The Weapons of InsanityArnold M Ludwig MD1 and Frank Farrelly ACSW2Reprinted from American Journal of PsychotherapyVol. XXI, No 4 – October 1967
It is becoming fashionable to view mental patients, especially chronic schizophrenics, as poor, helpless, unfortunate creatures made sick by family and society and kept sick by prolonged hospitalisation. These patients are depicted as hapless victims impotent against the powerful influences which determine their lives and shape their psychopathology. Such a view dictates a treatment philosophy aimed at reducing all the social and institutional iniquities responsible for the patient’s plight. However, in the process of levelling the finger of etiologic blame for the production and maintenance of chronic schizophrenia, theoreticians and clinicians have neglected another culprit – the patient himself. Professionals seem to have overlooked the rather naïve possibility that schizophrenic patients become “chronic” simply because they choose to do so.
Undoubtedly, a myriad of authoritative articles could be quoted to refute such an oversimplified approach to this problem. We do not deny the complexity of the problem of the multitude of theoretical factors which should be taken into account for the understanding and treatment of chronic schizophrenia. However, we do claim that all these theoretical considerations have little practical import for the current treatment of these patients. Since we cannot at this point in time unravel twisted genes, undo the past, reform society, or eliminate mental hospitals, we are left with a more modest, but still formidable task – the treatment of the patient himself. The major problem is in dealing with what is and not with what should be or might have been. In our own experience, the problem is not so much modifying factors outside the patient, but rather inc hanging certain patient attitudes and consequent behaviours, as well a complementary, newly traditional attitudes on the part of society and professional staff, which aggravate the basic problem and prevent effective therapeutic intervention.
We have had the opportunity to observe closely and work with a group of 30 male and female chronic schizophrenics, handled with a minimum of medication and housed together on an experimental treatment unit. In a previous article (1) we outlined a number of characteristic attitudes and behaviours, both on the part of patients and staff, which tended to perpetuate chronicity. These characteristics comprise what we have called “the Code of Chronicity”. Implicit in our discussion of the “code” are five important clinical “facts” which, we believe, underlie the behaviours of chronic schizophrenics.
i. First, these patients can use their insanity to control people land situations. ii. Second, they have an indomitable will of their own and are hell bent on getting their own way. iii. Third, one of the basic difficulties in rehabilitating these patients is not so much their “lack of motivation” but their intense, negative motivation to remain hospitalised. iv. Fourth, insanity and hospitalisation effectively pay off for these patients in a variety of ways. v. Fifth, these patients are capable of demonstrating an animal cunning in provoking certain reactions of the part of staff, family, and society at large which guarantee their continued hospitalisation and its consequent rewards.
Related to these characteristics are a number of other important ones, which are typical of these patients and which we want to elaborate on since they are relevant to our basic thesis concerning patient behaviour. These additional features have gradually come into focus for us during the various phases of our research treatment program; in this article we shall term them the “weapons of insanity”. It has become increasingly clear to us that patients both have at their disposal and employ effectively an array of counter therapeutic weapons against staff efforts to rehabilitate them. These weapons not only reach their targets but have the additional bonus of a “fallout” effect in the form of a series of predictable staff reactions. Since one of the most effective ways to cope with these weapons is
first to recognise them, we have felt the need to describe them and their effects. Moreover, since we have become convinced that for rehabilitative purposes these weapons of insanity must be jammed, there is a necessity to consider carefully the therapeutic implications and ethical issues involved. It is our purpose to do precisely this
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