Bruno Bettelheim, “Schizophrenia as a Reaction to Extreme Situations,” 1956

Bruno Bettelheim, “Child Schizophrenia Symposium, 1955: Schizophrenia as a Reaction to Extreme Situations,” American Journal of Orthopsychiatry 26, no. 3 (July 1956):507-18.

Complete original source available here.

Bruno Bettelheim, an internationally known psychoanalyst and author, was the most famous proponent of psychogenesis during the 1950s and 1960s. He began this piece by defending that theory as therapeutically optimistic, at least in comparison to biogenesis. Psychogenesis pointed toward immersive, permissive, and long-term residential therapy outside the family, whereas biogenesis offered no viable methods of treatment for the organic causes of autism, presuming those even existed. The title of Bettelheim’s contribution to this symposium, which took place in 1955, echoed the title of the 1943 article that made him famous, “Individual and Mass Behavior in Extreme Situations.” In that piece, Bettelheim reflected on his own survival of German concentration camps and argued that the terror they inflicted operated by fundamentally psychological means. The personality disintegration experienced by many prisoners, and the various accommodations they made to camp life, were rational adaptations to extreme situations, not indications of individual weakness. Bettelheim was careful to point out “the many differences between life in a concentration camp and the life of a child who develops schizophrenia,” but he also insisted that they were “strangely similar.” If anything, the child’s situation might be reasonably interpreted as worse since the “extreme situation” presented by his or her family was permanent. Until the late 1950s and even the 1960s, childhood schizophrenia and psychosis were terms used interchangeably with autism.

Bruno Bettelheim (courtesy of University of Chicago Photographic Archive, [apf1-09273], Special Collections Research Center, University of Chicago Library)

As long as those who hold the view that schizophrenia is organic in nature do not present us with methods of therapy that are more successful than those based on psychoanalysis, it is justified if, for the time being, we neglect the organic factor, about which we can do nothing as yet, and concentrate instead on that psychological understanding and treatment which yields some quite worth-while results….

In some psychoanalytic discussions, childhood schizophrenia has been viewed as a consequence of parental—particularly maternal—attitudes, occasionally so much so that reconstructions and study of the assumed cause of the disturbance—the mother—seem to have taken the place of the study of the disease itself. Direct connections have been established between maternal attitudes—about which relatively much was known, and which were easy to study—and the behavior of the schizophrenic child, about which little was known and which was difficult to understand. This may have been partly because it was possible to gain fairly adequate information from a relatively well-functioning parent who at least talks, compared with what can be gleaned from an autistic child….

Thus the  child, who suffers most of all from not having acquired an autonomous existence as a person, is again not regarded as an autonomous being even in treatment efforts designed to help him become a human being in his own right. As if in culmination of an all-too-subtle irony, treatment methods are advocated which rely on efforts to understand and help the schizophrenic child through the very person who, it is assumed, destroyed his humanity in the first place—his mother…. Trying to rehabilitate such children while they continue to live at home thus becomes a questionable procedure….

Schizophrenic children indeed need a therapist who “…offers herself in the flesh as…a steady, ever-present object…so that the patient’s personality could be…unified around this image.” From experience I can add that, after a few years with such a person, the child will relate and acquire a relatively stable and truly individual center for his personality….

Returning to the problem of the origin of childhood schizophrenia, it can be said that the mother’s pathology is often severe, and in many cases her behavior toward her child offers a fascinating example of an abnormal relation. But this proves neither that these mothers create the schizophrenic processes, nor that specifics of their pathologies explain those of the children. It seems that concentration on the mother, or the mother-child relation, is the consequence of an unrealistic ideal—that of the perfect infant-mother symbiosis, where both form a completely happy psychological monad….

Though the conditions of living in a concentration camp were more or less the same for all prisoners, one could observe practically all types of schizophrenic adaptations and symptomatology—so much so, that a description of prisoner behavior would be tantamount to a catalogue of schizophrenic reactions….

The difference between the plight of prisoners in concentration camps, and the conditions which lead to autism and schizophrenia in children is, of course, that the child has never had a previous chance to develop much of a personality. The important parallel, on the other hand, is that the youngster who develops childhood schizophrenia seems to feel about himself and his life exactly as the concentration camp prisoner felt about his, namely, that he is totally at the mercy of irrational forces which are bent on using him for their goals, irrespective of his….

Therefore, to develop childhood schizophrenia it is sufficient that the infant is convinced that his life is run by insensitive, irrational, and overwhelming powers, who, moreover, have total control over his life and death…. Thus, the psychological cause of childhood schizophrenia is the child’s subjective feeling of living permanently in an extreme situation….

Thus, in treating the schizophrenic child, we must provide him with truly need-satisfying persons—and not just for one hour per day, but all day long, every day of the year. Further, he must be permitted to live in an environment that exercises no, or only minimal pressures and is so comprehensive and simplified that it can be mastered even by the child’s weak ego…. [T]he most important fact is that these children must live in a setting that is totally therapeutic. They need an institutional treatment in which a therapist does not treat a child for a few hours a week, but where the need-satisfying person lives with the child….

Basically, what such a child needs is a mother free of the emotional demands so many mothers make, so that he can benefit from mothering without having to respond to it, or so that he is free to respond in his own good time and his own schizophrenic way. Only thus can he begin to re-establish his autonomy…. For him to begin life anew, the total extreme situation which destroyed his autonomy must be replaced with a total living situation over which he can exercise control. As he was overwhelmed by his environment, he must now be able to control it, and to control it successfully….

In practice, this certainly implies self-demand feeding of favorite foods, and this any time of day or night; no insistence on toilet training, or otherwise socialized behavior; no restrictions on motility unless they are clearly beneficial; opportunity for total rest whenever desired, etc….

Strangely enough, we have found that it takes a schizophrenic child about as many years to become ready to do this as it takes the normal child to develop his personality. It seems that, for the child to develop his personality, it requires, two, three, or four years of living uninterruptedly in a physical and human environment that promotes autonomous personality growth. The same time and conditions are required for the schizophrenic child to develop his new personality. Then these children feel reborn, and they begin a new life of their own.

Here, again, there is a striking parallel to the experience of concentration camp prisoners…. [A] personality that did not protect the individual against landing in an extreme situation seems so deficient as to be in need of widespread restructuring….

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