Epidemiology of a Schizophrenia

If we are to discuss the epidemiology of mental conditions, i.e., conditions partly induced by experience, our first task is to pinpoint a defect of an ideational system sufficiently so that we can go on from that pinpointing to postulate what sort of contexts of learning might induce this formal defect.

It is conventionally said that schizophrenics have "ego weakness." I now define ego weakness as trouble in identifying and interpreting those signals which should tell the individual what sort of a message a message is, i.e., trouble with the signals of the same logical type as the signal "This is play." For example, a patient comes into the hospital can-teen and the girl behind the counter says, "What can I do for you?" The patient is in doubt as to what sort of a message this is—is it a message about doing him in? Is it an indication that she wants him to go to bed with her? Or is it an offer of a cup of coffee? He hears the message and does not know what sort or order of a message it is. He is unable to pick up the more abstract labels which we are most of us able to use conventionally but are most of us unable to identify in the sense that we don't know what told us what sort of a message it was. It is as if we some-how make a correct guess. We are actually quite unconscious of receiving these messages which tell us what sorts of message we receive.

Difficulty with signals of this sort seems to be the center of a syndrome which is characteristic for a group of schizophrenics, so therefore we can reasonably look for an etiology starting from this symptomatology as formally defined.

When you begin thinking in this way, a great deal of what the schizophrenic says falls into place as a description of his experience. That is, we have a second lead toward the theory of etiology or transmission. The first lead is from the symptom. We ask, "How does a human individual acquire an imperfect ability to discriminate these specific signals?" and when we look at his speeches, we find that, in that peculiar language which is schizophrenic salad, he is de-scribing a :traumatic situation which involves a metacommunicative tangle.

A patient, for example, has a central notion, that "some-thing moved in space," and that that is why he cracked up. I somehow, from the way he spoke about "space," got an idea that space is his mother and said so. He said, "No, space is the mother." I suggested to him that she might be in some way a cause of his troubles. He said, "I never condemned her." At a certain point he got angry, and he said—this is verbatim—"If we say she had movement in her because of what she caused, we are only condemning ourselves." Something moved in space that made him crack up. Space is not his mother, it is the mother. But now we focus upon his mother whom he says he never condemned. And he now says, "If we say that she had movement in her because of what she caused, we are only condemning our-selves."

* This is an edited version of a talk, "How the Deviant Sees His Society," given in May, 1955, at a conference on "The Epidemiology of Mental Health" held at Brighton, Utah, sponsored by the Departments of Psychiatry and Psychology of the University of Utah, and the Veterans Administration Hospital, Fort Douglas Division, of Salt Lake City, Utah. A rough transcript of the talks at this conference was mimeographed and circulated by the organizers.

Look very carefully at the logical structure of that last quotation. It is circular. It implies a way of interaction and chronic cross-purposes with the mother such that for the child to make those moves which might straighten out the misunderstanding was also prohibited.

On another occasion he had skipped his therapy session in the morning, and I went over to the dining hall at supper time to see him and assure him that he would see me next day. He refused to look at me. He looked away. I made some remark about 9.30 the next morning — no answer. Then, with great difficulty, he said, "The judge disapproves." Be-fore I left him, I said, "You need a defense attorney," and when I found him on the grounds next morning I said, "Here is your defense attorney," and we went into session together. I started out by saying, "Am I right in supposing that the judge not only disapproves of your talking to me but also disapproves of your telling me that he disapproves?" He said, "Yes!" That is, we are dealing with two levels here. The "judge" disapproves of the attempt to straighten out the confusions and disapproves of communicating the fact of his (the judge's) disapproval.

We have to look for an etiology involving multiple levels of trauma.

I am not talking at all about the content of these traumatic sequences, whether they be sexual, or oral. Nor am I talking about the age of the subject at the time of trauma, nor about which parent is involved. That is all episodic as far as I'm concerned. I'm only building up toward the statement that the trauma must have had formal structure in the sense that multiple logical types were played against each other to generate this particular pathology in this individual.

Now, if you look at our conventional communication with one another, what you find is that we weave these logical types with incredible complexity and quite surprising facility. We even make jokes, and these may be difficult for a foreigner to understand. Most jokes, both canned and spontaneous, and nearly anywhere, are weavings of multiple logical types. Kidding and hazing similarly depend upon the unresolved question whether the kid-ee can identify that this is kidding. In any culture, the individuals acquire quite extraordinary skill in handling not only the flat identification of what sort of a message a message is but in dealing in multiple identifications of what sort of a message a message is. When we meet these multiple identifications we laugh, and we make new psychological discoveries about what goes on inside ourselves, which is perhaps the reward of real humor.

But there are people who have the utmost difficulty with this problem of multiple levels, and it seems to me that this unequal distribution of ability is a phenomenon which we can approach with the questions and terms of epidemiology. What is needed for a child to acquire, or to not acquire, a skill in the ways of interpreting these signals?

