Social interpersonal dimensions of the psychoses

Medical Hypotheses (1999) 52(4), 335–347 © 1999 Harcourt Brace & Co. Ltd Article No. mehy.1997.0636

Social interpersonal dimensions of the psychoses J. S. B. Lindsay Consultant Social Psychiatrist, Nedlands, Western Australia

Summary This paper looks at the patterns for the creation and social management of insanity and the involvements of those concerned. It describes an interaction model with people in a social reality of everyday living, built up of and defined by ‘subjective’ definitions of a situation. The psychiatric profession, involved in their conventional medical oneto-one confidential consultations with their patients, fails to be informed about the societal dimensions with two, three or more members as first described by Simmel (1902) (1). The differences are traditional, ‘Two is company’ and ‘Three is a crowd’. If one of the possible two-person relationships in a family develops some emotional change to define itself as ‘Two is company’, this may alter the emotional balance in the whole family and may lead to ‘split minds’ (schizo/phrenia) and involving relationships with and between other family members. The arrival of the first baby changes two to three and creates ‘Our Family’. ‘Two is company: but it is not our family.’ ‘Three is a crowd’ but now, with three possible pairs, who is the odd one to be left out, or to push in or be pushed out? This is proposed as the interpersonal relationships substrate of the manic–(push in) or depressive (pushed out) psychoses in an older family generation. Both propositions are to be developed using probability theory to define the number of members, the corresponding numbers of their possible kinetic interpersonal relationships, their social dynamism probabilities, and potential outcomes involving modern non-linear mathematics. These patients are described as ‘not themselves’ or ‘beside themselves’. Those who are themselves but described as neurotic or psychopathic will also be mentioned.

INTRODUCTION ‘The true logic of this world is in the calculus of probability.’ The calculus of probability is ‘mathematics for practical men’. (Maxwell, J. C. 1831–1879) (2). In 1792, the Society of Friends planned to develop a local decentralized pattern of caring for the mentally ill based on smaller units centred on an interpersonal style in the activities of daily living, communicating in a faceto-face family style in terms of work and play in a folk sense. This became known as moral treatment and the York Retreat opened in 1796 to accommodate 30 patients. The 200th Anniversary of this start was noted in the Therapeutic Communities journal in 1996 together with the 50th Anniversary of the post-war modern redevelopment of the same interpersonal therapeutic themes (3). Received 9 April 1997 Accepted 8 September 1997 Correspondence to: John S. B. Lindsay, 1/60 Broadway, Nedlands, 6009, Western Australia. Phone: +61 8 9386 3607

The moral treatment pattern 50 years later had developed some medical involvement and control implications over the Society of Friends’ ideas. The Asylum Act (1808) gave local authorities permissive power to build. The Asylum Journal, founded by Dr John Bucknill (4), appeared in 1853 and was changed to the Journal of Mental Science from 1858 to 1963 and then to the present British Journal of Psychiatry. Bucknill felt that the hygienic separation of the patients from the aggravating circumstances which precipitated their insanity was an essential function of the new asylums. Is there still some merit in these simplicities of daily routine living? However, by the late 19th century, the hospitals had become repressive, grossly overcrowded with pauper lunatics from the Poor Law workhouses, and short of fundings. Nevertheless, one-third of the patients certified and admitted each year still went home – the ‘spontaneous remissions’. Arieti (5) has commented that ‘Spontaneous recoveries were not spontaneous but were the result of a relationship that had been established between the patient and the nurse or attendant.’ He refers to four elements: 335

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‘deep involvement’ (bonding), ‘the patient became able to help the nurse’, ‘the climate of warmth and concern between them’ and outside hospital ‘some were not able to make it and relapsed’. (pp 545–546). The initial Medical Officers Association changed its name to the Medico-Psychological Association (MPA) in 1865 and gained a Royal Charter in 1926. The RMPA in its last year (1970) totalled 3995 names, 33 times larger than the 121 in 1855. The Royal College of Psychiatrists in 1991, with 7925 names, had doubled in 21 years. In 1995 the 7925 had increased to 8568 (6). The general population is not growing at that rate. The Society of Friends’ basic beliefs are clear in their designation of a friendly relationship. The designation of ‘not sane’, ‘not one of us’, conveys a message of uncertainty about an individual who is different. It is possible to carry out clinical medical examinations of such different persons and record their ‘symptoms and signs’. These clinical oneto-one detailed examinations of a series of insane patients were recorded by Kraepelin (7) in Germany at the turn of the century and published. He separated the dementia praecox from the manic–depressive insanity. It would also be possible to enter into some interactions with the person encouraging him/her to let his/her mind freely associate. This was developed by Freud (8) who, in 1893, argued that ‘the religious terminology of those dark and superstitious times should be replaced by the scientific one of to-day’. Was the religious terminology of the Society or Friends’ denomination or sect to be taken from ‘those dark and superstitious times’ in 1792 to be replaced by Freud’s scientific one? The Journal of Mental Science appeared in 1858 in the UK, still involved in the moral treatment era, when both Freud and Kraepelin were three years old. The Freudian Paradigm addressed the relationships between two members; the analyst and the analysand developed patterns of transfer in interpersonal relationships evident between them to become defined as psychoanalysis. Kraepelin developed his presentation of a Medical Disease Diagnostic Paradigm about the turn of the century, now repeated in the Diagnostic and Statistical Manuals (DSM) and the International Classification of Diseases (ICD) recipe books for diagnoses. Did it ever enter Kraepelin’s mind that the patients may have been influenced by social forces, or may even have been a product of society. Bleuler (9) may have been aware of this when he referred to split minds – ‘schizo/phrenia’. Two individuals in a professionally determined relationship is not a society of friends, it is company. The earlier model consisted of the pastoral role and confession. What does the individual psychiatrist do for each ‘not sane’ patient? Who makes up whose mind? Freud did create one set of three concepts, the ego, the superego, and the id. With any three variable items, it Medical Hypotheses (1999) 52(4), 335–347

is always possible to have four different interactions or arrangements on an either/or basis and each with its own kinetic interaction or dynamic probability. He wrote extensively about each of his four relationships: 1. 2. 3. 4.

