SCHIZOPHRENIA: THE CARE WE ADMINISTER
Does experience happen only when the brain gets sensory stimuli (sight, sound, taste, smell, touch) or for experience to happen does it have to undergo some other complex process? A newborn infant is alarmed by certain sounds but with passage of time understands that there is no danger associated with it. Hundreds of such stimuli bombard our senses daily but as we grow up we now have a repertoire of past experiences hence any sensory stimuli received is now, without conscious attentiveness, contrasted with memory to form perception. There is linkage, connectivity and correlation established and a strand of experience occurs. The raw sensory data is also embellished with imagination, fantasy and interpretations to form a meaningful whole.
In acute schizophrenia these sensory stimuli seem to remain as stimuli, isolated, detached and disjointed. A connection is not made hence there seems to be no perception and experience doesn’t seem to occur. Once meaning is attached to raw sensory data, experience occurs but in schizophrenia this meaning attachment doesn’t happen. As suggested by Ellwood (1995), ‘The schizoid individual has failed to transform certain sensori-motor experiences into representations, images, symbols and memories, a transformation that is essential for the construction of a normal apparatus for thinking.’
Is schizophrenia just an interpretation glitch invoked due to lack of meaning and significance creation in the patient’s mind, is it a breakdown of relationship with objects, is it an intra-psychic anomaly, is it a psychological disorganization or a genetic predisposition? There are multiple inferential strands, a few complimentary and others divergent. The scope to understand schizophrenia is vast however in this blog, I attempt to delineate the ‘experience creation’ angle of schizophrenia from schizoid regression and ‘object relations’ perspective.
This blog is technical, protracted in its construct and meant as recourse to psychotherapy trainees and fraternity. It presupposes some familiarity with Melanie Klein’s ‘object relations’ formulation hence doesn’t unfurl the meaning of certain terms. The blog presents aspects of Schizophrenia from a psychoanalytic standpoint.
INFANT’S OBJECT RELATIONSHIP
Object relations itself is pure conjecture however assuming this stance let us delve into an understanding of schizophrenia. The infant at first doesn’t recognize existence of the mother as it latches on to the breast for survival. Initially it doesn’t understand whole objects i.e. the infant doesn’t realise that the breast is attached to the mother and instead relates to only part objects for instance mother’s face, hands, breast etc. The initial object for the infant is the breast. As hunger pangs strike and when the breast is available the infant construes this as good (gratifying) breast and introjects it. Introjection, a defence mechanism posited by Freud, occurs when a subject takes into itself the behaviours, attributes, and beliefs of other external objects, especially of other people. Examples are, a child introjecting aspects of parent’s behaviour into his own personality and behaving authoritatively, aggressively, compassionately etc.
Introjection is not done with conscious and well-considered thought rather happens spontaneously. This introjection, as per Klein (1946), forms a vital part of ego development but when the breast is not available the child construes it as bad (frustrating) breast and projects it outside the self. This good versus the bad is the process of splitting and is happening in the infant’s phantasy (different from the word fantasy) and as per Klein is essential for healthy development. This splitting happens in the 0 to 5 month period and is called the ‘paranoid schizoid position.’
It is in the depressive phase (beyond 5 months) that the infant’s ego begins to develop and integration happens provided the infant is given a very high responsive parental care. The integration here means the infant beginning to develop a sense of the self, a sense of the other and how its interplay helps form an experience of reality. The word depressive here does not hold the same meaning as the word depression. In this depressive stage, the infant realizes that mother is a separate autonomous object from itself and that mother has her own needs. This reinforces the infant’s understanding of objects as a whole. I have rendered an extremely simplistic view of Kleinian tenets as the centrality of our discussion is around schizophrenia hence let us understand the importance of object relations and its linkage to schizophrenia.
EMERGENCE OF SCHIZOPHRENIA
Schizophrenia is a disorder that affects how one thinks, feel and behave. Hallucinations (hear, smell, feel or see something), paranoid delusions (feelings of persecution and harassment), disorganized speech, negative symptoms (emotionally drained, lack of drive, lack of sociability, focus problems, apathy) are common symptoms. Let us view the causality from ‘object relations’ perspective. Continuous parental rejections, lack of attentiveness, insufficient infant mirroring, and insensitivity to the infant’s needs induces in the infant; feelings of being unworthy and perceptions about absence of love. Any of these could coagulate into sub-optimal development of the ego in the depressive phase and the infant therefore could remain un-integrated and regress into paranoid schizoid phase where anxiety and fear is very high. The rudiments of schizophrenia are being planted.
