Schizophrenia: A Social Disease

SCHIZOPHRENIA IS CERTAINLY MORE UNUSUAL THAN MEASLES but people do, nevertheless, catch it, and to the tune, at the moment, of about 60,000 such patients in England and Wales. However, because the condition is categorized as a 'mental disease' it appears to be the particular, if not the exclusive, concern of the psychiatrist and his entourage of psychologists, psychiatric social workers, almoners, and the other cultural pitprops. A closer examination of the condition raises, however, a number of questions of general concern: why for example, do more people suffer from this condition today than in the past; while schizophrenia, as the writer of a recent pamphlet (3, p.3) on the disease observed, does not respect social class or intelligence, why is it that the lower socio-economic groups show a disproportionately greater incidence of the disease — a demographic fact conveniently ignored by the pamphlet writer; and thirdly, what kind of treatment does the schizophrenic patient receive?

The impact of such questions as these is, however, often parried, if not completely blunted, by the sophistry of the mental health movement itself. Let us look first at some of the usual counters. Firstly, that it is inappropriate to compare the present incidence of the condition with those of the past because the methods of diagnosis are today much improved; the implication being that there were many more in previous generations who ought to have been classified as schizophrenic but weren't, because of the poor medical facilities at the time. The same argument could, of course, be applied to all medical statistics. Nevertheless, we are able and do make comparisons between the mortality rates for different periods and although these are not by any means complete they are nevertheless useful as a means of comparison. Now, whilst people don't die from mental disease the salient characteristic of such a disease is the inability to cope — or a variety of reasons — with life in society. The records of the mental asylums, mad houses, workhouses, etc., show therefore the number of people who were at that time unable to cope with social existence. If they

Quote:
JOHN LINSIE is a teacher who after graduating in psychology worked as an educational psychologist in an approved school.

weren't so detailed then it can be assumed that, to some degree, they participated in the corporate life. Thus, the higher incidence of mental disease today could simply be an indication of a greater willingness upon the part of authority to allow people to withdraw, in most cases voluntarily, from the corporate life. As, for example, Professor Carstairs notes, "a new pattern of relatively short in-patient spells, with an increasing tendency to readmission, is being experienced by schizophrenic" (1, p.495) and other mental patients. That, in other words, the patient needs long and frequent stays at his psychiatric country-club in order to make living in society possible at all. Looked at from this point of view, contemporary changes in diagnosis are not altogether an unmixed blessing.

There is moreover, a tendency to assume that the higher incidence of undesirable traits in general in the "lower classes" — of which schizophrenia is only one — results from those with such undesirable traits dropping, as it were, down the social ladder. In America, however, Hollingshead and Redlich found that 91% of their sample of schizophrenics came from the same social class as their parents and of the remainder, there was a greater mobility upwards than downwards (cited by Martin Roth in 2, p.27).

As to treatment, it is important to emphasise that I mean medical treatment: this ought to be self-evident, but isn't in much psychiatric jargon-mongering. For psychiatry emerged as the opponent of the ill-treatment of the asylum inmate in the 19th century, and thus psychiatry has become confused in many people's minds with adopting an attitude of kindness and concern for the less fortunate. This is all very nice and all very necessary but it is not treatment in the therapeutic sense. Thus many psychiatrists and others, appear to justify their practice by invoking the moral seriousness of their enterprise and their own good intentions. These are not, however, presently in question, for they are irrelevant to the main issue: the psychiatrist's ability to cure his patients and not his skill in providing 'humane' custodial care.

Now let us consider in some detail, the condition itself. The majority of psychiatrists, and research workers engaged upon this 'disease', believe that there is in schizophrenia "a subtle change in brain chemistry which interferes in some way with nerve impulses." (6, p.5). Coupled with this is the belief that: "Whatever these chemical factors may be, we are sure that some, in any case, can be inherited although in a rather complex way." (3, p.5).

The general assumption is, therefore, that schizophrenia is transmitted via the genes and is, indeed, basically an abnormality in psychological functioning. Thus, for example, Mayer-Gross in his standard psychiatric text asserts:

"It may now be regarded as established that hereditary factors playa predominant role in the causation of schizophrenic psychosis. The evidence is extensive and is in the form of very thorough family and twin studies." (4, p.219).

