Family Process, 46(2):143-49, 2007

Lyman C. Wynne and the transformation of the field of family-and-schizophrenia

Carlos E. Sluzki

The December 2006 issue of Family Process included two articles co-authored by Lyman C. Wynne (Wynne et al. 2006a & 2006b), whose life we honor in the current issue of this journal. Those two articles summarize one of his most outstanding contributions, and that of his collaborators, to the field of family research and family therapy. In fact, the project summarized in those articles is part of Lyman’s life-long inquiry into the theme “family and schizophrenia” and, within that thematic umbrella, his exploration of the contributions of both genetic and rearing environment variables on the incidence of that disorder. In that regard, some bits of history may be in order.

One of the early banners that coalesced and, in fact, contributed substantially to the very development of the field of family therapy was the belief that schizophrenia was a condition resulting from interactive processes within the family. Therefore, family therapy, it was assumed, was promising to unlock the treatment of people with schizophrenia. This promise came in the wake of daring but habitually unsuccessful psychoanalytic attempts at individual treatment of patients - think of Frieda Fromm-Reichmann and her felicitous “I never promised you a rose garden” uttered in the course of the treatment of a psychotic patient as well as that same author’s highly criticized belief in a hypothetic “schizophrenogenic mother.” It also coincided in time with the “biological revolution” triggered in the 50’s by the discovery of a completely novel generation of medications (the neuroleptics, from chlorpromazine on) with powerful dampening effects on the “positive” symptoms (i.e., delusions, hallucinations) of patients with a diagnosis of schizophrenia. In fact, the symptom-controlling impact of these medications resulted in the second psychiatric revolutionary (the first having been Pinel’s unchaining the psychiatric patients at La Salpetriere in Paris, a hundred years before): the opening of the doors of the large psychiatric asylum in favor of community-based treatment - while realizing later that these drugs did not touch the so-called negative symptoms of schizophrenia (abulia, anhedonia, flatness of affect, et cetera), thus creating an underserved chronic population in the fringes of the community. In sum, neither of these two diametrically different approaches, psychoanalysis and psychopharmacology, appeared to be the longed-for Golden Bullet against that pervasive disorder.

Into that scenario made its debut in the late 50s this new approach - family therapy - offering the hint of a promise: there was something peculiar in the interactional patterns of families with a schizophrenic offspring; if that peculiarity was specific enough, causal enough and reversible enough, then disentangling that systemic knot through family therapy would undo schizophrenic behavior.

Research in the field of family-and schizophrenia flowered originally in the 50s, 60s and 70s at several sites. At the NIMH, Lyman C. Wynne, his main associate Margaret T. Singer and their team were developing communicational models on the intergenerational “the transmission of irrationality” as well as the “rubber fence hypothesis” of enmeshed boundaries (cf., e.g., Singer, Wynne and Toohey 1978; and Wynne et al, 1958), while Murray Bowen was hospitalizing whole families for intensive efforts at differentiating the “undifferentiated ego mass” that he proposed was underlying the individual and collective pathology. At Yale University, Theodore Lidz and Stephen Fleck were developing typologies of parental couples and proposing ways in which they would convey schizophrenia. In Palo Alto, Gregory Bateson and his team - Jay Haley, Don D. Jackson and John Weakland - were developing their communication/systemic “double-bind” model - generated, unlike the other models, from theory to practice, rather than the reverse. And, as they developed bridges between theory and practice, they were entering into a steady dialogue with iconoclastic clinicians who were in turn beginning to work with families using as a basis a mixture of psychoanalytic ideas, cybernetics and sheer geniality - Nathan Ackerman, Virginia Satir, Ivan Boszormenyi-Nagy, Carl Whittaker, Salvador Minuchin, and a growing legion.

Alas, while contributing in many ways to new ways of thinking about human dilemmas and problems and new approaches toward reducing interpersonal pain, family therapy did not fulfill its promise to solve the riddle of schizophrenia. The theme “schizophrenia” managed, at the most, to energize the nascent field of family therapy, which grew into becoming a new epistemology toward the understanding and the treatment of human suffering and distress.

