The International Journal of Psychosocial Rehabilitation

The Emerging View of Psychosis and its Possible Implications for Stigma

Dr Tony Benning

Keywords:    stigma,    psychotic symptoms,    continuum,   normality,   pathology

Much has been written on the subject of stigmatization in psychiatry in recent years and Numerous strategies   have been advanced to combat it.  One of the key factors underpinning and perpetuating stigma is the construction of certain groups as ‘fundamentally different’ or ‘other’.   Erving Goffman, author of an influential early work on stigma [2], recognized the common experiences among different ‘stigmatized persons’.  “ They  have enough of their situations in life in common to warrant classifying all these persons together for purposes of analysis”   and this exaggerated attribution  of  ‘otherness’ to certain groups  is no less important as a  factor in other areas where stigmatization is seen  including     race  ,  ethics ,   criminality etc   where    discriminatory attitudes are   predicated on   misconceived   binary   models  of   black/white   or  good/evil  etc   . An added  dimension in the phenomenology of discrimination   is  the erroneous assumption  of ‘sameness’ or homogeneity  amongst the  members of ‘the other’ group members so that the group is represented  , to use Gilroy’s phrase, in a  monochromatic   form [3]   that  denies  or minimizes  its internal diversity or heterogeneity.  One might claim that Psychiatry’s    most visible   symbols of ‘otherness’ have been identified and removed.  To some extent, this is the case.    Mental   asylums, for example, situated on the margins of cities or towns, by their very location, once served as great   symbols of ‘separateness’.   Prominent Parkinsonian side effects associated with the older generation of antipsychotic medication   also served to accentuate and highlight the person’s ‘difference’ and the newer generation ‘atypical’ antipsychotic medication represents, in this regard, a positive development.

Despite this, there is still something fundamentally stigmatizing about the way in which psychosis has been   constructed in modern societies and reproduced in the most influential psychiatric orthodoxy including classification systems that serves to accentuate rather than attenuate a psychotic person’s sense of estrangement from society.  Common place assumptions about    sane/insane and rational/irrational have, arguably, served to perpetuate stigma.  The origins of society’s interest in    such  conceptualizations of the relationship between rational and irrational are, if one follows  Foucault, to be traced to the  European enlightenment ,  when society, increasingly intent on defining itself as ‘scientific’ and ‘rational’ sought to distance itself from all that it perceived as irrational.[4]  But   Foucault’s ‘archaeology’ tends  not to be to everyone’s taste  and other writers are content to trace  this dualistic trend to psychiatry’s misappropriation of a biomedical model of   sickness based on notions of organ function/dysfunction . The two developmental perspectives are probably not mutually exclusive and  whatever the ultimate origin, we can say at least  ,  that  this model   in which  madness and sanity are   separated by a  fundamental dividing line ,  perpetuating  a sense of us and them ,    is reproduced in  so called  Neo- Kraepelinian psychiatry. Also referred to as the ‘disease model’ or ‘either – or model’ of psychosis, the Neo-kraeplinian model   has dominated psychiatry and has   governed the way in which we have conceptualized psychosis.   Jaspers’ doctrine:    ‘an abyss of understanding separates the schizophrenic from the normal person.’ [5]  did not help ,     leading to   the widespread belief, held almost  as an article of faith by psychiatrists  for decades in the fundamental  non understandability of psychosis . The position embraced by Jaspers proved influential and legitimized a rather nihilistic attitude on the part of Psychiatrists when it came to trying to understand and ascribe meaning to the person’s subjective experience.    This was to prevail over the decades despite   challenges from various corners. Rd Laing, for one, took particular exception to Jaspers’ view    professing his aim ‘to make madness and the process of going mad comprehensible’ in the preface to The Divided Self. [6] 