'Thorough' or not, such a view is, however, an inference from psychological evidence to the existence of genetic influences which are, at the moment at least, unobservable. Roth, for example, after reviewing the literature summarizes the position as follows:

"Hence no simple genetic hypothesis accords with all the facts. Moreover, whatever mode of inheritance is postulated manifestation can only be partial; For even uniovular twins which are genetically identical are not wholly concordent." (2, p.2l).

Further confusion arises because, whilst the explanation of schizophrenia is expressed in bio-chemical terms the diagnosis of schizophrenia is based upon the observation of behaviour and the evaluation of the patient's language patterns. For example, Sakel — who introduced insulin shock therapy for the treatment of schizophrenia, observed recently:

"Psychiatric diseases, contrary to disease recognised as physical, have the common denominator of presenting dysfunctions in the realm of mentally perceivable actions alone. They must, therefore, be considered as the end-product of a deviation from the phylogenetically imprinted pattern of the nerve cell in its response to external and internal stimuli in a way established as normal since the beginning of the development of man. These responses constitute in toto a sequence of actions which are commonly referred to as 'the mind' or 'emotional content'. Since we are not yet equipped with instruments of an optical or chemical nature with which we can separate or test the deviation of these actions from the normal, we have to accept the personality make-up and the mental reactions of the examining physician as the measuring rod for these actions. He can establish the deviation in such abstract functions only by comparing them to his own which he must take as normal." (5, p.7).

Clearly to assume that the operation of 'mentally perceivable actions' must 'therefore' be interpreted and explained by reference to phylogenetic deviations cannot be maintained simply upon psychological evidence. The observation upon which such bio-chemical explanations rest, has therefore, as yet, to be established. This does not, of course, mean that it will not but simply to remember that it has not. The scientific faith in the ultimate validation of an hypothesis is, moreover, quite a different matter from the dogmatic presumption of its truth. The physiological study of schizophrenia has produced much useful and valuable information. It is, however, doubtful, to put it at its mildest, that the current endeavour to explain schizophrenia in chemical terms can ever be successful — at least not in the manner generally imagined. To see why this is so it is necessary to first of all consider an analogous condition: the fear response.

Faced by some situation of danger to the individual, there is an immediate mobilization of the organism for 'flight or fight'. The blood vessels serving the stomach, intestines, and interior of the body tend to contract while those serving the muscles of the trunk and limbs tend to become larger. Thus blood is diverted from digestive functions to muscular functions. There is an increase in the rate of breathing and a dilation of the pupils. Adrenalin is also liberated which helps to increase the blood sugar content, and also stimulates the heart.

It could, therefore, be argued that these physiological changes 'cause' fear. It is, however, clearly possible to enquire why these physiological changes take place at a particular moment in time. To answer such a question demands, furthermore, reference to the mechanism of perception and the way in which the organism perceives danger.

Nevertheless, despite its past sterility and present unsatisfactory methodological status, established psychiatric opinion still hopes to explain psychotic behaviour in genetic and neurological terms:
"I believe that in the major forms of mental breakdown, such as schizophrenia and manic-depressive psychoses, our most important advances in knowledge are likely to come not from psychological but from biochemical research; social and psychological factors can certainly contribute to the onset of these diseases and to their course, but their influence is probably secondary to crucial biological factors". (11, p.855).
This belief in the chemical aetiology of schizophrenia has, furthermore, determined the fashion in the treatment of the 'disease'. In the main this treatment consists in the use of electro-convulsive therapy, drugs, and, in rarer cases, pre-frontal lucotomy. (Mayer-Gross emphatically rejects the use of any form of psychotherapy; indeed he suggests it is contra-indicated).

In all three instances the manner in which these techniques influence the patient is, however, unknown: their application remains, therefore, at the level of simple empiricism. Rube, in 1948, demonstrated however that the effectiveness of sulphur therapy was based, not upon its physiological action, but upon the psychological situation its application created between doctors, nurses, and patients. Rube observes:
"In the absence of any other factors, we conclude that the element capable of modifying prognosis in this treatment need not be sought elsewhere. According to us, this element of faith and enthusiasm carried with it into the patient's atmosphere a psychotherapeutic influence, which although it remained unconscious on the part of those who brought it, nevertheless was of primary importance for its beneficiaries." (6, p.314).
That such techniques are productive of some success might be taken as adequate justification for their use. The situation is not, however, as straightforward as that. There is, for instance, increasing evidence of the dangerous side-effects produced by some of the 'wonder drugs' introduced with such initial enthusiasm. Nor do such drugs — as Professor Carstam recognises — exert more than a palliative influence upon the course of psychotic disorders. They are in short, not therapeutics but anodynes for suffering (1, p.496). There is, moreover, little hope of preventing the spread of schizophrenia whilst our knowledge as to its aetiology remains fixed at a level of simple empiricism. There is a danger, therefore, that by emphasising the limited effectiveness of the traditional, empirical, techniques, the stimulus to more fundamental enquiry will be frustrated.