A research (Karon and Vandenbos, 1981) has indicated that the infant’s perception that the mother doesn’t love him and will abandon him, bears equivalence to pain and death. ‘This is the infantile terror that lurks behind the schizophrenic symptoms. The schizophrenic individual’s whole life is organized around the need to defend psychologically against this danger.’ (Karon & Vandenbos). Owing to such an incipient threat, whenever danger is perceived, the infant withdraws itself from the object and attempts to sort itself out with splitting. As Guntrip (1968) suggests, ‘The schizoid is driven by anxiety to cut himself off from all object-relations.’ This is in consonance with Freud’s view, ‘Schizophrenias are inclined to end in affective hebetude – that is, in a loss of all participation in the external world.’ Engagement with the external world is renounced and there is a detached disposition.
Guntrip interestingly states that in this phase there is intense mental activity through dreams and fantasies, but the patient’s conscious ego merely reports these as if he/she were a neutral observer and not personally involved in the inner drama akin to a press reporter describing a grotesque incident without much emotion or personal interest. The schizophrenic attains severance from the object and may closely resemble a narcissistic disposition, the key distinction being; narcissists are devoid of empathy for others, don’t lose touch with reality, have this sense of grandiosity and understands symbolism (which I will explain as we go along). The schizophrenics have some residual concern for the others and I agree with Bion (1967) when he states that ‘The concern for others felt by a weakened ego is not a fully healthy objective concern arising out of appreciation of the worth and the interests of the object. Fear in the ego for itself plays a big part and as Bion puts it, panic at the loss of a supportive object and guilt over the loss of a love-object are mixed together.’ Bion further suggests that it needs a robust ego to love disinterestedly and care for another person basically for that person’s sake and that in practice it is difficult to attain this maturity.
Due to lack of ego development and as the infant, child or adult regresses back into schizoid phase, the sense of meaninglessness prevails. Ogden (1992) defined this stage as non-experience (a concept he derived from Bion’s work) and suggests that the patient is not repressing or hiding something from himself rather, and as stated by Ogden, “He has limited his power to know and to think. Previous meanings are not denied: they remain raw data, things in themselves that are not attributed emotional significance. Even the meaninglessness (perceived by the therapist) was not experienced by the patient; nothing was experienced, including the state of meaninglessness and non thought.” Ogden presents it as a total shutdown of the capacity to create experience and to think. Robbins (2002) states that, ‘The subjective ‘I’, denoting the presence of conscious reflection and thought about beliefs, fantasies, emotions and conflicts is largely missing. Robbins suggests that by manipulating their own mental contents, the schizophrenic attempts to experience control over their world.
Why does the schizophrenic do so? My understanding points towards the lack of ego-development in the depressive phase which can remain undeveloped even in adulthood either due to incongruous maternal care or constantly present environmental anomalies around him. The schizophrenic takes help of the only organizing pattern in his mind which he had used at infancy hence retrogresses into schizoid position as a defence mechanism that may prevent him from perceiving annihilation (when the breast or bottle is not available to the infant, the infant perceives annihilation as if its world is going to end and the feeling that it won’t survive the hunger pangs). This affect in the infant is manifested as loud screaming, head arching to and fro etc.
Revisiting Ogden’s statement, ‘The schizophrenic has limited his power to know and think’, it is my contention that an infant’s regression into schizoid phase doesn’t happen as a permissive or conscious occurrence and I feel he doesn’t enter voluntarily into an experience shutdown mode rather it happens without his conscious awareness due to predominance of the only available coping mechanism that Johnson (1994) says will be called upon again and again to deal with the persistent issues of existence and survival. With the recurrence of instances from an uncaring world for him, he attains a kind of permanence in schizoid regression, which is now categorized as schizophrenia. This uncaring world is his parental care and as Searles (1979) suggests, ‘The ambiguous, and unpredictably shifting, family roles make it impossible for the child to build up reliable and consistent pictures of the world around him.’
DOES EXPERIENCE REALLY SHUT DOWN
Does the schizophrenic remain bereft of experience at any stage in his life? It is my understanding that unless memory is eroded, meaning making would be pervasive even in the schizoid phase but due to the enormity of the underdevelopment during depressive phase the schizoid remains in a kind of primordial interpretative world. Robbins (2002) suggested that, ‘A schizophrenic episode is painful to watch but the patient does not thoughtfully experience the emotional distress that the empathically attuned observer infers. Basically he short-circuits the necessity to know, think and feel.’ It is not appearing to his consciousness hence he isn’t distressed. Whilst this could be true, it is my view that experience nevertheless is happening and as Guntrip has stated above, dreams and fantasies does occur in the schizophrenic mind.
To support the experience creation argument, Searles (1965) offers an important distinction for me here. He suggested that the deeply schizophrenic individual subjectively is devoid of imagination. Any fantasy as it enters his awareness is perceived as real hence he, in this state, lacks a capacity to distinguish reality from fantasy. The schizophrenic language doesn’t discern between the mind and the world and everything is reality to him. Searles goes on to state that ‘Memories of past events are experienced by him not as such, but rather as literal re-enactments of those events by the persons around him.’ Perceiving therefore, a variance from Ogden’s thought, I infer that a total shut down of experience is not possible because meaning creation through fantasy and dreams is going on, in fact, the schizophrenic is actually considering these as his reality hence experience is happening. As Rosenfeld (1965) suggests, schizophrenics may be out of touch with their environment however they do retain a small amount of insight into their condition. This I feel is the basic requisite for initiating the therapy process.
