David Hill readings reprinted from The Politics of Schizophrenia: psychiatric oppression in the United States 1983 (University Press of America 1983) with the permission of the author (currently not in print).
Chapter 9
WHY PSYCHIATRY NEEDED A NEW INVENTION
Camouflaging Social Control and Personal Fears
Throughout history we have been faced with the fact that, within any particular group, some minority behaves in ways that are markedly different from the majority. The group norms, and the deviations from those norms, have been almost infinitely varied. The reaction of the majority to the minority, however, has been relatively consistent. Fear and anger may be con controlled or veiled, but their occurrence seems almost inevitable. Since the time when we first cooperated to kill an animal too powerful to be destroyed by an individual , two primary functions of groups--and of social behavior in general--have been the physical survival and psychological security of the group members. Norms were inevitably established in accordance with the tasks for which the group was created, one of which, usually, is the continued existence of the group. To go against the rules, therefore, threatens to sabotage not only the efforts of other group members but also the very existence of the group itself. When so much of our self-definition and sense of security is dependent on cooperation with others and the requisite control of our more selfish tendencies, our negative emotional response to those who fail to comply is readily understandable.
It should not be surprising that our conceptualizations of such noncompliance often result in a reduction in our anxiety about our own tendencies to break the rules. Following some definition of usual and unusual behavior, we have tended to not only exaggerate the differences by dichotomous thinking, but to characterize the atypical behavior as wrong, evil or crazy. Definition and categorization are inevitable components of our attempts to understand the world. To label some behaviors as normal and others as abnormal serves the dual purpose of strengthening the cohesiveness and norms of the majority group while minimizing the potential of the members of that group to act in an individualistic manner. Once an 'us/them' situation has been established it tends to be cemented by our propensity to project onto 'them' our own needs to go against the norm. Our evaluation of the behavior of the outgroup as 'wrong' reinforces, in turn, our own efforts not to be like them.
The self-perpetuating process is completed by the actions we take against the deviant group. There appear to be two basic strategies: exclusion by isolation or extermination, and attempts at enforced conformity. Most of the various implementations of these strategies are painful to the recipient and, therefore, encourage us in our efforts to avoid joining the ranks of the recipients, to conform.
We have seen how the norms to which we should conform have changed with the zeitgeists of different cultures and different historical periods. The particular behaviors that have made us fearful, and have therefore been labeled 'wrong', have been inextricably interwoven with each culture's unique view of the world. How each culture has dealt with its anxiety has differed--in content only--determined by the definitions, the means of control and the type of rationalization employed to conceal the true nature of the process. The process, however, has remained the same.
The works of Emil Kraepelin (1856-1926) and Eugen Bleuler (1857-1939) demonstrate the continuation of this process. Their notions of 'dementia praecox' and schizophrenia are perfect examples of the particular manner in which this process was to manifest itself in the mental health movement of the 20th century. Notable in this particular manifestation is the role of science in the task of defining acceptable and unacceptable behavior. This represented the culmination of a gradual change, beginning during the Renaissance, and it had several crucial consequences.
First, the existence of a social control process was once again concealed. Pinel had acknowledged that the 'medic' had been introduced into the asylum primarily as an authoritative representative of society's moral norms. The English Quakers had openly and even proudly espoused the goal of producing socially acceptable behavior. For a brief period the institutionalization of social control had been acknowledged for what it was. The invention of 'schizophrenia' and its subsequent widespread usage marked the culmination of a gradual return to the pseudo-scientific rationalizations of the 17th and 18th centuries. Second, the concepts of right and wrong, good and bad, acceptable and unacceptable were replaced by the notions of 'mental health' and 'mental llness' as defined and measured by 'mental health professionals.' Third, the attribution of personal responsibility for exhibiting unacceptable behavior reached an all time low as the medical profession promulgated the belief that such behaviors were symptoms of various diseases with physiological etiologies and hereditary predisposition.
I shall begin with a review of the influences en couraging the continuation of previously futile efforts to apply medical science to the field of deviant behavior. I shall then, relying almost exclusively on the works of Kraepelin and Bleuler themselves, attempt to support the following arguments: that 'schizophrenia' does not constitute a disease entity; that the notion represents little more than a grouping of many of those deviant behaviors which had remained unamenable to explanation in medical terms; and that the function ot the 'schizophrenia' notion and of those who employed it was to control these deviant behaviors in the guise of a humanistic concern with 'mental health'. In short, I hope to demonstrate my belief that 'schizophrenia' is simply our most recent attempt to deal with our own most primitive needs and the resulting fear that failure to control those needs might result in our breaking Society's norms. It does so by providing us with an out-group onto which we can project our own tendencies to be 'deviant' or 'crazy,' to rebel.
