Psychiatry and Anti-Psychiatry

David Cooper, David Cooper

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136438523
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Tavistock Press was established as a co-operative venture between the Tavistock Institute and Routledge & Kegan Paul (RKP) in the 1950s to produce a series of major contributions across the social sciences.
This volume is part of a 2001 reissue of a selection of those important works which have since gone out of print, or are difficult to locate. Published by Routledge, 112 volumes in total are being brought together under the name The International Behavioural and Social Sciences Library: Classics from the Tavistock Press.
Reproduced here in facsimile, this volume was originally published in 1967 and is available individually. The collection is also available in a number of themed mini-sets of between 5 and 13 volumes, or as a complete collection.

Chapter III
Studying One Family

'And a woman who held a babe against her bosom said, 'Speak to us of Children.'
And he said:
'Your children are not your children.
They are the sons and daughters of Life's longing for itself.
They come through you but not from you,
And though they are with you yet they belong not to you.
You may give them your love but not your thoughts,
For they have their own thoughts.
You may house their bodies but not their souls,
For their souls dwell in the house of to-morrow, which you cannot visit, not even in your dreams.
You may strive to be like them, but seek not to make them like you.
For life goes not backward nor tarries with yesterday.
You are the bows from which your children as living arrows are sent forth.
The archer sees the mark upon the path of the infinite, and He bends you with His might that His arrows may go swift and far.
Let your bending in the Archer's hand be for gladness;
For even as He loves the arrow that flies, so He loves also the bow that is stable.'

Kahlil Gibran, The Prophet

'Schizophrenia is caused by the fact that young people no longer obey their parents.'

Journal of Mental Science (1904, p. 272)

In each case the problem is to take the behaviour of the identified schizophrenic patient and attempt to discover to what extent this behaviour is intelligible in terms of the interaction between this person and other persons in the past and in the present.

In the cases we have studied¹ 'behaviour' includes most specifically the so-called 'clinical presentation of the illness' on and just prior to admission to hospital- the 'presenting psychotic symptoms'. '0ther persons' for our present purposes means the patient's nuclear family (his mother, father, and siblings), in some cases marital partner, and also staff and other patients in the ward community.

The 'material for analysis is collected by participant-observers, first in group situations with the families. Participant-observation means that the observer participates in a group interaction and that he is aware of and records his mode of participation and its effect in the total interaction as an essential part of the observational procedure. Participation is both an inevitable and an intrinsic part of this situation. Also in most of the interactions we have recorded there has been the clear intention to carry out 'family therapy'. Therapeutic interventions in this sense do not aim primarily at the interpretation of unconscious phantasy but assume the form of meta-communications (communications about communications) aimed at clarifying confusions that may be introduced by the primary communications - many of which are already communications about communications. Although we state that interpretation of unconscious phantasy is not our primary aim, it often happens that a meta-communicative intervention brings into group awareness 'unconscious processes'.

Second, participant-observations are made in die ward groups which include the patient during his stay in hospital. The 'therapeutic' organizing principles of these groups, which help to define the nature of the observations, are described in Chapter IV.

Family interactions selected for study are tape-recorded, and the recordings are transcribed into typescript. Non-verbal communications, however, unless cinematographic techniques are used, have to be noted as they occur by the observer in the group. Some of the para-linguistic aspects - intonation, inflection of voice, etc. - come through on the tape-recording.

The patient is usually first seen in an interview on his admission to the unit. This is the procedure in all 'urgent' admissions from home, but in some cases, when for example the patient is referred for admission from an out-patient clinic, the whole family, or perhaps the patient and one parent, are seen together on the first encounter and invited to state the problem, perhaps in the form 'Could someone say what the trouble seems to be?' After a two-person interview with a doctor, the patient entering the unit becomes part of the ward community group and in the earlier phases of the unit's functioning he would a little later be invited to join a group engaged in one of the work projects: to some extent he would choose his work group, but there were naturally limits to the maximum or minimum number of people who could work on a certain project. He is also expected to do his share of ward domestic work (cleaning, laying the dining-tables, and washing up). Finally he will participate in the various organized and informal social and recreational groups, usually with staff present.