Ego and superego interact, leaving the id out, or ego and id interact, leaving superego out, or superego and id interact, leaving ego out, or ego, superego, and id interact together to become the individual and the potential for his/her dynamic activity or necessary reproductive ‘libido’.

If I change to social dimensions by making the ego the mother, the superego the father, and the id the new baby, these three can establish three interpersonal kinetic pair relationships but only one at any point of time: 1. 2. 3. 4.

Mother and baby, leaving father out, or father and baby, leaving mother out, or father and mother, leaving the baby out, or mother, baby and father leaving no one out.

Simmel stated (1902) that ‘Society is present at the moment in which, instead of its absolutely single centre, a duality emerges’, and the two then become three members. But the possible relationships increase from one to four. This fourth outcome requires a plural pronoun, and a singular collective noun to define the social dynamism for ‘our family’ to be represented in three dimensions in the Figure for Three as a tetrahedron. The evolution of biology developed from the carbon atom, with its unique and unusual atomic tendency to form covalent bonds not only with other elements but with itself. The result is that carbon atoms can combine with one another indefinitely to give compounds like the diamond tetrahedron. Other extremely high-weight molecules have a 3-D structure that leads to an infinite variety of biological forms. I have explored some of the defined ways our own individual complex carbon-based

Fig. 1 The pattern of the four interpersonal relationships in a family of mother, child and father.

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structures and functions combine with each other to create a supra-biological human society and continue our evolution. So where is society going to now with our covalent bonding versus individual human rights? The social field in the space between individuals The disputes of the last century between physicists, who argued for and against either the particles or the charges, were solved when it was found that the field in the space between the particles and the charges was essential for the description of the physical phenomena. I am addressing the concept that the description of social phenomena depends on the field in the space between the individuals and their interpersonal emotional relationships. The individuals can be counted one by one, but interpersonal relationships have different and non-linear numerical systems. THE PROBABILITY PARADIGM The initial probabilities start with the individual. Birth and death have a probability of 1.0. With two individuals, a kinetic interpersonal relationship may develop between them. This may continue as togetherness, or may terminate in a separateness, or by the addition of a third member. The change from two to three is classically reproductive, seen in the family firstborn, and recorded above with three interactive kinetic pairs and a dynamic attractor in the two-generation family. The patterns between their four interpersonal relationships are then woven into a social structure with a plural pronoun and a singular collective noun, ‘our family’. The sociologist Simmel, in 1902, wrote about ‘the relationships of men to each other which, in the case of like purposes may be the most various, have not been the subject of a particular science’ (p. 49). How ‘the form and inner life of a societal group are determined by the numerical relations of the same. To every definite number of elements there corresponds a sociological form (an organisation, firmness of texture, relationship of the whole to the parts) which experiences a modification however immeasurably small with every added or subtracted element’ (p. 48). ‘Society is present at the moment in which, instead of its absolutely single centre, a duality emerges’ (p. 51). ‘A given quality and quantity of societary life produces a certain number of temporarily or chronically solitary existences which to be sure the statistician cannot exactly express in arithmetical terms’ (p. 50). Simmel’s basic observation was about ‘How the form and inner life of a societary group are determined by the numerical relations of the same.’ The form is the number of members and the inner societary life is the number and © 1999 Harcourt Brace & Co. Ltd

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pattern of interpersonal relationships that may develop between them. This may also be seen as a social field in the space between the persons and the emotional and interpersonal relationships between them. I have copied the field for the physical phenomena mentioned above. The numbers of members who present and their pattern of interpersonal relationships in societal groups will involve probability theory. The calculus of probability Maxwell’s probability was first defined in the early 17th century, when Chevalier de Mere wrote to Blaise Pascal (1623–1662), one of the ablest mathematicians, about the division of stakes at games of dice. Through correspondence with another celebrated mathematician, Pierre de Fermat, they developed the first theory of probability. This theory has been progressively developed by the researches of other mathematicians so that Maxwell could say, in the 19th century, that the calculus of probability is ‘mathematics for practical men’. And now what of the 21st century? Pascal’s Triangle Pascal’s Triangle is an intriguing table of numbers that are also able to indicate the probabilities within groups of any size of anything subject to random process. Each digit is the sum of the two numbers in the row directly above it. Each horizontal row total is half that of the next row down. The social interpersonal world extends to infinity. Table 1 also indicates the probabilities within groups of any size of anything subject to chance. The certainty of death is recorded for everyone as 1.0. The next four lines of probabilities are relevant to developments in family life and interpersonal relationships. To separate the specific figures for the relationships between individuals it is necessary to split the Triangle as indicated in Table 2 and move the (1 + n) oblique columns. This (1 + n) set of numbers, the digital count of individuals, has been noted before (by Simmel ‘to every definite number…’).