The Monopoly of the Physical Sciences
I have already traced the gradual encroachment of science into areas previously occupied by religion and philosophy. By the end of the 19th century the scientific method had a virtual monopoly in the marketplace of knowledge. Justification for its continuing expansion was easily found in its outstanding successes in almost all the areas to which it was applied. The physicist had emerged as the archetypal finder of knowledge; the methodology employed in this field was held up as a shining example to those seeking to apply the new religion to unchartered territories. We have also noted, however, the failure of the scientific method when applied to the problem of madness. We have seen how categorizing various behaviors had, in the 17th and 18th centuries, led to nothing but futile attempts to make antiquated etiological theories fit a never-ending list of newly 'discovered' entities. Nevertheless, following the 'Romantic Reaction' of the early 19th century, the categorizations and unsupported physiological explanations reasserted their dominance. What were the forces responsible for the resurgence of this time-worn approach, the approach which was to be the basis tor the invention of 'schizophrenia' and of the mental health movement of the 20th century?
While the success of the physicist was the guiding light to all researchers, progress made in the fields of medicine and biology had a particularly strong impact on those individuals grappling with the unsolved problem of insanity. Utilizing the principles of physics and chemistry, and such technological advances as the development of the achromatic lens and compound microscope, medical science was advancing with great rapidity. In 1847, Helmholtz had extended Mayer's law of conservation of energy in animals to all matter, including the human organism. The concept of contagious and infectious diseases had been established in the 1840s by Bassi's discovery, in Italy, that the silkworm disease was caused by a microscopic parasite. Meanwhile in Germany, Romberg had been establishing neurology as a seperate medical speciality. In the l860s, Lister had introduced the practice of anticepsis. Such successes inevitably encouraged those who continued to see medical science as the path to follow in their efforts to understand madness. Two breakthroughs were of special import in determining the particular manner in which such individuals would attempt to apply the medical approach.
In 1858 Rudolf Virchow, a German pathologist, published a book which in the opinion of Alexander and Selesnick "marks the beginning of the modern era in medicine. As early as 1761 Morgagni had argued that diseases start from localized disturbances of the organs. In the early part of the 19th century French physicians had specified the tissues of the organs as source of disease. In 1838 the Schleiden-Schwann cell theory had taught us that tissues are made up of cells which were the basic structure of all living matter. Virchow's work replaced the notion that cells come from some primordial protein substance with the discovery that cells come from other cells. More important1y, for attempts to understand madness, Virchow argued that all pathology could be explained in terms of disturbances, by abnormally severe stimuli, of the life processes of the cell. The other breakthrough was the discovery of a number of real disease entities. Addison's disease of the adrenal gland, Bell's facial paralysis, Bright's kidney disease, Parkinson's shaking palsy and Hodgkin's leukemia of the lymph gland were all discovered during the first half of the 19th century. The temptation to seek similar successes in the area of madness, by postulating disease entities with physiological etiologies, must have been strong indeed.
Influence from biology came primarily in the form of Darwin's theory of evolution. "The Origin of Species by Means of Natural Selection" (1858) appeared just a few months after the publication of Virchow's work on the primacy of the cell. By introducing the physicist's laws of probability Darwin rendered redundant Lamarck's notion of a vital force driving organisms towards pre-established goals. Biology, which had already provided the impetus for the endless categorizations of the 17th and 18th cent:uries, now added the new temptation of trying to discover the origins of craziness in hereditary influences. Magaro points out that:
The medical profession reverted to the disease hypothesis, adding further that the disease was disintegrative, afflicting only those persons with inferior heredity. Thus, doctors saw mental illness as evidence of Darwin's,theory of natural selection, as nature a way of eliminating the unfit of the species. (1976, p.67)
The works of both Kraepelin and Bleuler were clearly influenced by all these factors. I hope to demonstrate that the notion of 'schizophrenia' is essentially little more than the creation of a new category, by grouping various behaviors, which is then called a disease with a hypothetical physiological basis and an undemonstrated genetic predisposition.
