Schizophrenia and the Emperor's (not so) new clothes
Part One of a two part article on the secret history of schizophrenia
First published In Asylum - The Magazine for democratic psychiatry vol 12, No 1, 2000
Schizophrenia is often (mistakenly) compared to diabetes, especially by psychiatric workers trying to find a way of explaining the implications of the diagnosis. Both conditions, it is said, require life long treatment including medication, neuroleptics in the case of schizophrenia and insulin for diabetes. That is probably as far as the comparison goes, though, because whereas there is a very reliable physical test for diabetes, there is no such test for schizophrenia. The diagnosis of schizophrenia is based on a judgement made by a psychiatrist arising from the way an individual is behaving (usually very strangely) and what they are saying about themselves and others. If this pattern of behaviour and thought fits the current medical description of schizophrenia (I say current, because it has always been subject to change), then this experience will be considered to be an illness, just like diabetes. That is to say a disease arising from a physical cause, a problem within the brain, something that can only be put right with the appropriate medical treatment. And, because it is perceived as a pathological problem, there is no choice about the diagnosis, it is imposed upon you and has the authority not only of medicine behind it, but of the law as well.
This state of affairs has been controversial in its own right, but if you add to this the argument that schizophrenia is at best a hypothesis and at worst a scientific mistake it would be considered unsupportable. I think at this point I should add that I do not hold the opinion that "madness" does not exist, but what is regarded as an unwanted, disturbing even crazy behaviour in our society changes over time as do the names and labels given to these behaviours. To give one notable example of this; homosexuality was for many years regarded as a psychiatric illness and treatments were given to modify the behaviour of such people. What changed this situation was the change in status of homosexuals, who by exercising their civil rights, campaigned for changes to their legal status. Once this had been achieved, their status changed from one that was pathologised and criminalised to a new level of social acceptance that made the idea of treating homosexuals as mad or bad no longer viable. It is also possible to demonstrate that even when psychiatry treats people who display crazy behaviour, what it understands to be the cause of their madness also changes over time. For instance in the nineteenth century there was a condition known as infectious brain disease, which eventually fell into disrepute because it did not recognise the difference between patients with organic brain problems like tumours that can cause changes in personality and behaviour and those patients who had psychological problems. This is forgivable because at the time there were breakthroughs in the understanding of the relationship between diseases like syphillus that caused infections in the brain leading to "insanity" which led to the mistaken belief that all kinds of madness were caused by some kind of physical problem. This is as true today for some psychiatrists as it was one hundred years ago. But, perhaps there will also be a day when schizophrenia will be abandoned in the same way as the non-existent infectious brain disease.
To understand why we all seem to be taken in by the apparent scientific credibility of schizophrenia, I would like to compare why schizophrenia has become so dominant to the cautionary morality tale "The Emperor's New Clothes". The story, naturally enough is about an Emperor, a proud man, although sometimes prone to insecurity about how his subjects regard him, as he values their esteem and respect above everything. Like many of his kind, he is very susceptible to flattery, as well as wanting to be able to prove his superiority over his subjects. One day, two con men arrive in the country and realise they can exploit these weaknesses of the Emperor to their financial advantage. Disguising themselves as fashion designers, they gain access to the Emperor and tell him they are the most talented craftsmen in the land, able to create the most fashionable clothes from the finest material. The Emperor is terribly impressed by their sales pitch and immediately commissions them to create the most extravagant ceremonial robes for him to wear at the next royal procession. An event where he would be sure to be seen and admired by all his subjects. Of course, the con men have a ruse that they know will both confound the emperor and make them rich without any real effort at all. So, when they start to "make" the fabulous robes, they invite the emperor to choose the fabric and ingeniously show him a roll of material, apparently so fine, it is invisible to all those but the most discerning clients. Now, the Emperor could not see this marvellous cloth for the simple reason that it did not exist, but could he admit it? Well, he could not, even to himself. Neither could the Emperors courtiers, they could see no cloth, but they were not about to admit it, if the Emperor could see it, then indeed it must exist and anyway no one wanted to acknowledge that they lacked the discernment to be able to see such finery. The con men finish the "robes", receive their payment and sensibly disappear, never to be seen again in that part of the world. In the days leading up to the royal procession, the city was abuzz with rumours about the wondrous outfit the emperor was to wear. Expectations could not have been higher. The Emperor, himself, was even more convinced of the reality of his robes, even though he knew himself to be a fraud (lacking discernment as he did), whatever uneasiness he felt is more than compensated by the high praise the robes received from all those around him. "Such fine stitching", "so beautifully cut", "what lovely colours" they chorused.
The day of the procession arrived and with full pomp and ceremony the emperor paraded through the city - well - stark naked. The citizens, though, were not about to admit that what they could see (or not, as it happened) and cheered and roared their approval of the emperor and his new suit of clothes. This happy, if a little undignified delusion would have continued unhindered, except for one thing or rather one quite small child. The child, one of the many spectators, was waiting expectantly to see the emperor and the much heralded robes, but what did he see? A naked emperor or as Danny Kay's song of the story puts it "The king was in the all together", understandably disappointed and unable to stay silent, he shouts out, "He's completely naked". Of course, those around him laughed at his stupidity and told him to shut his mouth. The child insists "But he is, he is...".
