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Fam Proc 10:281-302, 1971

The "Shadow-of-Death" and Its Implications in Four Families, Each

with a Hospitalized Schizophrenic Member
RONALD M. C. WELLDON, M.D.a
aAcknowledgements: My thanks are due to Drs. Aaron Esterson, Ronald Laing, Colin Murray Parkes, Cicely Saunders, Dennis Scott,
and Albertine Winner, who most kindly, at my request, read critically the draft of this paper, focusing my attention upon various points
which I have sought to re-focus, and to Mrs. Mary Smith for typing endless drafts. My appreciation is due to Drs. Derek Kelsey and
Elisabeth Shoenberg, who, between them, were ultimately responsible for the cases described.

This paper summarizes the salient points from tape recordings of conjoint sessions with four families, each with a
hospitalized schizophrenic member carrying a poor prognosis. As the sessions progressed, a profound and
overwhelming sense of frustration, foreboding, doom and despair emerged, as if the family were attempting to preserve
what seemed destined to die.
Each family as a whole was involved in what can best be described as a vicious circle of displaced and distorted
mourning for a dead family member. This had deep and unresolved emotional significance for one or other parent. This
same parent was also more obviously involved with the schizophrenic child, whose own symbolic family role included
both being protected from anything in life carrying the possibility of death and distracting others from the source of this
"shadow-of-death."
The purpose of this paper is to illustrate by means of four cases certain implications of the change in perspective from
the traditional psychiatric diagnosis of schizophrenia in a young adult hospitalized patient that emerged from a series of
conjoint meetings between the same psychiatrist and patient, together with both parents and a co-investigator. The cases
were unselected; they were the first four coming under the author's immediate clinical responsibility (between July, 1966,
and January, 1968) in which there was some degree of mutual agreement among the five participants above mentioned to
meet on a regular basis for such an open-ended experiment. It seemed necessary for both parents and for two investigators
(preferably of complementary sex) to participate in order to provide a viable quorum. (A fifth and earlier series with a
twenty-year-old boy, his mother, and myself ended after three sessions because at every point of issue either mother or son
would evoke or blame the father, who was divorced and in Australia.)
The primary purpose was experimental and not therapeutic. All four patients continued with their conventional treatment
while in hospital. The case summaries, which follow, have been edited from typescripts of tape-recordings made by mutual
agreement of all concerned in each series from the second session onwards. They shall speak for themselves with a
minimum of interpolation. The sequence of cases is in ascending order of the number of sessions involved, which, in turn,
reflects the attitude of all concerned towards the experiment. This happens to be the reverse of their historical sequence.

Case 1: Alice
It was impossible for the hospital staff concerned to miss the family involvement in Alice's case. Paternal grandfather and
maternal grandmother had both died schizophrenics, and both parents had previously been admitted to the same hospital
with the diagnosis of paranoid schizophrenia. The chances of genetic factors predisposing to a schizophrenic type of
response were high; but it was equally certain that Alice had experienced little other than schizophrenic family
relationships.
Without the aid of a cine-camera and tape-recorder it is impossible to convey the intolerable sense of madness in these
family sessions, which began because Alice herself was inaccessible to normal interviewing and father was reluctant to let
her see me alone. Father was a little man full of nervous tics, peering suspiciously through half-closed eyes, which he
further shielded with one hand and at one time covered with two pairs of dark glasses. He intimated that he had eye trouble,
but when I asked him its nature he replied, "That's for you to find out, doctor." He apologized for almost every movement he
made, for his frequent belches, and for what he said, saying that he was a "nut-case" and how could he be of any help to the
doctor. He spoke in a monotonous and almost inaudible drone, except when directing highly sarcastic remarks to his wife
or to me in a high-pitched nasal tone. Somehow he had managed to maintain a job as a wood machinist with his chronic
schizophrenia uncontrolled by drugs. Mother, though outwardly calmer and coherent, was on tranquilizers and freely
acknowledged her ex-patient status and the help that the hospital had given her. Both parents were disturbed by Alice's
breakdown; they both wanted to talk but seemed to feel they should let the other speak. In fact, Mother did most of the
talking with interruptions from Father. Alice, herself, wandered in and out of the room, and repeatedly tried to undress
while Father kept redressing her. She was a very young, blonde, and slim twenty-year-old, an only child.
She had been well until a week before admission when she suddenly became "all religious." Father said that a week ago

