Interpretation of Schizophrenia (book)

Interpretation of Schizophrenia (first edition, 1955) is a book written by psychiatrist Silvano Arieti that won the 1975 scientific National Book Award in the United States. Interpretation of Schizophrenia sets forth demonstrative evidence of a psychological etiology for schizophrenia. In the award winning 1974 edition (ISBN 0465034292) Arieti expanded the book vastly.

Overview
Interpretation of schizophrenia is a 756-page book divided in 45 chapters. Only the central thesis of the work will be reviewed in this article.

Arieti begins his book stating that it is difficult to define schizophrenia. He asks if schizophrenia is an illness and answers in the negative, since schizophrenia is not understood in classic Virchowian criterion of cellular pathology (even in the twenty-first century with the advances in neuroscience). Though those searching for a biological basis of schizophrenia far outnumber those undertaking psychological approaches, Arieti supports the minority view. He believes schizophrenia is an unrealistic way to represent both the self and the world and praises psychiatrist Adolf Meyer for stressing the importance of psychological factors in the etiology of schizophrenia. Arieti also mentions that Freud felt that in schizophrenia the patient’s relationship with people is handicapped (an observation that resembles what presently is called autism).

Arieti then describes the psychogenic factors that lead to the disorder. The family environment and psychodynamics in the etiology of psychosis comes under scrutiny. Arieti describes the building of neurotic and psychotic defense mechanisms; the emerging schizoid personality, and fully developed schizophrenia understood as an injury to the inner self. Arieti claims that a state of extreme anxiety originating in early childhood produces vulnerability for the whole life of the individual.

A characteristic of Homo sapiens is a prolonged childhood with a consequently extended dependency on adults. This, according to Arieti, “is the basis of the psychodynamics of schizophrenia”, a claim that also appears in later writers on child abuse such as Alice Miller. Arieti reviews the 1948 paper by Freda Fromm-Reichmann about the “schizophrenogenic” mother and reaches the tentative conclusion that only 25 percent of the mothers of schizophrenics in his clinical experience fit that image. However, he adds that only in a minority of schizophrenia cases “the child is able to retain the good maternal image”. Arieti also mentions the work of Theodore Lidz, another trauma model author of schizophrenia. Like Lidz, Arieti emphasizes the weakness of the father of the schizophrenic patient in the paternal role. In Arieti’s own words:


 * In the first edition of this book I have described one family constellation [...] when a domineering, nagging and hostile mother, who gives the child no chance to assert himself, is married to a dependent, weak man, who is too weak to help the child [...]. In these families the weak parent [...] becomes antagonistic and hostile toward the children because [...] he displaces his anger from the spouse to the children, as the spouse is too strong to be a suitable target.

The roles can be reversed when the domineering spouse is the father. Arieti is convinced that each schizophrenia case is representative of those human situations in which something went extremely wrong. “If we ignore it, we become deaf to a profound message that the patient may try to convey”. For example, Arieti states about one of his patients that “his adolescence was a crescendo of frustration, anxiety and injury to self-esteem”. Arieti also mentions a catatonic patient who, after introjecting the mother’s engulfing behavior, believed that by moving he could produce havoc. The patient’s feelings, according to Arieti, became reminiscent of cosmic powers that may cause the destruction of the universe, so the patient chose immobility. For Arieti, the selectivity of certain motor actions is proof that catatonia is not a biological disease or illness, but rather a disorder of the will.

In Part three of Interpretation of schizophrenia, Arieti describes how in spite of its efforts to stay in reality, the patient’s defenses finally succumb. When the patient “cannot change the unbearable situation of himself any longer, he has to change reality”. Arieti examines the inner world of the schizophrenic.

