The puzzle of schizophrenia – in my eyes one of the greatest unsolved problems which confronts the medical sciences and, beyond them, the human mind in general – has been with me all my life: From my earliest childhood as a child of a mentally ill mother, during my medical studies and training as a professional psychiatrist, and finally as a specialized schizophrenia and rehabilitation researcher, psychoanalyst, psychosis therapist and founder of a novel therapeutic residential community for the treatment of acute schizophrenic disorders, I have a range of experiences that are beyond the equipment of most psychiatrists. And even now, at an advanced age, the schizophrenia problem continues to raise question after question for me.
I will try to explain how far I have come with my understanding (or with my current state of error…) of this mysterious ‘mental illness’.
Childhood experiences
My mother was diagnosed with schizophrenic psychosis after her first internment at the Bern Psychiatric Clinic "Waldau" in 1940, when I was eleven years old. However, her illness had already begun to manifest itself alread shortly after my birth in the form of different behavioural abnormalities which in retrospect must clearly be classified as so-called precursor symptoms, according to all available information. Even today I shudder to think about the uncanny, incomprehensible and unpredictable atmosphere attached to everything that had to do with mamma during my whole childhood.
Since my high school and student days, I have tried to free myself from this eternal burden as far as possible, thus unintentionally charging my sister Lill who had always been closer to our mother than I was and probably also had to pay for this with lifelong physical health problems and chronic feelings of insufficiency. Outside my mother's sphere of influence, however, first in school and with the scouts, and then during my medical studies, I consider that I lived, all in all, a quite happy and at any rate always highly intensive youth, without consciously dealing very much with my mother's illness.
In retrospect I think , though, that my early passionate interest in everything psychological was motivated mainly by the search for an explanation of the strange behaviour of my mother. I read almost everything of relevance that came to my attention during my high school years, especially C.G. Jung and Sigmund Freud. And during my medical studies, I found nothing more fascinating than the excellent psychiatry lectures of Professor Max Müller, then director of the Bernese psychiatric university clinic “Waldau” and father of my later boss Christian Müller. Even my first major crisis about the choice of a professional career and the abrupt change from literature to medicine during the first semester at university certainly had something to do with my mother's illness. I didn't realize this at the time, however, nor the deeper motives for turning to psychiatry without much hesitation after my basic medical studies although I had also flirted with the option of becoming a general practitioner or a specialist in internal medicine.
Professionalization
Shortly after completing my basic medical studies (1956), I took up a position as an assistant doctor in the "Waldau", where my mother hadn't been for a long time, but would return much later. There, I gradually got to know the thousand facets of schizophrenic psychosis, as well as, of course, all other clinical psychopathologies. Oddly enough, perhaps significantly, although I was aware of the current diagnosis of my mother I did not correlate her illness with that of the many bizarre figures with the same diagnosis which populated the rear departments of this huge old-style psychiatric hospital. These patients, with their delusions, hallucinations and states of agitation or rigidity, were very clearly recognizable as "crazy", while my mother's behavior had always been characterized by a strange mixture of normality and of an odd isolation into what I would now call an autistic world which, to outsiders, would seem more like a personality disorder than a true mental illness.
Today, most experts would probably bet on a schizophrenia simplex whose existence and affiliation to the ’schizophrenia spectrum’ is still controversial, that is one of those rare and symptom-poor so-called ’simple’ schizophrenias without any notable delusional, hallucinatory or catatonic secondary symptoms. What is certain, however, is that my mother constantly complained about "pressure in the head", "chronic sinus catarrh" and countless other mental and physical disturbances that have recently been regarded by the phenomenological school of psychiatry, together with a typical "loss of the normal evidence of common selfe, as the actual basic disorder of the schizophrenic psychosis.