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he had "interfered physically" with one of her girl friends and continued in a disconnected way about Alice's sexual feelings
and his own, saying that he knew Alice was upset by what he did. Mother denied that it had upset Alice at all. She had
arranged for her to see the psychiatrist, but on the day of the appointment Alice had disappeared and was found by the
police in the early hours wandering the streets. Father hinted darkly that she had probably been sexually assaulted, but
subsequent examination had ruled this out.
When Mother started talking about their marital relationship, father interrupted saying, "Alice is the sick one; we're
concerned about her, not about us." Later she tried again and father enquired of me, "How many hours have you?" They had
been married for twenty-one years; Father interposed that he was a virgin; Mother added they had not had intercourse for
twelve years. Four years ago she left him for another man but returned eighteen months later "for Alice's sake." Her
husband took her back but "punished me by refusing to have intercourse." She then described him as "the perfect
husbandnot pushing" but added bitterly that if he had been pushing he might have got somewhere, like his brother. At
this point she started crying, and her husband said how attractive his wife was but that this made him impotent, to which
she replied that both he and Alice made her feel inferior because of their superior education. Father then expressed anxiety
about Alice being left outside in the ward "with all those men around," and went to fetch her. But Alice did not want to
remain: "There's no point: God is all that matters." She fixed her distant gaze on me: "You understand: you have the faith."
Mother started crying again: "She doesn't need me." She and Father started arguing while Alice looked on with detachment
and pleaded, "Don't! You must love one another. Love is everything." Mother went over to her and wept on her neck: "You
know I love you." Alice stood stiffly and replied mechanically, "It's no use. Let me go." She broke away from Mother and
moved towards Father as if to embrace him. He stiffened and drew back; Alice hesitated; Father approached, and she left
the room.
With the aid of Chlorpromazine Alice gradually lost her gross schizophrenic symptoms and discharged herself after
seven weeks. So far there has been no further news. We had managed only four sessions and felt powerless to help the
family situation as a whole. It was too malignant. Father was so chronically disconnected and paranoid towards the world.
Impotent with his wife, he expressed overtly incestuous feelings towards Alice but also in his guilt had to deny them and
project them on to other men, including the doctor, who he feared would rape her. He refused to allow Alice to bring any
boy friend to the house. Mother, though emotionally more in touch, looked to the doctor for a magical solution to her
problems. She felt isolated and jealous, both of Alice and her husband, and their obvious emotional involvement, but felt
unable to compete with either. They both used Alice as a substitute, as a receptacle for areas of sexuality with which they
felt unable to cope themselves, and as a human shuttlecock to be batted hostilely from one to the other. It was amazing to us
that Alice had survived for so long in this intolerable family situation, capable of working as a typist and of relating well to
friends her own age. We felt that the most hopeful solution would be for her to escape physically from her parents. But
neither she nor her parents could contemplate this possibility. The more she recovered from her acutely disturbed state the
more strongly she denied that anything was wrong. She had to return home: "My parents need me." Alice seemed so caught
up in the tangled web of identity and emotion that was her family, that to leave without being able to resolve the conflicts
would be more like living without the essential parts of her guts.

Case 2: Betty
The G.P., who for several years had tried to persuade her mother to let Betty come into hospital, finally had her
compulsorily admitted on the pretext that she had infectious hepatitis. Betty was thirty-one years old, and apart from being
jaundiced she was grossly overweight, mute, inaccessible, and spent most of the past ten years in bed hugging a teddy bear,
covering her face, doubly incontinent, and fed by the family with a continuous supply of fluid, solids, and cigarettes.
Mother, in her sixties, resembled a human thundercloud about to explode and deluge everyone with her fury. Having
discovered the deception, she exploded at the consultant and staff in the infirmary ward to which Betty was first admitted.
Later she calmed down a little and agreed to take part in the family sessions, though, as she kept saying, she could not see
the point of them. Father, when he had the chance to speak, appeared timid and frail beside her. The brother, four years
older than Betty, spent most of his spare time helping to look after his sister and occasionally took her for rides in the
sidecar of his motorcycle.
Betty had been "put away" twice before. When she was twelve, she had been sent to a special boarding school by court
order for a year on the day of the funeral of her paternal grandmother with whom they had lived and of whom Betty was
very fond. Mother had kept her from school because she kept getting ill, and the family believed that Betty thought they had
sent her away. They were only allowed to visit her three times, and when she came home "she was completely different."
When she was twenty-five, she was compulsorily admitted to another mental hospital, whose case notes described a state
very similar to the present though she improved after treatment with E.C.T. and drugs. The family denied that this treatment
had done her any good at all. Mother proudly but shyly showed us her collection of photos of Betty, which she carried
around with other pieces of evidence in her handbag. They revealed a normal, healthy, and happy-looking little girl
becoming increasingly shy and withdrawn in her late teens.
In response to my suggestion that in many respects Betty had returned to babyhood, Mother said she became pregnant for
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the third time when Betty was nine. It was clearly an unwanted pregnancy for which she blamed her husband, but she
stressed that when she knew she was pregnant of course she wanted the child. "It was a terrible labour. The doctor said:
'One of you will die. '" However, mother and baby Lilian (named after mother's sister) both survived until four months later
when baby was taken to hospital with "colic" and died. "The death certificate said 'pneumonia,' but they always put
something like that," Mother hinted darkly. I asked whether there could be any connection between this and Betty's illness
and, without a moment's hesitation and her voice full of emotion, she replied, "You don't think I was going to lose her as
well, do you?"
After "an unhappy love affair" when she was twenty-one, Betty suddenly collapsed while watching television, became
mute, and the doctor came and put her to bed. The next day she was able to describe how, while taking the dog for a walk a
few days before, a strange man had given them both some liquid from a bottle. Betty was examined at the time for possible
sexual assault, which Mother considered irrelevant. "No one ever examined her head." The dog died three weeks later, and
the vet said it had been poisoned. Mother pointed out that since then Betty had never had a proper period, and that "the
poisons collected in her blood" and were responsible for her illness.
At first Betty remained mute during the sessions occasionally laughing to herself, her fists held against her eyes shutting
out the world. Mother insisted that she must have a headache. We could only guess at what her actions might mean. Mother
kept suggesting that Betty was asking the doctor to let her go home. She admitted that this was what she, herself, wanted.
"We can look after her just as well at home. After all she is our daughter." Once Betty presented me with a Bingo card, and
I asked what this could mean. Mother replied, "She's telling you that she trusts you, that she knows you can let her go
home." I asked, "How can I tell Betty that I like her and want to help her?" Mother replied, "Give her back the Bingo Card."
The student nurse who was present on this occasion suggested, "She might think you were rejecting her present." I agreed
with this suggestion, so instead I poured a cup of tea to specifications from Mother and brother and gave it to Betty, who
drank it steadily, looking at me over the cup as she did so.
The more successful the nursing staff became in their treatment of Betty, the greater the competition and the less
tolerable the mutual anger between ourselves and the family and, in particular with Mother, became. We gave up after six
sessions. Though we had gained new insight, this seemed to make the task of therapy more, rather than less, difficult.
Mother, with her rigid and paranoid defences, was impervious to change. She needed Betty to be ill in order that she should
nurse her. She was convinced that Betty would never be cured, and she knew that when she died Betty would have to be put
in a mental hospital. "So why can't I have her now?" She continually expressed the fear that the worst would happen, that
while Betty was in the hospital something would go wrongshe would catch pneumonia or be attacked by a male patient.
Father and brother, too, were caught up in this web of smothering and expiating over-protection. Mother once admitted,
"What else can I do? This is the only way I know of loving Betty?" The more effectively the hospital staff treated Betty, the
more strongly the rest of the family had to deny any improvement and to set up an underground resistance to restore the
family status quo in which Betty played so crucial and sacrificial a part.
Whatever else was achieved, this family provoked the most open discussion and profound disagreement among all levels
of staff that I can remember at this particular hospital. There seemed three possible courses of action:
1. To treat Betty as the patient and to exclude the rest of the family in so far as they interfered with her treatment. This
might logically mean permanent enforced hospitalization, which would clearly have been very similar to Mother's own
behaviour. This the consultant in charge was prepared to undertake for the evidence was that when the "treated" Betty
returned to the "untreated" family, both returned to their former status quo.
2. To recognize that the family, and Mother in particular, was an integral part of the patient, and to admit her to hospital
with a view to focusing on the relationship between Mother and daughter. But we had to admit that neither we, the staff, nor
the family would be likely to tolerate this.
3. To accept that after six months of hospital treatment, including Moditen and concentrated personal attention from the
staff, Betty had improved to the point at which she could add her own voice and actions to those of the rest of her family (at
first she said she wanted to stay in hospital, but later she said she wanted to go home), to admit that we could not alter the
chronically malignant status quo of this family, and to accede to their wishes. This was the most difficult course for all staff
members who had been closely involved in Betty's improvement to accept. However, Betty, with the connivance of the
whole family, had become more furtive than ever, and finally decided things for us. She sought every opportunity to escape
in the direction of home, having been primed by Mother with directions and bus fares, and finally she succeeded. The last
we heard was that the family had her at home and that the door was barred against all comers.

