Schizophrenia

Its Origins and Need-Adapted Treatment

Yrjo O. Alanen

• Publisher: Routledge
• Year: 2018
• Topic: Psychology
• eBook ISBN:
  9780429918735
• Subtopic: History & Theory in Psychology
• Index: Psychology

This book includes memorable case vignettes along with research findings and is recommended for clinicians, students, teachers of mental health and those in public policy involved in creating effective treatment methods.

Chapter One

Three patients

The attitude towards schizophrenia and schizophrenic patients is always a notably personal matter. I have repeatedly noticed this among researchers and psychiatrists: no matter how scientific and objective we wish to be, our theories of the nature and treatment of schizophrenia, shaped, as they are, by our psychiatric training and experience, are also influenced by our personalities and life histories. The attitude towards schizophrenia is often influenced by ideological considerations.

I begin this book by relating my own experiences with schizophrenic patients. I hope this will also introduce the reader into the world of schizophrenics—through the gate I used myself.

The first schizophrenic I know of having met was a young woman who was kept in confinement in the mental department of the Kurikka local authority home, waiting for a bed to be vacated in the district mental hospital. That was in the late 1940s, when I had started medical studies and went to see the local authority home with my father, the municipal officer of health for this rural community in Finland. Knowing my interest in psychiatry, he indicated the patient to me as a schizophrenic and encouraged me to get acquainted with her.

The cell was gloomy, its only “furniture” being a ragged sleeping bag with straw squeezing out of the tears. There was a small shuttered window near the ceiling. I was probably brought a chair, but whether the patient was, I do not remember. I only remember that she was sitting on her bag, her hair tousled, making strange faces from time to time. But she was interested in meeting me and spoke volubly, though in a way that was difficult to understand. Her speech revealed glimpses of problems related to her family, strange references to homosexuality, and many other things.

At that time, I was myself struggling with identity problems, though much less momentous than hers. Conflicts of family relationships and the personal pressures caused by them were of topical significance for me, too. The things this young woman was saying interested but also horrified me. It seemed obvious to me that what she said was not randomly incoherent, but reflected her problems, though in an uncanny and shocking way.

My father took a more objective attitude. He said he considered the illness hereditary, referring to the abnormality of the whole family. I do not remember whether he said that some other members of the family were also mentally ill, but I knew myself that the patient’s brother was considered odd and was called “Smarty Santanen”. The girl’s fate aroused pity in me: would she have to spend the rest of her life isolated in a hospital?

Another factor that influenced my preliminary conceptions of schizophrenia was more theoretical. Though a medical student, I also studied psychology at the university and was interested in art. In his book on developmental psychology, Heinz Werner (1948) compared the artistic productions of children, primitive people, and mental patients. He concluded that the art of the mentally ill is produced at a level that is lower than the “upstairs” logic of an adult in a high-culture community but which, nevertheless, exists in his dreams and subconscious mind. Picasso and other twentieth-century pioneers of modem art had been seeking stimuli on that more primitive level of expression to which we all have internal access, provided we have not been blocked by external and internal constraints implicit in our culture. I believe that the emergence of modem art and the psychological understanding of schizophrenia are not coincident by chance alone (even if the appreciation of art seems to have progressed more rapidly).

As I advanced in my studies, I found myself to be naturally oriented towards psychiatry, which also signified a permanent solution for a central part of my identity problem. While a student at the University Clinic in the Lapinlahti Hospital in Helsinki, I began, encouraged by my teacher Martti Kaila, to work on a doctoral thesis on the mothers of schizophrenic patients (Alanen, 1958) and simultaneously to learn about how to understand and treat these interesting patients. Never since that time have I lost this interest.

The first experiences of psychotherapeutic work are especially important for the professional development and orientation of a psychiatrist. I shall describe three patients who taught me much. (Their names have been changed.)

Sarah, my first patient

Sarah, a 25-year-old seriously schizophrenic language student, was my first long-term patient belonging to the schizophrenia group. When I first met her (in 1953), I was just beginning my psychiatric training and was only pne year her senior.

Sarah had suddenly become delirious while studying at a university summer school away from home. Her parents told me that when they had been informed of their daughter’s illness and had gone to see her, she had told them she was a medium and tried to hypnotize them, making rebuffing gestures with her hands. In the hospital Sarah told me that she had been used for experiments for the psychology courses simultaneously going on in the summer school. They had begun to hypnotize and train her in a group of ten people. She said she was now a clairvoyant, a medium able to converse with both spirits and many people far away, who were taking turns to speak through her brain. Later on these voices coalesced into one, which she called her “Guide”. The Guide lived inside Sarah but was a separate person from her. She was able to hear the Guide’s voice within herself and to talk to it. The Guide was also able to write, using Sarah’s hand.

