A dimensional conceptualization of psychosis that evolved from clinical experience has been replaced in recent decades by a categorical model useful for certain kinds of research. Although both dimensional and categorical paradigms have been valuable ways of viewing “madness,” the loss of a dimensional sensibility is arguably retarding our progress in developing therapies for psychotic suffering.
“Categorical paradigms, whether the ancient idea of demon-possession or contemporary references to the “disease of schizophrenia,” have been recurrently attractive, both to professionals and to those suffering from their own or others’ madness. The idea of psychosis as a blameless disease process has lifted shame and guilt from countless families. If your daughter is felled by a brain disease, she does not have a more diffuse sickness of the soul, and you are not a soul murderer. Categorical ways of framing schizophrenia have permitted useful research into the etiologies of psychotic suffering and have facilitated the development of pharmacological treatments that have made lives outside institutions possible for many who would once have been candidates for physical restraint, life-long hospitalization, or lobotomy.
But they have also constricted our therapeutic imaginations. In Mackler’s (2008) documentary, “Take These Broken Wings,” virtually every interviewee opines that schizophrenia is a brain disease, a neurotransmitter defect, a chemical imbalance correctable only by proper medications. I remember how, shortly after the discovery that chlorpromazine could mute many psychotic symptoms; we began to descend a slippery slope in talking with patients diagnosed with schizophrenia. To promote compliance with the new drugs, which offered great hope, we compared schizophrenic suffering to chronic illnesses like diabetes, implying that a lifetime of insulin equivalents was required. Not surprisingly, as Orwell said of recurrently repeated falsehoods, this account has, with help from pharmaceutical and insurance companies, become the conventional wisdom about the essential nature of madness.
A defect in the brain has no special meaning, can respond to no psychological intervention, involves only deficit, and offers nothing elevating or informative from which the patient and the rest of us can learn. It leaves no space for therapeutic identification and empathy, explorations of subjectivity, or the sense of competence that issues from a suffering person’s intimate acquaintance with, and mastery over, his or her internal psychological saboteurs. I worry that in these technocratic times we are losing a vital piece of ancient wisdom, Terence’s “Nothing human is alien to me.”
I argue here for restoring a dimensional sense of human suffering and the compassion it breeds toward fellow sufferers. When colonizers subdue conquered populations, they begin – without malevolent intent – by destroying indigenous languages. The language that has evolved from clinical experience is currently being replaced by that of corporate bureaucrats, pharmaceutical marketers, and policy experts eager to reference only the “evidence” provided by academic researchers, many of whom have little experience in the clinical trenches and insufficient grant money for the long-term follow-ups necessary to evaluate therapies for the seriously mentally ill.
I am not championing an exclusively dimensional view. Appreciation of qualitative difference permits the potentially life-saving awareness that “something here is way out of kilter.” Feeling something alien in psychosis can protect us from failures like those of some early psychoanalysts who concluded that because we are all on the human continuum, one therapeutic technique should apply to everyone. A categorical sensibility can foster curiosity about what we cannot understand by identification. It highlights our need for our patients to teach us, and it can inspire psychosis-specific treatments.
Every age and every known society has had to deal with those we currently describe as mentally ill. In other eras and cultures, responses to madness have been remarkable for their diversity – everything from torture and death to idealization and sainthood. A central challenge for our era involves addressing the multifarious consequences of accepting a categorical model in the absence of any dimensional sensibility. Embedded in phrases like “the psychotic,” “the schizophrenic,” “the disease of schizophrenia,” or “those who have schizophrenia” is the assumption that the best way to depict madness is as a condition in which one is taken over by an invading otherness or deforming calamity. While it is intuitively resonant that losing one’s sanity involves a qualitative distortion of the mind that categorical formulations capture nicely, the current tendency to see madness only via categorical metaphors unnecessarily constricts our vision.”
“The disquieting idea that we all have the potential for madness can correct an over-reified conception of extreme mental states and offer realistic hope for reducing psychotic anguish.”
“Holding both dimensional and categorical perspectives honors the fact that there may be many routes to becoming diagnosably psychotic, some involving more genetic tilt and some involving more disabling experience. Biology and psychology are inseparable and mutually interactive. Pharmaceutical intervention can reduce psychotic misery; psychotherapy changes the brain. Everything in the body, including the brain, can break. Yet even people with broken brains have psyches or, in an older language, souls. If our language tends to reduce a psychotic person to a malfunctioning brain, we have killed the psyche and are engaged in soul murder on a monumental scale.”