Psychoanalytic therapy of psychosis and long-term follow-up studies
Entirely new horizons of understanding opened for me when I moved to the Psychiatric University Hospital in Lausanne in 1963. The atmosphere there was dominated by the psychoanalytically oriented therapy of psychosis that Christian Müller, the new director of this clinic, had begun to develop together with Gaetano Benedetti and several other international pioneers since the 1950s. I became primarily responsible over the next ten years for the "Enquête de Lausanne”, a major research programme on the long-term course of mental illnesses of all kinds, also initiated by Müller. At the same time, however, like most of my colleagues, I rushed enthusiastically into this new therapy.
I don't want to talk here about the few psychotherapies of this type that I carried out in these years with varying success under the supervision of Christian Müller and later also Paul Racamier. Nor will I go into the psychoanalytic training I received over almost twenty years. I would only say that both opened my eyes to the hidden meaning of many peculiar psychotic symptoms and behaviors which can best be compared with the content of dreams, though their meaning is usually even harder to decipher than are the dreams of healthy people. And I often felt the deep existential suffering of all these "crazy" people with what sometimes was an overwhelming intensity.
My enthusiasm for psychoanalytic psychosis therapy suffered a considerable setback when, in one of those strange duplicates of cases which, as is well known, occur sometimes in medical practice, two patients of colleagues whom we had discussed for years in joint case seminars commtted suicicid owards the end of the 1960s, after their therapists had left for Paris for a few weeks for study purposes. Despite Freud's original teaching that schizophrenics were incapable of a so-called therapeutic transfert (bonding), the emotional ties that these two patient had developed with their therapists had obviously become so intense that even a temporary absence was perceived as an intolerable betrayal.
It also struck me that the length and emotional demands of these therapies are so enormous - every proper analytical psychosis therapy lasts several years and may require our almost constant presence in times of crisis - that a single therapist can only hope to treat a few privileged cases during his life with this technique, while the vast majority of "ordinary" schizophrenic patients are left on the shelf.
Due to these experiences and the endeavour to benefit as many patients as possible in a modified form from my findings from analytical psychosis therapy, I decided at the beginning of the seventies to accept Müller's offer to take over, in parallel to my ongoing research work, the management and further development of the Lausanne social psychiatric services¹, which at that time only existed in the embryonic stage. Later and for the same reasons, I tried again and again, as head of the Social Psychiatric University Clinic Bern (1977-94) and founder of the therapeutic community Soteria Bern (1984), to spread the emotional ties (the transfert, in psychoanalytic jargon) of our psychotic patients to the whole care team and the place of security as far as possible, instead of concentrating them on a single irreplaceable therapist.
Furthermore, one main conclusion of the "Enquête de Lausanne” became of central importance for my current understanding of schizophrenia, namely the discovery that many schizophrenic psychoses can heal in the second half of life (and sometimes earlier) even after decades of severe psychosis. Our follow-up examinations on schizophrenia, then and as far as I know still today the world's longest such study with a large number of cases, have shown, to the amazement and sometimes incredulity of the entire professional world, that a good quarter of the nearly three hundred former schizophrenic patients whom my staff and I personally reexamined in their current places of residence 36.7 years on average after their first hospitalisation had gradually healed over the years, and a further quarter had significantly improved. So only about half of all the long-term evolutions we studied matched the idea of the totally "silted up" chronically ill who, at that time, still filled all psychiatric institutions and had a decisive influence on the prevailing concepts on schizophrenia. Similarly surprising results had been obtained almost simultaneously by two other European studies which also included former patients who had long since disappeared from the field of vision of psychiatry, and subsequently by about twenty other long-term investigations worldwide.² The terrible dictum "once schizophrenic, always schizophrenic", which was equally devastating for doctors, for their relatives and for the patients themselves because it led to resigned passivity, thus seemed to be refuted once and for ever.
Yet even today, in the age of dominating short-term perspectives both in economy and also in neurobiology, it still haunts some minds, and even certain textbooks.
