Swiss Psychiatry & the Schizophrenias Switzerland is the country in which the term ‘schizophrenia’ was coined and it is where Carl Jung, early on in the development of psychoanalysis, worked with persons with schizophrenia, often with good results (interesting cases can be found in C. A. Meier’s book, Soul and Body: Essays on the Theories of C. G. Jung, published in 1986 by The Lapis Press. Meier was a student and assistant of Jung’s at the Burghölzli Clinic). Ludwig Binswanger, also at the Burghölzli and a friend and colleague of Freud, developed his existential analytic description of psychotic patients and demonstrated that every psychotic symptom is so connected with every other symptom as to form a schizophrenic ‘world’ of its own which can be explored only by psychological research.
In reading the work of Eugen Bleuler and his son, Manfred Bleuler, I am impressed by their understanding and insight into the human conditions we call the schizophrenias. In Eugen Bleuler’s Dementia Praecox or the Group of Schizophrenias, originally published in 1911, in a discussion on the “theory of the disease,” he noted: “We must add, however, that it is not absolutely necessary to assume the presence of a physical disease process. It is conceivable that the entire symptomatology may be psychically determined and that it may develop on the basis of slight quantitative deviations from the normal, just as in some people the disposition to hysterical symptoms is so strong that they become hysterical when confronted with the ordinary difficulties of life, in the average person, hysteria can develop only in consequence of a very severe psychic trauma...In addition to the fact that the anatomical findings do not correspond with the severity of the manifest symptoms, there are some other elements in favor of the theory that the genesis of this disease is a psychic one. Aggravations and improvements in the patient’s condition are often psychically determined [see current research on expressed emotion, affective style, experience of life events prior to first acute break,kindling, etc.]. Among the symptoms preceding the outbreak of schizophrenia, we find generally a disposition to introversion which may explain the appearance of autism and, indirectly, most of the other symptoms. The significance of the undeniable anatomical findings [from my perspective largely the result of the neural effects of profound anxiety, helplessness and stress and rooted in neuroplasticity] may be questioned on the basis of Schott’s interpretation of atrophy as the result of inactivity; or, according to Jung, by regarding them as the consequence of toxins produced by affects [we now know that cortisol, glutamate, calcium, etc. are neurotoxic at excessive levels in prefrontal and limbic areas-anxiety/stress causes a cascade of neural events including regulation of protein phosphorylation, second messenger protein kinases, alteration of gene expression through activation of such immediate-early gene transcription factors as c-fos, etc]”. Manfred Bleuler (1979), Eugen’s son, in an article published in the American Journal of Psychiatry, 136, 1403-1409, entitled “On schizophrenic psychoses,” noted: “What is effective in the treatment of most schizophrenic patients is also effective, and decisive, in the development of the healthy individual; clear and steady personal relations; activity in accordance with one’s talents, interests, and strengths; confrontation with responsibilities and even dangers; and, at the right time and in the right rhythm, rest and relaxation. Exactly the same influences that form and stamp the healthy personality, the ego, from babyhood on and restrain prelogical, unrealistic, disordered, and autistic mental life from overflowing are effective in the treatment of schizophrenia, in the treatment of the disordered ego-and hardly anything else is.” Bleuler urged clinicians to understand schizophrenic development as primarily a human rather than metabolic process: “When the tension between his own drives and between his drives and his social environment become overwhelming he retires into an autistic...contradictory world that is better adapted to his contradictory self than reality...This conception...summarizes well our present knowledge of schizophrenia. It tallies well with the symptomatology and with the course of the psychosis [Bleuler’s outcome research covered a 37 year follow-up and demonstrated, with an N of 289 patients, that 27% had a good clinical outcome and 39% had a social recovery]. It tallies particularly well with what has been proved to be essential in therapy: the same influences that develop the personality, the ego in the healthy are the essential therapeutic influences for reorganizing the split ego, that of the schizophrenic...We as doctors need no longer fear that our therapy is only symptomatic and is not directed at the primary process. Quite the contrary, the therapy that has proved to be efficient may be the great causal therapy adapted to the nature of the psychosis...The conception of the schizophrenic psychosis as due to a somatic disturbance that may be discovered in the future opens the way to laboratory research. It is important that some of us devote their lives to this research. The conception, however, of schizophrenic psychosis as a breakdown in the fight for the intact ego points in another direction, toward being beside and with the patient. In my opinion, it is the main and noble duty of a doctor to stay near and be with his patient.” Luc Ciompi, another Swiss psychiatrist, developed the concept of Affect-Logic (“the logic of affectivity” and the “affectivity of logic”) and the understanding of the schizophrenias as affective illnesses. Like psychotic depression and mania, schizophrenia is seen as an affective disease given that specific modifications of postulated fundamental organizing and integrating functions of affect on cognitions seem to play a role in all three conditions. Ciompi has integrated complexity theory in his understanding of the psychoses ( “Nonlinear phase transitions -bifurcations-toward psychotic patterns of functioning can occur under energetically overtaxing conditions far from equilibrium, with basic affects functioning as crucial control-parameters, and emerging aberrant cognitions as predominant order-parameters”). Ciompi understood the human psyche from a psychosociobiological perspective, as a complex hierarchy of functionally integrated affective-cognitive-behavioral programs that are generated by action and store in their structure the relevant past experience. The assumption of schizophrenia as an affective disease is also supported by the fact “that systematically reducing