Table 1

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Table 2

The relationship series is the vertical column in the centre of the upper part. These two number systems, one, the linear, dealing with individuals, and the other, the non-linear, dealing with their relationships are different but intimately interconnected. If a possible relationship number is doubled and that individual number added, e.g. 1 × 2 +2 = 4, 4 × 2 = 8 + 3 = 11, 11 × 2 = 22 + 4 = 26, … the next relationship number is indicated. The number series for individuals, the number series for all possible relationships for that number of individuals, and the number series for all relationships in a complete family of that number size are shown in the lower half of Table 2. The inter-relationships between families and their individual members involve a hierarchy of levels. Biologically, evolution does depend on appropriate fertile sexual relationships. Disputes between those treating the individual patient, and those who view his/her social interpersonal surround, need an integrated view of the relevant sets of numbers involved. It is clear that the numbers of relationships are the Pascal triangle row sums minus the (1 + n). Two individuals involved in one relationship is the simplest pattern. I have indicated this by the colon (:) between the two and the three individuals. This basic relationship between the two presumably first evolved from the biological need for sexual relationships to develop at the appropriate time in the reproductive cycle. It has been the model for later social interactions with their Father in Heaven in prayer, between priest and sinner, lawyer and client, and the one-to-one confidential medical consultation. The change from two to three is significant, noted by Simmel, and recorded in Figure 1. When the interpersonal relationships include all three members, their fourth relationship is the first and Medical Hypotheses (1999) 52(4), 335–347

only social dimension for the family unit of three to appear after the colon (:). The numbers of relationships then increase exponentially as the number of members increase. The family membership may be seen as togetherness with 1 × 1 = 1 or 1 + 1 = 2 separate individuals. These two are clearly different. They are not isomorphic. 2 × 2 does equal 2 + 2, they are isomorphic, and equal four. They suggest that a family of four (father (F), mother (M), son (S), daughter (D)) might be seen as a pair of pairs, sometimes being separate pairs (2 + 2), and sometimes with togetherness (2 × 2). This may imply that some intrafamily interpersonal social relationships and discussion may develop. How well and when do the six pair systems MSMS…, FSFS…, MDMD…, MFMF…, DSDS…, and FDFD interact? These six pairs can be arranged in three different patterns, involving generation differences, the same sex pairs, and the opposite sex pairs. The fourth pattern involves all four individual family members together, perhaps at the meal table. Simmel, in 1902, wrote that the pair of pairs (four) has certain qualities inherent in all pairs, but loses other qualities because each element in the pair is no longer an individual but the pair (p. 52). Where has the individual parent and his/her selfish genes gone to with his/her molecules of genetic biology repeating phylogeny in the evolution of bodiness? They are not in this suprabiological societal development. Competition in a singles tennis match involves individual assertive gene resources. A pair of pairs creates doubles matches which require some joint sharing of skills, experience and each learning about the other. Individual genes have to be subjugated or excluded to allow the development of the interpersonal relationships or ‘emotional units’ (10) in each of the six pairs. © 1999 Harcourt Brace & Co. Ltd

Social interpersonal dimensions of the psychoses

Figure for four relationships in a family of four.

This in effect defines an independent social pattern of inter-relatedness as a supra-biological human society, which develops as the family techniques of communication improve in the pairs and between the pairs at first inside the family perimeter. The family of five has ten ways of matching up ten pairs with ten threes and the whole family of five members. Six family members match up the two sets of threes with the three sets of twos for 25 different possible arrangements and plus one with the whole family of six members.

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Figure for eleven relationships in a family of five. Note: E/O is either male or female

The Pascal Triangle in Table 3 defines the individual and social context. It has been rotated from its vertical symmetry. The top line represents a series of one-to-one consultations, the next line counts the number of individuals (2) in a group or other social situation. The rest moves the increasing sets of numbers onto infinity on the right, to be the bases of social sciences. The totals for ‘All Members’ in the bottom row are based on the italicized numbers in the odd numbered sizes so that everyone

Table 3 The individual and social context.

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is correctly included and there are no ‘half persons’. This interpersonal social move from ‘two’s company’ to ‘three’s a crowd’ is routine in a normal family. THE PSYCHOTIC PARADIGM I need to change the ‘solitary’ in Simmel’s statement (p. 6) to introduce my ‘temporarily and chronically psychotic existences which to be sure the statistician cannot exactly express in arithmetical terms.’ These existences involve the more chronic schizophrenic psychoses and the briefer manic–depressive psychoses, and involve their social sciences and their infinite uncertainty. It is now necessary to look at all these players in Pascal’s triangle. The Pascal Triangle top has 1, the individual, Simmel’s ‘solitary’, which I have changed to ‘psychotic’. Two is company when two strangers decide to form a more stable relationship. This relationship may then have certain probabilities for relationships recorded on the third level of the Triangle as 1 2 1 or as 0.25, 0.50, 0.25 probabilities. On the second level, the relationship of two strangers is either/or, 1.1. The doctor and patient may or may not need to meet again. The next level 1.2.1. has been noted above and the probabilities as Two Heads, Head/Tail, Tail/Head, and Two Tails are relevant to any continued interpersonal relationships. The two in the middle clearly have splits in their minds. The further discussion about schizophrenia will be directed to the relevant interpersonal relationship probabilities between the model patient (P) and nurses (N) identified and counted as P1-N1, P2-N2, N3-P0. Three is a crowd and the relationship probabilities recorded in the next level of the Triangle, 1.3.3.1. which totals 8 or 23. This disorder presents in two opposite triangular dimensions or patterns. The depressed patient is usually about a generation older and appears to have survived the 1.2.1 interpersonal problems to enter the wider reproductive male and female world and to meet the social world of related and unrelated pairs. ‘The Worlds of Three Members’ will be deferred and continued on page ÁÁ under that heading to create a variety of social outcomes and some may temporarily move out of this sane world. Some may suicide to meed the 1.0 probability of the final attractor. TWO IS COMPANY One of the possible two-person relationships within the family, subject to some emotional change, may alter the balance for all the family members and in their interpersonal relationships. This then may cause some family relationships to split as implied in schizo/phrenia. These complex interpersonal relationships cannot be Medical Hypotheses (1999) 52(4), 335–347

