The main problems of schizophrenia have of late been neither neglected nor solved. Professor Benedetti and his colleagues in Switzerland, who not long ago decided to review contributions to the subject that had appeared between 1956 and 1961, were confronted with nearly three thousand articles and found it necessary to assure readers that only a minute fraction of these contained anything new in the way of findings or fruitful hypotheses. This implied no denigration of the investigators: it testified to the obduracy of the problems. Not all who scan the literature, however, see so little essential advance; the editor of an American survey, convering some four thousand articles on schizophrenia published in the decade 1946-1956, declared that “the essential, complexly integrated etiological factors are clearly available…and ready to be acted on therapeutically and preventively.”
Such diversity of opinion is particularly evident when the social and familial influences on the occurrence of schizopherenia are under examination. Some inquirers are convinced that the mothers of schizophrenics have been harmfully restrictive and inconsistent in their attitude to the child, or subtly dominating and overprotective, and that the fathers were mostly ineffectual and withdrawn: in this family pattern of relationships and upbringing they discren the genesis of schizophrenia. They may qualify this, as Frieda Fromm-Reichmann did, by limiting it to a particular culture; or they may, like Erik Erikson or Lauretta Bender, deny that a rejecting, domineering mother can play so large a part in determining that her child should become schizophrenic; but the argument either way usually turns on clinical evidence drawn from a small number of cases or a biassed sample. This is true not only where parental attitudes are in question, but also for the whole social environment as a cause of schizophrenia. Systematic, well-designed studies dealing as rigorously as possible with the social data, have been few.
Professor Hollingshead is pre-eminent among sociologists who have tried to describe and understand the settings in which schizophrenics live. The New Haven study, “Social Class and Mental Illness,” which he carried out in conjunction with Fredrick Redlich, the Professor of Psychiatry at Yale, was impregnably documented, and by its sober yet convincing analysis threw fresh light on the recognition, types, and current treatment of schizophrenia prevailing in different strata of society. He was therefore appropriately invited in 1956 to carry out, again with a psychiatric collaborator, an epidemiological survey of mental illness in Puerto Rico, where the Director of the Social Science Research Centre of the University had recognized the importance of such an inquiry in a rapidly changing society. But the full plan could not be pursued, because of lack of funds; it was therefore decided to restrict it to schizophrenia and to concentrate on personal and familial influences. For three years, from 1957 to 1960, field work went on under the close supervision of Professor Rogler, who was assisted by four psychiatrists, an anthropologist, and a number of interviewers and social workers; the subsequent analysis and presentation of the material were jointly undertaken by the authors at Yale University. In its bare outlines the study might seem a conventional excursion into the social aspects of a chronic disease, trundling along on established tramlines to an unexciting terminus. But this inquiry was about schizophrenia, it was conducted in the slums of a Puerto Rican city, and it turned on the interplay of family life—three reasons why it was most unlikely that in these hands it would be conventional and dully predictable. It was not.
As a rule the schizophrenics in mental hospitals have been the starting point and often the main subjects of research into schizophrenia, whether the heredity, the biochemistry, the psychotherapy or the prognosis and course of the disease was the main topic. Epidemiological studies based on such a selected population are certain to be biassed. Ideally all schizophrenics, whether hospitalized, or in the general community, should be gathered in the research net, and their social background observed over a wide enough range and for a long enough period to permit generalized conclusions about the connection between social factors on the one hand, and on the other the development of the mental illness and the effect it has on the people around the patient. This has been the aim which Hollingshead and Rogler set before themselves, except that they did not include any schizophrenics in hospitals; they had found that for the 10,000 or more psychotic people in Puerto Rico there were provided only about 1,500 mental hospital beds. The disproportion did not indicate that mental illness takes milder forms among Puerto Ricans than elsewhere; when more adequate facilities are available, they are fully used. Thus among Puerto Ricans in New York City between 1949 and 1951 the rate of first admission to mental hospitals exceeded that of the rest of the New York population by 102 per cent for men, and 57 per cent for women.
