On a recent Ted Radio Hour broadcast on National Public Radio, Eleanor Longden told a fascinating story that began when she first started hearing voices while in her second semester at the University of Leeds in Britain. She was eventually diagnosed with schizophrenia and was told by her psychiatrist, “Eleanor, you'd be better off with cancer because cancer is easier to cure than schizophrenia.” Referring to her subsequent medical treatment, she said, “I'd been diagnosed, drugged and discarded and was, by then, so tormented by the voices that I attempted to drill a hole in my head in order to get them out.” She eventually withdrew from all of her medication, learned to understand the voices as being part of her that she could use in a healing and restorative way, and, after ten years, graduated with a degree in psychology followed by a master’s a year later. Today, she is in the process of finishing her doctorate in psychology. One of the criticisms Eleanor had of psychiatry, apart from being “diagnosed, drugged, and discarded,” was that the most important question in psychiatry shouldn’t be what‘s wrong with you, but rather, what’s happened to you.
To understand modern psychiatry’s view and interpretation of schizophrenia, which, as Eleanor stated, largely disregards the fact that “a human animal is a unique being, endowed with an instinctual capacity to heal and the intellectual spirit to harness this innate capacity,” you have to understand its contextual “paradigm.” According to Webster’s Dictionary, a paradigm is a philosophical and theoretical framework of a scientific school or discipline within which theories, laws, and generalizations and the experiments performed in support of them are formulated. Thomas Kuhn stated that a paradigm results when two criteria are met. First, an idea or achievement must be sufficiently unprecedented that it attracts “an enduring group of adherents away from competing modes of scientific activity”. Secondly, it must simultaneously be “sufficiently open-ended to leave all sorts of problems for the redefined group of practitioners to resolve.”
So how did the paradigm that has given rise to current biomedical theories of schizophrenia develop? Its modern formation began in 1878 when Emil Kraepelin combined previously noted mental disorders into one category that he called dementia praecox or literally, dementia of early onset. Kraepelin believed that dementia praecox (schizophrenia) was due to “an endogenous process of chronic autointoxication that led to a ‘self-poisoning [Selbstvergiftung]’ of the body and, eventually, the brain. Kraepelin believed that prevention and treatment of dementia praecox was possible if “the mysterious mechanisms of the self-poisoning process could be discovered.”
The astute reader will immediately note that Kraepelin’s theory follows a typical medical model in that it blames some mysterious internal mechanism for causing the disease of dementia praecox.
In 1906, Swiss psychiatrist Adolf Meyer, director of the Pathological Institute of the New York State Hospitals, rejected Kraepelin’s concept of dementia praecox as a biological disease and proposed that the condition was triggered by life experiences, proposing a biosocial rather that biochemical explanation. As stated by Robert Proctor, “scientiﬁc attention always comes at a certain cost: the decision to investigate one area is simultaneously a decision to ignore another.” This is exactly what happened with schizophrenia and how the Kraepelinian paradigm came to dominate the thinking of modern psychiatrists. Richard Bentall contends, “The core assumptions of the Kraepelinian paradigm have often been embraced unconsciously, so that it has been extremely difficult for researchers and clinicians to ‘think outside the box’ formed by them.”
Our understanding of schizophrenia has strayed very little from the paradigm established by Emil Kraepelin in 1878 and endorsed later by Emil Blueler in 1908. Together, Kraepelin and Blueler established the preferential bias for the medical model that is prevalent in psychology and psychiatry today. The medical community has largely forgotten Adolf Meyer’s view that schizophrenia may result from stress associated with life situations. Richard Bentall argues that this is the reason why so little progress has been made in the treatment of psychiatric disorders. Referring to Kraepelin he states, “Most researchers and clinicians have been stuck at the end of the blind alley into which he [Kraepelin] led us over a century ago.”