managed by a psychiatrist just diagnosing one member as described by Kraepelin in 1904. The disturbed family balance must be addressed and not relegated to the psychiatrists’ terra incognita, terra nullius or his/her Freudian unconscious. Fairbairn, in 1952 (11), wrote that ‘the object in which the individual is incorporated is incorporated in the individual.’ He comments ‘This strange psychological anomaly may well prove the key to many metaphysical puzzles.’ In one sense, this may present in a variety of symbiotic relationships in which each adopts the reaction patterns of the other so that it is not clear when who owns which pattern. I recall my earlier uncertainty about two unnamed women patients from my past clinical work who were known only as ‘mother’ and ‘daughter’ but their ages made clear a total role naming reversal. How did this happen? What is the probability of this reversal? Were the mother/daughter each so dedicated to both helping and being the other? Each was incorporated in the other? Was this a limit case of ‘Two is Company’ madness? The rest of the family had had to leave then both in care and they were not seen. Engel, in 1962, described the symbiotic relationship: ‘Commonly, each party not only gratifies vicariously certain needs of the other but also supports the other’s ego defences’ (12). The anorexia nervosa patient loves cooking and feeding others. When she says ‘I am not hungry’ if others offer her food, is she modelling herself on her mother’s obsessional concern with her own earlier feeding? ‘You eat it up dear, I am not hungry’ (13). The research into the ‘high expressed emotion’ mother or father has shown an emotional imbalance across generations. The probbility of a schizophrenic relapse may identify ‘Two is Company’ involvements. A mother of her 25-year-old schizophrenic patient son commented ‘When I was admitted.’ This implies at least some incorporation of her son and indicates they have not yet cut their emotional need umbilical cord (14). Arieti (5) noted that ‘The only point of agreement of most authors who have studied schizophrenia psychodynamically is that in every case of schizophrenia studied, serious family disturbance was found. It indicates that although serious family disturbance is not sufficient to explain schizophrenia, it is presumably a necessary condition’ (pp. 80–81). If the schizophrenic patient comes into professional care, should the caring situation, in some way, replicate the same four patterns in the mother, father and child relationships from the arrival of their first baby? This arrangement has been successful in the evolution of our present species, homo sapiens, and our evolving suprabiological social structures so far. The family meets and lives with their first and later-born children. When © 1999 Harcourt Brace & Co. Ltd

Social interpersonal dimensions of the psychoses

does the family of expansion learn to change to their family of dispersion to start the next generation off?

In the beginning It will be argued that ‘The proper care of the infant can only be from the heart: perhaps I should say that the head cannot do it alone, but can do it if the feelings are free’ (15). In the first year of life, the communication patterns start with breastfeeding, with face-to-face visual and auditory communications and with body contacts alternating between mother and child, and may flow as MCMCM… With a third member, (father) there may be one more separate direct communicating sequence, FCFCF… The third system, FMFMF… may concern the child but may only be about him/her. How well and when do the three MCMC…, FCFC…, and MFMF… systems interact? Where or when will there be some MCFMCF… communications. The four levels of possible communication have been noted earlier (Fig. 1). The number ONE equals 1 × 1, TWO is 1 + 1. So the initial togethernesses can be symbolized as 1 × 1 = 1 and for the four relationships, the situation can be stated from birth with four probabilities which will vary from my given mean. [1 × 1 + 0] or [1 × 1 + 0] or [1 × 1 + 0] or [1 × 1 × 1] = 1 [M C F] [F C M] [M F C] [F M C] P = 0.25 + 0.25 + 0.25 + 0.25 = 1.00 The expected goal into the adolescent years is three separate people indicated by altering the (1× 1 = 2) to (1 + 1 = 2) to record their separate individuality in pairs and as a family of three as follows: [1 + 1 = 2] or [1 + 1 = 2] or [1 + 1 = 2] or [1 + 1 + 1] = 3 [M C] [F C ] [M F] [F M C] P = 0.25 + 0.25 + 0.25 + 0.25 = 1.00 In this family, the boundaries of each relationship and the whole family are progressively defined by their infinitely developing communication and interaction systems and sequences, e.g. MFMCMFCFCFC → Mum talks to Dad, she then takes the child to Dad who continues to play/feed/talk to him, and so on. Is it possible that some families may get by with just the three pairs interacting? It remains her family, his family and my family, but without a full sense of ‘our family’. A younger member may then find it difficult to define the family social perimeter dimensions he/she would need for his/her own precise social-identity formulation to move into a wider world. [1 + 1 = 2] or [1 + 1 = 2] or [1 + 1 = 2] [M C] [F C] [M F] P = 0.33 + 0.33 + 0.33 = 1.00 © 1999 Harcourt Brace & Co. Ltd

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Bleuler (9) wrote that ‘other factors must be taken into consideration (with schizophrenia). In particular we must consider the qualities of the patient’s relatives; they may easily ruin the patient as they may continue his education … If, upon release, the patient cannot be placed with his own family, the care he may receive from a strange family often serves as an adequate substitute’. For what? A family that has a socially defined fourth interpersonal relationship dimensions, e.g. CMFCMCMFMCFM… with 3 × F, 4 × C, and 5 × M all interacting. In those days, strangers were to be positively and correctly welcomed.

