Mark Cresswell from the School of Applied Social Sciences at Durham University is heavily involved in the politics of mental health. In his talk, ‘Between Sedgwick and Szasz: Schizophrenia as ‘Illness’ and ‘Myth’’, Mark addressed the apparent conflict between his endorsement of both the position of the libertarian Thomas Szasz that schizophrenia is a myth and the position of the socialist Peter Sedgwick that schizophrenia should be seen as an illness in order to politicise the field of mental illness and make demands upon health and welfare services. Which slogan is better suited to the needs of people who have a diagnosis of schizophrenia?
1) Schizophrenia is a myth
2) Schizophrenia is an illness like any other
Mark’s talk explored the complexities of the politics of mental illness and how the survivor movement’s position on schizophrenia may usefully shift depending on the political context. Is it even useful to have a fixed position on the status of schizophrenia as an illness or myth? Maybe in times of economic downturn and cuts to health services, it is useful to defend it as an illness in order to make demands on the health and welfare services, as Sedgwick suggested. At other times, this position may be less politically useful, especially as the term ‘illness’ obscures the possibility of radicalizing how we view human distress and thus to challenge how psychiatry has colonized human distress. Back in 1982, Sedgwick famously wrote that ‘the future belongs to illness’. Mark highlighted how in fact with the growth of the survivor movement, political demands need no longer be made in the name of illness, but could equally be made in the name of experience, distress or trauma.
The final talk of the series was given by the writer, psychiatrist and co-founder of the Critical Psychiatry Network, Phil Thomas. Phil’s talk, ‘Enlightenment’s Shadow: Dementia Praecox, Degeneration and the Birth of Schizophrenia’, explored the cultural significance of degeneration at the time when Kraepelin was formulating his ideas surrounding schizophrenia (or dementia praecox, as he termed it). Kraepelin held a very pessimistic view of the possibility of recovery from schizophrenia, believing that the disease was characterised by deterioration in the social and cognitive functioning of the sufferer over time. This view of schizophrenia has broadly endured to today with it still being generally seen as a condition with a high risk of recurrence and poor prognosis. While clinicians no longer use terms like ‘degeneration’, they regularly use terms like ‘deficits’, ‘deterioration’ and ‘end stage’.
Phil questioned the scientific evidence surrounding Kraepelin’s notion of degeneration in dementia praecox, comparing it with the psychiatrist and criminologist Cesare Lombroso’s arguments that criminal traits were degenerative features identifiable in the physiognomy of the individual through skull measurements and physical abnormalities affecting the ears and face. It appeared recently that some of Kraepelin’s ideas may be supported by scientific evidence when it was discovered that people with schizophrenia had reduced brain volumes compared with healthy people and that these reductions become more pronounced as the disease progresses. It was only later discovered that the greatest decrease in brain volumes were seen in those patients who had received the highest doses of neuroleptic medication. So this example of degeneration is nothing to do with the disease process, but rather with physical treatments.
Similarly, Phil explored and critiqued the idea that the self is fundamentally narrative in nature. He pointed to a case where a person diagnosed as schizophrenic and considered to be displaying significant ‘blunting of affect’ and ‘poverty of speech’ was understood by a psychiatrist to have deteriorated over time to the point where it no longer made any sense to speak of a narrative self. In other words, as this person no longer chose to communicate with people around her, she was considered no longer to be in possession of a self. She was in a sense no longer a person, properly understood. Phil countered this presumption by suggesting that silence can be a very useful way of coping with feelings of powerlessness. People in great distress may experience the world as so harsh and lacking in love and compassion that withdrawal from it may be seen as the most useful way of restoring meaning, purpose and richness to their existence, especially when the people around them – worried family members, nurses, psychiatrists and so on – may be perceived as threatening. To speak of prolonged periods of withdrawal in terms like ‘deficit’, ‘dysfunction’ and ‘deterioration’ and to suggest it may be attributed to a brain disorder is, as Phil highlighted, a potentially grave moral error. Perhaps as a culture it is time we heeded the words of Sara Maitland:
We are terrified of silence, so we encounter it as seldom as possible, even if this means losing experiences we know to be good ones, like children wandering alone or unsupervised in the countryside. We say that silence is a lack of something, a negative state. We deny the power and meaning of silence. We are terrified of silence and so we banish it from our lives. (A Book of Silence, pp 130-1)
Phil’s talk highlighted the need for a more detailed understanding of the historical and cultural origins of psychiatric knowledge. Many of the ideas we take for granted may have arisen in very different narrative and cultural contexts and many may be hopelessly out-dated and potentially detrimental to the recovery of people given a diagnosis of schizophrenia.
It is difficult to sum up any overall themes that arose from this series of talks. Perhaps all of the talks came from a position that was largely critical of mainstream ways of thinking about the diagnosis of schizophrenia. All of the talks confirmed that key questions still remain and need to be asked – that any confident assertion of the inevitable conquering of schizophrenia is both premature and even fundamentally misguided. Ultimately all of the talks confirmed what Angela had suggested in the first talk: that conflict is in fact the very essence of this diagnosis. As it reaches its 100th year, there is no sign of this changing. And this is no bad thing.