ON THE PSYCHOGENESIS OF SCHIZOPHRENIA¹

504It is just twenty years since I read a paper on “The Problem of Psychogenesis in Mental Disease”² before this Society. William McDougall, whose recent death we all deplore, was in the chair. What I said then about psychogenesis could safely be repeated today, for it has left no visible traces, or other noticeable consequences, either in text-books or in clinics. Although I hate to repeat myself, it is almost impossible to say anything wholly new and different about a subject which has not changed its face in the many years that have gone by. My experience has increased and some of my views have matured, but I could not say that my standpoint has had to undergo any radical change. I am therefore in the somewhat uncomfortable situation of one who believes that he has a well-founded conviction, and yet on the other hand is afraid to indulge in the habit of repeating old stories. Psychogenesis has long been discussed, but it is still a modern, even an ultra-modern, problem.

505There is little doubt nowadays about the psychogenesis of hysteria and other neuroses, although thirty years ago some brain enthusiasts still vaguely suspected that at bottom “there was something organically wrong in the neuroses.” Nevertheless the consensus doctorum in their vast majority has admitted the psychic causation of hysteria and similar neuroses. Concerning the mental diseases, however, and especially concerning schizophrenia, they agreed unanimously upon an essentially organic aetiology, although for a long time specific destruction of the brain-cells could not be proved. Even today the question of how far schizophrenia itself can destroy the brain-cells has not been satisfactorily answered, much less the more specific question of how far primary organic disintegrations account for the symptomatology of schizophrenia. I fully agree with Bleuler that the great majority of symptoms are of a secondary nature and are due chiefly to psychic causes. For the primary symptoms, however, Bleuler assumes the existence of an organic cause. As the primary symptom he points to a peculiar disturbance of the association-process. According to his description, some kind of disintegration is involved, inasmuch as the associations seem to be peculiarly mutilated and disjointed. He refuses to accept Wernicke’s concept of “sejunction” because of its anatomical implications. He prefers the term “schizophrenia,” obviously understanding by this a functional disturbance. Such disturbances, or at least very similar ones, can be observed in delirious states of various kinds. Bleuler himself points out the remarkable similarity between schizophrenic associations and the association-phenomena in dreams and half-waking states. From his description it is sufficiently clear that the primary symptom coincides with the condition which Pierre Janet termed abaissement du niveau mental. It is caused by a peculiar faiblesse de la volonté. If the main guiding and controlling force of our mental life is will-power, then we can agree that Janet’s concept of abaissement explains a psychic condition in which a train of thought is not carried through to its logical conclusion, or is interrupted by strange contents that are insufficiently inhibited. Though Bleuler does not mention Janet, I think that Janet’s abaissement aptly formulates Bleuler’s views on the primary symptoms.

506It is true that Janet uses his hypothesis chiefly to explain the symptomatology of hysteria and other neuroses, which are indubitably psychogenic and quite different from schizophrenia. Yet there are certain noteworthy analogies between the neurotic and the schizophrenic mental condition. If you study the association tests of neurotics, you will find that their normal associations are disturbed by the spontaneous intervention of complex contents typical of an abaissement. The dissociation can even go so far as to create one or more secondary personalities, each, apparently, with a separate consciousness of its own. But the fundamental difference between neurosis and schizophrenia lies in the maintenance of the potential unity of the personality. Despite the fact that consciousness can be split up into several personal consciousnesses, the unity of all the dissociated fragmerits is not only visible to the professional eye but can be re-established by means of hypnosis. This is not the case with schizophrenia. The general picture of an association test of a schizophrenic may be very similar to that of a neurotic, but closer examination shows that in a schizophrenic patient the connection between the ego and some of the complexes is more or less completely lost. The split is not relative, it is absolute. An hysterical patient might suffer from a persecution-mania very similar to real paranoia, but the difference is that in the former case one can bring the delusion back under the control of consciousness, whereas it is virtually impossible to do this in paranoia. A neurosis, it is true, is characterized by the relative autonomy of its complexes, but in schizophrenia the complexes have become disconnected and autonomous fragments, which either do not reintegrate back to the psychic totality, or, in the case of a remission, are unexpectedly joined together again as if nothing had happened.