The belief that the medical model was the most productive approach to madness received even stronger reinforcement from the discovery, in 1822, that a certain sub-section of previously inexplicable 'dementias' was directly related to pathological lesions of the brain. Bayle's work on 'dementia paralytica' provided ammunition for those eager to replace the Romantic Reaction with a purely physiological approach. Griesinger, a renowned German psychiatrist and neurologist, argued:
The first step towards the knowledge of the symptoms is their locality: to which organ do the indications belong: what organ must necessarily and invariably be diseased where there is madness? . . . Physiological and pathological facts show us that this organ can only be the brain; we, therefore, primarily, and in every case of mental disease, recognize a morbid action of that organ. . . Although in many cases this can not be ocularly demonstrated by pathological anatomy, still on physiological grounds it is universally admitted. (1867, p.1)
Zilboorg and Henry (1941) characterized this approach as "psychiatry without psychology." The most crucial implication, for the invention of 'schizophrenia,' however, was that demonstration of a physiological etiology was no longer a requirement for the establishment of a disease entity. The hope of discovering such an etiology at some point in the future would suffice.
The impact of Bayle's discovery can be estimated from the eagerness with which 19th century psychiatrists diagnosed 'dementia paralytica', one of their few constructs which met the old requirements for establishing a disease entity. Sullivan notes that:
Kraepelin, who was greatly influenced by the medical ideal, in 1896 diagnosed approximately 28 percent of his cases as dementia paralytica. After the adoption of Wasserman's serological technique for detecting syphilis, he diagnosed as dementia paralytica only about nine percent of his cases. (1962, p.298).
The outcome of these various influences, from various branches of science, was a climate within which even if one was sufficiently immune to develop a non-medical approach, the chances of anyone taking it seriously were slim indeed. Griesinger, his equally anti-psychological English counterpart Henry Maudsley, and other powerful psychiatric figures, were actively promulgating the medical approach. The status, and perhaps even the survival, of their discipline depended on it.
Freud provides us with an anecdotal example of the pressures on theoreticians to adopt the medical model if they were to have any chance of having their ideas accepted. Having overheard a conversation in which Charcot excitedly espouses a sexual etiology of hysteria, as compared to his publicly expressed position that hysteria is an organic neurologica1 illness, Freud comments:
I know that for a moment I was almost para-lyzed with amazement and said to myself: "Well, but if he knows that, why does he never say so?" But the impression was soon forgotten; brain anatomy and the experimental induction of hysterical paralyses absorbed all available interest. (1914, pp.13,14)
Szasz (1974) suggested that Freud himself was similarly influenced by the "contemporary scientific Weltenschauung according to which science was synonymous with physics and chemistry":
Bleuer and Freud approached hysteria as if it were a disease, essentially similar to physiochemical disorders of the body, for example, syphilis. The main difference be tween the two was thought to be that the physiochemical basis of hysteria was more elusive, and hence more difficult to detect with the methods then available. (1974, p.77)
Nevertheless, the ineffectiveness of applying the medical paradigm to madness is evidenced by the various 'discoveries' of 'mental illnesses' during the years preceding the 'discovery of 'schizophrenia'. Each one was discarded (or integrated into some more broadly defined disease) about as quickly as the etiological theories of 'schizophrenia' were to be invented and discarded in the 20th century. This continuing process of inventing 'mental illnesses'--now several centuries old--demonstrates, perhaps, the tendency of an established paradigm to ignore evidence that challenges the basic assumptions on which the paradigm is based (Chapter 32). The culmination of this process was the invention of 'dementia praecox' and its almost immediate reformulation into 'schizophrenia'.
It could be argued that by highlighting the particular influences outlined above I have paved the way for a biased interpretation of Kraepelin and Bleuler. I would suggest, however, that it is only by bearing these pressures in mind that we can understand the willingness of dedicated scientists, undoubtedly motivated--at the conscious level--by the most humanistic concern for their patients, to develop theories in the almost total absence of anything approaching scientific evidence and which are supported by the most obvious kind of illogical and circuitous proofs. It must be acknowledged that Kraepelin, to a certain extent, and Bleuler, repeatedly, make rather clear statements as to the lack of evidence for a physiological etiology or a genetic predisposition. They both remark on the tentativeness of their hypotheses. Such disclaimers, however, did not prevent either author from turning out hundreds of pages documenting the 'symptoms' of the 'disease'. Furthermore the disclaimers failed to discourage the majority of 20th century mental health professionals from diagnosing, treating, and researching our most recently invented 'mental illness', our most recent attempt to conceptualize and control the more extreme forms of deviant behavior.
In examining the works of Kraepelin and Bleuler I shall first deal with
their thoughts concerning the nature of their invention. I shall attempt
to demonstrate the extent to which their thinking parallels the processes
involved in the discovery and description of a medical disease entity, notably
the categorization of symptoms, and the demonstration of a physiological
etiology. I intend to suggest that their categoriza tions are--from a medical
point of view--quite arbitrary and that their arguments for a physiological
etiology are quite unfounded. Then, in Part 3, I shall offer a reinterpretation
of their observations from the social control perspective outlined at the
beginning of this chapter.