Division Review Schizophrenia: an unfinished history—Interview with Orna Ophir

Schizophrenia: An Unfinished History—Interview with Orna Ophir

Schizophrenia: An Unfinished History By Ophir, O. John Wiley & Sons, 2022, 224 pages, $35.00

Division/Reveiw: Please tell me a bit about what led you to write the book.

Orna Ophir: The initial reason was quite prosaic. First, it was a commissioned book. Pascal Porcheron, who was at the time an editor at Polity, started a new series about the history of health and illness, and he contacted us at the DeWitt institute for Psychiatry: History, Policy, and the Arts at Weill-Cornell Medical College here in Manhattan. He kindly asked me whether I would consider writing a book about the history of schizophrenia and whether, together with my colleagues, I could help him identify other authors who would write for the series about other psychiatric illnesses. At the time, I was working on a manuscript about the reception of Melanie Klein’s thought in America for Routledge, with the planned ironic title Klein in America (klein meaning “small” in German). Still, I also taught a course about the history of madness at the Humanities Center at Johns Hopkins University, a course which I have continued to offer at NYU’s Gallatin School for Individualized Studies since 2017. So, the idea of writing a book about the history of mental illnesses, in this case, schizophrenia, and of being further involved in advising the series indirectly was very appealing.

D/R: In my mind, the book broadly appeals to clinicians and academics interested in the history of psychosis and its treatment. I’m curious, though, if you anticipate it being received by psychoanalysts in the U.S. in any particular way.

OO: It was very satisfying to hear that the book also appeals to clinicians, which I heard from a few other colleagues. My hope and intention were to reach a wider readership, including those “in the trenches” of treating patients with these difficulties. I make the point in the book that, as clinicians, what we know about “schizophrenia” is often what we learned about it in our training. We are taught that “if it walks like a duck, swims like a duck, and quacks like a duck, it must be a duck,” or, in our case, if the patient hears voices or demonstrates disorganized behavior and speech, next to a flat affect, etc. then they surely must have schizophrenia. But I suggest that when it comes to theorizing or treating schizophrenia, or whatever other name we learn to call it, we should always try to be of “two minds.” Since my history points to what seems now like a shift in our diagnostic paradigm--one that passes from having clearcut categorical DSM diagnoses of disorders like schizophrenia, paranoid schizophrenia, or disorganized schizophrenia to the invocation of spectrums or dimensions such as the schizophrenia spectrum disorder (that also includes relatively mild cases of schizoid personality disorder or brief psychotic disorder)—I remind the readers of Thomas Kuhn’s (and, earlier, Ludwig Wittgenstein’s) famous reference to Joseph Jastrow’s image of the duck-rabbit illusion. Kuhn writes that when a scientific revolution takes place, and the paradigm shifts, what was a “duck” in the scientists’ view before the change (in what was up till then a “normal science”) becomes a “rabbit,” incommensurable with the preceding paradigm, after the revolution. As clinicians, I suggest instead that, when we are sitting with our patients, we might, at times, need to see and treat them as “ducks,” in other words, attributing to them terms of a different “kind” or “category,” while, at other times, we may need to see and approach them as “rabbits,” in other words, as being different only in degree from us. According to the latter view, such patients would be viewed and helped as being on the very same continuum or spectrum, albeit suffering the same anxieties, defenses, and object relations that those considered “normal” have but with a different intensity. In any case, I argue in the book that our patients are always much more complete as whole persons than our limited perception allows us to grasp and much more complicated than our restrictive categories of psychological and medical understanding instruct us to use.

A younger colleague, a psychologist whose insight and work I trust, wrote me a text after reading the book, saying it helped her to see her patient, now as a “duck,” then again as a “rabbit.” And the idea that something in this book could help a clinician in her everyday encounter with a patient in her office was deeply gratifying. But you asked, more specifically, how psychoanalysts in the U.S. did receive the book, and I must admit that I had two previews of how this might play itself out and what to expect well before the book was even published. When the two anonymous reviews of the submitted manuscript arrived, the first stated with enthusiasm: “wow, you managed to get psychoanalysis into this story, and even Klein, Chapeau.” Yet a second reviewer was devastated that there was a chapter about psychoanalysis at all and mortified that Melanie Klein was mentioned in it, implying that the chapter in question was an aberration in what was further a laudable project in the intellectual history of psychiatry. It should probably not have surprised me that psychoanalysis would evoke such strong passions even in very informed readers. Still, I had a genuine trial by fire when I presented the chapter on psychoanalysis to our esteemed group of colleagues in the history section at the DeWitt Wallace institute at Weill-Cornell. These psychoanalysts, who largely trained in the United States in the 1950s-1960s and are also medical doctors and psychiatrists with extensive clinical experience working in hospitals, have very strong opinions about the nature of mental illnesses and, especially what psychoanalysis is and should be. To my pleasant surprise and relief, they seemed, without exception, intrigued by my overall argument and proposal, which was exactly what I had wished for.

