1955 book by Silvano Arieti
Interpretation of Schizophrenia (first edition, 1955) is a book by Italy-born American psychiatrist Silvano Arieti in which the author sets forth demonstrative evidence of a psychological etiology for schizophrenia.
Arieti expanded the book vastly in 1974 () and that edition won the U.S. National Book Award in the Science category.
"Interpretation of schizophrenia" is a 756-page book divided in 45 chapters. 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 the disorder is not understood in classic Virchowian criterion of cellular pathology. 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.
The basis of schizophrenia.
Arieti examines the family history of people with schizophrenia, and references twin studies to support the notion that the potentiality for schizophrenia has a genetic basis, but maintains that this genetic potentiality is not enough to predispose someone to schizophrenia unless early life events also set up the vulnerability to breakdown later in life. A person who has the genetic predisposition, but was not subject to the life experiences necessary to develop this vulnerability will not become schizophrenic in later life.
He observed that in twin pairs, where one twin developed schizophrenia, the schizophrenic twin was less able to adapt to adverse life events compared to the healthier twin, and that following the schizophrenic breakdown of the other twin, in some cases the healthy twin was also vulnerable to developing schizophrenic symptoms, but these were quantitatively milder compared to the twin who first developed schizophrenia. Thus, even with the better adapted twin, a level of vulnerability remained towards a breakdown.
Pre-psychotic personality types.
Arieti divides the pre-psychotic personality into two subgroups, which are the schizoid and the stormy types. The pre-psychotic schizoid type of personality's main adaptation involves the withdrawal typical of the schizoid personality disorder, wherein the person has limited to no social or emotional bonds, and mainly resorts to isolation and eschewing human relations to avoid potential retraumatization by others. They frequently substitute real human relations with a rich inner fantasy life. The pre-psychotic schizoid avoids conflict with the parents by passively submitting to their wishes, but he does so without any real zest or ambition, just going through the motions with minimal effort.
The stormy personality on the other hand tries strives to maintain social relations and emotional bonds, but the person in question is confused about their sense of self, as they mainly adapt to social situations by mirroring the perceived expectations of those around them and integrating it into a false self presented to the outside world. The stormy personality is always uncertain about their sense of self, compared to the pure schizoid personality, and this leaves them with a lack of ontological security. The stormy personality, owing to their adaptation, fails to develop true, deep relations with anyone due to their need to maintain a false persona that is always changed based on the perceived expectations of others. The stormy personality tries to please those around them as much as possible to win approval, especially the parents, even to the point of self-abandonment.
Family as a cause.
Arieti then describes the psychogenic factors that lead to the disorder. The family environment and psychodynamics in the etiology of psychosis comes under scrutiny. He describes the building of neurotic and psychotic defense mechanisms; the emerging schizoid or stormy personality, and fully developed schizophrenia understood as an injury to the inner self following a series of adverse life events. Arieti believes that a state of extreme anxiety originating in early childhood produces vulnerability for the whole life of the individual, and that this anxiety can later be reactivated by adverse life events, where the individual's coping mechanisms fail to maintain a positive sense of self in face of these adversities.
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 and Colin Ross. Arieti reviews the paper by Frieda Fromm-Reichmann about the "schizophrenogenic" mother and reaches the tentative conclusion that only 25 percent of the mothers of people with schizophrenia 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". He clarifies that the internal maternal image is not based solely on the real mother, but is rather influenced by all relations the patient has throughout his life. The reason for this is that from infancy onward, the relationship with the mother lays the basis for all future relationships, and remains as an internal model for every relationship the patient has, and is shaped and altered by any future relations that influence the patient's view of the world, and of society at large. Arieti also mentions the work of Theodore Lidz, another trauma model author of schizophrenia. Like Lidz, Arieti emphasizes the parental dynamic of a domineering, hostile parent, and the other, weak spouse who is submissive to the dominant parent, and the role of this dynamic in the development of schizophrenia in the children of such dysfunctional parents. 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. If the child cannot build positive relations with the mother or the father, then he will try to find a positive maternal image in others. A brother, a sister, or other relatives, a teacher, or any other available individual the child can relate with. If the child manages to build up a relationship, where he receives healthy nurturance, reassurement and empathy, which allows them to build up a positive self-image, then the vulnerability to a schizophrenic breakdown can be averted entirely. In the cases of schizophrenia, however, the breakdown is proof that this attempt failed time and time again for the individual.
