Intruduction by Jack Rosberg
The following is a Newsletter written by Peggy Caton. I think that it is a very stimulating piece of work that bears close scrutiny. Peggy took her internship under my supervision and is now is acting as my psychological assistant. I think that the following is mind provoking. After forty-six years of practice, it is rewarding to see this kind of message. Much of what is written about schizophrenia today is not relevant. The majority of the literature is based on biologic concepts, which unfortunately, is so very dogmatic. We haven't yet discovered what schizophrenia is, even though there are so many theories about it. I think that it is time for us to look at things honestly and examine the alternative ideas with the hope that we can bridge the gap of misunderstanding.
I welcome any questions, or in fact, articles should people wish to respond to what Peggy Caton says. I would also welcome articles on schizophrenia from professionals and other interested parties.
Psychosis: Cause or Cure?
A person's belief about the nature of schizophrenia seems to affect and shape their attitude toward people with this condition. This attitude then influences the therapeutic alliance as well as the method of treatment. Some relevant areas of concern, in terms of attitude or perspective, could be stated as follows:
Schizophrenia as "brain disease", or as psychological condition
Predisposition as abnormality, deviance, or difference
Mental health system, mental patients, and secondary gain
Determinism versus choice, free will, and moral responsibility
Psychosis: cause or cure?
Not only does how a person views the condition affect the treatment, but it also affects how they do research about the cause and nature of the condition itself as well as the methodology they use to discover it. Some of the methods used to examine the nature of schizophrenia focus on physical differences or the presence of inhospitable prenatal conditions. Other methods look at the client in a contextual or clinical framework. Differences in viewpoint may account for some of the variation in hypotheses and findings about the cause of schizophrenia, which range all the way from a disintegrative developmental disorder to a predisposition for mystical genius.
Schizophrenia as brain disease, or as psychological condition
Although schizophrenia has been viewed in the past as a psychological condition, it appears that the current trend is to consider it as an organic illness or at least a biopsychosocial illness. However, those who do in effect call it a brain disease are unable to fully explain it in those terms or to say why there are so many different factors that seem to be relevant in the evolution of schizophrenia, a great number of which cannot be fully ascribed to biology. Even the discovery of physical correlations to this condition has not necessarily shown causality. The statement that those with some biological weakness or abnormality may be more predisposed to developing schizophrenia also does not show a causal connection, but only perhaps a susceptibility to psychological and social factors because of vulnerability or even sensitivity. Pictures and diagrams showing lesser brain activity in certain areas as tendencies in schizophrenia may not take into account that such a condition may be concurrently psychological and biological, or that the brain wave activity may be the physical manifestation and/or effect of the psychological condition.
What occurs, sometimes, is that one or more theorists form ideas of origin and these ideas become popular. Even the great amount of research being conducted on the physiological side of this condition may be influenced by the belief that schizophrenia is a brain disease. In the history of this condition, different theories have been popular, such as that of the schizophrenogenic mother. However, general agreement does not necessarily constitute proof. As one of the clients at the Clinic told me about these ideas, "Schizophrenia is not a popularity contest."
What is more important is how one's viewpoint about the condition affects the client. If I view this as a medical condition, a brain disease, I will probably treat it with medically based procedures, primarily medication. Whatever symptoms appear to remain I may attribute to the need for further medical research to pinpoint the specific physical cause and/or to the need to develop more effective medication. The primary purpose of psychological therapy, under these premises, would be to help the client learn to live with the condition, as ones does with Parkinson's or Alzheimer's, and to rehabilitate and remobilize the client as someone with a disability. Or, I may attribute the remaining symptoms to other factors, such as side effects of medication, malingering, or character disorder.
If I view it as primarily a psychological condition, I may still see the person as having an illness, but one that is mentally or emotionally based, for example, in faulty ego structures, psychosocial stressors or distortions in upbringing. I may ascribe the origin of this condition to the person's family, society, or to the person himself. However, this view may not consider temperamental or biological predispositions that cause someone to perceive or process his experience differently from others.
Abnormality, deviance, or difference
It is usually assumed that the psychotic process is an illness, a sickness, and an abnormality. In so doing, we see someone with psychosis as having a problem, a disability, as deformed or defective somehow, whether we ascribe the origin to be organic or psychological. In searching for these abnormalities, some researchers have found, for example, enlarged ventricles in the brain, but have also pointed out that such phenomena occur in the normal population and that some people with schizophrenia do not have enlarged ventricles.
Schizophrenia could be viewed as deviance, such as socially dangerous behavior. In some countries, political dissidents have been labeled as mentally ill to prevent them from influencing others. In other countries, psychosis may be considered a sign of special or mysterious ability.
Margaret Mead, in her study (Sex and Temperament), proposed that temperament followed a relative distribution range, but that a particular culture promotes a group norm of behavior. Those that naturally fit within that norm are comfortable, and those close to that can conform without too much difficulty. However, those people who are temperamentally highly divergent, or perhaps deviant according to social norms, may not be able to fit into those norms without psychological difficulty. In a number of societies, some people who show a tendency toward unusual behavior or nervous instability are chosen for training as a shaman or else are given special roles within that society that accommodate the natural differences they display.