507The dissociation in schizophrenia is not only far more serious, but very often it is irreversible.' The dissociation is no longer fluid and changeable as it is in a neurosis, it is more like a mirror broken up into splinters. The unity of personality which, in a case of hysteria, lends a humanly understandable character to its own secondary personalities is definitely shattered into fragments. In hysterical multiple personality there is a fairly smooth, even tactful, co-operation between the different persons, who keep to their respective roles and, if possible, do not bother each other. One feels the presence of an invisible spiritus rector, a central manager who arranges the stage for the different figures in an almost rational way, often in the form of a more or less sentimental drama. Each figure has a suggestive name and an admissible character, and they are just as nicely hysterical and just as sentimentally biased as the patient’s own consciousness.

508The picture of a personality dissociation in schizophrenia is quite different. The split-off figures assume banal, grotesque, or highly exaggerated names and characters, and are often objectionable in many other ways. They do not, moreover, co-operate with the patient’s consciousness. They are not tactful and they have no respect for sentimental values. On the contrary, they break in and make a disturbance at any time, they torment the ego in a hundred ways; all are objectionable and shocking, either in their noisy and impertinent behaviour or in their grotesque cruelty and obscenity. There is an apparent chaos of incoherent visions, voices, and characters, all of an overwhelmingly strange and incomprehensible nature. If there is a drama at all, it is certainly far beyond the patient’s understanding. In most cases it transcends even the physician’s comprehension, so much so that he is inclined to suspect the mental sanity of anybody who sees more than plain madness in the ravings of a lunatic.

509The autonomous figures have broken away from the control of the ego so thoroughly that their original participation in the patient’s mental make-up has vanished. The abaissement has reached a degree unheard of in the sphere of neurosis. An hysterical dissociation is bridged over by a unity of personality which still functions, whereas in schizophrenia the very foundations of the personality are impaired.

510The abaissement

(1) Causes the loss of whole regions of normally controlled contents.

(2) Produces split-off fragments of the personality.

(3) Hinders normal trains of thought from being consistently carried through and completed.

(4) Decreases the responsibility and the adequate reaction of the ego.

(5) Causes incomplete realizations and thus gives rise to insufficient and inadequate emotional reactions.

(6) Lowers the threshold of consciousness, thereby allowing normally inhibited contents of the unconscious to enter consciousness in the form of autonomous invasions.

511We find all these effects of abaissement in neurosis as well as in schizophrenia. But in neurosis the unity of personality is at least potentially preserved, whereas in schizophrenia it is almost irreparably damaged. Because of this fundamental injury the cleavage between dissociated psychic elements amounts to a real destruction of their former connections.

512The psychogenesis of schizophrenia therefore prompts us to ask, first of all: Can the primary symptom, the extreme abaissement, be considered an effect of psychological conflicts and other disorders of an emotional nature, or not? I do not think it necessary to discuss in detail whether or not the secondary symptoms, as described by Bleuler, owe their existence and their specific form to psychological determination. Bleuler himself is fully convinced that their form and content, i.e., their individual phenomenology, are derived entirely from emotional complexes. I agree with Bleuler, whose experience of the psychogenesis of secondary symptoms coincides with my own, for we were collaborating in the years which preceded his famous book on dementia praecox. As a matter of fact, I began as early as 1903 to analyse cases of schizophrenia for therapeutic purposes. There can, indeed, be no doubt about the psychological determination of secondary symptoms. Their structure and origin are in no way different from those of neurotic symptoms, with, of course, the important exception that they exhibit all the characteristics of mental contents no longer subordinated to the supreme control of a complete personality. There is, as a matter of fact, hardly one secondary symptom which does not show some signs of a typical abaissement. This characteristic, however, does not depend upon psychogenesis but derives entirely from the primary symptom. Psychological causes, in other words, produce secondary symptoms exclusively on the basis of the primary condition.

513In dealing with the question of psychogenesis in schizophrenia, therefore, we can dismiss the secondary symptoms altogether. There is only one problem, and that is the psychogenesis of the primary condition, i.e., the extreme abaissement, which is, from the psychological point of view, the root of the schizophrenic disorder. We therefore ask: Is there any reason to believe that the abaissement can be due to causes which are strictly psychological? An abaissement can be produced—as we well know—by many causes: by fatigue, normal sleep, intoxication, fever, anaemia, intense affects, shocks, organic diseases of the central nervous system; likewise it can be induced by masspsychology or a primitive mentality, or by religious and political fanaticism, etc. It can also be caused by constitutional and hereditary factors.