Although the illness manifested itself suddenly, it was the end-point of a long process of development. Sarah had always been withdrawn: she preferred to live in a fantasy world of her own and tended to cut herself off from her companions. Over the preceding couple of years she had developed a morbid fear of examinations and lecturers. She made no progress in her studies. She had also begun to isolate herself at home, studying at night and getting up in the afternoon, avoiding her parents. The summer school had been her last attempt to resume her studies in a new environment, but eventually it led to a break in her precarious psychic integration.

I met Sarah and her Guide about three months after her admission. By that time she had been given both insulin and electroshock therapy, and her psychosis appeared notably alleviated. Even so, she continued to be seriously ill, preferring to isolate herself, talking to herself and laughing with her voices. I interviewed her for my research, inquiring about her childhood memories and her relationship with her parents. She gave matter-of-fact and calm answers but kept looking out of the window and partly covering her face with her hand. Her narration was colourless and conventional. She showed some bitterness at her mother, but as soon as she expressed such bitterness, she began to defend her again. She emphasized having been a conciliatory, good girl at home, and she said that her homelife had actually been “quite ordinary”.

Having conversed with the patient for an hour, I asked her whether she still had the other person, the Guide, within her. What happened was quite astonishing. Sarah said: “Let your Guide speak now”, and then began to recite in a deep, monotonous, theatrical tone: “Miss K—Sarah herself—is not ill, she is a unique creature, she is a medium. There is another person in her, but Miss K does not know who this other person is; she is not quite certain whether she is a medium or a schizophrenic. The Guide thinks this is idle speculation.” The Guide continued, saying that it had long been dissatisfied with Miss K’s “smooth words”, and that it was annoying to watch such different personalities as Mr and Mrs K—Sarah’s parents—having to live together. Sarah now began, in her own voice, to blame the Guide for ridding her from her responsibility towards her parents, and there followed an animated dialogue between her and the Guide. In the role of the Guide, Sarah walked about in the room, gestured theatrically, laughed, and even began to sing.

Sarah’s mother belonged to the series I was collecting for my doctoral thesis, and I met her soon after this. I described her as follows (Alanen, 1958, p. 175):

When I questioned this mother (M) about the patient’s childhood, she willingly led the conversation to her own childhood home, saying that “there, if anywhere, one would have found complications”. M’s own father, to whom she was attached, was an alcoholic and had shot himself when M was 16. Following this, M had had to leave her school, against her own wishes, and take a job in order to be able to help her mother, with whom she had strained relations, in supporting the younger children. Since that time M’s attitude towards life was dominated by powerful, martyr-like resentment. “When life runs evenly, I always think that some blow is soon coming from somewhere.” … She married a businessman of labile temperament, nervously hasty, with hypomanie traits, who at times used a great deal of alcohol. The patient (P) described her father saying that there is always some kind of air “of an imminent catastrophe” about him. M had felt frustrated as she had to be alone great deal. The first child came after a year’s marriage; it was a girl, and the mother regarded her as beautiful; her attitude towards her has always contained more attachment than her attitude towards P, a second girl. P was born 4 years after her sister; but this time the parents had wished for a boy. Meanwhile M had taken a job with which she felt satisfied, but she relinquished it after the birth of her second child. M did not say so herself, but both the father (F) and P herself knew that P’s birth had been a very unpleasant event for M. She had often felt very sick during the pregnancy—”very ill”, as she later used to tell P—and felt bitterness towards F. After P’s birth she remained at home. She says that from that time on she had sacrificed herself to her family. She had taken care of the children all alone and had also sewn their clothes. Her conversation revealed resentment against this role, which, however, she assumed with a martyr-like eagerness; it appeared as if M would be repeating masochistically the situation after her father’s death, when she had also “had to sacrifice herself”. There was, for instance, something quite typical in that M related, with great self-pity, how her sisters had wondered and felt pity for the fact that her hands, which had been admired as beautiful, were spoiled by constant laundering. …M’s attitude towards P has always been covertly hostile, with an admixture of contempt, and M’s attitude towards P’s illness was surprisingly cold.

I had read in the psychoanalytic literature—for example in Otto Fenichel’s The Psychoanalytic Theory of Neurosis (1945), that schizophrenic symptoms can be divided into two categories, the first pertaining to the breakdown and regression of the patient’s normal psychic functions (regressive symptoms) and the second to the effort to regain the equilibrium that had been lost, but within the illness and in a pathologic manner (restitutional symptoms). Sarah’s Guide was a most illuminating example of the latter category: it was her supporter and guide, and simultaneously a kind of ideal ego, which also helped Sarah to express her emotions better than she would otherwise have been able to do—though in a way that was separate from her own personality. In retrospect, I also would stress the significance of the Guide in serving Sarah’s symbiotic needs: this hallucinatory figure followed her like a helping parent.