Further on ‘But on the psychological side, a baby deprived of some quite ordinary but necessary thing, such as affectionate contact, is bound, to some extent, to be disturbed in emotional development and this will show in personal difficulty as the young person grows up’ (15). It is possible that in some families the M + F communication system may try to be consistent with both the M × C and the F + C communication systems. The balance between these two relationships may be upset. [1 × 1 = 1] or [1 + 1 = 2] or [1 + 1 = 2] [M C] [F C] [M F] P = 0.33 + 0.33 + 0.33 = 1.00 Here, the son or daughter, idealizing the individual father, sees the mother in another dependent mode. Will the split between the parents also create a split in his or her own self-identity meeting a non-family stranger? As 1 × 1 does not equal 1 + 1, these two mathematical statements are not isomorphic. To move in either direction from one belief statement (two is company) to the other (two individuals) will obviously distort some interpersonal shape or space for one or both members. This view with some mathematical precision defines interface space and shape problems between an individual and a family or other interpersonal relationship. It may be that the son or daughter does get lost in the shape or space between the distorted self and distorted others, is then diagnosed as schizophrenic and treated as a patient [1]. Would any pairing do? In the other symbols, the 1 2 1 has moved to a 1 1 either/or uncertainty and finally is 0, an individual lost in infinite social uncertainty, searching for 1 alone and unpredictable. Would any .1.1. do?

Hospital paradigms If the schizophrenic patient, with some uncertainty about part of the emotional perimeter of his family social space, is admitted to hospital, can his admission be seen Medical Hypotheses (1999) 52(4), 335–347

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in terms of a basic three-member family pattern, or its three separate pair relationships. After admission, he/she may be seen positively in relationships with both the psychiatrist and the nurse in the ward (both M + F roles). This may in effect provide an acceptable alternative parental (male/female) definition for the missing family model. He/she recovers with the quasi full-family early situations in the ward that identifies him/her as an individual member and now with acceptable and relevant relationships. One third have a remission. If the next one is seen positively and acceptably by either a relevant male (psychiatrist) or female (nurse) this creates either a (role M) or (role F). This still misses out somewhere in the earlier three-member family situation. It is likely that one or more further admissions will be needed to complete the establishment of acceptable and relevant interpersonal relationships. These one, two or three readmissions will lead to a partial remission for the second third of these patients. The third one misses out all together (role O); they fail to recover but may become a long-stay patient in mental hospital care, or continue to be recycled between the hospital community staff and the general community staff. Each staff group develop their own technical skills to move the ‘long-stay’ patient expeditiously into the care of another staff group. The probability of not being insane In Table 4, the probability of 1.0 is the final destination for all which some may consider. The isolate individual A may or may not meet another isolate individual B. The probability is random but may be 50%:50% (11). A and B may form a pair. With two there are certain probabilities. Using two coins, BOTH may be heads (and see things the same way), or then EITHER a head/tail, OR a tail/head (who can be alike but with accepted differences) or NEITHER (with things not heading anywhere) and each with P = 0.25. The four choices are for BOTH together (0.25), for EITHER/OR (0.50), or NEITHER (0.25). (1 2 1) is the line in Pascal’s triangle. With individual patients, the first choice is forming a relationship with another individual. This is 50:50 or 1:1. Translating these options to eight interpersonal ward situations between a staff member (N) and a new schizophrenic patient (P) the first choice is some acceptance by four (+0.50). The other four make no direct move to relate (–0.50). The BOTH N-P1 pair forms. Some mutual dependence pattern may persist, or may gradually resolve, or P may be lost to a new partner (+0.125). The EITHER (N-P2) OR (N-P3) each form relationships Medical Hypotheses (1999) 52(4), 335–347

and may redefine their own interpersonal patterns of behaviour (+0.25). The NEITHER (N-P0) pair try to relate but no real interactions seem to occur and it fails. (–0.125). Two (25%) have achieved some self-definition, one perhaps remains in the pair relationship (12.5%) and the fourth patient is added to the other four non-starters (–62.5%). About one-third of these patients have benefited from the institutional social interpersonal care, the ‘spontaneous remissions’ that Arieti (5) described as ‘the result of relationships that had been established between the patient and the nurse/attendant.’ With the development of physical treatments, leucotomy operations, insulin coma, electroconvulsive treatment (ECT) from the mid-1930s to the mid-1950s, each and every patient would be individually assessed and involved in treatment situations with staff members. The result, with the increase toward 100% interpersonal involvements, doubled the ‘institutional spontaneous remission’ of one-third to 65–70% or two-thirds (16). With 16 new patients now there will be four in the BOTH N-P1 category. In time, probability indicates they may resolve into the same four different relationships. One may remain, N-P, two may provide real outcomes, N-P2 and N-P3, and the fourth may be an ‘unreal pair’ P-0. Assuming these chance developments do occur, the probable sequence can be illustrated as shown in Table 4. These interpersonal relationship patterns between patients and nurses evolve as defined by the calculus of probability. The convergence on the two-thirds infinite limit includes both the N-P2 and N-P3- (33.3% + 33.3%), which is consistent with the spontaneous remissions, partial recoveries, and the ‘long-stay’ patients, each about one-third. Healy (17) stated that ‘Outcome studies repeatedly give the outcomes for schizophrenia as 33% fully recover, 33% partially recover, and 33% fail to recover’ (p. 134). The probability options between two individuals presumably arose in evolution and the various biological arrangements to ensure that sexual reproductive relationships between sexes occurred at the most fertile time. Homo sapiens, since this initial reproductive focus, has progressively constructed a supra-biological communicating social world which is subject to change. Any interpersonal interaction hypotheses will involve the social Table 4 Probability outcomes Cohort Size

