The Psychiatric Team and the Social Definition of Schizophrenia: An Anthropological Study of Person and Illness

Psychiatrists have long been willing, and indeed anxious, to see their profession reflected through the eyes of sociologists and anthropologists. Occasionally, these observations catalyzed large shifts in psychiatric thinking and practice. Goffman’s account of the potentially harmful effect of the “total institution” (1) pointed to community-based care as an alternative. Similarly, Estroff’s description of the sometimes oppressive experience of being a patient in a community-based program (2) heightened awareness of the importance of peer support and patient participation in self-defining treatment goals.

Robert Barrett is a self-described organizational stereotype, the “skeptical insider—who has been stalking around since the very inception of the asylum.” A graduate student in anthropology (and a physician), he describes a “Schizophrenia Team” in an Australian public hospital where he works as a staff psychiatrist. The Team’s approach is modern (circa 1980s), compassionate, and scientifically informed by a “biopsychosocial” model of etiology and treatment. Barrett’s aim is interpretive: to uncover a core set of culturally defined constructs that, invisible and taken for granted, shape our ideas about illness and its treatment. His data are the everyday operations of “Ridgehaven Hospital”—its architectural and organizational structure, the formal and informal discourse of its staff, and the way patient interview data are translated into medical records and case formulations.

The idea of Ridgehaven as progressive is central to the institution’s self-identity and public image. With a charge to reduce beds, progress implies the movement from hospital to community, from old to modern, and from ignorance to knowledge. Pressure to discharge patients links movement and progress to clinical thinking; treatment is conceived as keeping patients moving along an expected trajectory. Value and worth are also aligned with these notions. The hospital’s acute units treat patients whom the staff value most (those expected to follow a progressive trajectory) in a modern and well-staffed building adjacent to the positively valued community. Patients deemed unlikely to progress are housed in old and isolated buildings adjacent to a prison and institution for mental retardation.

As progress shapes views of the institution, disintegration and degeneration invisibly shape thinking about the illness. Although psychiatrists emphasize to the public that schizophrenia is not “split personality,” in informal (unprofessional) conversation, staff often refer to patients as cracking up, falling apart, or going to pieces. An acute psychotic episode is called a break, and the design of psychiatric book covers and pharmaceutical advertisements often feature split or fractured images. Psychodynamic concepts represent this as the dissolution of ego boundaries and personality accompanied by a unmodulated emergence of primitive and incomprehensible experience. Biologists express this idea in terms of neural circuits released from inhibitory control, perhaps by an unmodulated excess of neurotransmitters. Barrett the psychiatrist competently reviews the history of these formulations, but Barrett the anthropologist is concerned not with their scientific merit but, rather, the cultural meanings they carry. He argues persuasively that different theoretical perspectives reflect common, deeply embedded conceptions expressed in different idioms. Clinicians, scientists, patients, and the public alike are influenced by these cultural images and metaphors.

The modern unit of organization that constructs the social definition of schizophrenia is the Team. Members from each professional discipline who constitute the Team merge their distinct perspectives into “the fully worked up case.” One patient is viewed as a passive sufferer, another as a willful and calculating strategist. An optimal treatment trajectory implies progressive attribution of intentionality to the patient from a “schizophrenic” to a “person with schizophrenia” to a “person managing schizophrenia.”

Nonmedical social scientists have sometimes mistaken the sick role for the sickness itself. Barrett does not make this mistake. He recognizes that schizophrenia and the suffering it causes are real. Unlike his predecessors, however, Barrett does not seem to have an axe to grind. I found myself wishing he did. His insights are interesting, but, given the reality of schizophrenia, description without some prescription misses the mark.