But let’s return to the mid-60s. Each of the family-and-schizophrenia early teams was developing with passion their distinct models, with some dialogue between them but without excessive reciprocal enrichment. They remained firm in their psychosocially-minded conviction, utilizing the epidemiological evidence that indicated high incidence of schizophrenia clustered in families only to support the psychosocial hypothesis, with little attention paid to possible genetic as well as biological contributions.

However, the ground trembled in 1967, during a conference on “The Transmission of Schizophrenia.” It was a major event supported by the then powerful Foundation’s Fund for Research in Psychiatry that convened in Puerto Rico all the salient figures in the field, with the intent of harvesting an encompassing panorama of what was known on the subject (cf. the conference’s proceedings in Rosenthal and Kety, 1968). This conference included epidemiologists, neurophysiologists, genealogists, geneticists, sociologists, linguists, and all the first line of researchers in family-and-schizophrenia (it also included a few young researchers from all over the world, including the writer of this note, a very wet-behind-his-ears witness of that encounter of giants.) The conference evolved in the sometimes-fascinating sometimes-boring way conference do, until Seymour Kety, David Rosenthal - Harvard University and NIMH, respectively – and their team introduced the first results of a totally novel research strategy on the subject: the “high-risk adopted-away” approach, namely, a life history follow-up of offspring of a parent with confirmed diagnosis of schizophrenia given for adoption at birth to a family without any known pathology. If, when compared with a matched cohort of offspring of parents without psychopathology also given away to similarly non-pathology adoptive families, the “high risk” cohort would show a higher prevalence of schizophrenia during early adulthood, then this would prove that schizophrenia is genetically predetermined, regardless of family-interaction variables. This study, carried on in Denmark (where records are impeccable and thorough), showed, in fact, that the “high risk” cohort presented, when reaching early adulthood, a statistically meaningfully higher proportion of schizophrenia in the offspring than the control sample (Kety et al, 1968; Rosenthal, Wender et al 1968; Wender, Rosenthal and Kety 1968. Cf. also Rosenthal, Wender et al, 1971; Kety, Wender et al 1994). This study by itself had the potential of demolishing most of the presumptions of relevance of interpersonal variables: schizophrenia manifested itself, apparently, on the basis of a genetic load. Nurture appeared to have lost the battle.

However, in the design of that research there was an important unexplored window, summarized in the question: Given a child born to a mother who had schizophrenia (a “high risk” child, given the statistically higher incidence of schizophrenia in an offspring of a parent with schizophrenia), does the interactive style of the adoptive family where that child was raised play any role - be it protective or facilitative - in the potential expression of that genetic proclivity? In fact, in the course of that very conference, Lyman asked that question in an impromptu discussion and, guided by that intriguing possibility, and imbued by what was later called “systemic optimism” by his disciple and friend Helm Stierlin (Stierlin, 1988), Lyman conceived a longitudinal research project aimed at tackling that issue, and enlisted for its development Pekka Tienari - by then a young researcher and currently a distinguished professor from Oulu University in Finland, also attending and presenting at that conference.

Finland presented a unique research opportunity, because of a combination of tight records, high accessibility to them, a period of extreme economic hardship following WWII that increased the number of newborns given for adoption because of inability of the biological parents to care for them, and a local team of extremely competent researchers that could carry on the project. This longitudinal project was, in one sense, comparable with the Danish study (but with a much larger sample): two large cohort of children given for adoption at birth - one cohort whose mother had a diagnosis of schizophrenia and another whose mother didn’t manifest any psychiatric disorder - were followed-up until young adulthood. But in another sense it was much broader: the research protocol included a systematic analysis, both quantitative and qualitative of the adoptive family’s interpersonal/ communicational style. The set of publications that document the rigorous, methodic, flawless research protocols, its carefully drawn ethical parameters, and its copious and carefully analyzed conclusions during these past thirty-five years is impressive and eloquent: Isohanni M et al. 2000, 2004 & 2005; Mäki et al. 2005; Metsänen et al. 2004, 2005 & 2006; Siira et al. 2004; Tienari, Lahti et al. 1987; Tienari, Wynne, at al 1994, 2000a and b, 2002, 2003a and b, 2004, 2005; Wahlberg 2003; Wahlberg, Wynne et al. 1997, 2000, 2001a, 2001b, and 2004; and last but not the least, the two articles mentioned at the beginning of this note, Wynne et al. 2006a and 2006b.