N-P 1

N-P2 N-P3

Four Eight Sixteen Sixty-four 256; (44)

1(25%) 2 (50%) 2 (25%) 4 (50%) 1 (6.5%) 10 (62.5%) 1 (1.5625) 42 (65.625%) 1 (0 3905%) 170 (66 406%)

N-P 0–PO 1 (25%) 0 PO 2 (25%) 0 PO 5 (31.25%) 0.P0 21 (32.8125%) 0.P0.85 (33.203%)

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patterns that exist in the relationships between 30 individuals, which is where the Society of Friends started. THE WORLDS OF THREE PERSONS The world of three persons and their manic–depressive psychoses have more or less survived these Two’s company family outcomes from 15 to 25 years. They have established or started some marital, family or other situations with some different sets of outcomes. The age range is 25–55 years and the distribution between the sexes presents some significant differences. With Three’s a crowd, and three possible pairs, who is the one who is left out or pushes in? The classical features of the manic–depressive psychoses are in the bipolarity, two different symptom groups which cannot both occur at the same time but may alternate. This is a feature of three-pair relationships in a new family of three, only one of the three pairs can interact at any point of time. What can the other singles do? In the world of individuals, three persons can be seen as the three points of a triangle. In their relationship world, the three kinetic interpersonal patterns may be indicated by the sides of the triangle which may change in length and be seen as either good or bad (or positive or negative). The social unity of the three relationships is the whole triangle. In each and every triangle, only two points can have lines or sides of the opposite sign radiating from them. If both signs are present two individuals can have both positive/good and negative/bad relationships but the third individual cannot. He/she (A) is the focus of either positive or negative relationships from B and C. A + + B – C

A – B

– +

C

This seems to be one way to determine the positive and negative poles in the relationships in three family members. These two may correspond to the manic and depressive elements. Or does one individual attempt to change the situation by changing the pairing? In the family or group of three there may be an imbalance between the same sex pairs and the other sex individual, or the bisexual pair and the other single who may be man or woman. The normal process for the relationship patterns is to circulate round the three members. If the relationship sign between A and B is reversed, the focus then for A and C is directed to B. This of course is the learning pattern to deal with the ‘three’s a crowd’. Everyone should have a turn and no one always be left in or out. The one who is really left out, the lonely isolate, may arrive in hospital to find and meet some other person © 1999 Harcourt Brace & Co. Ltd

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for some two-person, one-problem relationship situation as noted earlier. Does the manic patient attempt in some overactive way to generate a solution to the uncertainty between B and C? Does the depressed patient develop ideas of unworthiness and a loss of energy to compete with the B and C? Are both these patterns part of the Social Competition hypothesis of depression? Price et al (18) argued that ‘the depressive state evolved in relation to social competition as an unconscious, involuntary losing strategy, enabling the individual to accept defeat in ritual agonistic encounters and to accommodate to what would be unacceptably low social rank’ (p. 309). Each member in a competitive social encounter has their own resource holding potential (RPH). Are some ill-health reasons used at times to avoid some confrontation with uncertainty and a possible untoward outcome? Is not the manic state an attempt in the other direction ‘in terms of a creating a more positive self-concept about status and Resource Holding Potential (RHP)’? It is conscious; it does not always create sane behaviour, and leads into the inevitable collapse in his/her RHP with a need to come to terms with the probabilities involved in his/her not sane relationships within the family and beyond. Does this involve the single member of one sex and the reconciliation with the other sex pair? Or is one member of either sex to be rescued by the joint efforts of the other bisexual pair? Simmel, in the traditional Latin of his time, defined three patterns for this interaction and control. His tertius gaudens refers to the third member profiting from the dissensions between the other two; his unpartisan and mediator soothes the other two for their own good; his divide et Impera made separate personal arrangements with each of the other two (p. 56). Is it possible for tertius gaudens to carry the rejoicing from his profits to a hypomanic level? How sad does the nice unpartisan and mediator have to feel to make the other two feel better? Some of the joint activities, undertaken by one or two members together, may then be criticized by the other member or the two members left out? Do those individuals criticized by the other pairs take an overactive and uncontrolled manic response or retreat to a negative overcontrolled depressive response with feelings of guilt and being unworthy? The divide et impera psychiatrist retreats from the wider social overview to create his/her own control for his doctor–patient ‘two-person one relationship’ universe. His doctor–family member ‘two-person one relationship’, if it occurs, may create a separate social universe. Is not the psychiatrist trapped in his own diagnostic system which clearly will split the family into two sections, the sane and ‘not sane’ and, in so doing separate the ‘Two Medical Hypotheses (1999) 52(4), 335–347