Case 3: Janet
Janet had already spent the last six of her twenty-three years deteriorating in the hospital. At my first encounter with her
she screamed to me to go away and ran off herself. She was explosively incoherent, and full of writhing, athetoid
movements and grimaces. Her talk was repetitive and obscure, containing references to people from her past whom she
projected upon those around her, and full of fearful expressions, such as, "I nearly got the blame for it," and "I nearly

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walked to my doom."
At the first session Janet screamed and shouted and refused to come into the room, much to her parents' embarrassment.
When Father finally persuaded her to do so, she sat quietly in a corner watching the rest of us talking. When I commented
on this she approached us and her parents began making deprecatory comments about her. Janet resembled an animal in a
cage, frightened and frustrated, hopeless and helpless in her isolation, emanating a feeling of danger to herself and to others.
She would alternate between periods of silence and keeping up a flow of excited and largely incoherent chatter, as if to shut
out what might be going on. This flow would increase in intensity if I tried to speak directly to her or comment on what
seemed to be going on. At times she would rush towards some object in the room as if to break it in her frenzy, only to pull
up in front of it and simmer down. As the sessions progressed, she made more frequent sorties from the room. At the same
time Father began to talk freely with us about himself and his strong sense of identification with Janet. He said that she
expressed the very feelings that he had inside him but that he himself could not express.
Janet had always seemed to him a "funny little thing." She had never been a lovable child and had always resented her
parents kissing her. At school she was isolated; the other children teased her because of her odd ways and her stammer. She
came bottom of the class, and when she was twelve the headmaster told her parents that there was definitely something
wrong with Janet and that the school could do nothing for her. This made Father extremely angry. From this age both
parents noticed a definite difference in Janet, but they could not specify what it was. She used to ask why she was not like
other girls and seemed to try desperately to convince herself that she was the same as the others. At sixteen things became
so bad that they took her away from school. The headmaster had warned the parents, "You'll be driven mad if you try to
look after her at home." Shortly afterwards she was admitted to hospital.
Father explained that Janet spent her whole life imagining things. She worried about what other people were saying and
would come out with the most embarrassing comments about other people, such as: "I'm worried about what Daddy says
about Mummy," and vice versa. She had a compulsion for asking questions, and if she did not get her own way she would
scream and shout, pull her hair, and press her thumbs into the side of her neck. She had a morbid fascination for illness,
graveyards, and death, and also for animals. They once had a dog but Janet used to squeeze it so mercilessly that they had it
put away. Since then the sight of a dog terrified her.
At this point Father began talking about himself. He and his sister were the children of a second marriage. Their father
put his first family through university but not the second, which he (Janet's father) bitterly resented. He always had a terrible
premonition of his parents' death. They were an elderly couple, and when he was twelve, his premonition came true; they
died within months of one another. He always had to fend for himself, felt isolated and unable to confide in other people,
even his wife. He was obsessional about his work as an operating assistant for a petroleum company, where he had got as
high a position as possible without a degree, and felt that those who possessed degrees were really no better equipped for
the job than he was. He felt he had never been able to talk to anyone like this before. He was hypersensitive to criticism of
Janet but admitted that he had reached the end of his own tether with her.
I pointed out that Father had been doing all the talking and had identified himself with Janet, who had left the room, and
that Mother must feel very isolated. She admitted to this with tears. "My husband brings his work home with him. It's all he
can talk about besides Janet. I can't talk to him." She explained that she identified with their older son, who left home to join
the navy when he was fifteen in order to get away from his father and from Janet.
At this point in the sessions Janet became ill. She suddenly developed an unidentifiable pyrexia, which continued
intermittently despite the use of numerous antibiotics. Her physical and mental resistance seemed to have diminished. She
was less accessible than ever and grossly emaciated. At times she recognized people and seemed convinced that she was
dying. She was now in an infirmary ward and out of my direct care, but we had two further sessions with her parents. They
said that for a long time they had the premonition that Janet would die, and they asked if I thought this was now imminent.
Father compared this to his feelings about his own parents. It seemed as if Janet were fulfilling her own and her parents'
prophecies, as if she were the guardian of some fearful and unintelligible secret that could not be divulged. We were left to
wonder whether it was coincidental that this should happen just at the point at which Father and Mother were beginning to
talk, seemingly for the first time, or whether our intervention had speeded up some malignant family process involving the
extrusion of Janet that had been operating for a long time. Understandably, both parents found this state of hovering on the
brink of death an intolerable experience and we were able to offer them little consolation. She lingered on in this way from
24/7/67 until her eventual death from insufflation of food on 8/3/69. The postmortem reported evidence of hypostatic
bronchopneumonia, low-grade septicaemia and toxaemia.

