Schizophrenogenic Mother Debate?
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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?

Thank you

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 Google 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 here).

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 families.

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.

Dr. Phelps

Published November, 2003 


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