514The more common form of abaissement does not affect the unity of the personality, at least not seriously. Thus all dissociations and other psychic phenomena derived from this general form of abaissement bear the stamp of the integral personality.

515Neuroses are specific consequences of an abaissement; as a rule they arise from a habitual or chronic form of it. Where they appear to be the effect of an acute form, a more or less latent psychological disposition always existed prior to the abaissement, so that the latter is no more than a conditional cause.

516Now there is no doubt that an abaissement which leads to a neurosis is produced either by exclusively psychological factors or by these in conjunction with other, perhaps more physical, conditions. Any abaissement, particularly one that leads to a neurosis, means in itself that there is a weakening of the supreme control. A neurosis is a relative dissociation, a conflict between the ego and a resistant force based upon unconscious contents. These contents have more or less lost their connection with the psychic totality. They form themselves into fragments, and the loss of them means a depotentiation of the conscious personality. The intense conflict, on the other hand, expresses an equally intense desire to re-establish the severed connection. There is no co-operation, but at least there is a violent conflict, which functions instead of a positive connection. Every neurotic fights for the maintenance and supremacy of his ego-consciousness and for the subjugation of the resistant unconscious forces. But a patient who allows himself to be swayed by the intrusion of strange contents from the unconscious, a patient who does not fight, who even identifies with the morbid elements, immediately exposes himself to the suspicion of schizophrenia. His abaissement has reached the fatal, extreme degree, when the ego loses all power to resist the onslaught of an apparently more powerful unconscious.

517Neurosis lies on this side of the critical point, schizophrenia on the other. We do not doubt that psychological motives can bring about an abaissement which eventually results in a neurosis. A neurosis approaches the danger line, yet somehow it manages to remain on the hither side. If it should transgress the line it would cease to be a neurosis. Yet are we quite certain that a neurosis never steps beyond the danger-line? You know that there are such cases, neuroses to all appearances for many years, and then it suddenly happens that the patient steps beyond the line and clearly transforms himself into a real psychotic.

518Now, what do we say in such a case? We say that it has always been a psychosis, a “latent” one, or one concealed or camouflaged by an ostensible neurosis. But what has really happened? For many years the patient fought for the maintenance of his ego, for the supremacy of his control and for the unity of his personality. But at last he gave in—he succumbed to the invader he could no longer suppress. He is not just overcome by a violent emotion, he is actually drowned in a flood of insurmountably strong forces and thought-forms which go far beyond any ordinary emotion, no matter how violent. These unconscious forces and contents have long existed in him and he has wrestled with them successfully for years. As a matter of fact, these strange contents are not confined to the patient alone, they exist in the unconscious of normal people as well, who, however, are fortunate enough to be profoundly ignorant of them. These forces did not originate in our patient out of nowhere. They are most emphatically not the result of poisoned brain-cells, but are normal constituents of our unconscious psyche. They appeared in numberless dreams, in the same or a similar form, at a time of life when seemingly nothing was wrong. And they appear in the dreams of normal people who never get anywhere near a psychosis. But if a normal individual should suddenly undergo a dangerous abaissement, his dreams would instantly seize hold of him and make him think, feel, and act exactly like a lunatic. And he would be a lunatic, like the man in one of Andreyev’s stories, who thought he could safely bark at the moon because he knew that he was perfectly normal. But when he barked he lost consciousness of the little bit of difference between normal and crazy, so that the other side overwhelmed him and he became mad.

519What happened was that our patient succumbed to an attack of weakness—in reality it is often just a sudden panic—it made him hopeless or desperate, and then all the suppressed material welled up and drowned him.

520In my experience of almost forty years I have seen quite a number of cases who developed either a psychotic interval or a lasting psychosis out of a neurotic condition. Let us assume for the moment that they were really suffering from a latent psychosis, concealed under the cloak of a neurosis. What, then, is a latent psychosis exactly? It is obviously nothing but the possibility that an individual may become mentally deranged at some period of his life. The existence of strange unconscious material proves nothing. You find the same material in neurotics, modern artists, and poets, and also in fairly normal people who have submitted to a careful investigation of their dreams. Moreover, you find most suggestive parallels in the mythology and symbolism of all races and times. The possibility of a future psychosis has nothing to do with the peculiar contents of the unconscious. But it has everything to do with whether the individual can stand a certain panic, or the chronic strain of a psyche at war with itself. Very often it is simply a matter of a little bit too much, of the drop that falls into a vessel already full, or of the spark that accidentally lands on a heap of gunpowder.

