Schizophrenia and the Irish family

In The Political Unconscious (1981), Frederic Jameson begins with the phrase ‘always historicise!’ This refers to the process of examining ideas, not simply as immutable objects outside of history, but as a collection of linked themes that evolve over time. This is the basis of a critical analysis of discourse (1). How then can it be applied to mental health discourse? Schizophrenia is the perfect concept to answer this question. Schizophrenia is a chronic enduring mental health problem of no definite aetiology and a variable outcome (2). Indeed, the prevalence in Ireland is not entirely known, but has been estimated to be approximately 3.4 per 1000 (3). More complicated still, is the shifting meaning of schizophrenia within the Irish discourse on mental health. In line with international standards, the paradigm of care for chronic enduring mental health problems has changed. This shift has been from large scale institutions to community based care (4). In congruence with this change, the burden of caring for someone with an enduring mental health problem has fallen upon their family (5). This is most particularly true for people with schizophrenia in Ireland (4). It is well known in the literature that caring for family members with enduring mental health problems can have very detrimental effects, including family dysfunction and carer burnout (6, 7). In order to parse out the complexities of having this societal arrangement, a deeper analysis of the historicity of schizophrenia is required.

In 1908, Eugen Bleuler coined the term schizophrenia in a lecture he gave on case reports of psychosis. He later coined the phrase ‘group of schizophrenias’ in a book published in 1911, and this phrase was used to denote the clinical unity of a collection of mental health problems that had dysfunctional perception, cognition, and affect (8, 9). Before this development, schizophrenia was termed dementia praecox by Heinrich Schüle in his textbook on psychiatry published in 1886. Arnold Pick continued to use this term in his well-known case report of a patient diagnosed with hebephrenia. Both these theorists proposed that dementia praecox referred to a type of cognitive failure (dementia) in young people which was distinct from Alzheimer’s disease, which occurs in much older patients (10, 11). Meanwhile, Sigmund Freud had attempted to popularise the term paraphrenia, and through a number of secondary sources attempted to describe the underlying psychology of this condition (12). Although Bleuler initially attempted to apply psychoanalytical ideas to patients with schizophrenia, it was Carl Jung, who worked with both Bleuler and Freud, who successfully synergised these perspectives. Jung not only widened the theoretical construct of schizophrenia, but he also emphasised the therapeutic alliance between doctor and patient by exploring the phenomenology of madness with them. In 1907, Jung published The Psychology of Dementia Praecox which established him as an important figure in the development of schizophrenia research. In this book he applied various methods (psychoanalysis, word association experiments, and theories from anthropology) to clinical observations of patients in his clinic. The book was an international sensation because it blended the known accounts of pathophysiology with the subjective psychology of patients experiencing psychosis (13). However, 20th century academic psychiatry divided the concept of schizophrenia along neuroscientific and psychological lines (14).

Indeed, with the findings from genome wide research studies and cognitive neuroscience, the concept is ever evolving (15). There are now thousands of candidate genes and risk factors that attempt to delineate the essential features of this condition (16). However, the wide variety of discoveries largely neglect the experience of the individual with the condition. There have also been attempts at applying psychoanalysis and other forms of psychotherapy to schizophrenia, and the results have been mixed (17). The problematic nature of this particular discourse is that in the search for an essential schizophrenia, it has become a waste basket term into which a whole host of undifferentiated forms of mental health problems have been cast (14). This challenging situation is not simply a clinical issue, but manifests in all the areas that border on the role of madness in society. Schizophrenia can then become a controversial label and fall into political discourses. Indeed, two of the most famous examples of this are to be found in The Protest Psychosis (2010) by Jonathan Metzi and The Divided Self (1960) by R.D. Laing. Both these books highlight the elasticity of the diagnosis of schizophrenia as it pertains to human existence in the twentieth century. What is also apparent is the often neglected voice of the service user amidst the efforts of society to tame this construct of unfettered madness. Indeed, the complexity of the term schizophrenia reflects a whole host of preconceived myths about the role of madness in society (18, 19). With the political development of patient advocacy groups and the service user movement, there has been a more concerted effort by academic psychiatry to incorporate clinical research into the personal narratives of service users (20).

Indeed, a successful modern approach has been the development of Open Dialogue. This method, first developed in the 1980s in Finland, focuses upon the use of a needs based approach to service user management of psychosis, especially at times of crisis. The psychotherapeutic intervention is performed in the presence of family and carers to establish a robust support system for a collaborative dialogue. Such an approach focuses on addressing the needs of the service user and their family (21). In particular, this method promotes the therapeutic alliance through psychological continuity as well as acknowledging the ever present uncertainty pertaining to the service user’s condition (22). A consensus regarding the importance of these principles in caring for vulnerable service users and their family’s is emerging in the UK’s NHS (23). In congruence with this development, the Republic of Ireland is also ripe for such innovation. In contemporary Ireland, the majority of care is delivered at the interface between community clinics and family supports. As acknowledged by A Vision for Change (2006), a modern mental health system requires partnership between all stakeholders involved in caring for the individual. This is to ensure that the individual has access to all the supports required to secure their recovery. More recent research has highlighted that the needs of parents caring for children diagnosed with schizophrenia emphasise all the key domains that are addressed by an applied Open Dialogue approach (4). Unfortunately, Irelands mental health system is severely under resourced and currently operates at 75% of staffing levels as recommended by A Vision for Change (2006) (24). According to the Mental Health Commission report (2015), it has also been found that in this context of having an inadequately resourced infrastructure, family members (23%) and Gardaí (45%) are the primary referrers for the involuntary admission of individuals (25).