Case 4: Nicholas
Nicholas had had four hospital admissions in the previous three years, and at the age of eighteen, institutionalization
seemed only a matter of time. The B.S.W. and I were interested in exploring the family situation, and both parents agreed to
try anything, "We're that desperate." Nicholas, himself, seemed content to go along with us.
On his admissions Mother had supplied the information, since Nicholas was too disturbed. His birth was extremely

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difficult and mother had "nearly died." He was a very good child, friendly with adults, but like many only children had
difficulty in getting on with other youngsters. He was emotionally labile, did everything in a hurry, hated having things done
for him, and hated any form of violence. His school record was chequered by four different moves on account of bullying.
The third move, when Nicholas was thirteen, was recommended by a psychiatrist, who had been consulted and who
diagnosed "a schizophrenic episode related to school work." The whole family, including "Nan" (Mother's mother), who
lived with them throughout, moved to the opposite end of London. But again the boys bullied and disturbed Nicholas with
their sexual talk. Father had told him "the facts of life" when he was twelve, and mother had given him several Catholic
books on the subject. "Nan," mother, and Nicholas were Catholics, while father was Church of England.
Just before his first admission Nan and Father had both gone into hospital for minor operations, and the parents of his
school friend, who were also of mixed religion, had separated. Prior to his fourth admission he had been refused work at
thirteen consecutive shops, had struck his father, and frightened his mother by overturning funiture. His behaviour in
hospital was more chaotic than ever. Four themes of violence, punishment, work and sex ran through his talk. He wanted
people to give him the punishment that he felt his father had been unable to give him; he whispered in my ear, "I've had
intercourse with my mother!" After various tranquilizers had been tried, he gradually settled down but remained vacant,
unapproachable, and unable to concentrate on conversation or work of any kind.
Four different diagnostic labels have been applied to Nicholas over the years:
1. "A schizophrenic episode related to school work" (Consultant psychiatrist at Childrens' Dept., St. Georges' Hospital
when Nicholas was thirteen).
2. "Hysterical adolescent crisis" (the result of his first admission to Claybury Hospital).
3. "Schizophrenia" (the result of a number of private O.P. visits to the Consultant Psychiatrist at the Tavistock
Adolescent Unit during 1965; the next five admissions to Claybury Hospital and formal psychological testing during
his third admission).
4. "Manic-depression in an immature personality" (the result of his two latest hospital admissions).
This diagnostic confusion is echoed in the variety of drugs that have been prescribed for Nicholas over the years and at
any one time.
This family proved to be the most amenable of the four to these conjoint family sessions, which continued weekly for
twenty-one months. From more than one hundred hours of tape and transcript, four main problems emerged.
1. The problem of listening to and disentangling two simultaneous forms of conversation: that of the parents, which was
intelligible, and that of Nicholas, which was conducted in the much less intelligible language of jokes, whistling,
interruptions, and various other actions. The parents were anxious to please the doctor and reluctant to admit the full force
of their frustration and embarrassment in the face of Nicholas who showed no such anxiety or embarrassment.
2. The problem of encouraging the parents to see the possible relevance of Nicholas' communications as a means of
transmitting to them his own sense of frustration. The break-through occurred unexpectedly when we re-played the
recording of a previous session (10). Father immediately spotted the significance of Nicholas' whistling as a form of
interruption and succeeded in conveying this insight to his wife. Shortly afterwards Mother suddenly realized that Nicholas
might also be feeling frustrated, and Nicholas showed amazement that she had never appreciated this before. At the same
time there was the more difficult problem of showing to Nicholas that he was involved in his parents' frustration.
3. The problem of assisting the parents, and particularly Mother, to realize that difficult areas of their own emotional
experience might be involved in some way in Nicholas' illness and his struggle for identity.
When the discussion turned to Mum and her feelings, she felt guilty and embarrassed at finding herself the centre of
attention. Nicholas had always been "Number One" in the family and the number one problem in these sessions. At the
same time mother admitted that she had never before had anyone to confide in. Nicholas, too, became uneasy at the
unfamiliar prospect of the spotlight being switched to Mum. He put on his coat saying, "Well, I think it's time we stopped
now." But his parents disagreed. Mother went on to talk about her twin sister, who, though older by half-an-hour, was less
robust and considered by their mother (Nan) to be more intelligent and attractive. She described how, from the age of
seventeen, they both had secretarial jobs in different parts of the city, and every lunchtime she would go to her sister's
office, as if she had some compulsion to make sure that she was all right. I remarked on the comparison with Nicholas' need
to ring his mother up from hospital, especially at lunchtime. They all agreed, and Mother reminded her husband that he
used to phone her every lunchtime from the office (where they originally met as co-workers) until this trouble with Nicholas
started. She went on to talk about the effect of the sudden death of her sister just before their twenty-first birthday,
something she had never before discussed in front of Nicholas, for fear of upsetting him. She had never been able to
express her own feelings about this tragedy, which had shattered her whole life and faith. "It was unbearable, like losing a
part of myself ... I never felt I could take anything for granted since." She seemed to have carried with her a sense of