There is not only the miracle that any of them acquire the skills—and a lot of them do—there is also the other side, that a great many people have difficulty. There are people, for example, who, when Big Sister in the soap opera suffers from a cold, will send a bottle of aspirin to the radio station or recommend a cure for Big Sister's cold, in spite of the fact that Big Sister is a fictitious character within a radio soap opera. These particular members of the audience are apparently a little bit askew in their identification of what sort of a communication this is that is coming from their radio.

We all make errors of that kind at various times. I'm not sure that I've ever met anybody that doesn't suffer from "schizophrenia P" more or less. We all have some difficulty in deciding sometimes whether a dream was a dream or not, and it would not be very easy for most of us to say how we know that a piece of our own fantasy is fantasy and not experience. The ability to place an experience in time is one of the important cues, and referring it to a sense organ is another.

When you look at the mothers and fathers of patients for an answer to this etiological question, you meet with several sorts of answers.

First of all there are answers connected with what we may call the intensifying factors. Any disease is made worse or more probable by various circumstances, such as fatigue, cold, the number of days of combat, the presence of other diseases, etc. These seem to have a quantitative effect upon the incidence of almost any pathology. Then there are those factors which I mentioned—the hereditary characteristics and potentialities. To get confused about the logical types, one presumably has to be intelligent enough to know that there is something wrong, and not so intelligent as to be able to see what it is that is wrong. I presume that these characteristics are hereditarily determined.

But the nub of the problem, it seems to me, is to identify what real circumstances lead to the specific pathology. I acknowledge that the bacteria are not really by any means the sole determinant of a bacterial disease, and grant also therefore that the occurrence of such traumatic sequences or contexts is not by any means the sole determinant of mental illness. But still it seems to me that the identification of those contexts is the nub of understanding the disease, as identifying the bacteria is essential to understanding a bacterial disease.

I have met the mother of the patient whom I mentioned earlier. The family is not badly off. They live in a nice tract house. I went there with the patient, and when we arrived nobody was home. The newspaper boy had tossed the evening paper out in the middle of the lawn, and my patient wanted to get that paper from the middle of that perfect lawn. He came to the edge of the lawn and started to tremble.

The house looks like what is called a "model" home—a house which has been furnished by the real estate people in order to sell other houses to the public. Not a house furnished to live in, but rather furnished to look like a furnished house.

I discussed his mother with him one day, and suggested that perhaps she was a rather frightened person. He said, "Yes." I said, "What is she frightened of?" He said, "The appeariential securities."

There is a beautiful, perfectly centered mass of artificial, plastic vegetation on the middle of the mantle. A china pheasant here and a china pheasant there, symmetrically arranged. The wall-to-wall carpet is exactly as it should be.

After his mother arrived, I felt a little uncomfortable, intruding in this house. He had not visited there for about five years, but things seemed to be going all right, so I decided to leave him there and to come back when it was time to go back to the hospital. That gave me an hour in the streets with absolutely nothing to do, and I began to think what I would like to do to this setup. What and how could I communicate? I decided that I would like to put into it something that was both beautiful and untidy. In trying to implement that decision, I decided that flowers were the answer, so I bought some gladioluses. I took the gladioluses, and, when I went to get him, I presented them to the mother with a speech that I wanted her to have in her house something that was "both beautiful and untidy." "Oh!" she said, "Those are not untidy flowers. As each one withers, you can snip it off."

Now, as I see it, what is interesting is not so much the castrative statement in that speech, but the putting me in the position of having apologized when in fact I had not. That is, she took my message and reclassified it. She changed the label which indicated what sort of a message it was, and that is, I believe, what she does all the time. An endless taking of the other person's message and replying to it as if it were either a statement of weakness on the part of the speaker or an attack on her which should be turned into a weakness on the part of the speaker; and so on.

What the patient is up against today — and was up against in childhood—is the false interpretation of his messages. If he says, "The cat is on the table," she replies with some reply which makes out that his message is not the sort of message that he thought it was when he gave it. His own message identifier is obscured or distorted by her when the message comes back. And her own message identifier she continually contradicts. She laughs when she is saying that which is least funny to her, and so on.

Now there is a regular maternal dominance picture in this family, but I am not concerned at the moment to say that this is the necessary form of the trauma. I am only concerned with the purely formal aspects of this traumatic constellation; and I presume the constellation could be made up with father taking certain parts of it, mother taking certain other parts of it, and so forth.

I am trying to make only one point: that there is here a probability of trauma which will contain certain formal characteristics. It will propagate a specific syndrome in the patient because the trauma itself has impact upon a certain element in the communicational process. That which is at-tacked is the use of what I have called the "message-identifying signals" — those signals without which the "ego" dare not discriminate fact from fantasy or the literal from the metaphoric.

What I tried to do was pinpoint a group of syndromata, namely those syndromata related to an inability to know what sort of a message a message is. At one end of the classification of those, there will be more or less hebephrenic individuals for whom no message is of any particular definite type but who live in a sort of chronic shaggy-dog story. At the other end are those who try to overidentify, to make an overly rigid identification of what sort of a message every message is. This will give a much more paranoid type of picture. Withdrawal is another possibility.

Finally, it seems to me that with a hypothesis of this kind, one could look for the determinants in a population which might lead to the occurrence of that sort of constellation. This would seem to me an appropriate matter for epidemiological study.

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