Schizophrenia has significantly changed over the course of its history and is now part of a more nuanced paradigm. Despite the lack of a comprehensive account of schizophrenia, there is something to be recognised. Over a hundred years since the publication of The Psychology of Dementia Praecox, Jung’s method and theories have foreshadowed many of the discoveries from clinical research. In particular, the most noted example is the relationship between clinical neuroscience and the phenomenology of the individual who suffers from this extreme state. At the centre of this innovation is the role of the therapeutic alliance and the larger support structures needed for recovery and ultimately individuation (26). Political and societal discourses on madness coupled with the role of the service user in society have also fundamentally changed, but unresolved problems persist. What is needed now is to develop this initial application of psychoanalytical theory to exploring and appropriating into the discourse new methods of dialogue. To support this initiative, there is a much needed critical analysis of the relationship of the individual service user and their family to the term schizophrenia. This concept must further evolve upon an evidentiary basis, which includes the development of a critical analysis of psychosis. Various assumptions about this diagnosis must be challenged and an open dialogue encouraged. This theoretical appropriation will help nurture a culture of hope over fatalism.

 

References

 

  1. Fredric, J. (1981). The Political Unconscious: narrative as a socially symbolic act. UK: Methuen.
  2. (2014). Psychosis and schizophrenia in adults: Treatment and management. London: National Institute of Clinical Excellence.
  3. Youssef, H. A., Scully, P. J., Kinsella, A., & Waddington, J. L. (1999). Geographical variation in rate of schizophrenia in rural Ireland by place at birth vs place at onset. Schizophrenia research, 37(3), 233-243.
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  6. Viana, M. C., Gruber, M. J., Shahly, V., Alhamzawi, A., Alonso, J., Andrade, L. H., … & Girolamo, G. D. (2013). Family burden related to mental and physical disorders in the world: results from the WHO World Mental Health (WMH) surveys. Revista Brasileira de Psiquiatria, 35(2), 115-125.
  7. De Silva, D., & De Silva, S. (2014). A preliminary study of the impact of long term psychotic disorder on patients’ families. Ceylon Medical Journal, 46(4).
  8. Bleuler E. Die Prognose der Dementia Praecox (Schizophreniegruppe). Aligemeine Zeitschrift für Psychiatrie und psychisch-gerichtliche Medizin. 1908;31:436–480.
  9. Bleuler E. Dementia praecox oder Gruppe der Schizophrenien. In: von Aschaffenburg G, ed. Handbuch der Psychiatrie. Leipzig, Germany; Vienna, Austria: Deuticke. 1911:1-420; reprinted Nijmegen, the Netherlands: Arts&Boeve . 2001
  10. Schüle, H. (1886). Klinische Psychiatrie:Specielle Pathologie und Therapie der Geisteskrankheiten, 3rd edn. Leipzig: F.C.W. Vogel.
  11. Pick, A. (1891). Ueber primäre chronische Demenz (so. Dementia praecox) im jugendlichen Alter. Prager medizinische Wochenschrift 16: 313–315.
  12. Freud, S. (1936). Psycho-analytic notes upon an autobiographical account of a case of paranoia (dementia paranoides). The Psychoanalytic Review (1913-1957), 23, 297.
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  18. Metzl, J. M. (2010). The protest psychosis: How schizophrenia became a black disease. Beacon Press.
  19. Laing, R. D. (1960). The Divided Self: An Existential Study in Sanity and Madness. Tavistock Publications. London.
  20. Mckeown, M., Dix, J., Jones, F., Carter, B., Malihi-Shoja, L., Mallen, E., & Harrison, N. (2014). Service user involvement in practitioner education: Movement politics and transformative change. Nurse education today, 34(8), 1175-1178.
  21. Seikkula, J., Aaltonen, J., Alakare, B., Haarakangas, K., Keranen, J., & Lehtinen, K. (2006). Five year experience of first episode nonaffective psychosis in open-dialogue approach: Treatment principles, follow-up outcomes, and two case studies. Psychotherapy Research, 16(02), 214–228.
  22. , (2014). Introduction to peer-supported open dialogue. London: North East London Foundation Trust.
  23. Razzaque, R., & Wood, L. (2015). Open dialogue and its relevance to the NHS: opinions of NHS staff and service users. Community mental health journal, 51(8), 931-938.
  24. A Vision for Change. Report of the Expert Group on Mental Health Policy 2006
  25. Mental Health Commission Annual Report 2014 Including Report of the Inspector of Mental Health Services
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