impending diaster. At the time she had to look after her mother, who had "gone to pieces" with grief, and her father, who
was also terribly upset and was himself crippled with arthritis. Dad commented how she always had to take on everybody
else's troubles. In doing so she was able to avoid the full implications of her own. Now she had Nicholas to worry about.
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She remembered suddenly thinking, as Nicholas was taken to hospital for the first time, "This is Emily (her sister) all over
again." She went on, "After thirty years it still feels like yesterday. I remember at the time wishing that it had been me
instead of her." She felt convinced that the depression she had never been able to express must somehow have gone
underground and come up in Nicholas. He had said recently at home that he would be better off dead. He was terrified of
his own tears, which also embarrassed his parents; no one really knew what they were about. He was also very afraid of his
mother crying and had to try and cheer her up.
4. The problem of helping Nicholas and his parents to discover more acceptable means of expressing what, up to now,
he had only been able to express through his acting out, which was unacceptable to everyone. This involved the
re-canalising of his childish feelings of omnipotence; his rage at being thwarted from getting what he wanted, when and
how he wanted it; and his anxiety about his own sexual feelings and fantasies. All his life Mother, and Father, too, though
against his better judgement, had put Nicholas first in such a way that continually placed him in competition with
themselves. Both parents felt they had to protect Nicholas from any experience that might disturb him, including the news
of the death of anyone close. Mother felt trapped between Nicholas on the one hand and her own mother on the other. She
was always terrified lest he upset "Nan," but "Nan" would side with Nicholas and criticise his mother's treatment of him.
This made it all the more difficult for the parents to define the boundaries, which Nicholas found equally difficult to accept.
So much of his parents, and his grandmother, also, seemed to be involved in Nicholas that it was difficult to know where
they ended and he began.
Nicholas was discharged from hospital and attended a Local Authority Day Centre, where he worked for thirteen
successive weeks, a personal record. After much mutual discussion he had stopped relying on medication. Everyone was
beginning to think in terms of a job in the outside world. Then the two therapists announced that they were due to leave the
hospital, and it seemed as if this news, plus the surprise of his own success and problems of sexuality that were beginning
to be discussed during the sessions, were too much for Nicholas and his parents. His behaviour again became
uncontrollable, and he had to be re-admitted to hospital, and later to the locked male ward. We continued to see the family
through this crisis and managed to hand them over to two other interested therapists. It may well be that our leaving, after
twenty-one months of intimate involvement, stimulated something of Mother's original feelings at the loss of her twin sister.
But this possibility was not discussed. (Cf. Edelson, M. (4)). Suffice it to say that the parting was felt as a personal loss to
everyone concerned. The family sessions continued for several months with the new therapists, and Nicholas again became
a day patient and attended the Day Centre. But relationships between the ward staff and the "external" therapists proved
difficult, and the sessions were terminated. Nicholas was later re-admitted to hospital for the eighth time and is currently in
a long-stay male ward.

DISCUSSION
Patients, Parents, and Death
Four cases, particularly when they are such extreme examples, provide an inadequate basis for making generalizations
about a subject so complex as schizophrenia. Nevertheless, their exaggerated pathology highlights certain features that may
be only not as obvious in less extreme and more amenable cases. In each family there were stronger emotional links
between the schizophrenic child and one parent rather than the other, and the more obvious and pathological these links the
more intolerable the sessions proved to be. This "involved parent" might be either Father or Mother. Sexual factors were
clearly involved, but we were unable to explore these in detail.
The most obvious and accessible theme, common to all four families, was a strong and at times overwhelming mixture of
helplessness, hopelessness, fear, and despair. In Alice's family this undercurrent, though experienced to an intolerable
degree by the investigators, was expressed and at the same time denied by the family members in actions rather than words.
But in the other three it was expressed verbally and variously, mainly by the more involved parent: a sense of impending
disaster and death, an inability to look forward to anything good, a feeling of being trapped and unable to do anything about
it, etc. The obvious focus for these emotions was the fact of the child's psychosis. But as the sessions progressed, it became
abundantly clear in the latter three families that this was neither the only nor the primary focus for such despair. In each
case the child was of special significance to this parent, not just as himself nor because he had become ill, but also because
the child and the illness had come to symbolize a dead family member of deep and unresolved emotional significance to this
parent. The details were unique for each family.
Betty's mother had another baby girl nine years younger than Betty. The manner in which she blamed her husband and
her protest that she wanted the baby as soon as she knew she was pregnant suggested that she strongly resented the
pregnancy. The birth was difficult and, in Mother's words, threatened her own life and that of the baby. She, herself, made
the connection between this baby's subsequent and, as she felt, suspicious death and Betty's subsequent baby-like
regression: "You don't think I was going to lose her as well, do you?"
Janet's father recalled his own powerful premonition of his parents' deaths, which occurred within months of one another