While retaining a both-and nature-nurture approach to the riddle of schizophrenia, the research evidence stemming from this project show the key position of the rearing family in the clinical destiny of the adopted offspring: the degree of adoptive family functionality/dysfunctionality (a composite index of global ratings and qualitative observations, including Bob Beavers’ questionnaire as well as variables stemming from Lyman and Margaret Singer’s earlier research on family and schizophrenia - cf. Tienari, Lahti et al, 1987; Singer 1968) proved to be a significant predictor of the development of schizophrenia-spectrum disorders in adoptees of high genetic risk when reaching early adulthood: A high index of functionality in the adoptive families acted as protective factor against the expression of the genetic trend of the “high risk” adopted offspring. In turn, the impact of different levels of family functionality in the long-term outcome of “low risk” adoptees - offspring of biological mothers without prior psychiatric disorder - is negligible. Neither a purely genealogic nor a family-focused approach, nor a transversal, short term (vs. longitudinal, long term) strategy could have illuminated per se this correlation.

The Finnish “high-risk adopted-away” project, one of Lyman’s masterworks, depicts many of his personal outstanding qualities. It required the display of a complex, dialectic thinking, defying many Cartesian, linear booby-traps: genetic assumptions - diathesis - combines with relational data, rather than challenging them. It was extremely rigorous in its methods - including a re-checking of all the clinical records of the biological mothers to update as well as discard “gray zone” diagnosis. It was utterly creative in its instruments - specifically those who evaluated interactive processes in the adoptive families - and detailed in their operational definitions so as to assure thoroughness of the analysis of results as well as the replicability of the project. It required extreme patience and discipline because of its long-term design, bypassing the temptation of shortcuts prematurely linking independent and dependent variables and thus placing the conclusions at risk. And, within it, Lyman has been consistently generous, as he himself took frequently a position of secondary author in the multiple publications on the subject, sharing the limelight with, when not offering it altogether to, his co-authors.

As any exemplary research project should, this study, in addition to answering many questions, opened up a broad range of lines of inquiry, lodged in the center of the complex terrain of nature cum nurture: Which are the traits of a “high risk” child that are buffered in “functional” and not buffered, or perhaps enhanced in the “dysfunctional” families? When are those traits expressed, and at what level of processes they operate (communicational, identity formation, reality construction, resilience enhancing)? Does the presence of any of those traits challenge the family toward an enhanced “functionality” or “dysfunctionality”? These questions are some of the many seeds that the research line opened by Lyman and his team has sown. The reader is encouraged to re-read the two above-mentioned articles published by Family Process in its December 2006 issue and discover by self the crucial importance of its finding as well as the rich panoply of questions that flow from them. In doing this, the reader will join us in rendering homage to Lyman C. Wynne, whose passing away we mourn, on whose solid intellectual shoulders we can stand to better envision the vast horizon of bio-psycho-social inquiry in which family processes play a crucial role.

REFERENCES

Isohanni M, Jones P, Kemppainen L, Croudace T, Isohanni I, Veijola J, Räsänen S, Wahlberg K-E, Tienari P, Rantakallio P (2000): Childhood and Adolescent Predictors of Schizophrenia in the Northern Finland 1966 Birth Cohort - A Descriptive Life-Span Model. European Archives of Psychiatric and Clinical Neuroscience, 250:311-319.

Isohanni M, Isohanni I, Koponen H, Koskinen J, Laine P, Lauronen E, Miettunen E, Mäki P, Riala K, Räsänen S, Saari K, Tienari P, Veijola J, Murray GK (2004): Developmental precursors of psychosis. Current Psychiatry Reports, 168-175

Isohanen M, Lauronen E, Moilanen K, Isohanni I, Kemppainen L, Koponen H, Miettunen J, Mäki P, Räsänen S, Veijola J, Tienari P, Wahlberg K-E (2005): "Predictors of schizophrenia - evidence from the North Finland birth cohort".  British Journal of Psychiatry, 1987:(suppl. 48): 4 - 7.