emotional tensions by combined psychotherapeutic-milieutherapeutic methods , such as those employed [in the Soteria projects in the USA & Berne, Switzerland],had in two controlled studies similar 2 year effects on acute psychotic symptomatology, relapse rates, and social functioning as standard hospital treatments with 3-5 times higher total doses of neuroleptics.” For those interested in studying the work of Luc Ciompi see the following: Luc Ciompi (1998). Is schizophrenia an affective disease? The hypothesis of affect-logic and its implications for psychopathology. In W. Flack & J. Laird (Eds.) Emotions in Psychopathology: Theory and Research, pages 283-297, Oxford University Press. Luc Ciompi (1997). Non-linear dynamics of complex systems: the chaos-theoretical approach to schizophrenia. In H. Brenner, W. Böker & R. Genner (Eds.) Towards a Comprehensive Therapy for Schizophrenia, pages 18-31. Bern: Hogrefe & Huber Publishers. Luc Ciompi (1988). The Psyche and Schizophrenia: The Bond between Affect and Logic. Cambridge MA: Harvard University Press. Luc Ciompi (1997). The concept of affect logic: an integrative psycho-socio-biological approach to understanding and treatment of schizophrenia. Psychiatry: Interpersonal and Biological Processes, 60 (2), 158-170. Swiss psychoanalysts who have devoted themselves to working with more severely mentally ill individuals have included Carl Jung, Marguerite Sechehaye, Medard Boss, Norman Elrod and Gaetano Benedetti. Boss (1994) used a daseinanalytic phenomenology to understand what is at stake in the schizophrenias. He noted: “Schizophrenia will be recognized in its encroachment on the freedom of being-in-the-world when human experience itself is seen as open, responsive...being-in-the-world. It is human existence as a primary realm of openness that makes possible any relation to that which is and will be encountered...It is this lack of freedom and openness with regard to what is encountered that demonstrates fundamental disturbance in the very existence of the schizophrenic, not some postulated lessening of assumed thought processes or associations. Only thus may we understand why schizophrenia cripples the sufferer’s response to the phenomena of the world to such an extreme degree: what he encounters engulfs the schizophrenic; it destroys his selfhood. No wonder, then, that he strives to escape this destruction by maintaining a rigid distance from encountering beings, especially human beings....Human being is nothing but its perceptive, responsive openness, and so this characteristic mode of behavior of the schizophrenic-in psychiatry called schizoid behavior or autism-amounts to a radical destruction of human being...Therefore, schizophrenia is an illness that can be characterized only negatively; it has no positive characterization...the schizophrenic becomes subject, in varying degrees, to the modes of being of other people and of things in the world. To an extent unknown to other illnesses, the Da-sein of the schizophrenic is engulfed in the overwhelming other; sufferers of this illness exist largely outside of themselves. accordingly, they often experience things through voices that speak to them, or feel that their thoughts and actions are not their own but are performed by others [A neurobiological view on this was formulated by Richard Keefe which he termed “autonoetic agnosia” and can be found in his article “The neurobiology of disturbances of the self: autonoetic agnosia in schizophrenia” published in Xavier Amador & Anthony David’s edited volume Insight and Psychosis, 1998, Oxford University Press].” Boss, like many others including Harry Stack Sullivan, saw a relation between obsessive-compulsive neurosis and the schizophrenias (I have seen this in my practice as well). For Boss, the difference is that “in schizophrenia, the patient loses his freedom and with it his dwelling place [see the work of Marti Siirala, Finnish psychiatrist-psychoanalyst, on the role of placelessness in psychosis and collective splitting processes in the wider culture] in the world to a much higher degree. Obsessive-compulsion may encroach on the patient’s freedom, but it does not engender its destruction [my own view is that these illnesses are on a continuum of disturbance in the self-boundary, difficulties in establishing an internal sense of self that is separate, yet related to the non-self, external world, e.g., inside easily becomes outside, and outside inside, e.g., thoughts are experienced concretely as things out there, an aggressive thought is experienced as an action, and an other is experienced as colonizing, invasive, etc, perhaps due to severe difficulties in maintaining a sense of separation from the object]. The quotations of Medard Boss are taken from his Existential Foundations of Medicine and Psychology, published by Jason Aronson. Gaetano Benedetti, a colleague of Manfred Bleuler at the Burghölzli Clinic in Switzerland, has worked psychotherapeutically with schizophrenic individuals for over 50 years and continues to engage in psychotherapeutic research. Benedetti’s contributions include his concepts of progressive psychopathology [similar to Marti Siirala’s comment that the illness as it is encountered is the illness at the next stage, i.e., drawing attention to the relational aspects of this group of illnesses, e.g., a patient of mine because of our therapeutic symbiosis, hard won through a great deal of paranoid anxieties and hatreds, no longer feels his body drastically changes in what he experiences as paranoid attacks on it, rather, he experiences, in still a psychotic form, the extrusion of the somatopsychic traumas he was subjected to, to be slowly leaving his body, a concrete reflection of our psychotherapeutic work together]; transitional subjects; transforming therapeutic images emerging from the therapist’s unconscious, e.g., in dreams; transformation of the pathological symbiosis into a therapeutic symbiosis; and with his younger colleague, Maurizio Peciccia, their view of schizophrenia as a de-integration of the separate and symbiotic self (for a discussion of their concepts see Brian Koehler’s “Interview with Gaetano Benedetti, MD” in The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 31 (1), Spring 2003, pages 75-87). A rich source of Benedetti’s work is found in his Psychotherapy of Schizophrenia, published by New York University Press in 1987. I highly recommend this volume for an excellent view of how psychoanalysis has evolved in our understanding and therapy of schizophrenic individuals. Brian Koehler PhD 80 East 11 Street #339 New York NY 10003 212 533-5687 brian_koehler@psychoanalysis.net
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