Systems theory, Piaget and the roots of affect logic
The late sixties were a time of upheaval not only for the Western world in general, but also for psychiatry, at least in pioneering institutions such as the Lausanne Clinic. The ideas of the so-called “antipsychiatry” - a reform movement originating in Great Britain, the USA and Italy which primarily wanted to abolish the old-style prison-like psychiatric hospitals - and the confrontation with the so-called "systemic paradigm" in Lausanne raised doubts about many previous therapeutic concepts, including even Müller's psychoanalytic psychosis therapies.
This avant-garde view claimed that the actual "site of the disturbance" was not primarily the individual patient who had previously been considered exclusively, but the family system and, beyond that, the entire social system dominated by a rigidity and a belief in authority. On this basis, completely new family therapy methods were created, partly adapted from foreign models and partly actively further developed by Lausanne colleagues such as Luc Kaufmann, Gottlieb Guntern and Elisabeth Fivaz-Depeursinge, and which soon fascinated me, too.
At about the same time, I came across the fundamental importance of Jean Piaget's decades of research into the development of thinking in children. At the end of the sixties, as the person responsible for psychiatric training, I had the opportunity to invite the Geneva psychologist to a lecture in Lausanne. I had to drive my famous guest from Geneva to Lausanne and back again, so I got to know him personally on this occasion - and not only himself, but also his legendary study in Geneva, with its narrow passages buried between tall stacks of books. The deeper I looked at Piaget's monumental theory, genetic epistemology, the clearer it seemed to me that this was an equally important complementary view to the mainly affect-centred psychoanalytic approach which, together with systems theory, had hitherto been my almost exclusive theoretical basis of understanding of both the healthy and the ill psyche.
Conversely, however, I missed in Piaget's work the attention that should be paid to the influence of emotions both on the development of thought and on all other intellectual activities. I therefore focused my attention more and more on the interactions between feeling and thinking, taking into account both psychoanalytical and genetic-epistemological findings. Piaget's discovery that all thinking originates "from action" or, to be more precise, from the activation, automatization and ultimately mentalization of partly innate, but mostly acquired sensorimotor schemata or "programs", became one of the most important keys to my own ideas which progessively took on a clearer form.
Although Piaget himself had repeatedly stressed that the actual motor of all action was ultimately emotional, he never systematically incorporated this insight into his theory. In my own thinking, in contrast, all these ingredients - my long-term studies, Freudian psychoanalysis, systems theory and Piaget's genetic epistemiology - gradually developed into an integrated theory in the course of the following years, mostly in innumerable small steps, but sometimes also in enlightenment-like major leaps. I called this theory “Affect logic” and presented it to the professional world for the first time in 1982 in a German book of the same name, translated into English in 1988³.
Affect-logic and Schizophrenia
This is not the place to present the scientific foundations of Affect-logic in detail. This has already been done sufficiently in the book I have mentioned and in numerous subsequent publications⁴. However, I will briefly summarize those elements of Affect-logic that are of particular relevance to my understanding of schizophrenia today.
At the centre of Affect-logic is the notion, now widely confirmed by modern brain research, that all so-called cognitive activities (such as attention, perception, concentration, memory, combinatorial thinking and decision making) are not only constantly accompanied by conscious or unconscious emotions and their filtering and switching effects, but are also to a large extent influenced and evn guides, by them. There is no such thing as a thinking which is completely emotion-free. Even relaxation, "neutrality" or indifference still correspond to specific affective states in the sense meant here, with pronounced effects on all cognitive functions. Also our systems of norms and values are interspersed with originally quite conscious affective components, which, however, thanks to the mechanism of habituation, become almost automated in time and bed down into becoming apparently self-evident. The loss of these "natural self-evidences" (as phenomenological research has shown in particular) is, by the way, a central characteristic of the schizophrenic psychosis⁵.
Another postulate of Affect-logic that is important for my understanding of psychosis is the fact that emotions correspond to vital energies (or more precisely, to situation-specific patterns f energy consumption anchored in evolution) with the basic implulses of "towards" or "away from". Such emotional "motors" ultimately drive all psychodynamics and sociodynamics.