Lets return to Eleanor Longden’s story and her statement, “I'd been diagnosed, drugged and discarded and was, by then, so tormented by the voices that I attempted to drill a hole in my head in order to get them out.” In his book Roots of Renewal in Myth and Madness, John Perry states, “In the psychotic state called acute schizophrenia, the symbolic concerns in which a person becomes engrossed belong to a subjective reality. Although these concerns are usually totally out of keeping with objective reality, they are meaningful and not merely random disorder. Such ideation may be suppressed by medication, producing a superficial appearance that normality has been restored. However, if the ideation is given full attention rather than being suppressed, the individual in the psychotic state has an altogether different experience of it that changes the very nature and phenomenology of the psychosis.” It wasn’t until Eleanor Longden withdrew from all of her medication and learned to understand the voices as being part of her and began to use them in a healing and restorative way that she began to emerge from the torment of her psychosis. John Perry stated, “When medication is avoided and the imagery coming from the psychic depth is heeded, it may be found that nature’s own healing process is thereby allowed to do its work. The individual is relieved to know that he is in a legitimate altered state of consciousness in which certain processes tend to come into play for the reorganization of the self.”
It’s amazing how Eleanor Longden’s recent personal story of learning to live with the psychosis associated with her schizophrenia corroborates everything John Perry stated in 1976. One wonders, then, why psychiatry and psychology remain, as Richard Bentall stated, “stuck at the end of the blind alley into which [Kraepelin] led us over a century ago”. The problem seems paradigmatic in nature. The Kraepelin’s medical model has been used to justify an enormous expenditure of time and money on research pursuing an understanding of the mysterious “disease” of schizophrenia. Though perhaps a blind alley, the venture has indeed proven to be profitable. Pharmaceutical companies saw $84 billion in profits in 2013 with Abilify—an antipsychotic—as the top-seller with nearly $6.5 billion in sales.
Nonetheless, Kraepelin’s paradigm is currently undergoing serious challenges. A number of recent publications have called for reconsideration of Meyer’s biopsychosocial model. For example, Mary and Philip Seeman stated in their 2014 article entitled “Is Schizophrenia a Dopamine Supersensitivity Psychotic Reaction?” published in Progress in Neuro-Psychopharmacology and Biological Psychiatry that Adolf Meyer may have been correct in reframing mental illness in terms of biopsychosocial “reaction types” rather than biologically-specific disease entities.
In 1956, Gregory Bateson, Don Jackson, Jay Haley, and John Weakland published their seminal article entitled “Toward a Theory of Schizophrenia.” The key construct of this theory, labeled the Double Bind Theory by Bateson and his colleagues, involves the occurrence of mixed or conflicting signals—“ schizophrenogenic” messages—received as communication within a family system. Regarding this publication, Joel Cullin accurately stated:
Few in number are the published articles that encapsulate and risk so much as 'Toward a Theory of Schizophrenia', that evoke simultaneously such strong support and such vehement criticism, that change so fundamentally the viewpoints of so many already good thinkers, and that are rejected as non-scientific nonsense by so many others at the same time.
Gregory Batson and his colleagues proposed the biopsychosocial Double Bind Theory of schizophrenia at a time in history when Kraepelin’s biomedical theory was almost universally accepted. It should therefore be no surprise that it was summarily rejected by the majority of the scientific community. However, in light of recent publications that question the medical model of schizophrenia, are we now ready for a paradigm shift that would incorporate a more holistic, biopsychosocial view of mental and emotional dis-ease such as the Double Bind Theory? The pharmaceutical companies may be hoping not. It should be stressed here that it is not being suggested that everyone experiencing psychosis discontinue his or her medication. A balanced holistic approach in treating psychosis should allow for the use of antipsychotic medication, but the goal of treatment should be to help an individual understand the meaning of their psychosis so that, as John Perry stated, ". . the imagery coming from the psychic depth can be heeded so that nature’s own healing process is allowed to do its work." As Eleanor Longden suggested, we as clinicians need to start asking our clients, "what’s happened to you," not, "what’s wrong with you."
Bentall, R. P. (2003). Madness explained: psychosis and human nature: Allen Lane.
Cullin, J. (2006). Double Bind: Much More Than Just a Step 'Toward a Theory of Schizophrenia'. Australian & New Zealand Journal of Family Therapy, 27(3), 135-142.
Kuhn, T. S. (1996). The Structure of Scientific Revolutions: University of Chicago
Press.Noll, R. (2011). American Madness: The Rise and Fall of Dementia Praecox: Harvard University Press.