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News Gram™ June 2004

June 2004 ~ Vol. 10, No. 11

What is it like to be schizophrenic? What kind of experiences does a person have that make his world so strange, erratic and frightening? Most American psychiatrists base their diagnoses on very different questions. They ask for the signs of schizophrenia, family history, drug use, laboratory tests and a myriad of other things that might add up to a diagnosis. But there are others who want to know what the patient is really experiencing, what he or she feels, sees, hears, tastes and smells. These doctors want to know what it is like to be schizophrenic - and that is a very different approach from the one taken by most psychiatrists today.

We refer to the more common approach with the term, 'objective psychiatry.' This school of thought treats schizophrenia as a disease much like hepatitis, ulcers or heart disease. The language of the objective school is the language of medicine. Practically speaking, it appears very helpful when someone needs a label or some kind of diagnosis for legal, insurance or medical purposes. But it has its limitations.

Objective psychiatry pays little attention to what the experience of being crazy is all about. They want signs and symptoms, the elements of the diagnostic process. Second, the patient is regarded as being afflicted with a pathological process that requires doctors. The doctors treat the patient and bill insurance companies - just as if they were treating and billing for someone with pneumonia. The modality of treatment leans heavily toward psychopharmacology and less toward talk.

In the course of treatment, the psychiatrist has only to pay attention to the way the patient is eating and sleeping, to such signs and symptoms as autism, delusions, hallucinations, tangentiality and a host of others. Meetings with the patient may be a few short minutes and center on adjusting medications. Some believe that in such treatment, the patient is lost.

When it comes to the other school of thought in psychiatry, sometimes called the 'phenomenological school,' the medical model that is so prominent today is often cast aside. Instead of signs and symptoms, the vocabulary is that of the person's experience. In the case of schizophrenia, a patient may have the sense that someone or something is putting thoughts into his head, or that he is "broadcasting" his thoughts to someone else, or that he is being controlled by someone or that the radio is talking to him personally.

The sense of control is an important matter. Typically, in schizophrenia, the person has the feeling that he is not in control of himself. Instead, he feels put upon by the world, thinks the world is talking about him, even plotting against him. This state of mind is what we mean when we say someone is paranoid. It is interesting to take a closer look at what is happening to produce such a state of mind in a person.

When it comes to delusions and hallucinations, the process that occurs is a dissociation of the experience of thinking something from the sense of one's own identity. If I think to myself, "I'd like to go to the beach today," I recognize that thought as my own idea. I believe I am the author of my own thoughts, in general. A schizophrenic person does not always have that assuredness of authorship. As a result, his experience of his own thoughts is very different.

The experience may come down to a command such as "Go to the beach today," rather than a contemplative thought. The experience is that of a hallucination, something the person hears, something he or she has not produced. There is a gap forged between the sense of ownership of the products of one's thinking and the idea itself. "Go to the beach" sounds like an order from outside the person, as if the thought came from elsewhere. As a result, the person is apt to look for the origin of the thought in things beyond him. Fluorescent lights, radios, computers, satellites and many other devices are popular candidates.

When one thinks about this process, it makes sense that the person who hears a voice telling him to go to the beach should try to find out who is talking to him. It also makes sense that such a person will likely be troubled and frightened by the experience. He may have the sense that someone is out to get him. Within every paranoid person is the belief that he or she is losing control of his own self. The reason is that the person no longer feels that he can hold himself together, can act and feel like a singular, whole individual. Instead, the altered awareness is one of fragmentation, dissociation and strangeness. It is interesting that the phenomenological group appears to have little interest in the medical approach of the objective group. And vice versa. They are more like opposing soccer teams than collegial assemblies of professionals. Commonly, they go to different meetings, read different journals and usually have different friends.

Certainly, the objective doctors can quiet someone down with medications, help that person to think more clearly or to feel less depressed. But it is not clear that he understands him. And the experience of being understood is fortifying and central to being human. The phenomenological people believe that making progress with schizophrenic patients requires a deep understanding of what is going on inside of them. They recognize that progress is less certain, longer and more difficult. But most of them also believe that pills cover over rather than help to rebuild the fractured world of the crazy person.

In the end, whether one does objective or phenomenological psychiatry has much to do with what kind of person the psychiatrist is. It is an esthetic preference as much as any other. While the objective approach seems to have eclipsed the phenomenological one, the conflict is not yet resolved. Nor will it be any time soon. There is still much to learn.

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