It is, moreover, the limited success of techniques like electro-convulsive therapy which have contributed to the general belief that the causative factor in the disease is chemical. Despite such evidence referred to earlier that a more detailed examination of the application of these techniques clearly reveals psychological factors at work in determining the patient's reaction.

With both these therapeutic and prophylactic needs in mind I shall next outline an explanatory system which is consistent with the general research findings upon schizophrenia.

An Explanatory System for Schizophrenia

Statistically, the typical male schizophrenic is in his late 20's to early 30's, unmarried, and of low socio-economic position. Psychiatric study of his family relations reveals a common pattern of a weak or over domineering father and a mother who tends to dominate her son. For example, Jackson, et al, collected the opinions of twenty psychiatrists upon the 'nature' of the 'schizophrenic parent'. These opinions revealed three types of mother: 'puritanical', 'helpless' and 'machiavellian' and three types of father: 'defeated', 'autocratic' and 'chaotic'. The study of Kohn and Clausen also supports the view that schizophrenic patients, more frequently than normal persons of comparable background, report that the mother played a strong authoritarian role and the father a weak one.

Taking these established demographic and psychological observations what explanatory theory do they suggest? At least what explanatory theory do they suggest appropriate to the lower class male? For it is now gaining acceptance that schizophrenia is not a single disease but a collection of different conditions. This being so it might, initially, be necessary to formulate a number of different explanations of limited application before some all embracing general theory can be formulated. Thus I am here particularly concerned with schizophrenia as it affects the lower class male.

It is clear, from the family studies cited above, that in the typical schizophrenic:
(a) there is a lack of an adequate male model upon which he can base his own behaviour.
(b) there is inhibition of outward-going tendencies; of aggressive actions — and here, of course, I do not use 'aggressive' as synonymous with 'brutal' but as referring to the tendency of an individual to act upon his surroundings rather than let his surroundings act upon him.
This inhibition of aggression results, itself, from:

(1) lack of paternal encouragement and support; indeed the father, because of his own failure will tend to see the son's aggression as a real threat and not as enjoyable play.
(2) the close relation with the mother will further frustrate aggressive tendencies because of the influence of the general cultural taboo against showing aggression towards women. And, furthermore, whilst the non-aggressive 'techniques' of the mother are appropriate to the female role in western culture they are, nevertheless, damaging to success in many masculine activities.
(3) the weak relation between the mother and the father also fails to provide the child with an adequate model of how people conduct close relationships.

Furthermore, because of these weak bonds between parent and child the child not only fails to acquire proficiency in cultural skills and information via the parent. He also has difficulty in learning from those people placed by society in positions of loco parentis. The child in this situation is, therefore, deprived of culture. And, by 'culture' here I mean the word in its general anthropological sense as simply 'a way of life' which provides, or attempts to provide, satisfaction of the needs, etc., of the individual. It is clear from the above that whilst I have taken the material of the psychoanalysis, that of family relations, I have interpreted this data not in terms of the deprivation of emotional needs — of such vague notions as 'love' and 'security' — but that such abnormal relations frustrate and inhibit the transmission of culture. I am, therefore, primarily concerned with the consequences following upon 'cultural deprivation'.

For, when an individual grows up without an adequate culture in which to participate he is, of necessity, forced to create his own, individual attitude and responses to experience. Mead, for example, puts this situation very clearly in the following extract from Growing up in New Guinea:

"Those temperamentally restive persons who stand in the vanguard of new causes or create new art forms have not usually been given their drive by identification with some well understood person of their close acquaintance (although occasionally rebellion against a father or guardian may have directed their choices). Instead they have built up, in their need, fantastic and strange conceptions of life; they have drawn hints from past periods and different civilisations, and from these curious combinations they have fashioned something new. Even the very gifted among these innovators have been dependent upon two things, the socially defined lack in their own lives, and rich material from which to build." (7, p.184).