The reason for selecting the very poor in the slums of San Juan as the subjects of this study was that previous investigations had shown a very much heavier incidence of schizophrenia among the lowest social class than in the rest of the population. There had been—and still is—much dispute about the interpretation of this finding, but however interpreted it cried aloud for further sociological and clinical examination; the investigators saw it as an intellectually challenging venture.
The intellectual challenge was met with experienced foresight and thoroughness, as the candid chapter on methodological procedures makes clear. There was, however, an emotional challenge also, especially for the interviewers: they had to face the most distressing situations. Even in the unimpassioned language of the text there is much that is painful to read and picture—the poor of San Juan live in squalor and great misery, with much ill-will, and sometimes brutish ways.
Twenty families in which the young husband or wife was schizophrenic were selected and compared with another twenty families free from psychotic illness but drawn from the same age-group, area and socio-economic class as the schizophrenic families. The members of each family were interviewed some thirty-five to forty times during six or seven months, and a large body of information was collected, which was rich but elusive when it had to be digested and reduced to quantitative terms. This material, as presented in the book, is pregnant with so much wretchedness and passion, so much human misunderstanding, hatred, and failure, that it invites psychological as well as social analysis. The authors have steered their way skillfully through these turbulent waters, and have kept their introductory promise to present their findings in straightforward prose, with minimal use of technical terms; their language is direct, and at times vividly descriptive.
The crucial feature in a study such as this is the diagnosis. If the people studied who are considered to be schizophrenic are not schizophrenic, the bottom falls out of the inquiry. But Hollingshead and Rogler were fully alive to this notorious snare, and did their best to ensure that they were not caught in it. Besides careful examination of each person’s mental state by Puerto Rican psychiatrists working with a uniform diagnostic schedule, there were extensive statistical analyses of the items recorded on this schedule and on another they used which had been developed by Allister Macmillan in the Leightons’ Stirling County study. These analyses confirmed the expectation that the persons diagnosed as schizophrenic differed in relevant respects from the non-schizophrenics, and that there was uniformity and consistency in the diagnostic procedures of the four examining psychiatrists. Further than this the authors could not go. It is possible that the criteria of schizophrenia that were applied here would be regarded by other psychiatrists as unduly wide, or as likely to select, say, manic-depressives; some of the excerpts quoted from the case-records raise doubts on this score. But there are no laboratory tests or other extraneous checks that can be used to validate a clinical diagnosis of schizophrenia. It is common knowledge that psychiatrists of diverse training and outlook differ in their readiness to make the diagnosis, for which there is as yet no final arbiter. The precautions taken in the Puerto Rican study, reinforced by sufficient clinical detail for other psychiatrists to make an independent diagnostic judgment, are the most that can reasonably be asked for in an ecological study of this sort.
The findings that emerged from the investigation are illuminating and suggestive; they do not purport to be conclusive. The life-histories of the schizophrenics prior to their marriage did not differ appreciably from those of the mentally healthy or neurotic people in the control group: there were the same hardships and efforts, the same physical illnesses, personal dilemmas, responses to the strain of transition from a rural to an urban mode of life. But at a particular point in time, which in these people was closely related to assumption of the roles which marriage entails, the schizophrenics had a “break in the trajectory of their life-arc.” Then and thereafter they were exposed to more material difficulties, conflicts, illness, and dissension than the non-schizophrenics. Whether, as the authors suppose, the accumulation of problems and awareness of failure to fulfil the required social roles conduces to the development of schizophrenia in vulnerable people is a question which their data cannot answer. A different sample of schizophrenics drawn from another social class and a different cultural setting might lead to a different inference. The hypothesis of a critical point in role performance is at any rate a stimulating one for further inquiry.
The harmful impact of recurring social dilemmas on the emotional well-being of the Puerto Rican schizophrenics had its counterpart in the effect which their illness and consequent behavior had on the members of their family. The burden falling on the mentally healthy spouse was sometimes too much to be carried with fortitude or resignation. When the husband was the affected person, there was a reversal of roles; when it was the wife who was schizophrenic, sexual tensions and domestic chaos ensued, and the children suffered.
The title chosen for this book aptly conveys its authors’ attitude to the trapped unfortunates they have been studying—people enmeshed in a cruel social net. The indictment of the circumstances in which they live is implicit, but crushing.
November 11, 1965