This insight makes it possible to apply the central findings of Chaos theories to the acquired “programs” of feeling, thinking and behaving. I first came across Chaos theories (better called "Complexity theories" or, to be pedantic, "Theories of the nonlinear dynamics of complex systems") founded by natural scientists such as the Belgian thermodynamicist and Nobel Prize winner Ilya Prigogine and the famous German laser researcher Hermann Haken in the late 1970s.
What particularly fascinated me was the observation that critically rising energetic tensions in complex open systems of all kinds can provoke sudden nonlinear shifts or phase jumps (so-called bifurcations) from one global mode of operation to another. In warmed liquids, for example, honeycomb-like convection patterns suddenly appear at a critical point, strange chain shapes form in certain chemical solutions, the stock exchange decays into wild fluctuations, and in psychosocial systems there may occur a sudden change from peaceful coexistence to an armed conflict. I immediately linked this chaos-theoretical discovery with the famous English research on the so-called expressed-emotions⁶ which had shown that the rise of emotional tensions to a critical level can leai to a sudden snapping from a normal to a psychotic way of feeling, thinking and behaving in specifically vulnerable people. As soon as one understands emotions as energetic phenomena, this discovery provides a plausible explanation for the mechanisms at work in this mysterious "phase jump" into psychosis.
For all these reasons, I studied chaos theories intensively in the following years. During a sabbatical in the summer of 1986, a spell at the interdisciplinary research institute of Ilya Prigogine in Brussels deepened my understanding. I also got to know the closely related synergetics of Hermann Haken in several seminars that he led. Both theoretical approaches, together with the clinical facts I have mentioned, seemed to confirm my hypothesis that emotional energies play a key role in the onset of schizophrenic psychosis.
An emotion-centered understanding of psychosis
Traditionally, schizophrenia is understood as a confusion of thought, a cognitive disorder, while emotions are not seen as significant probably because they are so strangely encoded and (supposedly) "flattened" in most psychotic states. But all the above-mentioned elements of the schizophrenia puzzle led me more and more clearly, together with additional research data and the generally accepted stress and vulnerability hypotheses of Zubin and Spring⁷, to a much more emotion-centered understanding of psychosis that I can briefly outline as follows⁸:
Persons at risk of schizophrenia are people who have become particularly vulnerable and "thin-skinned" due to complex interactions between unfavourable genetic and biographical influences. They tend to react to certain situations of stress with excessive emotional tensions. If these tensions exceed a critical level, they may develop acute psychotic disorders for the reasons I have mentioned.
In my view, emotional energies also play an important role in the run-up and long-term course of schizophrenia. According to numerous recent studies into the background of people at risk of psychosis, they tend to have a history of excessive traumatic experiences such as sexual assaults, neglect or serious discontinuities in their lives which are difficult to cope with emotionally and naturally reinforce their vulnerability. And the apparent "emotional flattening" of many chronically ill persons can probably be understood to a large extent as a habitual (and, thanks to the phenomenon of so-called neuronal plasticity, perhaps also organically solidified changes in the brain) defensive armour against renewed painful emotional overloads. This can be inferred, among other things, from the observation that even apparently totally "silted up" chronically ill people can sometimes, as a reaction to unexpected unpleasant events such as a forced change of environment, react with sudden, violent emotional outbursts.
Such an emotion-centered understanding of schizophrenia is not only of theoretical interest, but also leads to tangible practical consequences. My staff and I tried to make practical use of some of these consequences in the therapeutic residential community "Soteria" for the treatment of acute schizophrenic psychoses for instance, founded in Bern in 1984.