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". As described in the book, in case of two brothers, Peter and Gabriel, of whom Gabriel later suffered a schizophrenic break, Arieti states that, as described by the brother, "his adolescence was a crescendo of frustration, anxiety and injury to self-esteem". Of the two brothers, Peter was the favorite of the father, who was an extremely narcissistic man who depended on Peter to maintain his self-esteem by telling fabricated stories of his time in Germany during World War II, whereas Gabriel was mostly ignored and neither parent ever really paid attention to him or gave him any affection. Gabriel tried to turn to Peter for help, but he was rejected by Peter throughout his childhood. Gabriel went through his childhood without ever disagreeing with or asserting himself in front of his parents. He later developed schizophrenia in his teens, not long after returning to home from a private school. Gabriel expressed his anxiety regarding private schooling, and wished to return home so he could work on one of the family farms. However, even at his own work he was not allowed to make decisions for himself: Ignoring what Gabriel was taught in school, his mother practically told him how to plant every single vegetable on the farm, and how to tend to other needs. Gabriel, much like in his childhood, did not try to assert himself. As a result of this he tried to give up on his job, which incited further ire and hostility from the parents. Following these events, Gabriel soon developed a complete psychotic break, and was institutionalized multiple times, before committing suicide.
Pre-psychotic panic.
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 attacks on the self-image both from outside and within cause the anxiety to become too unbearable. When the patient "cannot change the unbearable situation of himself any longer, he has to change reality". Arieti examines the inner world of the person with schizophrenia, and the genesis of the schizophrenic regression.
Arieti maintains that even with the schizophrenic potentiality laid down in early childhood and by genetic predisposition, not all of these cases will develop psychosis, as new defense mechanisms are acquired throughout the life of the individual. For schizophrenics however, all such attempts eventually fail at staving off a complete break. The negative self-image that is dissociated from the conscious mind of the individual may be reactivated by any number of life events, such as entering a into a new relationship, the birth of a child, or a tragic accident, the death of a relative, especially the death of parents, moving out of home, stress at work, the loss of a job, or a promotion at work which destabilizes the individual's sense of competency at his own job, or a combination of several of these factors.
This anxiety triggers the pre-psychotic period, which precedes the eventual psychotic break. These adverse life events bring the dissociated, negative self image from early childhood into consciousness, causing the person to view themselves as utterly defeated, unlovable, incompetent, worthless, etc. This type of anxiety cannot be tolerated by the individual for long, and as his defenses fail to defuse this anxiety, he will resort to increasingly inadequate coping mechanisms to maintain a positive self-image and reduce their anxiety.
Arieti describes the concept of paleological/teleological thinking, which is typical of small children and primitive peoples, with concrete examples of such thought in African tribal societies and in small children. At the beginning of the pre-psychotic panic, the individual's feelings of self-accusation and self-defeat are slowly transformed into feelings of vulnerability, fear and anguish. He feels cut off from the world itself because of his failure and worthlessness, and feels like he cannot join in with the rest of the world. He is overwhelmed by a vague perception of danger, a need to escape, and of confusion. "He feels threatened from all sides, as if he were in a jungle. It is not a jungle where lions, tigers, snakes and spiders are to be found, but a jungle of concepts, where the threat is not to survival, but to the self image. The dangers are concept feelings, such as that of being unlovable, inadequate, unacceptable, inferior, awkward, clumsy, not belonging, peculiar, different, rejected, humiliated, guilty, unable to find his own way amongst the many different paths of life, disgraced, discriminated against, kept at a distance, suspected, and so on."
These feelings of terror and persecution are then transformed into concretized concepts and projections. The schizophrenic, in an attempt to ward off unbearable anxiety, will resort to using paleological thinking to distort reality in such a way that reduces anxiety. Projection is used to displace self-accusations and attacks on the self-esteem to the outside world in the form of persecutors and persecutory forces.
The individual in the pre-psychotic stage may still recover if he manages to adopt adequate coping mechanisms, but if this fails, the pre-psychotic period will eventually be followed by a complete schizophrenic break when he experiences a total and complete defeat of his self-worth and self-esteem.
Schizophrenic thinking.
Arieti describes a distinct type of logic, separate from the aristotelian logic used by modern man in advanced societies, called "paleological thinking", or primary process thinking. In paleological thought, nature's events are attributed to the will of outside forces. "If the greeks were afflicted by an epidemic, it was because Phoebus wanted to punish Agamemnon."