521Under the stress of an extreme abaissement the psychic totality falls apart and splits up into complexes, and the egocomplex ceases to play the important role among these. It is just one among several complexes which are all equally important, or perhaps even more important than the ego. All these complexes assume a personal character although they remain fragments. It is understandable that people should get panicky, or that they eventually become demoralized under a chronic strain, or despair of their hopes and expectations. It is also understandable that their will-power weakens and their selfcontrol becomes slack and begins to lose its grip upon circumstances, moods, and thoughts. It is quite consistent with such a state of mind if some particularly unruly parts of the patient’s psyche then acquire a certain degree of autonomy.

522Thus far schizophrenia does not behave in any way differently from a purely psychological disorder. We would search in vain for anything characteristic of the disease in this part of the symptomatology. The real trouble begins with the disintegration of the personality and the divestment of the ego-complex of its habitual supremacy. As I have already pointed out, not even multiple personality, or certain religious or “mystical” phenomena, can be compared to what happens in schizophrenia. The primary symptom seems to have no analogy with any kind of functional disturbance. It is as if the very foundations of the psyche were giving way, as if an explosion or an earthquake were tearing asunder the structure of a normally built house. I use this analogy on purpose, because it is suggested by the symptomatology of the initial stages. Sollier has given us a vivid description of these troubles cénesthésiques,³ which are compared to explosions, pistol-shots, and other violent noises in the head. They appear in projection as earthquakes, cosmic catastrophes, as the fall of the stars, the splitting of the sun, the falling asunder of the moon, the transformation of people into corpses, the freezing of the universe, and so on.

523I have just said that the primary symptom appears to have no analogy with any kind of functional disturbance, yet I have omitted to mention the phenomena of the dream. Dreams can produce similar pictures of great catastrophes. They can manifest all stages of personal disintegration, so it is no exaggeration to say that the dreamer is normally insane, or that insanity is a dream which has replaced normal consciousness. To say that insanity is a dream which has become real is no metaphor. The phenomenology of the dream and of schizophrenia are almost identical, with a certain difference, of course; for the one occurs normally under the condition of sleep, while the other upsets the waking or conscious state. Sleep, too, is an abaissement du niveau mental which leads to more or less complete oblivion of the ego. The psychic mechanism that brings about the normal extinction and disintegration of consciousness in sleep is therefore a normal function which almost obeys our will. In schizophrenia it seems as if this function were set in motion in order to bring about that sleep-like condition in which consciousness is reduced to the level of dreams, or in which dreams are intensified to a degree equalling that of consciousness.

524Yet even if we knew that the primary symptom is produced with the aid of an ever-present normal function, we should still have to explain why a pathological condition ensues instead of the normal effect, which is sleep. It must, however, be emphasized that it is not exactly sleep which is produced, but something which disturbs sleep, namely, the dream. Dreams are due to an incomplete extinction of consciousness, or to a somewhat excited state of the unconscious which interferes with sleep. Sleep is disturbed if too many remnants of consciousness go on stirring, or if there are unconscious contents with too great an energy-charge, for then they rise above the threshold and create a relatively conscious state. Hence it is better to explain many dreams as the remnants of conscious impressions, while others derive directly from unconscious sources which have never been conscious. Dreams of the first type have a personal character and conform to the rules of a personalistic psychology; those of the second type have a collective character, inasmuch as they contain peculiarly mythological, legendary, or generally archaic imagery. One must turn to historical or primitive symbology in order to explain such dreams.

525Both types of dream are reflected in the symptomatology of schizophrenia. There is a mixture of personal and collective material just as there is in dreams. But in contradistinction to normal dreams, the collective material seems to predominate. This is particularly evident in the so-called “dream-states” or delirious intervals and in paranoid conditions. It seems also to predominate in the catatonic phases, so far as we can get any insight into the inner experiences of such patients. Whenever collective material prevails under normal conditions, it produces important dreams. Primitives call them “big dreams” and consider them of tribal significance. You find the same thing in the Greek and Roman civilizations, where such dreams were reported to the Areopagus or to the Senate. One meets these dreams frequently in the decisive moments or periods of life: in childhood from the third to the sixth year; at puberty, from fourteen to sixteen; in the period of maturity from twenty to twenty-five; in middle life from thirty-five to forty; and before death. They also occur in particularly important psychological situations. It seems that such dreams come chiefly at those moments or periods when the man of antiquity or the primitive would deem it necessary to perform certain religious or magic rites, in order to procure favourable results or to propitiate the gods for the same end.