From Theory to practice: The Soteria Project
The central aim of the "Soteria Bern" residential community which has been functioning successfully for over thirty years, is to create a therapeutic environment that sustainably lowers the level of emotional tension and excitement in and around psychotic people plagued by delusions and hallucinations. This relaxation is not achieved, as is usually the case, primarily by damping with so-called neuroleptic drugs nor by ephemeral relaxation exercises, but by means of an understanding and continuous human accompaniment by a carefully selected and trained team of carers in as normal, small-scale, open and family-like an environment as possible. Further important elements of the Soteria approach are the systematic involvement of the family, the targeted therapeutic use of everyday activities such as day and meal planning, shopping, cooking, cleaning, creative activities, leisure activities, etc., as well as the systematic preparation and accompaniment of long-term social and professional reintegration.
I cannot go into more details here and refer you to the relevant publications⁹. It should only be noted that, according to the results of empirical comparative studies, the Soteria approach is objectively at least on a par with conventional clinical treatment methods and is often superior in the subjective experience of patients and their relatives. Contrary to occasional claims the total costs are also significantly lower.
During my annual visits since the handover of responsibility to Dr. Holger Hoffmann (1997), I have always been impressed by the "spirit of Soteria" which is transmitted from generation to generation as if by magic and inspires the whole team. Without betraying this "spirit", which is not quite easy to grasp, but which has been condensed into a series of precise principles of treatment since the very beginning, my successors have constantly refined the original treatments over time and supplemented them with a whole network of outpatient and semi-outpatient transitional institutions, including an early detection service. In several places in Germany, the Netherlands, Israel and elsewhere, institutions based on the Bernese Soteria model have also emerged in recent years. Nevertheless, this approach still meets with considerable scepticism in psychiatric mainstream thinking, just like the whole of Affect-logic and presumably for similar reasons.
Open Questions
At the beginning of my reflexions I have claimed that the schizophrenia problem is one of the biggest unresolved questions facing not only medicine, but the human mind alltogether. This is not surprising since three highly complex subject areas overlap and intertwine in it, which we do not sufficiently understand even individually. First there is the area of the mental and spiritual including the unsolved problem of consciousness; secondly, the area of the brain (as is well known, the most differentiated matter that exists at all); and thirdly, the social and societal area. What is the human mind? How does it interact with matter? What is consciousness, and how can the mind become so globally disturbed and confused that the whole world appears altered and distorted as if in a dream to persons who are, however, awake? And it is just as unclear how a schizophrenic psychosis can completely or partially regress even after decades of severe progression.
In addition to these major questions, there is a wealth of individual problems that are particularly evident in connection with the understanding of psychosis in terms of Affect-logic. Why do certain people react to critically increasing emotional tensions with a psychosis, while others become violent, panic-stricken, or sink into depression? What is the schizophrenogenic vulnerability, more specifically? Is this perhaps, as I have long suspected - not without reference to Eugen Bleuler's core symptom of "disorder of associations" - a both genetically and biographically conditioned lability of basic affective-cognitive systems of reference (or “programs” of feeling, thinking and behaving), especially in the area of interpersonal relationships (the so-called object representations, in psychoanalytical terms)? And how do such different symptomatologies arise from case to case so that already “the old Bleuler”¹⁰, the creator of the concept of schizophrenia in 1911, used to speak of a "group of schizophrenias" instead of merely of "schizophrenia"?
Postcript
I feel compelled to add a postscript to this presentation in order to refer however briefly to the concepts of the great Italian thinker and psychotherapist Professor Giovanni Ariano from Naples, which, as I have only recently fully realized, happily complement and deepen my own understanding of psychosis.
Ariano's "Structurally Integrated Model" ("Il Modello Strutturalo Integrato" = MSI) is based on four closely interwoven aspects of the psyche: the body, emotionality, thought, and the "fantasmatic realm" (what is commonly called "fantasy"). To consider these four areas separately is therapeutically usefull, says Ariano, because they can be selectively disturbed and thus also selectively in need of treatment. Among psychotic disorders, Ariano distinguishes between chaotic, rigid and undifferentiated forms, which require quite different psychotherapeutic approaches: The "chaotics" primarily need a reassurance and reorganization, the “rigids” on the other hand first a systematic softening and disorganization of their delusionally or compulsively solidified patterns of feeling and thinking, and the “undifferentiated” (and most difficult) forms a long-lasting psychotherapeutic work of restructuring in all four aforementioned areas. Without such restructuring, the treatment of psychoses, according to Ariano, would remain superficial and unlikely to prevent relapses in the long run.