Thus, whilst the potential schizophrenic is similar to the artist in that his 'acculturation' has been incomplete, the 'potential schizophrenic' differs from the artist in two important respects:
(a) his aggressive, outward-going, tendencies have been suppressed,
(b) a 'poverty' of material out of which he can elaborate symbolic need satisfaction.
The painter, for example, is able, through his paints and canvas to externalise his needs and to relate them to the wider activities of other painters and to other artists. The potential schizophrenic is, however, afraid to externalise his 'creations' and, even if he does so, because they are created out of intensely personal material, he is unable to talk about them with other people.

If the standard of comparison for the 'potential schizophrenic' is moved from the 'artist' to the 'normal' this aspect of communication is seen to be even more important. The 'normal individual' is able to enjoy his vicarious need satisfaction within a community of others: he is, for example, not only able to listen to the 'Dales' and the 'Archers' and so on but he is also able to talk about his vicarious exper-
ience with other people. For the 'potential schizophrenic' however, the world of vicarious living and fanciful need satisfaction is of his own creation, intensely personal, and, therefore, a world about which he can, only with difficulty, communicate with others. It is, moreover, a world about which a few may understand but no one can share.

From this point of view, the initial, or germinating, factors in the aetiology of schizophrenia are:
(a) the suppression of aggressive and outward-going activities;
(b) a failure to acquire a culture, adequate to the satisfaction of most of his needs.
The 'potential schizophrenic' is however, confirmed in his schizophrenia by factors outside the home, and by his 'education'. Upon leaving school the 'potential schizophrenic', because of his low socio-economic status, will drift into one or other of the many unskilled jobs associated with contemporary manufacture, and thus spend long hours working repetitively, in many cases, at a machine. It is, moreover, in the factory habitat, or its equivalent, that the culturally deprived individual is confirmed in his schizophrenia.

For, despite the improved sanitation of the modern factory, its canteen and other welfare facilities, when viewed from a physiological viewpoint it obviously provides very little stimulation to the human senses. It is, in short, an habitat to which the individual very quickly adapts. For, whilst the casual visitor to a factory might experience loud noises, intense heat, etc., there is, however, little change in the strength of the stimulation to the receptors of ear, eye, etc., and it is change which determines physiological stimulation.

The combination of these two factors, namely low physiological stimulation and repetitive behaviour, produces the experience of considerable 'security' in the sense that each object in the individual's environment behaves in a completely expected and anticipated manner.

Within such a situation the mind of the individual is left free to wander: freed from the problems and dangers of immediate reality the mind of the potential schizophrenic will in this factory situation obviously enter the inner world of his own creation. It is, moreover, clear that because the potential schizophrenic works for 40 to 60 hours a week in such a situation he is, therefore, living for long periods in his personal world. It is not surprising that he is unable to move from this personal world even when he leaves the pathogenic habitat of the factory. In time, in other words, his personal world becomes structured and he becomes shut off from sensory changes even when they do take place. It is this condition which gave rise to the common sense observation of 'split mind'.

This explanation of schizophrenia is, therefore, based upon two factors:
(a) the general influence of cultural deprivation;
(b) the specific influence of protracted factory employment. For the schizophrenic reaction to occur it is necessary for both these factors to be operative. Thus, the factory habitat whilst pathogenic for the culturally deprived individual need not necessarily be harmful to the individual with a viable, aggressive, culture outside its gates.

The following extract from Alan Sillitoe's Saturday Night and Sunday Morning provides a useful example of the day-dreams of the 'normal' factory worker as he, repetitively, performs even highly skilled operations: there is also a clear recognition of the rapid adaptation to the physiological stimulation of the factory:
"The noise of motor-trolleys passing up and down the gangway and the excruciating din of flying and flapping belts slipped out of your consciousness after perhaps half an hour, without affecting the quality of the work you were turning out, and you forgot your past conflicts with the gaffer and turned to thinking of pleasant events that had at some time happened to you or things that you hoped would happen to you in the future. If your machine worked well — the motor smooth, stops tight, jigs good — and you sprung your actions into a favourable rhythm you became happy. You went off into pipe-dreams for the rest of the day. And in the evening, when admittedly you would be feeling as though your arms and legs had been stretched to breaking point on a torture-rack, you stepped out into a cosy world of pubs and noisy tarts that would one day provide you with the raw material for more pipedreams as you stood at your lathe." (8, p.31).