SIGNIFICANCE OF SYMBOLISM IN SCHIZOPHRENIA
Symbols have additional meanings beyond the literal. A chain can symbolize connecting two things, a rose can symbolize romance and black can represent death or evil. As per The Teaching Company (2002), ‘Symbolic processing develops in children in the 2nd year of life.’ A metaphor is a figure of speech that uses symbolism in which an implied comparison is made between two disparate things but which seem to have a common characteristic. For example:
Life is a journey
A blanket of snow-covered the ground
The tutor planted the seed of wisdom
Stench of failure
In daily life we use many implicit and explicit metaphors. ‘Metaphors augment conversion of stimuli, incidents, events, and situations into perception leading on to creation of an experience. In schizophrenia there is an inability to perceive, symbolize and understand metaphors. Basically absence of ‘A capacity to maintain a clear symbolic distinction between self and environment or between inner and outer worlds.’ (Burnham, et al. 1969). Hence the state of meaninglessness. As suggested by Bion (1967), there is severe splitting in the schizophrenic mind that incapacitates his ability to use symbols, substantives and verbs. Strong object relations therefore are requisites for symbolization. ‘Symbol-making function is one of man’s primary activities, like eating, looking, or moving about. It is the fundamental process of his mind.’ (Langer 1942, cited by Searles). It is my observation that, all of us may not understand poetry, simile, allegory, alliteration etc. but most of us understand the rudimentary metaphors and symbolization to form experience. Symbolism distinguishes us from animals and as stated by Steven Pinker (1994) ‘Whereas animals are rigidly controlled by their biology, human behaviour is determined by culture, an autonomous system of symbols and values.’
I am in agreement with Karon & Vandenbos’s statement ‘There is nothing in the schizophrenic reactions which you will not find in the potentiality of all human beings. All of us can and will develop so-called schizophrenic symptoms under enough stress of the right kind.’ Eduard Einstein (Albert Einstein’s son), Dr. John Nash and many others are cases of diagnosed schizophrenics.
Birchwood & Jackson (2001) highlights the societal structure from the studies of (Murphy, 1978; Waxler, 1979) and I infer the following: Our societal structure was predominantly rural and agrarian. The roles between the village and family were blurred as the village maintained the functional integrity, independence and economic viability hence families were able to reintegrate a troubled individual back to the community due to the influence the relatives, villagers and community had over the child that promoted ego development.
Contrast this with the western culture we live in; due to the severe economic pressures, labour being viewed as a marketable commodity, prevalence of unemployment and technical sophistication requisites; the society doesn’t have time to take care of an individual rather families are left with this responsibility and with both parents working in stressful situations this can sometimes result in neglect of psychological growth of the infant. Patients with residual schizophrenic traces are not cared for and left isolated that further exacerbates their condition.
Schizophrenia could be a genuine condition or perhaps a social construct as it is not possible to exactly infer what is happening in the patient’s mind without delineating experience comprehensively. If certain symptoms persist, then psychiatrists are prone to categorising them as ‘schizophrenic’, perhaps a mandated step to prescribe antidepressants. To advance a psychoanalytic thought or standpoint, schizophrenic mending cannot be effected without re-establishing ‘object relations’, which is needed for meaning creation through symbolism. Paranoid schizoid position i.e. the splitting of both self and object into good and bad is an organization phase for the infant in its phantasy and a needed one to prevent the infant’s sense of annihilation and assuage its death instinct invoked by the experience of hunger and frustration. I feel a better design of the mind would have been one where the bad object is just not internalized by the infant at all and the infant remains tolerant with the hope that something else will turn up to aid its survival. This tolerance is learnt by the infant/child/adult in the depressive phase with strong ego development that must prevent schizoid regression.
Animals when they give birth to their young ones in the Serengeti, in matter of hours and days get up and running and in a short span of few months attain independence. Due to the predatory nature of the terrain it becomes mandatory to do so for survival but in human beings the development process is protracted, it takes 2 years for the child to attain linguistic capabilities and years thereafter to attain reasonable independence. Till such time we, as mature adults need to provide this caring environment to the child not just with our physical presence but more in terms of precise engagement with the child’s representations.
In a way, we are born psychotic due to schizoid coping (0 to 5 months) but luckily for us we had that nurturing environment in the depressive stage to promote our ego development. The schizophrenics didn’t. Acute schizophrenic patients take a long time for recovery. The social infrastructure cost, therapist’s dexterity, societal understanding, cultural variances all these pose severe constraints in the care administered to them. Let us eliminate the need for such an administration strategy by providing, at the very inception, exemplary care and attention to the children who are within our remit.