526We may safely assume that important personal matters and worries account for personal dreams. We are not so sure of our ground when we come to collective dreams, with their often weird and archaic imagery, which cannot be traced back to personal sources. The history of symbols, however, yields the most surprising and enlightening parallels, without which we could never follow up the remarkable meaning of such dreams.

527This fact makes one realize how inadequate the psychological training of the psychiatrist is. It is, of course, impossible to appreciate the importance of comparative psychology for the theory of delusions without a detailed knowledge of historical and ethnic symbols. No sooner did we begin with the qualitative analysis of schizophrenia at the Psychiatric Clinic in Zurich than we realized the need of such additional information. We naturally started with an entirely personalistic medical psychology, mainly as presented by Freud. But we soon came up against the fact that, in its basic structure, the human psyche is as little personalistic as the body. It is far rather something inherited and universal. The logic of the intellect, the raison du coeur, the emotions, the instincts, the basic images and forms of imagination, have in a way more resemblance to Kant’s table of a priori categories or to Plato’s eida than to the scurrilities, circumstantialities, whims, and tricks of our personal minds. Schizophrenia in particular yields an immense harvest of collective symbols, the neuroses yield far less, for with few exceptions they show a predominantly personal psychology. The fact that schizophrenia disrupts the foundations of the psyche accounts for the abundance of collective symbols, because it is the latter material that constitutes the basic structure of the personality.

528From this point of view we might conclude that the schizophrenic state of mind, so far as it yields archaic material, has all the characteristics of a “big dream’’—in other words, that it is an important event, exhibiting the same “numinous” quality which in primitive cultures is attributed to a magic ritual. As a matter of fact, the insane person has always enjoyed the prerogative of being the one who is possessed by spirits or haunted by a demon. This is, by the way, a correct interpretation of his psychic condition, for he is invaded by autonomous figures and thoughtforms. The primitive valuation of insanity, moreover, lays stress on a special characteristic which we should not overlook: it ascribes personality, initiative, and wilful intention to the unconscious—again a true interpretation of the obvious facts. From the primitive standpoint it is perfectly clear that the unconscious, of its own volition, has taken possession of the ego. According to this view it is not the ego that is enfeebled; on the contrary, it is the unconscious that is strengthened through the presence of a demon. The primitive, therefore, does not seek the cause of insanity in a primary weakness of consciousness but rather in an inordinate strength of the unconscious.

529I must admit it is exceedingly difficult to decide the intricate question of whether it is a matter of a primary weakness and corresponding dissociability of consciousness, or of the primary strength of the unconscious. The latter possibility cannot easily be dismissed, since it is conceivable that the abundant archaic material in schizophrenia is the expression of a still existing infantile and therefore primitive mentality. It might be a question of atavism. I seriously consider the possibility of a so-called “arrested development,” in which a more than normal amount of primitive psychology remains intact and does not become adapted to modern conditions. It is natural that under such conditions a considerable part of the psyche should not catch up with the normal progress of consciousness. In the course of years the distance between the unconscious and the conscious mind increases and produces a conflict—latent at first. But when a special effort at adaptation is needed, and when consciousness should draw upon its unconscious instinctive resources, the conflict becomes manifest; the hitherto latent primitive mind suddenly bursts forth with contents that are too incomprehensible and too strange for assimilation to be possible. Indeed, such a moment marks the beginning of the psychosis in a great number of cases.

530It should not be overlooked that many patients seem quite capable of exhibiting a modern and sufficiently developed consciousness, sometimes of a particularly concentrated, rational, obstinate kind. However, one must quickly add that such a consciousness shows early signs of a defensive nature. This is a symptom of weakness, not of strength.

531It may be that in schizophrenia a normal consciousness is confronted with an unusually strong unconscious: it may also be that the patient’s consciousness is just weak and therefore unable to keep back the inrush of unconscious material. In practice I must allow for the existence of two groups of schizophrenia: one with a weak consciousness and the other with a strong unconscious. We have here a certain analogy with the neuroses, where we also find plenty of patients with a markedly weak consciousness and little will-power, and others who possess remarkable energy but are subjected to an almost overwhelmingly strong unconscious determination. This is particularly the case when creative impulses (artistic or otherwise) are coupled with unconscious incompatibilities.