Well, to bring this tale to an end, eventually the crowd began to get restive, uncertain whispering broke out as did the occasional guffaw of laughter. Then like a punctured ball, the pomp began to deflate as spectators, courtiers and Emperor alike realised that what the child was saying was indeed true. I don't have to describe the subsequent embarrassment and hoohah that followed, needless to say the emperor was taught a very harsh lesson in pride coming before the fall and the courtiers and city dwellers the importance of not believing everything you're told, even if it comes from apparently unimpeachable sources. It also carries another equally powerful message, after all it is only the child who sees through the charade. The story of the Emperor's new clothes tells us that overweening pomposity and grandeur usually gets its come uppance and sometimes from the most unlikely source, for after all how could a small, odinary child be a threat to the highest authority in the land.
The moral of this story, for me anyway, is that just because something is accepted as a universal reality, it could be just because powerful people have a vested interest in seeing it like that. Even if they wanted to, they couldn't see it any other way, because if they did express doubt it would not only undermine the so called "truth", but their own position as well. Maybe, it takes someone who has nothing to lose (like the child) to point out what is obvious. What has this got to do with schizophrenia then? Well, I for one, have come to the conclusion that the claims made for schizophrenia have more then a whiff of the "Emperors new clothes" about them. It is claimed that the cause of schizophrenia will soon be known and that a "cure" is around the corner, which is all very well. That is if schizophrenia actually exists at all. Perhaps there's nothing to find and nothing to cure, in fact no clothes at all and not even an emperor.
This is the problem. Although there is an emperor (psychiatry) even if it is a pretender to the throne, there is in reality no equivilant to the young child, who sees through the chirade. Well, maybe that is not exactly true, rather, there is a child who does see the nakedness of the emperor, only the child is not listened to, in fact the child is regarded as quite mad, even to question the reality of the clothes. To raise the possibility that there is no such thing as schizophrenia is to invite an extremely powerful reaction, partly reproach and partly sorrow. This is followed by anger, because you cannot or will not see that which is obvious and an exasperated impatience that you continue to resist the temptations of the model. To challenge the homogeniety of schizophrenia is like waving a red rag at a bull, certainly ill advised and potentially lethal for your prognosis or professional reputation But, not only is the child absent or perhaps sensibly holding his/her tongue BUT the con men come back every year with a new improved set of invisible clothes and the emperor and even more importantly the courtiers and the subjects (who in this tale are those diagnosed as having schizophrenia and the wider general public) fall for the same con tick. These guys are making a mint!
So, Emperor Psychiatry, with the invisible clothes, (schizophrenia) comes equipped with a new set of scientific arguments which are not only made made to prove it exists, but to contend that the cause and the cure are just around the corner. It is my contention that these arguements are like the emperors invisible clothes - on the one hand potent symbols of power, on the other proof of nothing.
Maybe, we've all become fixated by all the claims made for schizophrenia, stretching as they do now, for over a century. We can't see the fundamental reality, that schizophrenia as a "disease" is to say the least problematic, and it could be that we should ditch the whole concept. If the scientists have failed in their own terms to prove that it exists, don't always agree what it is anyway and have a tendency to change the rules when faced with uncomfortable facts that don't appear to fit. Why then, is there still so much faith in it?
Could it be that we too have some unsustainable beliefs in the power of science? Mary Boyle thinks so, she says that we believe schizophrenia must exist (like the Emperors clothes) because science says it does and if science says it is so, then it must be. And because schizophrenia is without doubt a scientific concept, therefore by implication it must be beyond challenge, it must be the truth, an unpleasant one perhaps, but unassailable all the same. It is beyond criticism because it is scientific, therefore to criticise schizophrenia is to be unscientific. It is this kind of seeming authority, like the emperors, that blind us from seeing things as they really are, whilst also silencing those who see things differently. For fear of ridicule and rejection are powerful disincentives. Unless like the child, these essentially adult concerns have no effect, s/he had to say loudly what it was s/he could see and what s/he couldn't. There is a good reason for our response, we are understandably confused and scared If you have been diagnosed as having schizophrenia or have a relative or friend who has, the fact that these strange, inexplicable experiences have been given a label is reassuring. Perhaps that is as good a reason as any to take a very careful look at what the scientific claims for schizophrenia really amount to and to understand the difficulty psychiatry has in even admitting that there are doubts about the existence of schizophrenia.
This is a very important starting point, because it is up to the scientific community to prove that schizophrenia exists and to do so within the exacting terms demanded by science itself. However, we need to be careful about what we expect science to be able to deliver. Science cannot say that this is a fact or that this is true, rather it can only say that there is something happening that appears to have meaning and to seek to understand more about what that meaning could be. Science is a voyage rather than a destination, an intriguing possibility rather than a certainty. The unreal expectations we have of science are not the fault of scientists, rather the fault, if it can be described as such of a human desire for certainties in an uncertain world.
Schizophrenia then, has to meet some basic scientific standards. If it exists, it should firstly be a description of something tangible, something that stands up to the tests required by medicine, of showing physical cause and of coming to an understanding of what this physical cause might be. Secondly, it must show that the symptoms that occur amongst a group of people (like schizophrenics) do so for reasons other then chance and that there is some kind of underlying unifying process at work. By this bench mark, schizophrenia fails the test, so far all we have is a set of assumptions that have yet to be substantiated, in spite of over a hundred years of research.
Next: Part Two; Why this matters and why it would do us all good to dump schizophrenia now.