I find it interesting that the figure of 1% is often quoted as the percentage of the population worldwide with schizophrenia. Could it be that the generality of this figure may point to an underlying temperamental difference? And following that argument, why should it be 1% at the lower end of the bell shaped curve? Why not at the upper end? A predisposition toward schizophrenia, in actuality, may be a neutral temperamental difference, such as enhanced sensitivity to stimuli. This argument of the highly sensitive person would conclude that this trait might require special consideration, which, if appropriately recognized and trained, could possibly produce remarkable results. However, if not properly understood and cultivated, or subjected to early trauma, it may, in actuality, become an increased vulnerability to mental illness.
This figure of 1%, however, can be challenged, and has been, for example, by S. Arieti in his study of incidence of schizophrenia in Italy (Interpretation of Schizophrenia). He found higher percentages of people with schizophrenia in large industrialized cities than in small rural locations, and countered the argument that perhaps they were diagnosed differently or fewer cases were reported for cultural reasons. Such studies do call into question the notion that this might be a stable occurrence independent of cultural and social factors.
Mental health system, mental patients and secondary gain
Some of the characteristics of schizophrenia are often stated to be lack of motivation, reduced movement, and lethargy. There are several ways to view these attributes. One could say they are characteristics of the "negative" symptoms of the condition. They could also be ascribed to the side effects of medication. It could be depression. It could be the result of years in mental institutions combined with lack of adequate treatment.
However, these characteristics could easily be, as well, the achievement of a comfort level as a result of being assigned the sick role, being taken care of, and having not much expected of them in terms of self-care or productivity. While infantilizing many, the mental health system also affords many people with schizophrenia the freedom to act in ways that would be unacceptable in society at large, and to have room, board, and services with little or no effort on their part. This can be a tempting, self-justifying and self-perpetuating situation. The rewards for improvement, or for social conformity, are that one loses a great deal of this support system. The mental health system also benefits from this arrangement, as it too can be a self-perpetuating entity.
Determinism versus choice, free will and moral responsibility
If one follows the concept of organic illness exclusively, it may tend to reduce socially unacceptable behaviors to quirks and impulses of the brain. The person suddenly hits someone, or yells and curses at them, spends all day in bed, or aggressively overeats. This behavior is then both explained and excused as thought disorder, or malfunctioning of the brain. This concept of medical illness tends, I believe, to decrease the humanity of people with this condition by stating, in effect, that they no longer have the capacity for choice or free will over their own responses, that they are victims whose behavior is determined by the vagaries of the disease.
Are people with schizophrenia responsible for the choices they make in regards to their actions? I have heard of people with this condition terrorizing others, their parents, roommates or caregivers, with excessive demands, impulsive overeating, cursing and physical threats, while this behavior is excused as an organically based disorder for which the "patient" is not responsible. If we consider people as having the power of choice or free will as a sign of their humanity, and we take away the sense of responsibility for their actions from people designated as mentally ill, are we not also depriving them of an essential part of their humanity as well?
Psychosis: cause or cure?
As mentioned, conventional wisdom takes psychosis to be a mental malfunction, with therapy attempting to reduce its symptoms in some way, primarily by medication. However, there are those who would see the prepsychotic state as actually being the malfunction, with psychosis an attempt by the psyche to dissolve and reorganize itself on a healthier basis. Psychologist Jack Rosberg spent many years treating patients in the acute phase of schizophrenia, with psychotherapy and without medication, and achieved considerable success. Dr. John Perry also successfully treated many patients in the acute phase (Trials of the Visionary Mind), without medication, using Jungian-based psychotherapy.
Though it could be suggested that persons so treated successfully may not truly have been schizophrenic but rather suffered from short-term or temporary psychosis, their success in treatment during the early onset may also suggest that the organic model of schizophrenia could be incomplete or flawed in conception, or, that the predisposition does not necessary lead to inevitable disintegration but may be halted and reversed, by helping the person learn to reintegrate himself on a stronger and healthier basis.
How we view someone is bound to affect how we treat him or her. If I view someone with schizophrenia as having a degenerative brain disease, this belief will likely lead to treating him as a sick or disabled person. If I view that person as deviant, I am likely to see him as someone who needs to be controlled or locked up.
If I view that person as someone with special sensitivity to nuance, I might be more respectful. And, if I view that person as someone who is touched by the transpersonal, I might train him to be a shaman or priest.
Or, if I view that person as someone who is struggling to find a more authentic basis on which to live, I might view him as more like myself, also seeking to grow, develop and become a better person.
And when we discuss our theories about the origin and nature of the condition, they inevitably affect the client's view of himself. People with this condition are often led to believe they have an incurable chemical imbalance and are ill. Even when we tell them they are not responsible for their illness, we inadvertently take away some of their personal power while trying to destigmatize a condition that is viewed as an illness or disability to begin with. How can a person possibly develop a sense of self-worth if they have been told they have such a debilitating condition?
On the other hand, how would it affect their self-esteem if they were told they were, for example, highly sensitive individuals who pick up nuances in their environment and that this can be a useful trait in a society of diverse people. It is not just a covert reframing of the definition of illness, it focuses on a positive aspect of what exists and this can give the person a sense not only of pride in themselves but also of being understood and accepted for what they truly have to offer. This increased self-esteem in itself may be able to help the person overcome some of the motivational problems that are associated with the negative symptoms of schizophrenia.
Peggy Caton, Psy.D.