My research on the mothers convinced me that disorders in the intra-familial relationships were significant for the pathogenesis of schizophrenia, but it also made me realize that neither the mothers nor the fathers should be blamed for their child’s illness; rather, they needed to be understood. We are actually dealing with the—mostly unconscious—consequences of the parents’ problems that they have been helpless to face, problems that have been inherited by them from their own homes and have usually been aggravated by their marital relationship. I found it easy to agree with Sarah’s Guide, who criticized her mother for suppressing her normal feelings of anger (“Mrs. K thinks a good child is a child whose behaviour is three times more controlled than that of an adult”), but I could also visualize this mother as a young girl who had herself been forced to support the mother she secretly hated after her father’s suicide.

After her discharge, Sarah continued in psychotherapy with me for more than a year. Her condition seemed to develop favourably. But there came a setback: the examinations and teachers continued to seem as frightening as before, her anxiety increased, she did not sleep well, she was unable to concentrate, and the accusing and frightening elements began to dominate her hallucinations. I soon concluded that a rehospitalization was approaching.

Then, in his perplexity, the young and inexperienced psychiatrist-tobe made an inappropriate move. During one session, Sarah leaned her head against the table in desperation. Feeling sympathy, I began softly to stroke her hair. I had not permitted myself to approach her thus before. The outcome was astonishing. Sarah lifted up her head and said she now heard my voice in herself: “Yrjö Alanen is speaking, he has become my Guide.”

Transference psychosis, with which I was now faced, was a new and embarrassing experience for me. I denied talking to Sarah in any way other than I had been talking to her previously—that is, through our conversation. This was confusing to Sarah, because she kept hearing my voice in her head instead of her previous Guide. Sudden as the shift was, I realized that there had been predictive signs of it: the Guide had already acquired features reminiscent of me prior to this occasion, which was shown by, for example, its increasing medical knowledge.

The inclusion of the therapist as part of the patient’s psychotic world—whether in a good or a bad sense—is relatively common in the psychotherapy of schizophrenia, and I have subsequently had several experiences of it, though not as dramatic as in Sarah’s case. Several therapists—for example, Searles (1965) and Benedetti (1975)—consider transference psychosis a regular and even a necessary part of the course of psychosis therapy.

I have subsequently considered it a mistake that I denied Sarah’s delusion pertaining to myself. It would not have been necessary for me to confirm this internalization verbally; it would have been enough not to contradict it, but to understand it as one stage of the therapeutic process. I also consider it a mistake—due to my own insufficiently controlled countertransference feelings—that I stroked Sarah’s hair, and ever since that time I have avoided an approach of this kind. Frieda Fromm-Reichmann (1952) has written that the therapist should try to maintain his or her empathically listening attitude unchanged in different situations, and this seems to me optimally to guarantee the therapeutic relationship and the continuity of the therapeutic process. The interaction between Sarah and myself might have developed more peacefully and in better accord with our internal resources if I had abstained from showing her my empathy in the form of physical contact.

Sarah’s fate was ultimately sad. After the transference psychosis, she became increasingly restless and was rehospitalized, which would probably have been unavoidable anyway. I continued to meet her there, but our therapeutic relationship was never again the same as it had been originally. She continued to hear my voice inside her head, and this “Yrjö Alanen” probably grew more and more different from the one who came to see her on the ward. Another psychiatrist even applied electroshock treatment to try to remove him from Sarah’s head.

Having been discharged from hospital, Sarah continued psychotherapy with another therapist, who was as inexperienced as I was—there were hardly any others available in Finland at that time. A few years later she was hospitalized as a chronic patient. I tried to contact her while I was writing the manuscript for this book, but I was told that she had died of cancer, having been in the hospital almost without interruption for more than 20 years. She had been living in her own world, her personality seriously disintegrated, talking to her hallucinations....

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• CONTENTS
• PREFACE AND ACKNOWLEDGEMENTS
• FOREWORD
• INTRODUCTION
• CHAPTER ONE Three patients
• CHAPTER TWO General notes on schizophrenia
• CHAPTER THREE The origins of schizophrenia: an attempt at synthesis
• CHAPTER FOUR Contemporary ways of treating schizophrenia and psychotherapy research
• CHAPTER FIVE Need-adapted treatment of schizophrenic psychoses: development, principles, and results
• CHAPTER SIX Therapeutic experiences
• CHAPTER SEVEN Treatment of schizophrenia and society
• REFERENCES AND BIBLIOGRAPHY
• INDEX