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when he was twelve. At the same age they began to notice an indefinable change in Janet, who had always been an odd,
unlovable, and isolated child. She became increasingly pre-occupied with death, and Father recognized in her many of his
own deep and inexpressible feelings. He also had a premonition of Janet's death that both she and her mother shared.
Nicholas'mother had clearly never been able to express her own feelings of grief over the sudden death of her favoured
twin sister. She had been pre-occupied with looking after her parents in their grief. "It was like losing a part of myself... I
wished it could have been me instead ...after thirty years it still feels like yesterday ...." And when Nicholas first went to
hospital, she thought, "This is Emily all over again." As the sessions went on, she recognized for the first time that her
depression seemed to be coming out in Nicholas. He, too, expressed the feeling that he would be better off dead, in marked
contrast to the manic features of his illness.
Alice's paternal grandfather and maternal grandmother may well have been doubly significant to Alice's respective
parents; both were dead and both had been schizophrenic. But the sense of madness in this family made it impossible to
explore the situation further.
In each of the three families the parent in question had been able to accept neither the reality of his significant relative's
death, nor the confusion of his own emotional reaction, which had become internally buried and preserved. During the
sessions this parent made the connection between the source of these repressed emotions and the illness, behaviour, or
emotional expression of his subsequently schizophrenic child. The latter had become inextricably involved at an
unconscious level with the "shadow" of the dead relative that haunted the whole family. (Cf. Scott, 18). In the intensely
symbiotic interdependence between parent and child, the former regarded the latter as both a substitute for and a reminder
of the parent's own feeling of irreparable loss. This symbiosis contained a confusion of love and destructiveness, of mutual
sacrifice, satisfaction, and despair. It resembled a mutual protection racket in which the child had become the repository for
intolerable parental emotion in return for parental over-protection against any potentially disturbing experience, and
particularly against the shadow of deaththe very experience that most disturbed the parent. Each schizophrenic illness
began around the time at which a child normally begins the struggle of establishing his own identity. But in these cases the
vicious mutually protective circle with its underlying shadow of death proved inescapable. In many respects the child's
illness resembled a compromise between individual life and death, a psychotic or "living death" (Cf. Kastenbaum, (7)). To
use a cellular analogy, each family resembles a cell paralyzed at a stage of meiotic division. It can neither regress to the
former state of de-differentiation nor progress to full differentiation of its constituent members until the chromatidsthe
mutual involvement of parent and child in the emotional shadow of the dead membercan be enabled to give up their
mutual hold upon one another.
When seen in this perspective, a number of other features common to all four cases become more intelligible:
1. The unacceptability to the parents of the child's schizophrenic behaviour and expression which are a reminder of the
former's own unacceptable and inexpressible feelings.
2. The isolation existing both within the family and between family and outside world. The intense relationship between
one parent and the ultimately schizophrenic child makes for exclusion of the other parent, and of any siblings, and
stimulates a reaction of jealousy and anger. Collusion in the symbiosis and its sequelae (as in the case of Betty's father and
brother) is an obvious means of dealing with this isolation. The parents understandably blame the schizophrenic illness
with its embarrassing consequences for the family's social isolation. But the pathological preoccupation with its own
conflicts and needs reduces the family's ability and energy to cope with the demands and problems of normal social
relations.
3. The ambivalent attitude to treatment of both parents and child, which frustrates most therapeutic efforts. All four
children were either unconcerned or saw treatment as totally irrelevant, while their parents either hoped for a miracle from
the doctor or would have nothing to do with him. Mere medical control of the schizophrenia is likely to prove unsatisfactory
to everyone, except perhaps the psychiatrist. Not only does it threaten the parents' accustomed emotional repository, but it
also exposes the child to unfamiliar demands and dangers. Betty's mother had good reason to be suspicious of efforts to
enforce treatment. But her own compulsive alternative was no better, as her poignantly tragic plea momentarily admitted,
"What else can I do? This is the only way I know of loving Betty." In Betty's case it proved impossible for Mother, family,
and ourselves to tolerate the sessions for long enough to discover why this had to be the only way and to explore other less
destructive ways of loving.
4. Finally, the rigidity and despair, which so dominated each family and which the therapists themselves experienced, is
both understandable and inevitable, for the original loss could never be satisfactorily denied or replaced by any substitute. It
can only be recognized and accepted in all its emotional confusion, unbearable and dangerous though this may seem. The
emotional conflict itself is not what constitutes the unbearable danger but rather the attempt to escape from it by denying the
reality of the conflict.

