Commentary on “Breaking the Covenant: International Schizophrenia Research and the Concept of Patient-Centredness 1988-2004” by Timothy Calton, Anna Cheetham, Karen D’Silva and Christine Glazebrook published in the new ISPS volume "Fifty Years of Humanistic Treatment of Psychoses: In Honour of the History of the International Society for the Psychological Treatments of the Schizophrenias and Other Psychoses, 1956-2006" edited by Yrjö Alanen, Ann-Louise Silver & Manuel Gonzalez de Chavez in 2006. 
Brian Koehler PhD
 
One of the principles of therapeutic community is for the hospital, institution and/or community to examine and treat itself.  I believe that Dr. Timothy Calton and his colleagues paper “Breaking the covenant: International schizophrenia research and the concept of patient-centredness 1988-2004” does just that for our ISPS organization.  I thought of this principle as I read with great interest the excellent synopsis of Dr. Calton and his group in the UK on the degree to which presentations at ISPS and the International Congress on Schizophrenia Research (ICSR) and the Biennial Winter Workshop on Schizophrenia (BWWS) conform to what is termed a “patient-centred model,” i.e., a model which focuses also on the subjective experiences of patients.  Calton and colleagues note that a core feature of the patient-centred model is to give equal weight to the objective theories of disease and the subjective experiences of the patient.  Their stated goal was:...”to investigate the extent to which recent research presented at the most prominent international forums dedicated to schizophrenia research could be considered to be patient-centred.”  Their application of this model involved a principle that half of all research projects in the study of the schizophrenias should be devoted to the subjective experiences of patients.

Calton and colleagues highlight the growing positivist reductionism in our field.  They are holding up a mirror to our organization, showing us what we have become.  The papers given at ISPS congresses are increasingly moving away from an emphasis on subjectivity and phenomenology, as reflected in fewer case studies and theoretical papers.  Papers devoted to service delivery and empirical, quantitative research are taking their place.  However, ISPS still produces more psychosocially oriented papers than either ICSR or BWWS.  My own view is that radical reductionism is crucial, but invalid if left at this level of scientific inquiry.  The move away from reductionism in the physical sciences, such as physics, to emergence, is reflected in the work of Robert Laughlin, a professor of physics and Nobel Laureate for his work on the fractional Hall effect.  Laughlin noted that the natural world is not only regulated by molecular essentials, but also the powerful principles of organization which flow out of them: This organization can acquire meaning and a life of its own, and begin to transcend the parts from which it is made.  At higher levels of complexity, such as is found in human beings and their relational and cultural contexts, cause-and-effect relationships are more difficult to document.  The reductionistic positivist ideal that nature will be revealed and understood through division into smaller and smaller component parts or through sophisticated neuroimaging techniques such as fMRI, PET and DTI scans-needs to be supplemented by the study and understanding of how nature organizes itself, i.e., reductionism giving way to emergence.

The principle of giving equal weighting to subjective experience and objective neuroscience research has a long history in psychiatry: I think of George Engel’s biopsychosocial model, Leon Eisenberg’s caution to steer between a mindless and brainless psychiatry and his quip that the human brain is all biological and all social, John Strauss and Larry Davidson’s emphasis on the interaction between person/identity processes and disorder, Yrjö Alanen’s pointing out that an important starting point for all integrated psychobiological psychiatry is the insight that interactionality with other people is part of human biology, etc. Kenneth Kendler, psychiatric geneticist, in delineating a philosophical structure for psychiatry, underscored the importance of attending to subjective, first-person experiences.  He noted that the goal of psychiatry is the alleviation of the human suffering that arises from dysfunctional alterations in particular domains of subjective experience.  Kendler cautioned us not to take advantage of the advances in molecular biology and neuroscience at the expense of abandoning our grounding in the realm
of human experience and suffering.