D/R: What is fascinating about the history you trace in the book is that the debate around category versus spectrum goes back thousands of years, though with very different idioms and aetiological theories, not to mention treatment approaches. In psychoanalysis specifically, the same distinction seems evident in—on the one hand —Freudian (including Lacanian) distinctions between neurosis and psychosis, and—on the other hand—Kleinian object-relations conceptualizations. The latter lend themselves more to a dimensional approach, while the former is categorical or structural. All this to say that within psychoanalysis, not to mention psychiatry—we have the same debate as the ancients!

OO: Yes, and this is the case, perhaps, because we seem to have two ways of thinking about differences, either qualitative or quantitative. Freud sometimes sees an “absolute difference” between different categories of psychopathology, while, at other times, he imagines the different pathologies to be on a continuum. In any case, he is clearly not that impressed by what he calls the “academic question of diagnosis” but is more interested in “working with the living material,” which always escapes our definitions. What is common to Freud, Lacan, and Klein when it comes to the question of the psychoses is that they all had read judge Schreber’s memoir and used it as a point of reference when thinking through the difference between the neuroses and the psychoses. Freud, on the one hand, found profound similarities between Schreber’s more severe pathology and the neuroses, notably in the latter’s use of splitting between the upper” and “middle Flechsig” or between the “lower” and “upper” God as well as in the experienced conflict between love and hate regarding the parental object. Yet, on the other hand, he also emphasized the difference, which is found in the withdrawal of the libido from the world of objects and, hence, in the inability to form relationships of transference in patients diagnosed with schizophrenia. In the same way, in reading Schreber he writes that

even though while listening to the delusion, we find ourselves on familiar ground (known from dreams, myths, and creative writing), we must likewise acknowledge important differences and realize that there are abnormal changes in the ego, a structural defect, which set this mental illness clearly apart.

Nathaniel London has observed that Freud had two theories about schizophrenia: the unitary theory, which sees the difference between the normal and the different pathologies in quantitative terms, and the specific theory, which sees the difference in question as a matter of qualitative discernment. According to the unitary theory, the difference lies in the degree of regression, such that, in schizophrenia, we see merely a more severe manifestation of the very same behavior, with the trauma of greater significance having occurred earlier and thus rendering the pathology far more pronounced. According to the specific theory, schizophrenia is seen as categorically different, marked by a qualitative difference, with the inability to engage in transference relationships being its main distinguishing feature.

We see this duality in Freud’s work prevails in his legacy in post-Freudian psychoanalysis when it comes to schizophrenia, and this nowhere more clearly than in what came to be known as the so-called “defect school” and “conflict school,” respectively. The defect in the ego that is responsible for schizophrenia is seen as either a constitutional defect or attributed to early object relations. In contrast, the conflict that results in schizophrenic symptoms is only different from the neurotic conflict in terms of its intensity. Karl Abraham, who continued the work with psychoses after the Burghölzli clinic’s “divorce” from psychoanalysis, followed Freud’s conflict model along these lines. Abraham’s work on psychosexual development and the aggressive drive significantly influenced Klein’s view on development in its relationship with pathology.

In Klein, as you rightly point out, it is abundantly clear that everyone is suffering from primitive anxieties, just as all use similar defenses and construct typical object relations. The only difference is that these reactions are excessive in the more severe pathologies, thereby characterized by a quantitative difference, not a difference in kind. Klein, who also read Schreber’s memoir, commented on the excessive use of splitting that divided the judge’s doctor into no less than forty-six different souls and inflicted fragmentation on Schreber’s ego. Bion, who would continue Klein’s work on schizophrenia, similarly writes about the excessive death drive in schizophrenia. And Meltzer, finally, writes about massive projective identification. We can see, then, that this psychoanalytic school of thought revolves around the themes or poles of libido and aggression, or love and hate, of integration and splitting or fragmentation, and portrays them as being located on a scale, in other words, on a continuum. It is worth mentioning, in this context, that also Harry Stack Sullivan, as an analyst who worked with patients with schizophrenia and suggested that the schizophrenic is the most disorganized of all patients, believed that there is a spectrum on whose sides we find, on one extreme, organization and, on the other, disorganization.