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who were Company’. Some relatives can of course join the Relatives of the Mentally Ill to remain in contact with the present system. The imbalance between men and women Some data sets from 1908 to 1980–81 have been reported. Recent research into Kraepelin’s 1908 clinical data about manic depressive insanity by Jablensky (19) recorded 108 female and 26 male (80%/20%) admissions. He noted that the proportion of clinic first admissions were high while the schizophrenics were a small proportion (27/26). The male manic–depressive insane also numbered 26. Did the clinic attract the 108 women? Norris (20) in 1947–49 recorded 255 men and 539 women (32.1%/67.9%) first admissions (p. 139) and the total admissions of 800 men and 1498 women (34.8%/ 65.2%) with manic–depressive psychoses in the UK hospitals she studied. By 1949, only 36.5% of men and 46% of women were certified admissions (p. 142). She noted that on 31 December 1949 there were 10 618 men and 20 330 women (34.3%/65.7%) in mental hospitals in England and Wales suffering from manic–depressive psychoses (p. 141). The Lewis & Joyce 1980–81 national cohort (21) was directed to the new ‘revolving door’ patients with 14.6% recording four or more admissions. In this study, 35.1%, 28.1% and 26.9% of patients with schizophrenia, mania and depression became their revolving-door patients. Their Table 6 records the manic group of 50 with 28 women and 22 males, (56%/44%), the depressive group with 60 women and 32 men (65.2%/34.8%, schizophrenia recorded 126 women and 160 males (44%/56%). Their Table 4 for the whole cohort recorded 110 women and 67 men with mania (62%/38%) and 321 depressive women and 189 men (63%/37%) with totals of 431 women and 256 men (63% to 37%). Schizophrenia recorded 427 men and 409 women (51%/49%). These figures indicate that the cohort of manic– depressive patients significantly differed in their family interpersonal relationships compared to the simpler either male or female cohort of schizophrenic patients. The one-third/two-thirds ratio is typical of the totals in any two adjacent (above/below) lines in the Pascal Triangle. Does this have some involvement in the emotional problems in threes when the sex differences are of this order? Trevathan (22), in 1987 has argued that the newborn baby is an extra-gestate fetus out of its womb. She cites the total dependency and the caretaking needs that are very different from all other primates. The baby leaves a floating intra-uterine life. Biologically the mother is programmed to provide the needed nourishment for the baby to become able to move, to imitate its mother’s movements, and return her smile. These patterns are Medical Hypotheses (1999) 52(4), 335–347

imprinted in the other’s central nervous system and with the baby they create the need for the head to increase in size as the brain establishes basic patterns for movements and communications in the family interpersonal relationships. The change from crawling to bipedalism extends into the third year and the distances between mother and her children of either sex increase. Simmel’s sociological form changes as the numbers vary. He argues that in the small group ‘there must be some undifferentiated unity of belief and way of life… and with a greater degree of intimacy than in the larger group’. This would be relevant for the males and females in family situations. He then moves onto larger groups and leaves the basic family interpersonal relationships and interactions to be directed by their own feedback. He wrote, ‘the large groups tend to be negative and destructive and one factor in its unity is its power of negation and prohibition.’ He refers to the ‘relationship of the whole to the parts’. Again, there are three large groups, the men, the women, and the children, that form the statistical whole. So then again there are three pairs, mothers and fathers, mothers and children, fathers and children and each pair may ignore or criticize the other third. Does one parent criticizing the other parent create a model for two that is not company? The goal is the unity of all three in a happy country with happy families. Family Courts seem to be involved in predicting the unpredictable in dealing with the inevitable disputes from the various levels of trading when one variable blames the other pair or vice versa. The women and children are roughly twice the number of men. Which parent owns the rights of the children and criticizes the other parent? Each pair may argue for certain rights and forget how their overall responsibility should also involve the junior or other sex member. The probabilities for outcomes in groups of three are recorded in the Pascal Triangle. It is possible to create a model for their interactions with a cohort of 24 patients with some bipolar psychoses. The cohort of 24 divides into eight cohorts or families of three ((23), p. 147.) They are arranged in threes at the (1 3 3 1) level in Pascal’s triangle One triad Three pairs and three singles Three singles and three pairs One triad that nearly starts Total

3 0.125 M2F2C2 9 0.375 M2F2C1 M2F1C2 M1F2C2 9 0.375 M2F1C1 M1F2C1 M1F1C2 3 0.125 M1F1C1 24

The probabilities for outcomes for the eight items of © 1999 Harcourt Brace & Co. Ltd

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three are listed. It is clear that the reproductive family triad must have one member for one sex and two members of the other sex. Is this the basis for the male– female differences in the manic–depressive psychoses compared with the schizophrenic patient situations’. The infant in time finds he/she can influence the behaviours of the parental pair, who have to arrange who will respond to the infant’s messages. They have to indicate which responses can be done by either parent or those that need both together. This introduces the possibility of three-person interpersonal relationships which will have to be experienced and learnt. Returning to the triads, there are two predominant probabilities complementing each other. For three sets (0.375) the bisexual pairs are the executive group and the single is either sex. ‘Your father and I want you to…’ FM→C. In the converse sets (0.375), the one sex single is the prime mover, and the pair two of the other sex or one of each. ‘I want you and Dad outside…’ M→CF. How do these two interpersonal interactions look in the crossgeneration relationships or relationships between sexes in the growing up family? How do these work out when the interpersonal situations become more adultorientated and the appropriate responses to either sex are part of the interpersonal situations? The individual separate parents–child relationship roles, with the inherent two-person probabilities, should become contained in these three-person social units. If this fails, do these two different pair relationships have anything to do with the difference between the