532If we now return to our original question, the psychogenesis of schizophrenia, we reach the conclusion that the problem itself is rather complicated. At all events we ought to make it clear that the term “psychogenesis” means two different things: (1) an exclusively psychological origin, (2) a number of psychological conditions. We have dealt with the second point, but we have not yet touched upon the first. This envisages psychogenesis from the standpoint of a causa efficiens. The question is: Is the sole and absolute cause of schizophrenia a psychological one or not?

533Over the whole field of medicine such a question is, as you know, more than embarrassing. Only in a very few cases can it be answered positively. The usual aetiology consists in a competition between various conditions. It has therefore been urged that the word causality or cause should be expunged from the medical vocabulary and replaced by the term “conditionalism.” I am absolutely in favour of such a measure, since it is well-nigh impossible to prove, even approximately, that schizophrenia is an organic disease to begin with. It is equally impossible to make its exclusively psychological origin evident. We may have strong suspicions as to the organic nature of the primary symptom, but we cannot ignore the well-established fact that there are many cases which developed out of an emotional shock, a disappointment, a difficult situation, a reversal of fortune, etc.; and also that many relapses as well as improvements are due to psychological conditions. What are we to say about a case like the following? A young student experiences a great disappointment in a love-affair. He has a catatonic attack, from which he recovers after several months. He then finishes his studies and becomes a successful professional man. After a number of years he returns to Zurich, where he had experienced his love-affair. Instantly he is seized by a new and very similar attack. He says that he believes he saw the girl somewhere. He recovers and avoids Zurich for several years. Then he returns and in a few days he is back in the clinic with a catatonic attack, again because he is under the impression that he has seen the girl, who by that time was married and had children.

534My teacher, Eugen Bleuler, used to say that a psychological cause can produce only the symptoms of the disease, but not the disease itself. This statement may be profound or the reverse. At all events it shows the psychiatrist’s dilemma. One could say, for instance, that our patient returned to Zurich when he felt the disease coming on, and one thinks one has said something clever. He denies it—naturally, you will say. But it is a fact that this man was still deeply in love with his girl. He never went near another woman and his thoughts kept on returning to Zurich. What could be more natural than that once in a while he should give way to his unconquered longing to see the streets, the houses, the walks again, where he had met her, insanity or not? We do not know, moreover, what ecstasies and adventures he experienced in his insanity and what thrilling expectations tempted him to seek the experience once more. I once treated a schizophrenic girl who told me that she hated me because I had made it impossible for her to return into her beautiful psychosis. I have heard my psychiatric colleagues say, “That was no schizophrenia.” But they did not know that they, together with at least three other specialists, had made the diagnosis themselves, for they were ignorant of the fact that my patient was identical with the one they had diagnosed.

535Shall we now say that our patient became ill before he fell in love and before he returned to Zurich? If that is so, then we are bound to make the paradoxical statement that when he was still normal he was already ill and on account of his illness he fell in love, and for the same reason he returned to the fatal place. Or shall we say that the shock of his passionate love was too much for him and instead of committing suicide he became insane, and that it was his longing which brought him back again to the place of the fatal memories?

536But surely, it will be objected, not everybody becomes insane on account of a disappointment in love. Certainly not, just as little as everyone commits suicide, falls so passionately in love, or remains true to the first love for ever. Shall we lay more stress on the assumption of an organic weakness, for which we have no tangible evidence, or on his passion, for which we have all the symptoms?

537The far-reaching consequences of the initial abaissement, however, constitute a serious objection to the hypothesis of pure psychogenesis. Unfortunately nearly all that we know of the primary symptom, and its supposedly organic nature, amounts to a series of question marks, whereas our knowledge of possibly psychogenic conditions consists of many carefully observed facts. There are indeed organic cases with brain-oedema and lethal outcome. But they are a small minority and it is not certain whether such a disease should be called schizophrenia.

538A serious objection against the psychogenesis of schizophrenia is the bad prognosis, the incurability, and the ultimate dementia. But, as I pointed out twenty years ago, 4 the hospital statistics are based chiefly upon a selection of the worst cases; all the milder cases are excluded.