D/R: I’d like to ask a concluding question that is more political. Your book culminates in discussing recent efforts by those with lived experience of psychosis in advocacy. There has been the rise of hearing voices groups and peer-based work aimed at empowerment, not to mention basic dignity, given the perilous history of psychiatric treatment. What is your sense of psychoanalysis’ reception, or even awareness, of such efforts? Are there opportunities for psychoanalysis and dynamic therapies to have a place in addressing psychosis, given the shifts occurring at the level of broader social changes in the discourse around serious mental illness, as well as the inclusion of those with lived experience in clinical and academic settings?

OO: As psychoanalysts, we always work with the lived experience of our patients, and what we value most is how patients learn from their experiences as we do from ours. Psychoanalysis as a profession does not need convincing that what matters first and foremost is the lived experience. Still, we work with the individual patient rather than with the experience of special interest groups, associations, or organizations. We also assume that there is more to the experience than the conscious one the individual is reporting. Therefore, whether the individual who seeks the help of a psychoanalyst identifies themselves as voice-hearers, as neuro-diverse or as survivors, as service-users, clients, or patients, what matters most is the meaning they attribute to any of these self-identifications. As analysts, we listen to what they say, but also to their dreams and what they do not say, and communicate non-verbally instead. As much as individuals are being helped and supported by peer groups pressing to drop the label “schizophrenia” and to normalize or demedicalize voice-hearing, others have different experiences. When I spoke about the book in a Soteria House in Israel and presented the chapter on the hearing-voices movement, one of the younger female residents said she would not want to be forced to give up the label “schizophrenic.” I asked her to tell me more about this statement, and she said there was something about the word, the way it sounds and its strangeness, that feels most accurate in describing her experience.

To come back to your question, I want to believe that, as psychoanalysts, we are also aware of ourselves as citizens in a specific political climate and thus be informed of broader social changes. Historically, individuals who were diagnosed and treated (or rather mistreated) in institutions for the mentally ill have managed to organize and bring about significant changes. The first petition by a group of patients I know of was at the notorious Bethlehem hospital in the early seventeenth century. One can see how these resistances have been both empowering for individuals involved and had powerful effects on reforms in society. But, in the analytic hour, there is something about the “negative capability,” what Bion refers to as ‘no memory and no desire’ (which I am almost reluctant to cite here since it is already so saturated with meaning), that is, precisely, what makes psychoanalysis unique as a method. Our patients are, of course, always part of a larger socioeconomic context and political climate. But what usually comes up in our sessions with them is the here-and-now, which is heavily influenced by the transference relation. Only today, an exact week before the winter break, I heard from three different patients about their phantasies related to homelessness. None of them is near becoming the mentally ill unhoused person we see in the subway and on the streets, and who seemingly instigated these phantasies. Yet in the context of analysis, not to mention the coming and going of winter/Christmas or holiday breaks, they are connected to this more primitive anxiety, which sadly enough is also the empirical, external reality of all too many mentally ill individuals in the city. We can ask whether psychoanalysis could be helpful also for these people. As we know, once psychoanalysis widened its scope—to use Leo Stone’s term from his well-known 1954 paper—we have come to see psychoanalytic thinking and psychoanalytic work expand and immerse itself in settings we couldn’t imagine before that. They include populations whose supposed diagnosis was traditionally considered a counter-indication, unfeasible for any psychoanalytic work. As you may remember, Stone referenced the theoretical innovations of the work done by Karl Abraham on “manic depressive insanity,” but also the institutional efforts undertaken by Ernst Simmel, as he opened the psychoanalytic sanatorium in Berlin and started working with psychoses and addictions, the efforts by Aichhorn working in Vienna with juvenile delinquents, and, of course, Anna Freud’s and Melanie Klein’s treatment of young children.

Some people who hear voices or have auditory hallucinations (the wording depends on who is describing the phenomenon),