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manic and depressive clinical patterns and the fact that some patients present with both cycles? Calculus of togetherness and separateness I have argued (24) that the initial togethernesses in the family may use plural pronouns ‘we are going…’ and in time move to singular pronouns: ‘I am taking you to…’ to indicate separateness. The separateness can be indicated by using ‘2’ as in M2C2F2 in the top row (0.125), and togetherness with ‘1’ as in M1C1F1 in the bottom row (0.125). There are six variations between the grown-up separatedness in M2C2F2 and the initial togetherness starting with M1C1F1 (25). I will reverse this normal growth patterns and regress back from the separateness M2C2F2, (0.125). There are then three that have two separatenesses differently arranged with one togetherness, and listed in the figure above, to be followed by the next three have two togethernesses and one separateness differently arranged, The M1C1F1 (0.125) with three togethernesses creates the ‘Three’s a crowd’; but, with three possible pairs, who gets left out or pushes in? This is the triad that nearly starts (0.125). The situation here is (1 × 1 × 1 = 1 crowd) with three possible versions of (1 × 1 = 1 relationship) leaving one member without an ‘otherness’. The individual may define him/herself as a hopeless ‘half a pair’ (1 + ?) in terms of his resource holding potential (RHP) and the plurality of the other two. The other alternative

Fig. 4 This presentation of two groups of four includes the three versions of pairs in the family on the left. On the right, there are three versions of pairs involving family and professional staff members. Each member can talk to each of the other three.

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is to inflate his RHP into some manic diversion. Someone will do something to control the resulting situation in time. How is this divided family to be brought together again? Does this rest with clinical, family, or social probability decisions? It is likely that ‘one two-person relationship’ with the psychiatrist will be unable to deal with the relevant variables. Is there a possible basis for some family social consultation to be arranged as a MicroSociety of Friends (26)? With four members, all four can be arranged in four different ways, three pairs of pairs and the whole family of four members. There is then no room for ‘half a pair’. Figure 2 may be reconstructed as a family and therapy staff social discussion group as in Figure 4. Each member is paired up with each of the other three on the three levels. Would the anorexic daughter and mother be able to redefine their togetherness and separateness balance interacting with a pair of therapists? The balance between pairs and threes is evident in the eleven levels in the figure for five members. THE SELF The self is its own observer, both I and Me, and subject and object The general pattern of those who are aware of themselves can be examined in terms of the Calculus of Togetherness and Separateness addressed here to the next higher 1.4.6.4.1. level of the Pascal triangle and moving on from the psychotic groups of threes. For those who are looking for separateness as an individual self the model will be A2B2C2D2. Those who seek to share some togetherness will be recorded as A1B1C1D1. These two refer to the 1 and 1 limits. Moving then toward the central six, there will be four variants each with one letter changed in the appropriate number, e.g. A2B2C1D2 and A1B2C1D1. In the centre are the six ways of having two of each number variously arranged, and easily changed. Those who present with more ill-judged togetherness, A1B1C1D1, have trouble in managing their relationship with others in ways that may be described as psychopathic disorders. I quote from sociologists’ writings. ‘His lack of social separateness is clear in his inability to form deep and permanent relationships, little or no concern of the other’s rights when recognising them, if they would interfere with his personal satisfaction in any way. There is a lack of anxiety and distress over social maladjustments with an inability to accept any responsibility for his own maladjustments. There is a tendency to over evaluate immediate goals with deficient role playing abilities’ (27). Those who seek to be separate as individuals present a number of neurotic handicaps to feeling the proper self Medical Hypotheses (1999) 52(4), 335–347

they would like to be. These include panic disorder and agoraphobia: syndrome, social phobia: syndrome, specific phobias: syndrome, obsessive–compulsive disorder: syndrome, and generalized anxiety disorder: syndrome. I am aware of these from the excellent work of a former colleague, Professor Gavin Andrews, who is the Director of the Clinical Research Unit for Anxiety, in the University of New South Wales. His Department has produced a book, The Treatment of Anxiety Disorders, subtitled Clinician’s Guide and Patient Manuals (28). The Clinician’s Guide (102 pages) and the Patient Manuals (230 pages) create an initial professional therapeutic togetherness to graduate to an increasing self-awareness through personal application to the Manual for Advice and Instructions.

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18. Price J., Sloman L., Gardner Jr, R., Gilbert P., Rhode P. The social competition hypothesis of depression. Br J Psychiatry 1994; 164: 309–315. 19. Jablensky A., Hugler H., von Cranach M., Kalinov K. Kraepelin revisited: a reassessment and statistical analysis of dementia praecox and manic-depressive insanity. Psychol Med 1993; 23: 843–858. 20. Norris V. Mental Illness in London. Maudsley Monograph No. 6. Chapman Hall, London, 1959. 21. Lewis T., Joyce P. R. The new revolving-door patients: results from a national cohort of first admissions. Acta Psychiatr Scand 1990; 82: 130–135. 22. Trevathan W. R. Human Birth: An Evolutionary Perspective.

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Aldine De Gruyter, New York, 1987. 23. Lindsay J. S. B. Probability and schizophrenia. Br J Med Psychol 1966; 39: 145–156. 24. Lindsay J. S. B. Types of family and family types. Family Process 1968; 7: 51–66. 25. Lindsay J. S. B. On the number and size of subgroups. Human Relations 1976; 29: 1103–1114. 26. Lindsay J. S. B. Science in search of psychiatry. Med Hypotheses 1993; 40: 117–124. 27. Lindsay J. S. B. Psychiatry and chaos. Med Hypotheses 1997; 40: 117–124. 28. Lindsay J. S. B. Two limits of the sociological universe. Int J Comp Sociol 1995; 36: 150–163.

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