I am revisiting my previous material about schizophrenia because there are two new books which raise some important issues and current research regarding this mental illness. “Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness” (2019) by Anne Harrington covers some material I have covered in previous posts and she also moves further into the current state of biological psychiatry with separate sections on Depression, Bi-Polar Disorder, and Schizophrenia. I will focus specifically on this latter section for this post. “Hidden Valley Road: Inside the Mind of an American Family”(2020) by Robert Kolker investigates the case of the Galvin family from Colorado Springs who had twelve children, six of them diagnosed with schizophrenia. Kolker traces the history of various psychiatric/psychotherapeutic approaches to understanding and treating schizophrenia, particularly with the Galvin family children.
Neither Robert Kolker or Anne Harrington are clinicians or former patients, therefore they are not what I have referred to as “insiders”. Kolker is a journalist, and Harrington is a professor of the history of science.
While Kolker spends a good deal of his reportage on the lives of the individuals in the family and I believe this appeals to a wide readership he brushes over highlights of the history of theories, interpretations, treatments, and research regarding schizophrenia, he ends up spending the last half of his book reporting on the unfolding advances in genetic research. He is careful not to assume anything conclusive (since there is nothing conclusive), but he essentially discards family dynamics as a possible significant ingredient in the outcomes of what happened in the Galvin family. The mother, Mimi, obviously created double-binds, and both parents covered up the illnesses of their children with distractions, denials, and secrets. Both parents failed to protect their young girls from the predatory behavior of Jim (the second oldest brother). One son committed murder-suicide. I believe there was more denial than Kolker reports. The direct and indirect trauma was ongoing and insidious throughout the lives of all children. So with or without so-called markers for a genetic predispossession, the family dynamics played a role in the various outcomes – those with established diagnoses of schizophrenia and obvious symptoms – and those without.
In fairness to Harrington, her book is primarily about biological psychiatry and not psychotherapy or psychoanalysis, so my comments about how she lightly touches base with psychoanalysis and family therapy and then presumes them to be fairly dealt with may expect too much. Yet, the epistemology of linearity in the historian’s chronological treatment diminishes a more nuanced and complete understanding of how both psychoanalysis and family therapy contributed to and continue to contribute to a dynamic picture of the complicated disease we still refer to as schizophrenia. Psychoanalysis and family therapy are dealt with almost as straw men to be put in place as historical failures in treating schizophrenia.
An example of Harrington not being a clinician is her bad habit of lumping people who suffer from a variety of mental illnesses that may not rise to the level of psychosis as “worried well” – a hackneyed reference which would not be used by either a clinician of a patient.
There is also a “cherry-picking ” problem. Harrington refers to Thomas McGlashan’s meta-analysis of case records from Chestnut Lodge, a psychiatric hospital near Washington, D.C. which cared for schizophrenic patients, “The Chestnut Lodge Follow-up Study: Long-term outcome of Schizophrenia and the Affective Disorders” (1984). She summarizes his conclusions with this “he reviewed the case records of some 446 patients and found that they showed, he said bluntly, that psychotherapy was ineffective for schizophrenia” and in McGlashan’s words, “‘ the data are in and the experiment failed'”(p.181). What does “failed” really mean? Yes, McGlashan was a clinician at Chestnut Lodge, and yes, he followed the psychotherapeutic approaches of Harry Stack Sullivan, Frieda Fromm- Reichmann, and Otto Will, generally known as Interpersonal Psychotherapy. His analysis of cases assumedly included those of these three clinicians, (each of whom had a period of directing the hospital), as well as other psychiatrists. I have not read his study, though I have read case material from Sullivan, Will, and Fromm-Reichmann. Without knowledge of the Interpersonal Psychotherapy treatment approach, an evaluation of “success” or “failure” seems a simplistic conclusion. Context is significant. To begin with, McGlashan had likely already been considering a medical-biochemical approach to treatment with schizophrenic patients and moving away from psychotherapy. He did shift into an enterprise of early medical intervention with pre-schizophrenic patients, which ultimately did not succeed. To be fair to the clinicians who devoted their careers to helping severely ill patients, the Interpersonal Psychotherapy practiced at Chestnut Lodge includes published accounts of their process as well as what they considered successes and failures with patients. While I might question some of the theoretical assumptions of Sullivan and Fromm-Reichmann, their shift away from some classical psychoanalytic positions and their humane treatment of all patients who they treated, deserve more intentional consideration.
Carlton Cornett, in “Being withPatients” (2017), writes about Harry Stack Sullivan and Otto Will, as well as Frieda Fromm-Reichmann and a few other clinicians who worked with schizophrenic patients and generally followed the approaches of Sullivan. He refers to Otto Will’s approach to treating patients, ” He noted that the more you come to know a patient, the less he will seem like a disease or disorder and will then take the form of an unhappy, despairing, and discouraged person confused by his relationships with others”(p.120)
Cornett summarizes his interpretation of Interpersonal Psychotherapy:
“Interpersonal psychotherapy is composed of a variety of elements that are treated as mutually exclusive: social learning theory, behaviorism, psychoanalysis, attachment and cognitive theory. I tend to favor the psychoanalytic aspects over others, but I know that all contribute significantly to the whole. How Interpersonal Psychotherapy primarily differs from psychoanalysis is its practical emphasis. It avoids the oft-disputed question of whether one’s technique is appropriately ‘analytic’ for the more important question of whether we are helpful” (p.160).
The case material from Sullivan, Will, and Fromm-Reichmann, indicates evidence of various successes in helping seriously disturbed patients overcome most of their symptoms, gain insight into their life challenges and relationships and manage their affairs outside of the hospital environment. The treatments did not include medication or any other experimental practices, such as electric shock. We now know that some combination of the most current medications, plus some form of psychotherapy, may be the most effective treatment at this time, but we also know that bio-psychiatry and pharmacological treatments alone have not provided answers for the sufferers of schizophrenia. Harrington includes in her chapter on schizophrenia sections on serotonin, dopamine, amphetamines, genes. she concludes with:
In 2008 a group of researchers launched a multipart project designed to identify and critically assess all ‘facts’ currently established for schizophrenia. Each was graded on a 0-3 scale for reproducibility, relevance for understanding schizophrenia, and durability over time. Some turned out to be more robust than others, but none got full marks. More important, even the most robust individual facts pointed in a range of different directions; they did not, as group, lead logically to any coherent explanation of schizophrenia” (p.182).
I will continue my investigation into schizophrenia, to include a proposed systems approach to understanding and treating this challenging disease, in my next post.