The family investigation is a part of the total investigation, which in a given case may take anything from three to four hours up to forty to fifty hours of investigation and therapeutic time. On the basis of an initial family assessment, plus assessment of the patient's problems as evident in the ward group interactions, the amount of time to be spent with the family is decided by the doctor therapist. It is decided in fact whether a number of sessions of family therapy are indicated; therapy, that is to say, in the sense of an attempt to modify the existing patterns of interaction in the family or, rather, therapy as the provision of a controlled situation in which the family members modify themselves in relation to each other in such a way that the identified patient member discovers an increasing area of autonomous action for himself while at the same time the other family members become more 'self-sufficient', at least to the extent of not breaking down in a manner judged to be psychotic.

In certain cases (the majority, partly due to limitations of therapist time) it may be decided not to involve the whole family to any extent directly in the therapeutic situation; then the aim of work with the patient will be more simply to provide the sort of situation in which he will find social experiences, transitional from his family experience, which lead to his being able to exist in the community without becoming the focus of attributions of mental illness. If this works out well, he learns to exist independently of his family and ultimately of the ward. Often he graduates through the stages of full 'in-patient' status, then working out from the ward in a local job, then living in lodgings and attending only once a week or fortnight for an out-patient session. In other cases, on the basis of the initial family assessment, it may be decided that some other member of the family who more or less willingly takes the role of primary patient may come into an inpatient or outpatient therapeutic situation and the original patient admitted with schizophrenia may be promptly discharged: in our experience in the unit this sick-role reversal has happened most often between 'normal' mothers and 'schizophrenic' sons.

The admitted patient is interviewed alone for at least one hourlong session by the doctor. The whole family, at least the parents and the patient, siblings too if available, meet with the doctor for a variable number of hour-long sessions. Various dyads and triads from the family meet in similar sessions, the main combinations, in addition to the basic whole family group, being the two parents together, each parent in turn with the schizophrenic child, and a 'non-schizophrenic' sibling together with the patient. There are also two-persons sessions in which each parent in turn and at least one sibling see the doctor alone. These latter sessions are particularly apt to bring out highly contradictory views of the patient, his 'illness', and the family (Laing and Esterson, 1964).

There are two interview rooms in which the families may meet. In one they sit around a table, in the other there is a circle of armchairs. Consent for tape-recording the sessions is obtained before the machine is switched on - we have never experienced any objection to tape-recording or undue conscious preoccupation with the machine during the sessions. There is no other formal structuring of the situation or set of injunctions given apart from a statement by the therapist at the beginning of the first session to the effect that 'perhaps we could discuss what led to X's coming into hospital' or, alternatively, 'perhaps we could discuss what seems to have been the trouble here'.

It has been our experience that this sort of family investigation, coupled with observations in the ward-group interactions, can make intelligible those 'symptoms' regarded, in the conventional view of schizophrenia, as being most absurd or meaningless. By this means we can usually discover the method in madness, the secret sense of nonsense.

To illustrate these remarks we shall consider the case of Eric V. The family investigation here consisted of twenty-five interviews with Eric and both his parents, two interviews with his parents on their own, one interview with Eric and father, one with Eric and mother, one with Eric and his younger sister Jean, one with sister alone, two with mother alone, and two with father alone. There are also a number of observations on his interaction with others in the ward community.

Eric V was admitted to our mental hospital, as a legally detained patient, for the first time in 1960, when he was nineteen years of age. The clinical 'mental state' examination at that time included statements to the effect that he was impulsive and uncooperative and that he showed 'thought disorder' and could give no coherent account of himself apart from vehement denials that there was anything wrong with him and demands that he be allowed immediately to return to the University in Wales which he had left of his own accord two days earlier. He would (in his pyjamas) make wild dashes from the ward which were physically restrained by the nurses and by large doses of sedation. He had ideas of references and aural hallucinations: he believed that people, even those who did not know him, looked down on him and called him 'soft'. He believed he heard staff telling him that he had no right to be in hospital and that he should go home which he tried forcibly to do despite staff restraint.

The immediate background to his admission was that a week earlier, a fortnight before the end of his first term, he had telephoned his father to announce without explanation that he was returning to his home in London from the university. He did in fact commence the train journey home but got off at a station half way and attempted to hitch-hike back to the university. He appeared obviously distressed and confused and was picked up by the police who put him on a train to London.