Psychotic symptoms are beginning to be seen differently.   Far from being considered un understandable, they   are increasingly being understood as reflecting a person’s real life experiences. Rhodes and Jakes for example, showed that the content of delusions often reflects the person’s biographical experiences and personal concerns [7].   Bentall,   too,  [8]  cites evidence to support the claim that  that delusions may  often  contain a ‘nugget of truth’ in  reflecting  an individual’s life experiences such as powerlessness and victimization .     A Great deal of interest in understanding the content of  delusions, then,  has been re- awakened and these recent steps   amount to small but significant  attempts  towards  bridging Jasper’s notorious  abyss.  There has recently been renewed interest too, in the study of ‘hallucinations in the sane’.   In addition to the special conditions in which hallucinations have been well described e.g.  post  bereavement,  solitude and  the twilight periods between sleep and wakefulness etc,  there have  been attempts to  enunciate the prevalence of hallucinations in various other   ‘normal’ populations. Bentall and Slade [9]  for example,  found that as many as 15.4% of a population of 150 male students were prepared to endorse the statement ‘In the past I have had the experience of hearing a person’s voice and then found that no one was there’.   Millham and Easton   [10]   reported a prevalence of auditory hallucinations amongst mental health nurses as 84% based on a questionnaire study. Evidence for the continuity of psychotic experience across the illusory boundary between ‘normal and ‘pathological’ also comes from analysis of delusions. Writers ,   advancing the continuity or dimensional  argument in delusions stress the widespread nature of  ‘abnormal’ and bizarre beliefs ( be they  UFO’s , Fairies or  Goblins )  in the ‘normal’ population .   A powerful   contemporary analysis is offered by   American psychologist, Louis Sass who   further constricts the ‘ontological gulf’ between sane and insane, though from the other direction (so to speak).  In paradoxes of delusion , [11]  drawing on a broad repertoire  of  clinical cases and  literary references , Sass argues that people experiencing  delusions are not as oblivious to conventional reality as might be commonly supposed . To the contrary, Sass argues that a sort of ‘double orientation’ is embraced.  All this   lends support to a continuum or dimensional model of psychosis and undermines the Neo- kraeplinian ‘either/ or’ disease paradigm which has prevailed for decades and which   has contributed to    estrangement and alienation experienced by sufferers of psychosis.  A less binary and therefore a potentially less alienating and less stigmatizing view of psychosis seem to be emerging. In this view ,  the artificial Neo Kraeplinian dichotomy  is essentially  being  eroded and being replaced by  a ‘continuum model  of psychosis’  and this is supported by findings from genetics [12]   as well as  epidemiology. Psychosis , no doubt interferes with  a person’s sense of self  but the way in which society responds or accommodates or interprets (or allows the person to interpret) their experience is not without significance. To the contrary, emerging evidence from Cognitive behaviour therapy demonstrates that the outcome can be favourable depending on attribution or imputed meaning. It is noteworthy  that  The new conceptualization   seems to converge with an orientation towards sanity and insanity which, although    anathema to ‘scientific’  psychiatry, has been more willingly entertained in   the  humanities : Albert  Camus explored this relationship  In  Caligula [13] , in which he  contrasted  the consequences of individual insanity with collective insanity, a theme  which recurs in the writing of    Erich  Fromm [14]  , Aldous  Huxley [15]  and  RD laing [16] 

We may also be informed by examining the Anthropological literature.  The outcome of psychosis  in developing countries , where the  forfeiting  of  role or status in society is not as inevitable a corollary of psychosis  as it is in developed countries ,    has  consistently been shown to be superior  than in  developed countries. [17]  This is not to   romanticize psychosis nor to be   dismissive  or ignorant  of the suffering associated with it for the person and their carers but psychosis occurs against a backdrop which might be considered to be the ‘deep structures’ within society , as the Belgian anthropologist , Devereux called them. [18]. these ‘deep structures’, though traditionally of interest to Anthropologists, have regrettably,   tended to fall outside the concern of psychiatry. The  possibility that  the ‘deep structures’  in modern society, act to  alienate or estrange  a psychotic person  more than is absolutely necessary ,  is  not a particularly palatable one but one which anthropology / ethnography sensitizes us to considering.