Kety SS, Rosenthal D, Wender PH and Schulsinger F (1968): The types and prevalence of mental illness in the biological and adoptive families of adopted schizophrenics. Chapter in Rosenthal and Kety 1968, Op. cit. (pp. 345-362)

Kety, S. S., Wender, P. H., Jacobsen, B., et al (1994) Mental illness in the biological and adoptive relatives of schizophrenic adoptees. Replication of the Copenhagen study in the rest of Denmark. Arch Gen Psychiat, 51, 442-455.

Mäki P, Veijola J, Jones PB, Murray GK, Koponen H, Tienari P, Miettunen J, Tanskanen P, Wahlberg K-E, Koskinen J, Lauronen E & Isohanni M (2005): Predictors of schizophrenia. British Medical Bulletin, 73(1):1-15.

Metsänen M, Wahlberg K-E, Saarento O, Tarvainen T, Miettunen J, Koistinen P, Läksy K, Tienari P (2004): Early Presence of Thought Disorder as a Prospective sign of Mental Disorder. Psychiatry Research, 125:193-203.

Metsänen M, Wahlberg K-E, Saarento O, Hakko H, Tarvainen T, Koistinen P and Tienari, P (2005): Stability of Thought Disorder among high-risk and low-risk adoptees in the Finnish adoptive family study of schizophrenia. European Psychiatry, 20:35-40.

Metsänen M, Wahlberg K-E, Hakko H, Saarento O & Tienari P (2006): The Thought Disorder Index: a longitudinal study of severity levels and schizophrenia factors. Journal of Psychiatric Research (in press)

Rosenthal D & Kety SS (1968): The Transmission of Schizophrenia. Oxford, Pergamon Press.

Rosenthal, D, Wender PH, Kety SS, Schulsinger F, Welner J and Ostergaard L (1968): Schizophrenics’ offspring reared in adoptive homes. In Rosenthal and Kety 1968, Op. cit. (pp. 377-392)

Rosenthal D, Wender PH, Kety SS (1971): The adopted-away offspring of schizophrenics. Am J Psychiat, 128, 307-311.

Siira V, Wahlberg K-E, Miettunen J, Läksy K, Tienari P (2004): Schizophrenia-related psychometric deviance measured by MMPI in high-risk adoptees and their adoptive controls. J Personality Assessment, 83:14-31.

Singer MT (1968): The consensus Rorschach and family transaction. J Projective Techniques and Personality Assessment 32:348-351

Singer MT, Wynne LC & Toohey, ML (1978): Communication disorders and the families of schizophrenics. In L. C. Wynne, L. R. Cornwell & S. Mathysse, Eds.: The Nature of Schizophrenia: New Approaches to Research and Treatment. (pp.499-511) New York, Wiley & Sons

Stierlin H (1988): Systemic optimism-systemic pessimism: Two perspectives on change. Family Process, 27(2):121-132, 1988

Tienari P, Lahti I, Sorri A, Naarala M, Wahlberg KE, Morring J et al (1987): The Finnish adoptive family study of schizophrenia: possible joint effects of genetic vulnerability and family interactions. In K. Hahlweg & M. J. Goldstein, Eds.: Understanding Major Mental Disorder: the Contributions of Family Interaction Research, pp. 33-54. New York: Family Process Press.

Tienari P, Wynne LC, Moring J, et al (1994): The Finnish Adoptive Family Study of Schizophrenia: implications for family research. Brit J Psychiat, 164 (suppl. 23), 20-26.

Tienari P, Wynne LC, Moring J, Lasky K, Nieminen P, Sorri A (2000a): The Finnish Adoptive Family Study: Sample selection and DSM-III-R diagnoses of schizophrenic mothers and their Adopted-away offspring.. Acta Psychiatrica Scandinavica, 101, 433-443.

Tienari P, Wynne LC, Sorri A, Lahti I, Läksy K, Moring J, Naarala M, Nieminen P, Wahlberg KE, Miettunen J (2000b): Genotype-environment interaction in the Finnish adoptive family study - Interplay between genes and environment?. In H. Häfner, Ed.: Risk and Protective Factors in Schizophrenia. Darmstadt : Springer, pp. 29-38.