Recently, Chris Harrop and Peter Trower noted that the direction of the causal relationship implicating biology driving symptomatology (upward causation) has not been satisfactorily demonstrated, and that downward causation may be an equally plausible possibility, i.e., the biological symptoms may actually arise from the symptoms of the disorder.  From my review of the neuroscience research, I would say that it is not so much the symptoms which drive the biology, e.g., Edward Hundert pointed out that delusions are often a reflection of the brain’s [person’s] evolutionary strategy for survival, rather, the biology is the result of experience, in particular profound and chronic stress/fear/anxiety, including exposure to various traumas and prenatal stress.  Psychotic symptoms are often very meaningful phenomena when viewed within the context of the individual’s life and from within the wider sociocultural surround, as well as from the framework of transgenerational transmission of trauma, which recent research has demonstrated not only has a psychological/symbolic etiology, but a biological one as well (epigenetic modification of gene expression).  There are examples of epigenetic, or nongenomic, inheritance, where traits of the parents, particularly defensive responses to threat, are transmitted to offspring in a manner not dependent on information encoded in the nuclear genes.  Epigenetics refers to regulation, e.g., by social factors, of gene expressions that are controlled by heritable but potentially reversible changes in DNA methylation and/or chromatin structure.  For many years I have been comparing the neuroscience research of schizophrenia with the neuroscience of stress/fear/trauma/social isolation and defeat and have found a very significant convergence of findings. It is becoming increasingly clear that the neuroscience findings in schizophrenia research are generally non-specific, possibly due to the important role of epigenetics and neuroplasticity.

At our ISPS conference in London in 1997, Peter Fonagy cautioned our field to not give up our emphasis on intensive psychotherapeutic work with persons with a severe mental illness.  Should we abandon this immersion experience with patients within an intersubjective context, what would we have by way of knowledge and skill to teach and pass on to future generations of clinicians?  His was a quiet, but powerful voice calling us back to, and not to sever our roots.  Perhaps a sequel to the informative and relevant research by Calton and colleagues would be a qualitative study examining the factors influencing this movement away from phenomenology and subjectivity (from the objective standpoint, clinicians may treat their patient’s subjective accounts of their experience as indistinguishable from the illness itself,e.g., a reflection of impaired insight, and/or believe that speaking with patients about their delusions and hallucinatory experiences only leads to an exacerbation of the illness itself).

In their summary discussion of their qualitative research study, Calton and colleagues, in an imaginative leap, draw “metapsychiatric” parallels between the psychopathology in schizophrenia, in particular, laterality and disconnectivity, and the splits and disconnectivity in the field of schizophrenia research, especially the split between subjectivity/intersubjectivity research and third person objective research.  In response to this metapsychiatric speculation, I would like to conclude with some thoughts of the two co-founders of ISPS, Christian Müller and Gaetano Benedetti.  Christian Müller wrote a paper on the resistances we engage in while doing, or to avoid doing long-term psychotherapy with persons with schizophrenia.  One could surmise that part of the movement away from subjective to objective accounts at ISPS conferences is a countertransferential retreat from the painful affects stirred up in our dialogical work with patients; work which can potentially reveal to us our own patienthood.  Gaetano Benedetti saw the ISPS as a place in which we could autonomously develop our psychotherapeutic understanding and treatment approaches without interfering with other fields of knowledge, such as the progress being made in psychiatric molecular biological or psychopharmacological approaches.  Benedetti believed that intensive psychotherapy reveals more deeply the nature of psychosis, in particular, and the human condition, in general.  He wished for the ISPS group to return with new and fresh ideas to the significant contributions made by our forerunners, such as Federn, Sullivan and Fromm-Reichmann.  My hope is that, as the human cell and person must retain its essential structure as it interacts with its surround, ISPS will remain open to potentially beneficial influences from other domains of scientific inquiry, such as ICSR/BWWS, without abdicating its role as an organization devoted to the psychotherapeutic understanding and treatment of persons struggling with a severe mental illness.

References cited in this commentary are available by request to the author

Brian Koehler PhD
New York University
Long Island University
80 East 11 Street #339
New York NY