The difference between the 'normal' factory worker and the 'potential schizophrenic' is not, therefore, in the simple fact of day-dreaming — since both can indulge in this — but in the raw material out of which the latter weaves such dreams. The acceptance of the above explanation of schizophrenia, in relation to the high incidence of this condition amongst lower class males, requires the examination of the factory situation from a new standpoint — that of physiological stimulation.

There is increasing evidence to support the view that the normal functioning of the waking brain depends on its continuous exposure to sensory bombardment which, thereby, produces a state of arousal. Work now being done by S. K. Sharples at McGill University indicates, furthermore, that when stimulation does not change it rapidly loses its power to cause this state of arousal. Thus the maintenance of normal, intelligent, adaptive behaviour probably requires a continuously varying sensory input. The modern factory situation clearly fails to provide the conditions necessary for such variations in sensory stimulation.

It appears, therefore, as dangerous to place an individual of low acculturation within a factory situation as it would be to employ an alcoholic in a brewery. It is, however, those of low acculturation who, of necessity, form the bulk of our present army of semi-and unskilled workers.

Schizophrenia is, therefore, in two senses a 'disease of industry': firstly through the general breakdown in culture resulting from the Industrial Revolution itself and the fragmentation of family life which it caused; and secondly, through the low physiological stimulation the worker is forced to endure in the modern factory.
From such a viewpoint it is clear that the present chemico-physiological explanation of schizophrenia serves to divert attention from an examination of the cultural factors at work in the creation of the condition. The function of such an attitude is, in short, not to explain schizophrenia but to obscure its social genesis. Such an attitude is, of course, an established one in the West and not limited, by any means, to schizophrenia. For the explanation of cultural inferiority has traditionally been based upon an inference from biological inferiority. Orwell, for example, writes of the relation between the white ruler and black slave:

"You can only rule over a subject race, especially when you are in a small minority, if you honestly feel yourself to be radically superior, and it helps towards this if you can believe that the subject race is biologically different." (Tribune, 20/10/44 quoted from 9, p.75).

An essentially similar attitude was, of course, taken up towards women in the past and the poverty of the great mass of the people in the 19th century was explained in the same way. Thus, whilst the chemico-physiological explanation of schizophrenia finds little confirmation from scientific investigation, it enjoys, nevertheless, strong ideological confirmation. The chemico-physiological explanation of schizophrenia rests, in short, upon ideological prejudices and 'mythological' beliefs and not upon the firm evidence of particular scientific disciplines. The medico-scientific 'explanation' of schizophrenia is, in other words, based upon a desire to obtain scientific sanction and authority for received and established pre-scientific attitudes towards human behaviour. A desire itself created by the weakening of the traditional justificatory myth of power and privilege produced by the Industrial Revolution. For, as Dahrendorf observes:

"The difference between the early stages of industrial society in Europe and its historical predecessor was not just due to a change in the personnel of social position; it was due above all to the simultaneous abolition of the system of norms and values which guaranteed and legitimized the order of pre-industrial society." (10, p.6).

Thus, schizophrenia, in addition to being a condition of serious personal suffering, also represents one of the growing points and changing aspects of society, where a specific scientific discipline, in order to develop, must conflict with the established ideology of its time. It is, therefore, not a condition the concern only of psychiatry and psychology, hermetically sealed off from general consideration.

REFERENCES:
1. G. M. Carstairs, "Practitioner", October, 1961.
2. D. Richter (editor), "Schizophrenia, Somatic Aspects", Pergamon Press, 1957.
3. Mental Health Research Fund, Pamphlet No.1, "Schizophrenia", 1962.
4. W. Mayer-Gross, et aI., "Clinical Psychiatry", Cassell and Co., 1954.
5. M. Sakel, "Schizophrenia", Peter Owen Ltd., 1959.
6. P. Rube, "Healing Process in Schizophrenia", J. nero ment. dis. 1948, lOS.
7. M. Mead, "Growing Up in New Guinea", Penguin Books, 1942.
8. Alan Sillitoe, "Saturday Night and Sunday Morning", Pan Books, 1960.
9. J. Atkins, "George Orwell" John Calder, London, 1954.
10. R. Dahrendorf, "Class and Class Conflict in an Industrial Society", Routledge, 1959.
11. "The Listener", November 22, 1962.

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