I fully agree with the need for systematic psychotherapy following acute treatment. A mere elimination or reduction of symptoms is not enough. For this reason, the initiation of a systematic psychotherapeutic follow-up treatment was an important part of the Soteria concept right from the beginning. In my opinion, the most important thing is not so much the exact psychotherapeutic school but the deep long-term personal commitment of the therapist. Unfortunately, Ariano's breakthrough concepts have remained virtually unknown outside Italy because they have not yet been translated. In his eyes as well as in mine the combination of a Soteria-like acute treatment with a long-term psychotherapeutic restructuring in the sense of the MSI would be ideal.
Luc Ciompi (born 1929), Swiss psychiatrist, Schizophrenia researcher, pioneer of integrative psychiatry and founder of Affect-Logic celebrates his 90th birthday. He lets us participate in his personal, scientific and ideological reflections. It shows, that even an old age can be a fascinating time full of unexpected highs and lows.
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¹ Social psychiatry is the branch of psychiatry which seeks to include the social environment in its understanding and in the treatment of mental disorders. The services consist in particular of day hospitals, rehabilitation workshops, sheltered housing and other transitional institutions established outside the hospital, thus favouring the social and occupational reintegration of psychiatric patients.
² For more informaton, see Ciompi L., Harding C.M., Lethinen, K. Deep concern. Schizophrenia Bulletin 36, 437-439, 2010.
³ Ciompi L. (1988) The psyche and schizophrenia. The bond between affect and logic”. Harvard University Press, Cambridge/Mass. (USA) and London (GB)
⁴ see mainly Ciompi L. (1997) The concept of affect logic: an integrative psycho- socio-biological approach to understanding and treatment of schizophrenia. Psychiatry. 60:158–170, and Ciompi L (2015) The key role of emotions in the schizophrenia puzzle. Schizophrenia Bulle-tin 41:318-322, 2015, and also my homepage <www.ciompi.com>
⁵ Blankenburg, W ( 1971) Der Verlust der natürlichen Selbstverständlichkeit. Ein Beitrag zur Psychopathologie symptomarmer Schizophrenien (The loss of the natural aelf evidence. A contribution to the psychopathology of symptom-poor schizophrenias) Enke, Stuttgart,
⁶ Leff J., Vaughn C. (1985) Expressed emotions in families. Its significance for mentalillness. Guilford Press, New York-London - Kavanagh D.J. ( 1992) Recent developments in expressed emotion and schizophrenia. Brit. J. Psychiat. 160:601-620,.
⁷ Zubin J., Spring B. Vulnerability - a new view on schizophrenia. J. Abnorm. Psychology 86:103-126, 1977.
⁸ For a detailed explanation, Ciompi L (2015) The key role of emotions in the schizophrenia puzzle. Schizophrenia Bulletin 41:318-322, 2015.
⁹ in particular Ciompi L, Hoffmann H.( 2004 ) Soteria Berne: an innovative milieu therapeutic approach to acute schizophrenia based on the concept of affect-logic. World Psychiatry. 3:140–146. - Carlton et al.( 2008) A Systematic review of the Soteria paradigm for the treatment of people diagnosed with schizophrenia. Schizophr Bull. 34(1): 181–192.
¹⁰ This refers to the Swiss psychiatrist Eugen Bleuler, director of the psychiatric university clinic "Burghözli" in Zurich from 1898 to 1927, in contrast to his son Manfred, the “young Bleuler”, who was also a psychiatrist and head of the "Burghölzli" in 1942-69.