Psychosis, Doctors and Death

There is little disagreement among psychiatrists about the fact that the relationships and communication between the
7

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schizophrenic patient and his family (or, indeed, society at large) are disturbed. The argument centers around which came
first: the faulty relationships, or the schizophrenia. Such "chicken-and-egg" arguments are sterilethey serve mainly to
perpetuate the power struggle between the protagonists, whether they be two psychiatrists, or psychiatrist and patient.
The difference between the initial medical approach and the emergent historical perspective in these four family series is
such that an outsider could not be blamed for failing to recognize them as two approaches to the same reality. One approach
is a detached, didactic, and professional description of external behaviour with the object of diagnosis and control. The
other is an involved, open, and personal description of internal experience, emotion, and motivation, with the object of
understanding what goes on and why.
The difference between two such extremes is more a matter of Gestalt configurations than of reason. It is not a matter of
one "coming first," but of the preconceptions that determine what one sees. For the limits of one's vision, what one wants
and wants not to see, contribute to one's "results," and these in turn serve to confirm the former.
The weight and authority of medically-based psychiatry regards schizophrenia, together with mental illness as a whole, in
terms of "disease entity." The vast majority of schizophrenic individuals will continue to find their way to being diagnosed
and treated as such in psychiatric units or hospitals, with ever newer and more efficacious methods by psychiatrists, who
await the ultimate evidence of the physical basis of the disease. Understandably, such workers will not waste valuable time
with the family as a whole, except to fill in details, to explain the nature of the illness in appropriate terms, to encourage
them to visit the patient in hospital and to take him home when he is deemed better, to ensure that he continues his
medication, and to be generally co-operative and understanding. Everyone has his particular role and, provided the rules are
observed, things can continue more or less according to the medical plan. But the players do not always abide by the rules,
even if it would seem to be to their advantage to do so. Many patients do not consider themselves "ill," require forcible
removal to hospital, discontinue their medication on leaving, become re-admitted more speedily the next time, etc. Some
parents seem to be in competition with the hospital, or actively to interfere with treatment, as if they want their child to
remain schizophrenic, either in hospital or at home. In the absence, to date, of any more positive physical evidence (despite
unremitting search), to pursue such an approach may be to substitute a more subtle and repressive "solution," which has
both social and medical approval, for a naturally occurring familial "attempt-at-a-solution" to a problem whose basic nature
remains obscure.
The course of these family sessions expanded my personal and professional conception of schizophrenia as disease by
adding an historical and social perspective that seemed of implicit relevance to the immediate context. The family
implications of death denied by one parent manifested as a blanket of protection about a particular child ("nothing must be
allowed to happen to him") with inevitable and deadening repercussions ("I know the worst will befall him in the Bnd"),
leads to arrest of the very life whose preservation is so diligently sought. The result of arrested life is death: in these cases
psychotic death. Of the four, Janet dramatically withdrew at the point of our intervention into an inexplicable and moribund
state, which terminated in actual death twenty months later. Nicholas improved while our sessions continued but became
interred in hospital shortly after these ended. Betty, however, escaped from hospital to be re-interred at home, while Alice
disappeared home without trace.1
I soon found that my observations were not original, but that they confirmed evidence already published by two
independent groups of workers. Scott and others (16, 17, 18, 19) at Napsbury Hospital had discovered the importance of
the "shadow" of a deceased mad relative in a series of twenty-four families with a schizophrenic member. Paul and others
(10, 11, 12, 13, 14, 15) at Boston State Hospital (Mass., U.S.A.) found "unresolved mourning" in the parents' background
to be the central factor in fifty families with a schizophrenic member.
It may be no coincidence that so dramatic a "family underworld," with two such notable exceptions should have escaped
formal psychiatric description. Before we could begin to "get the message" in each of these four families we had to admit
that we had not already got it, but that there was at least the possibility of a "message" being hidden somewhere in the
existing confusion. The process of deciphering involved each participant in the task of becoming "open" to the others,
which proved difficult for patient, parents, and co-worker, as well as for myself. In only one of the four cases were we
clearly able to do so together with any confidence. Each of the three categories of patient, parent, and therapist, had to face
a challenge to their accustomed role of responsibility or irresponsibility. In this respect the challenge to my own role, and
that of my co-worker, as "the doctor" or "the therapist" who normally takes professional responsibility for other people, "the
patient" and "the relatives," was at least as difficult as the equivalent challenge to parents and to patient.2
The content of "the message" that emerged during these sessions, the helplessness, hopelessness, doom, and despair, was
something none of the participants wanted to know, but which to some extent we all found ourselves sharing. The fearful
"out-of-control" sense of doom attaching to "madness" seems to have been controlled or toned down by substitution of the
more respectable, hopeful, and scientific term "mental illness." Modern medicine has so enabled us to succeed in our efforts
to treat, and at times to cure, "disease" that death itself seems to have receded. But when our efforts can no longer postpone
it, death seems to come back at us with even greater momentum. As doctors, we tend to regard death as professional and, at
times, personal failure; it threatens to overwhelm us with feelings of unaccustomed helplessness, which we would prefer

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not to know. What a doctor tells his patients about unpleasant but real probabilities, such as cancer or death, reflects at least
as much the doctor's own fears about the subject as it does those of the patients. A recent survey of 2,000 G.P.'s in Britain
(23) showed that 48 per cent never tell the terminally ill patient that he is dying whereas 95 per cent are likely to tell the
relatives. For reasons of legality and conscience, a doctor feels that he must tell someone connected with the patient. One
would expect G.P.'s to be more in touch with the personal and family situation than hospital doctors, and such would seem
to be the case.
Allowing for differences between the United Kingdom and the United States, 219 doctors in an American hospital (9)
revealed that 88 percent would never tell a patient he had a cancer that was likely to prove fatal, although 60 per cent of the
same doctors admitted that they would like to know if they were in the same circumstances. At least one study (6) suggests
that doctors (including psychiatrists) may be personally more afraid of death than groups of seriously and terminally ill
patients and healthy controls, even though they may consciously deny such fear. The suicide rate is also high among
doctors, and the greatest risk may be among psychiatrists (2). What may well be an important motivating force in saving
lives may also lead to both personal and professional complications. The message of death, which at least three out of these
four schizophrenic families concealed, may be as unwelcome to the therapists as it is to the parents of the schizophrenic
members, and both therapists may prefer to continue to deal with the problem at one remove. It may be that the majority of
us, both psychiatric and lay, will continue to wait or work for the kind of message that we want about schizophrenia (or for
that matter about any unsolved problem) until we are able or willing to recognize and accept the unwanted message
involved in the problem itself.