Tienari P, Wynne LC, Lasky K, Moring J, Nieminen P, Sorri A, J,Lahti I, Wahlberg KE (2003a): Genetic boundaries of the schizophrenia spectrum evidence for the Finnish Adoptive Family Study of Schziophrenia. Am J Psychiat, 160(9): 1587-94

Tienari P, Wynne LC, Wahlberg K-E (2003b) : ’Die Adoptionsstudies der Schizophrenie und ihre klinische Bedeutung.“ In Volknmar Aderhold, Yrjö O Alanen, Gernot Hess, Petra Hohn, Eds.: Psychotherapie der Psychose- Integrative Behandlungsansätze in Scandinavien. Giessen: Psychosozial Verlag :pp. 39 - 50

Tienari P, Wynne LC, Sorri A, Lahti I, Laksy K, Moring J, Naarala M, Nieminen P, Wahlberg KE. (2004): Genotype-environment interaction in schizophrenia-spectrum disorder. Long-term follow-up study of Finnish adoptees. Br J Psychiatry. 184:216-222.

Tienari P, Wynne LC, Sorri A, Lahti I, Moring J, Nieminen P, Joukamaa M, Naarala M, Seitamaa M, Wahlberg KE, Miettunen J. (2005): Observing relationships in Finnish adoptive families: Oulu Family Rating Scale. Nord J Psychiatry, 59(4):253-63.

Tienari P, Wynne LC, and Wahlberg K-E : Genetics and Family Relationships in Schizophrenia and the Schizophrenia Spectrum Disorders. Chapter 16 in S. M. Miller, S. McDaniel, J. Rolland, & S. Feetham, Eds: Individuals, Families, and the New Era of Genetics: Biopsychosocial Perspectives. New York, Norton, 2006

Wahlberg K-E (2003): Meaning of and Possibilities for Familial Prevention of Schizophrenia. In A. Grispini, Ed.: Preventive Strategies for Schizophrenic Disorders: Basic Principles, Opportunities and Limits. Roma, Giovanni Fioriti Editore, pp.69-82.

Wahlberg K-E, Wynne LC, Oja H, Keskitalo P, Pykäläinen L, Lahti I (1997): Gene-environment interaction in vulnerability to schizophrenia: findings from the Finnish Adoptive Family Study of Schizophrenia. American Journal of Psychiatry, 154, 355-362.

Wahlberg KE, Wynne LC, Oja H, Keskitalo P, Anais-Tanner H, Koistinen P, Tarvanien T, Hakko H, Lahti I, Moring J, Naarala M, Sorri A, Tienari P (2000): Thought disorder index of Finnish adoptees and communication deviance of their adoptive parents. Psychol Med, 30(1):127-36

Wahlberg K-E, Wynne LC, Keskitalo P, Nieminen P, Moring J,Läksy K, Sorri A, Koistinen P, Tarvainen T, Miettunen J, Tienari P (2001a): Long-term Stability of Communication Deviance. Journal of Abnormal Psychology , 110:443-448

Wahlberg K-E & Wynne LC (2001b): Possibilities for prevention of schizophrenia: Suggestions from research on genotype-environment interaction. International Journal of Mental Health, 30:91-103.

Wahlberg K-E, Wynne LC, Hakko H, Laksy K, Moring J, Miettunen J, Tienari P. (2004): Interaction of genetic risk and adoptive parent communication deviance: longitudinal prediction of adoptee psychiatric disorders. Psychol Med, 34(8):1531-41

Wender PH, Rosenthal D and Kety SS (1968): A psychiatric assessment of the adoptive parents of schizophrenics. In Rosenthal and Kety 1968, Op. cit. (pp. 235-250)

Wynne LC, Ryckoff LM, Day J & Hirsch (1958): Pseudomutuality in the family relations of schizophrenics. Psychiatry, 21:205-220

Wynne LC, Tienari P, Nieminen P, Sorri A, Lahti I, Moring J, Naarala M, Laksy K, Wahlberg K-E, Miettunen J (2006a): I. Genotype-Environment Interaction in the Schizophrenia Spectrum: Genetic Liability and Global Family Ratings in the Finnish Adoption Study. Family Process, 45 (4), 419-434.

Wynne LC, Tienari P, Sorri A, Lahti I, Moring J, Wahlberg K-E (2006b): II. Genotype-Environment Interaction in the Schizophrenia Spectrum: Qualitative Observations. Family Process, 45 (4), 435-447.