4. Eugen Bleuler (1857–1939): first used the term ‘schizophrenia’, in 1911 Eugen Bleuler (1857–1939)
Bleuler first coined the term schizophrenia in 1911. It followed many years of careful study in the Burghölzi hospital in Zurich. Bleuler’s situation could hardly have been more different from Kraepelin’s. He had grown up using the same dialect as his patients, lived in the hospital where his sister was a patient with schizophrenia, and often spent evenings talking to his patients. In every way he was primed to try to understand and make sense of their inner world rather than just observe as Kraepelin had done.
His definition of schizophrenia is based on the content of the patient’s experience. This approach allowed him to make the diagnosis (providing the features were present) even if the outcome was good. Of course there were many schizophrenia patients with poor outcomes but Bleuler confirmed there were some with good outcomes.
Bleuler considered that the primary disturbances in schizophrenia were a withdrawal from close relationships and disturbances of thinking and mood. He believed that hallucinations and delusions were attempts by the patient to make sense of these experiences. He defined schizophrenia using his famous ‘Four As’ – Autism (withdrawal), Affect (mood disturbances), Association (thought disorder – different associations or meanings being attached to words), Ambivalence (lack of direction and motivation). Bleuler’s approach has been superseded in recent years by a focus on the ‘positive’ symptoms (delusions, hallucinations, thought disorder) because of their greater ease of recognition and responsiveness to drug treatment. His was certainly a more humane approach to this, the most devastating of the mental illnesses, which accords meaning to the experiences of even the most deteriorated patient.
Sigmund Freud (1856–1939)
Like Kraepelin Freud had to abandon his preferred career for marriage. He pursued the only available alternative for a Jewish doctor at that time – private practice. Freud had little experience of asylums and worked almost exclusively with neurotic patients; he always recognized the limitations of his approaches for more severely ill patients. However, a careful reading of his case histories leaves little doubt that he treated some pretty disturbed individuals. His investigations took him in a completely different direction: the founding of psychoanalysis (Chapter 3). He thought of himself as much a scientist exploring the mind as a doctor curing it. He always believed that physical treatments (medicines) would eventually be the cure for mental illnesses.
5. Freud (1856–1939): the father of psychoanalysis
We might anticipate antagonism or avoidance between these groups a century ago but this doesn’t appear to have been the case. This was still a ‘pre medical-model’ psychiatry. Working in large asylums, all that was available to the doctors after they had classified their patients into broad diagnostic groups was to talk with them. Moral therapy evolved into a rough and ready psychotherapy. Few believed this cured the disease, but the role of doctors has never been restricted to just cure, but also to bringing relief from suffering. The journals of asylum doctors of this time testify to the time spent talking with patients – attempting to bring comfort and using reasoning to calm them.
The work of another great German psychiatrist, Karl Jaspers (1883–1969), exemplifies this. Jaspers wrote his masterpiece in Heidelberg by the age of 30: General Psychopathology (1913). This book is still in print and has never been bettered as a description of the mental processes in psychotic illnesses. Jaspers was initially quite comfortable with the writings of the psychoanalysts and his book clearly distinguishes the two different approaches to researching mental illnesses. The first is verstehen‘understanding’ and the second erklären ‘explaining’. Both were considered legitimate and necessary: what is the meaning of what the patient says and what is causing it? This is a dichotomy that still causes conflict in psychiatry – particularly between the psychologically minded and the biologically minded. Jaspers eventually lost patience with Freud because he felt that he implied that to understand was to explain. In its origins psychiatry needed and valued both approaches.