Based on these  tentative reflections  on some aspects of  the social phenomenology of  stigmatization , there appears to be  reason to suppose that the emerging view of psychosis represents  a small step in the right direction when it comes  to the amelioration of  stigma experienced by   people suffering  with psychosis . Therapists working individually with people suffering from psychosis have employed a   strategy   of emphasizing the continuity of ‘symptoms’ across the illusory boundary between ‘pathological’ and ‘normal’. [19]   In some respects then ,   the widespread ‘uptake’ of  the  continuity model the evidence for which is superficially  presented above,  takes these therapeutic strategies   and applies them on a ‘ society wide  scale’.  As a continuation of this argument, it is not surprising that the very concept of ‘schizophrenia’ as a unitary entity has come under renewed attack.    Linguistic categories themselves, by their very nature, when applied to people or to groups of people, perpetuate the very myths that we seek to dispel; those of   distinctiveness, difference and internal homogeneity. The term schizophrenia is no exception in this regard  and   its dubious  utility  both in terms of predicting symptoms  ( construct validity ) and in terms of  predicting outcome (predictive validity) have been explicated  by Bentall and Slade  [9]   lending  support to the claim of its meaninglessness as a useful or justified concept . The term ‘schizophrenia’, as the argument goes,  encompasses too diverse or heterogeneous a  group of people to be a  meaningful concept  and the question of whether or not it has any positive function that counters its stigmatizing function   needs  to be confronted squarely     

References

[1]      Roy Porter (ed.)  (1991) The Faber Book of Madness (London: Faber and Faber).

[2]     Goffman E (1963) Stigma: Notes on the Management of Spoiled Identity. (Englewood Cliffs, New Jersey: Prentice-Hall, 1963)   (Harmondsworth; Penguin, 1968).         [3]      Paul Gilroy.     Between Camps: Nations, Cultures and the Allure of Race  Routledge,an imprint of Taylor & Francis Books Ltd; 2Rev Ed edition 2004

[4]      Foucault, M (1961) Madness and Civilization (Routledge classics) Taylor & Francis Group (2001)

[7]     Rhodes J. E. & Jakes S.  British Journal of Medical Psychology, Volume 73, Number 2, June 2000, pp. 211-225(15)

[8]     Bentall, R. P. (2003) Madness Explained: Psychosis and Human Nature. London: Penguin Books Ltd

[11]     Sass. L.A The Paradoxes of Delusion. Ithaca: Cornell University Press, 1994

[12]     Craddock, N. & Owen, M. J. (2005) The beginning of the end for the Kraepelinian dichotomy. British Journal of Psychiatry,  186, 364 -366  

[13]    Camus A .   Caligula (1944, tr. 1948).   Penguin (1965)

[14]   Fromm, E. (1956) The Sane Society. London. Routledge & Kegan Paul

[15]    Huxley, A. (1958) Brave New World Revisited. London / NY Chatto & Windus / Harper & Collins

[16]    Laing, RD (1967) The Politics Of Experience ( P.O.E) and The Bird of Paradise.  New York. Pantheon.   

[17]    Rosen A. Destigmatizing day-to-day practices: what developing countries can learn from developing countries? World  Psychiatry. 2006;1:21–24.

[18]    Littlewood, R & Dein, S. (2000) Cultural Psychiatry and Medical Anthropology. The Athlone Press.

[19     Kingdon, D. G. & Turkington, D. (1994) Cognitive-Behavioural Therapy of Schizophrenia. New York: Guilford Press.

[20] ]   Stein, L. I. & Test, M. A. (1980) Alternative to mental hospital treatment I. Conceptual model, treatment program, and clinical   evaluation. Archives of General Psychiatry, 37, 392 -397.

[21]   Bradfield, B. (2002). Mental illness and the consciousness of freedom: The phenomenology of psychiatric labelling. Indo-  Pacific Journal of Phenomenology, April, 1-21.