained the pros and cons of each choice, and then softly added, “Hope that helps. Go ahead and choose.”

I was so happy. My dog mindedness and desire to help had paid off.

Group therapy is meant to allow people to develop bonds with each other in ways that they can’t in one on one therapy. I believe that the silent man’s breakthrough and subsequent activity in the group spoke to his developing a willingness to reach out and participate with those around him when a game was fun. Maybe, after all that time, he felt comfortable.

The group continued on for all the years I remained at the hospital, and I was certain the experience made their bleak lives better. To be honest though, I still have no idea why exactly the group became moderately successful, but I felt hopeful. On the other hand, I was saddened by the realization that something so small could make such a monumental difference.

For more posts on Susan Lewis and her book, click HERE.