Q: Whatever happened to the schizophrenogenic mother debate, as reported
years ago by Dr. Fromme- Reichman. I suspect that this indeed could cause
a kindling effect and bring on symptoms of a bipolar type disorder.
Is anyone pursuing this at any University?
Dear Ilene --
For readers not familiar with this concept, the idea was basically that mothers
who placed their children in "double binds" -- situations where there was no
successful course of action for the child, she/he would lose either way -- were
part of the cause of schizophrenia. This is relevant to bipolar disorder
for two reasons:
A. In many cases it's hard to distinguish between schizophrenia and bipolar
disorder, and the newest genetic research is beginning to suggest that the two
illnesses (as we've called them) have some genetic commonalities at least.
B. As the story below goes along, you'll see that it leads directly to one
of the most important new results in bipolar treatment research.
The mothers-can-cause-it perspective has been through several shifts, as I've
watched during my career, which began just as that point of view was falling out
of favor. Here are some points on the progression that seem the highlights to
me, though I'm not a student of this issue:
1. The psychoanalytic folks, deriving originally from Freud, were largely the
group from whom this notion arose. As you know, Fromme-Reichman came from that
tradition. There was a Palo Alto (California) group led primarily by Gregory
Bateson, who put this idea forward strongly (try a
search on "Bateson schizophrenia" for some interesting history, which to my eye
nowadays looks pretty embarassing even though he was a pretty amazing thinker --
that's time for you I guess; surely much of what I write now will look pretty
ridiculous in 40 years). There was little research behind this, mind you; it
came from the analytic tradition, which was not based in "testable hypotheses",
shall we say.
(Do I have any expertise in this area from which to speak, you might want to
know? Not much, so my views should be taken as such. I did write a paper as a
resident, when I was trying to explain all this history to myself, entitled A
Brief History of Psychotherapy in Graphic Display (Academic Psychiatry, 1996;
20: 99-100/charts ) which emphasized a "big picture" view, from which I speak
2. As I was being trained, the mothers-can-cause-it perspective was waning in
part simply because a more science-based tradition was gaining strength. As I
recall, the mothers-hypothesis just slipped from view for a time.
3. Then the "science" perspective really took hold, continuing to the
present. During that time, a "patient and family advocacy" movement also
started, primarily with the efforts of the National Alliance for the Mentally
Ill (NAMI). When this group acquired a national voice, one of the first things
they did was to complain very strongly about the idea of a mothers-can-cause-it
hypothesis with no real data behind it. And so that hypothesis became quite
rapidly "politically incorrect".
4. In that context, it must have been very difficult for researchers to
propose to test the idea that there was something families were doing
that made the illness worse. However, slowly a new theory emerged: "expressed
emotion". This suggested that in families where there was a lot of highly
charged emotional expression (they left it that vague at first), patients would
do worse. Note that this hypothesis did not attempt to blame parents for
causing the illness, but -- as you note in your question -- they were
suggesting that the family environment could "kindle" a small flame into a
bigger one; and vice versa, that a different family environment could help
keep the illness from progressing, or at least slower than in the other
Here we have a testable hypothesis, you see. And these researchers, who I
regard as quite brave because of the political charge of the times in which they
undertook this, did indeed demonstrate: a) that the hypothesis held up when
families were compared, and their children's illness course monitored over time;
and even more important, that (b) if the families were instructed on how to
lower "expressed emotion", their children's illness seemed to be less
severe. You can see that the latter is the real bombshell idea.
5. To jump rapidly to the present, the principle that teaching families how
to change their communication will affect the course of bipolar disorder
has very recently been proven true by the research teams of David Miklowitz. His
book The Bipolar Survival Guide: What you and your family need to know
explains this research and their results and tries to make the techniques they
taught available to the general public.
In an odd way then, we've come full circle to showing that there is a glimmer
of truth to Fromme-Reichman's idea -- not as a cause of bipolar disorder per se
but as a course-modifier that can become part of the treatments
that a patient and family should receive.
For a summary of the several different psychotherapies which recently have
been shown to modify the course of bipolar disorder, of which the Miklowitz work
is only one (though perhaps one of the most important, as the others just seem
to make sense as part of good treatment), see my summary of
Psychotherapy in Bipolar Disorder.
It includes some of Miklowitz's results.
Published November, 2003