He arrived at his parents' home very tired and hungry. According to his father he was quite 'rational' but not prepared to talk about himself. His mother welcomed him but he walked straight past her, brusquely brushing her aside. Immediately afterwards, however, he contradicted this gesture of rejection by turning and hugging and kissing her. Later that evening he said he wanted to return to the university and refused to go to bed despite persuasion. His parents, feeling unable to deal with this situation, called in the family doctor, who gave him a sedative. He went to bed but later came downstairs weeping, asking 'What can I do?' His father assured him that he had done the right thing in coming home where he could get help with his problems. Eric, however, denied that he needed help of any sort. He slept well that night but the next morning, although the doctor had advised him to spend the day in bed, he again announced his intention to return to the university. He shocked Ms family by saying that he hated his mother. It was at this stage that his doctor called in the Mental Welfare Officer, who arranged, with the formal authority of the doctor, for his admission to the mental hospital 'just for a short rest'.

When Eric's father saw the doctor alone shortly after Eric's admission to the ward, he was extremely distraught. He said that he had never really known his son, that Eric had always longed for affection but had always been diffident about accepting it, especially from him. He said that Eric had never wanted to be fondled as a child and had always shunned any form of affection that seemed in any way 'effeminate'. It was a terrible shock to hear him say that day that he hated his mother. His father seemed anxious to hear not that Eric would 'get better' but that he and, somewhat more vaguely, his wife had nothing to reproach themselves about in relation to the boy's 'illness'. Mr V did not know anything about what had gone on at the university and the only 'evidence of illness' that he produced was (a) that Eric had been somewhat extravagantly interested in politics over the last year, (b) that he had returned home from university for no apparent reason, (c) that he said, on arriving home, that he wanted to return to the university but did not want to discuss the matter with his parents, (d) that he said he hated his mother. Eric's home life, according to his father, was generally happy and 'better than average'.

In the first family group meeting during Eric's first week in hospital the interaction assumed a fairly rigid form which persisted during the next two meetings: Eric was firmly defined as the 'sick one'. Father adopted an inquisitorial attitude in which he would legalistically interrogate Eric regarding his symptoms, very much as in the conventional psychiatric mental state examination. Eric was sick; the doctors and his parents were going to help him get better; he should co-operate, have confidence in these good people, stay in hospital, and accept treatment (Eric was at this time making repeated efforts to leave the ward and go home or back to the university). During these sessions mother remained very much in the background, occasionally confirming father's pronouncements.

As these early meetings progressed father adopted an increasingly moralistic tone. It was no longer clear to what extent Eric was being regarded as ill and to what extent as bad (lazy, uncooperative). Father would point to various small resemblances between his son and himself and, in various contexts, gave his son repeated injunctions to identify with him, to cope with social situations in the same way that he did - after all he had had the same difficulties, It became increasingly evident that in these sessions father was trying to present to Eric in a highly condensed form the sort of fathering that is accorded most small boys throughout their childhood. Had Eric lacked this experience of a father before? In the third to fifth sessions this became more and more clearly affirmed by mother, who finally mounted a full-scale attack on father in terms of his never having made himself available to the family as a person. When Eric was twelve his father went to India, where he remained for eighteen months. This absence was regarded by mother as an extreme threat to the integrity of the family and she exposed her husband as never having made a serious decision about the family: they went to India to join father and it was mother's decision which led the whole family to return to England and settle down. Eric joined in this attack on his father, accusing him of evading his responsibilities. Father presented only a very feeble defence of himself, but then countered the attack with assertions to the effect that his wife had over-mothered Eric and had never allowed him any independent movement.

At this stage the parents were interviewed without Eric. It was clear that in between sessions a great deal had been going on between them and now they felt that their relationship, and consequently the family, was in great danger. The relationship, mother said, had never been secure owing mainly to father's 'withdrawal' from the family. Father, while accepting blame for this, complained that mother was putting the entire responsibility for Eric's illness on to him. The original facade of a united family with a son who had just 'got ill' for no apparent reason began rapidly to break down. Mother expressed her own fears of a mental breakdown and said that she was in fact ill now "through always taking other people's troubles on to myself. Important further information regarding the background of the parents was now forthcoming. Father had had a working-class background in the North ...