539Two facts have impressed themselves on me during my career as a psychiatrist and psychotherapist. One is the enormous change that the average mental hospital has undergone in my lifetime. That whole desperate crowd of utterly degenerate catatonics has practically disappeared, simply because they have been given something to do. The other fact that impressed me is the discovery I made when I began my psychotherapeutic practice: I was amazed at the number of schizophrenics whom we almost never see in psychiatric hospitals. These cases are partially camouflaged as obsessional neuroses, compulsions, phobias, and hysterias, and they are very careful never to go near an asylum. These patients insist upon treatment, and I found myself, Bleuler’s loyal disciple, trying my hand on cases we never would have dreamed of touching if we had had them in the clinic, cases unmistakably schizophrenic even before treatment—I felt hopelessly unscientific in treating them at all—and after the treatment I was told that they could never have been schizophrenic in the first place. There are numbers of latent psychoses—and quite a few that are not so latent—which, under favourable conditions, can be subjected to psychological analysis, sometimes with quite decent results. Even if I am not very hopeful about a patient, I try to give him as much psychology as he can stand, because I have seen plenty of cases where the later attacks were less severe, and the prognosis was better, as a result of increased psychological understanding. At least so it seemed to me. You know how difficult it is to judge these things correctly. In such doubtful matters, where you have to work as a pioneer, you must be able to put some trust in your intuition and to follow your feeling even at the risk of going wrong. To make a correct diagnosis, and to nod your head gravely at a bad prognosis, is the less important aspect of the medical art. It can even cripple your enthusiasm, and in psychotherapy enthusiasm is the secret of success.

540The results of occupational therapy in mental hospitals have clearly shown that the status of hopeless cases can be enormously improved. And the much milder cases not in hospitals sometimes show encouraging results under psychotherapeutic treatment. I do not want to appear overoptimistic. Often enough one can do little or nothing at all; or again, one can have unexpected results. For about fourteen years I have been seeing a woman, who is now sixty-four years of age. I never see her more than fifteen times in the course of a year. She is a schizophrenic and has twice spent a number of months in hospital with an acute psychosis. She suffers from numberless voices distributed all over her body. I found one voice which was fairly reasonable and helpful. I tried to cultivate that voice, with the result that for about two years the right side of the body has been free of voices. Only the left side is still under the domination of the unconscious. No further attacks have occurred. Unfortunately, the patient is not intelligent. Her mentality is early medieval, and I was able to establish a fairly good rapport with her only by adapting my terminology to that of the early Middle Ages. There were no hallucinations then; it was all devils and witchcraft.

541This is not a brilliant case, but I have found that I always learn most from difficult and even impossible patients. I treat such cases as if they were not organic, as if they were psychogenic and as if one could cure them by purely psychological means. I admit that I cannot imagine how something “merely” psychic can cause an abaissement which destroys the unity of personality, only too often beyond repair. But I know from long experience not only that the overwhelming majority of symptoms are psychologically determined, but that in an unspecified number of cases the onset of the disease is influenced by, or at least coupled with, psychic facts which one would not hesitate to declare causal in a case of neurosis. Statistics in this respect prove nothing to me, for I know that even in a neurosis one is likely to discover the true anamnesis only after months of careful analysis. In psychiatric anamnesis there is a lack of psychological knowledge which is sometimes appalling. I do not say that the general practitioner should have a knowledge of psychology, but if the psychiatrist wants to practise psychotherapy at all he certainly ought to have a proper psychological training. What we call “medical psychology” is unfortunately a very onesided affair. It may give you some knowledge of everyday complexes, but far too little is known of anything outside the medical department. Psychology does not consist of medical rules of thumb. It has far more to do with the history of civilization, of philosophy, of religion, and quite particularly with the primitive mentality. The pathological mind is a vast, almost unexplored region and comparatively little has been done in this field, whereas the biology, anatomy, and physiology of schizophrenia have had all the attention they want. And with all this work, what exact knowledge have we of the heredity or of the nature of the primary symptom? I should say: Let us discuss the question of psychogenesis once more when the psychic side of schizophrenia has had a square deal.

1 [Written in English and read at a meeting of the Section of Psychiatry, Royal Society of Medicine, London, April 4, 1939. Published in the Journal of Mental Science (London), LXXXV (1939), 999-1011.—EDITORS.]

2 [Cf. supra, pars. 466ff.]

3 [Cf. Le Mécanisme des émotions, ch. IV, esp. p. 208.—EDITORS.]

4 Cf. supra, “On the Problem of Psychogenesis in Mental Disease.”