According to Arieti, when a patient states he is Jesus he is compensating a feeling of extreme humiliation at home. The paranoid schizophrenic, Arieti explains, resorts to “teleologic causality” or animism to understand the world. Arieti writes that whatever occurs to the patient is interpreted as willed by the parental alters of the patient. In deterministic or teleologic causality, if Nature's happenings were not willed they simply would not occur. In paranoid projection the schizophrenic takes out from him/herself a disagreeable part of the self onto the world. In Interpretation of schizophrenia Arieti illustrates all of the above theoretical constructions with concrete cases of his clinical experience as a psychiatrist.

Arieti claims that in every case of schizophrenia that he studied serious family disturbance was found. When the patient idealizes the parent the idealized image of the parent is maintained in the patient’s mind at the expense of an unbearable self-image. He speculates that psychosis starts only when the malevolent image of the parent is transformed “into a distressing other”. The parent or parents alters enter the mind accusing the patient of “bad child” or other equivalent accusations in voices that only the adult patient hears.

Since the 1980s, and into the beginnings of twenty-first century, biological psychiatric models of schizophrenia almost completely took over the psychiatric profession. Current research into the disorder focuses on neurobiology. Psychological approaches to schizophrenia like Arieti’s are a rarity in the profession.

List of chapters
Part One: The manifest Symptomatology and Other Basic Notions. Chapter 1 The basic questions. Chapter 2 Historical review of the concept of schizophrenia. Chapter 3 The manifest symptomatology. Chapter 4 The diagnosis and prognosis of schizophrenia.

Part Two: The Psychodynamics of Schizophrenia. Chapter 5 First period: early childhood and family. Chapter 6 Second period: late childhood. Chapter 7 Third period: adolescence and early adulthood. Chapter 8 Fourth period: the psychosis. Chapter 9 Patients studied through family members. Chapter 10 Study of catatonic patients. Chapter 11 Study of paranoid patients. Chapter 12 Study of hebephrenic patients. Chapter 13 Postpartum schizophrenic psychosis. Chapter 14 Adverted schizophrenia: relation between psychosis and psychoneurosis.

Part Three: The World of Schizophrenia: A Psychostructural Approach. Chapter 15 The break with reality. Chapter 16 The cognitive transformation. Chapter 17 Disorders of gesture, action and volition. Chapter 18 Changes in the body image. Chapter 19 The retreat from society. Chapter 20 Creative activities of schizophrenic patients: visual art, poetry, wit. Chapter 21 Emotional change and expansion of human experience.

 Part Four: A Longitudinal View of Schizophrenia. Chapter 22 The first or initial stage. Chapter 23 The second or advanced stage. Chapter 24 The third or preterminal stage. Chapter 25. The fourth or terminal stage. Chapter 26 Recapitulation and interpretation of schizophrenic regression.

 Part Five: The Somatic and Psychosomatic Aspects of Schizophrenia. Chapter 27 Heredity and constitution in schizophrenia. Chapter 28 The biochemistry of schizophrenia. Chapter 29 Endocrine and cardiovascular changes in schizophrenia. Chapter 30 The central nervous system in schizophrenia.

 Part Six: Transcultural Aspects and Prevention of Schizophrenia. Chapter 31 Epidemiology of schizophrenia. Chapter 32 Transcultural studies of schizophrenia. Chapter 33 The prevention of schizophrenia.

 Part Seven: Psychotherapy and Schizophrenia. Chapter 34 The choice of treatment. Chapter 35 The psychotherapeutic approach to schizophrenia: a historical survey. Chapter 36 Establishment of relatedness. Chapter 37 Specific solutions of psychotic mechanisms. Chapter 38 Psychodynamic analysis. Chapter 39 Other aspects of psychotherapy. Chapter 40 Two cases treated with intensive psychotherapy. Chapter 41 Psychotherapy of chronic schizophrenia.

 Part Eight: Physical Therapies of Schizophrenia. Chapter 42 Drug therapy. Chapter 43 Other physical therapies.

 Part Nine: The Larger Horizons and the Concept of Schizophrenia. Chapter 44 Syndromes related to schizophrenia. Chapter 45 The concept of schizophrenia.