The treatment for and manic-depression have shockingly deteriorated throughout my professional lifetime, dating back to 1971. During the hopeful period of deinstitutionalization, it seemed like we were turning the corner. We had expected that patients would return to the community. There they would have individual and family therapy; housing; assistance with working; and help with activities of daily living, when necessary. Finally, an enlightened age, finally. It didn’t happen. So many became homeless. As Allen Frances documented, we have closed a million psychiatric beds and locked up a million psychiatric patients in prison. – “Psychiatry and Recovery: Finding Common Ground and Joining Forces.”
Here’s the problem. Historically people are frightened by the schizophrenias and manic-depression mostly because of changes in consciousness itself – delusions, hallucinations, paranoia, bizarre behaviors, etc. Schizophrenic individuals most easily lend themselves to be characterized with labels, as if they are just things, not people. Experts have always presumed that ‘they’ could be defined with whatever is the ‘in vogue’ theory of today – whether it was witches, demonic possessions (still going on), devils, or ‘all we need are drugs.’ In our recent history, the treatment of the severe mentally ill had, in fact, an enlightened period. In the late 1890’s and early twentieth century the theory then was that the cause of schizophrenia was industrialization. And the treatment of choice was a ‘pastoral cure’. All over Massachusetts, huge tracts of beautiful land were bought for the purpose of pastoral retreats, both public and private. Unfortunately, when the money ran out, so did the enlightened period. Soon, schizophrenic patients were warehoused on this beautiful property.
It didn’t take long until the warehousing turned into the snake pits of the forties and fifties. The next major turn was that Thorazine and Lithium were discovered (both by accident). In some private institutions psychoanalytic therapy was undertaken with mixed success. This then lead to the deinstitutionalization and the paradoxical deterioration of psychiatry today. Let me add here that there have been traditions of caring that have been truly remarkable. See – “Reflections on Geel – Schizophrenia is not a Medical Disease. Human beings with schizophrenia do best with care and respect.” Also wonderful places like Westwood Lodge, under Harry Stack Sullivan.
Here’s the secret. People with schizophrenia and real manic-depression are people. They are not objects. Our human plays of consciousness are very complex, but they are ordered as a story. In the psychotic worlds, there is an additional disruptive dimension to the regular stories of life. Do to some combination of maternal deprivation, a genetic propensity or something epigenetic, there is additional damage to these plays - an unmanageable limbic nuclear rage. The cortex cannot encompass this powerful rage in a cohesive way. It fragments the cohesion of the play itself and the intactness of the self persona. When the self and its primal play flies apart, it generates a state of terror, the dimensions of which are far more powerful than regular anxiety. This terror/rage is the central characteristic of all the psychotic character worlds.
Although the self and its plays are fragmented, consciousness continues its ongoing process of playwriting. Consequently, the cortical imagination now writes new plays that are anchored in this limbic rage/terror experience. Disrupted plays of a fragmented self and terror-filled feeling and otherworldly plots are written and inhabited. The feeling of these plays are captured by words like awe, dread, or horror. This leads to the delusions, hallucinations, and bizarre behavior. Schizophrenia has, as its foremost feature, the rupture of the self. This reflects the fact that its pre-psychotic character world is in fact problematic, hollow, and not sustainable. It is a false self, like a cardboard cutout. The eruption of the psychosis is a built-in inevitability. The fragmentation is not anchored in the Authentic-Being and always becomes unmanageable. The resultant terror/rage is the worst and most unbearably frightening state of all potential human experience.
There is another tragic feature of schizophrenia – The Humpty-Dumpty factor. Once the self and the plays are fractured, they cannot fully be put back together again. Due to the powerful limbic rage and terror, they are more vivid and compelling than non-psychotic plays. As a result of the fragmentation, what would be regular thoughts in an intact play, are experienced as literal, heard voices in the plays of paranoid schizophrenia. These auditory hallucinations are given form by the cortical imagination as voices of otherworldly figures who generate terror and awe. Since the psychotic world is an invisible play of consciousness, just like non-psychotic plays, voices are heard, but no personas are ever seen. There are no visual hallucinations in schizophrenia. Visual hallucinations come exclusively from toxic states, tumors, drugs, seizures, or incomplete morning.
In manic-depression, the central feature is that limbic feeling cannot be contained by the ruptured play. It spins out of control without limits. Manic flights of feeling are likewise not to be romanticized. A patient in a real manic psychosis can be quite humorous in his early mood-elevated phases. It can even feel ebullient. It is contagious and manic people make us laugh. It, however, always escalates out of control. In its final and inevitable form, shows itself to be a terror/rage state. At that point it is almost indistinguishable from a catatonic state.
None of the psychoses operates as stand-alone states. They each reflect severely damaged characterological plays. The various bizarre plays of otherworldly characters and terror/rage feelings are in the potential cortical imagination of all of us. This is recognizable in the broad appeal of the genre of horror moves. The difference in psychosis is that the play that is believed is a horror movie, with its built-in characteristic horrific imagery and horrific feeling.
Unlike the rest of psychiatric problems, there is a brain element in schizophrenia and manic-depression. Thus, there is an appropriate usage of Thorazine and lithium. Please see the appendix to my book – “Do no Harm: The Destructive History of Pharmaceutical Psychiatry and its Bedfellows-electro Shock, Insulin Shock, and Lobotomies.” Drugs, however, do no treat the human problem. They can help keep the horrendous terror at bay. And when this is necessary, there is a tradeoff and a downside that often is worth it. The real issue is the human story. And this what needs to be treated, just like all the rest of our character issues.
There are a number of remarkable stories where people overcome and manage their schizophrenia and live wonderful, difficult, and productive lives. Unfortunately they are the exception. In today’s world, it is our moral obligation to treat people who really need it, and so many are ignored. This will require a renewed effort to understand the complex issues of living a life that has some damage, but is no less valuable. We must take care of people who cannot help themselves; people who are isolated; to provide what cannot be done independently; and to have places of refuge where people can go to periodically heal, and come back out again for a productive life. There are a number of places out there that struggle to provide this environment, but nowhere near enough. For a full human life we do not need a medical model, but a human one.
Robert A. Berezin, MD is the author of “Psychotherapy of Character, the Play of Consciousness in the Theater of the Brain.”