Book
Schizophrenia as a Human Process
Schizophrenia as a Human Process is a posthumous collection of Harry Stack Sullivan's papers on schizophrenia, most of them written between 1924 and the early 1930s out of his clinical research at the Sheppard and Enoch Pratt Hospital in Towson, Maryland, where he worked from 1922 to 1930, from 1925 as director of clinical research. Until then the record of that work was scattered across journals; Helen Swick Perry gathered the papers for the first time, with an introduction and commentaries placing each in the growth of his thought, and W. W. Norton published the volume in 1962. Among them are “Schizophrenia: Its Conservative and Malignant Features” (1924), “The Onset of Schizophrenia” (1927), “Tentative Criteria of Malignancy in Schizophrenia”, “Research in Schizophrenia”, “Socio-Psychiatric Research” and “The Modified Psychoanalytic Treatment of Schizophrenia” (1931). Against the Kraepelinian picture of dementia praecox as a fixed organic deterioration, Sullivan treats schizophrenia as a human way of meeting a crisis in living: even the strangest thinking and symbols of a patient remain within the human range and can be understood with enough contact. The illness typically breaks out in panic, after a collapse of self-esteem before experiences the person cannot integrate, often in the area of sexual adjustment and relations with peers. Its early regressive features are conservative, attempts to reintegrate experience through older modes of thought, while its malignant features mark a turn toward lasting dissociation and deterioration; some patients come out of an episode more capable than before. The outcome depends heavily on the human setting: the papers describe the special ward for young male patients that Sullivan organised apart from the hospital's routine, staffed by attendants he chose, and a psychotherapy modified from psychoanalysis that lowers anxiety and builds a relationship instead of relying on free association. The collection documents the clinical origins of Sullivan's interpersonal psychiatry.
Main ideas
- Schizophrenia is a human process, a disordered but understandable way of living through a crisis, not a predetermined organic deterioration as the Kraepelinian concept of dementia praecox held.
- However disturbed, a patient's thought and symbols never fall wholly outside human experience, so they can be understood through sustained, close contact.
- The early regressive features of the illness are conservative: a return to genetically older modes of thought in an effort to reintegrate experience that has failed to hold together. Malignant features signal a turn toward lasting dissociation and deterioration.
- Illness can be an attempt to solve a problem in living: an acute episode may end in reorganisation, and some patients emerge more capable than before.
- The onset is marked by panic following a collapse of self-esteem and security, typically before experiences, often in sexual adjustment and relations with peers, that the person cannot integrate.
- The course of the illness depends on its human surroundings: Sullivan's special ward for young male patients, run apart from hospital routine with attendants he selected, made the relations between patients and staff themselves therapeutic.
- Psychoanalysis must be modified for schizophrenic patients: free association is generally unsuitable, and the psychiatrist works first to reduce anxiety and build a relationship in which the psychotic experience can be talked through.
- Schizophrenia is also a problem for social research and mental hygiene: its study requires attention to the social and cultural conditions of development, and points toward prevention.
- Read together with Perry's commentaries, the papers show Sullivan's interpersonal psychiatry, with its ideas of self-esteem, anxiety, dissociation and participant observation, taking shape in clinical work with psychotic patients.