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British Medical Journal, "Suicide Among Doctors," pp. 789-790, March 28, 1964.
British Medical Journal, "Mental Disturbance in Doctors," p. 448, November 22, 1969.
Cobb, S., Schull, W. J., Harburg, E., Kasl, S. V., Tabor, J., Hunt, P., French, J. R. P. and Nrsteb, G., "The
Intrafamilial Transmission of Rheumatoid Arthritis," Journal of Chronic Diseases, 22-4, 193-296, September,
1969.
Edelson, M., The Termination of Intensive Psychotherapy, Springfield, Ill, Charles C Thomas, 1963.
Esterson, A., Cooper, D. G. and Laing, R. D., "Results of Family-Orientated Therapy with Hospitalized
Schizophrenics," British Medical Journal, 5476, 1462-1465, 1965.
Feifel, H., Hanson, S., Jones, R. and Edwards, L., "Physicians Consider Death," Proceedings of the 75th Annual
Convention of the American Psychological Association, 2, 201-202, 1967.
Kastenbaum, R., (19693) "Psychological Death in Death and Dying," in Pearson, L. (Ed.), Death and Dying:
Current Issues in the Treatment of the Dying Person, Cleveland, Ohio, Press of Case Western Reserve
University.
Laing, R. D. and Esterson, A., Sanity, Madness and the Family: I. Families of Schizophrenics, London, Tavistock,
1964.
Oken, D., "What to Tell Cancer Patients," J. Amer. Med. Asst., 175, 1120-1128, 1961.
Paul, N. L., (1966) "Effects of Playback on Family Members of Their Own Previously Recorded Conjoint Therapy
Material," in Cohen, I. M. (Ed.), Family Structure, Dynamics and Therapy, Washington, D.C., Psychiatric
Research Report No. 20, The American Psychiatric Association.
Paul, N. L., "The Use of Empathy in the Resolution of Grief," Perspectives in Biology and Medicine, 11, 153-168,
1967.
Paul, N. L. and Grosser, G. H., "Family Resistance to Change in Schizophrenic Patients," Fam. Proc., 3, 377401, 1964.
Paul, N. L. and Grosser, G. H., "Operational Mourning in Family Therapy," unpublished research project, 1963.
Paul, N. L. and Grosser, G. H., "Operational Mourning and its Role in Conjoint Family Therapy," Community
Mental Health Journal, 1, 339-345, 1965.
Paul, N. L. and Grunebaum, H. U., "Family Maladaptation to Loss and Schizophrenia," unpublished, 1963.
Scott, R. D. and Ashworth, P. L., "The 'Axis Value' and the Transfer of Psychosis," Brit. J. Med. Psychol., 38,
87-116, 1965.
Scott, R. D. and Ashworth, P. L., "'Closure' at the First Schizophrenic Break-down: A Family Study," Brit. J. Med.
Psychol., 40, 109-145, 1967.
Scott, R. D. and Ashworth, P. L., "The Shadow of the Ancestor: A Historical Factor in the Transmission of
Schizophrenia," Brit. J. Med. Psychol., 42, 13-32, 1969.
Scott, R. D., "Violation of Parental Role Image and Outcome in Schizophrenia," unpublished lecture given at
Tavistock Centre Scientific Meeting, 1970.

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20.
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Searles, H. F., "Schizophrenia and the Inevitability of Death," in Collected Papers on Schizophrenia and Related
Subjects, New York, International Universities Press, 1965, reprinted from Psychiat. Quart., 35, 631-665, 1961.
Siegler, M. and Osmond, H., "Models of Madness," Brit. J. Psychiat., 112, 1193-1203, 1966.
Siegler, M., Osmond, H. and Mann, H., "Laing's Models of Madness," Brit. J. Psychiat., 115, 947-958, 1969.
Smith and Nephew Pharmaceuticals Ltd., Postal Symposium No. 1, Management of Terminal Illness, 1970.
Tillich, P., "The Meaning of Health," Perspectives in Biology and Medicine, 5, 92-100, 1961.

Reprint requests should be addressed to E. V. Welldon, Flat 2, Walden House, 32 Marylebone High St., London W.1.
England.
BIOGRAPHICAL NOTE
The author of this article died unexpectedly in November of 1970, survived by his widow and nine-month-old son. Four
months before this he had undergone a laminectomy and had been in severe pain from a slipped disc for the last year of his
life. It was during these last few months that he completed work on this article, begun four years previously.
An abridged version of his obituary in The Lancet follows. It was prepared by Dr. Cicely Saunders, Director of St.
Christopher's Hospice.
"Educated at Tonbridge School, Jesus College, Oxford (to which he won an Open Exhibition) and the London Hospital,
Ronald Welldon had a brilliant academic career. Having taken his degree in Anthropology and Geography he won a
Goldsmith's Postgraduate Travelling Fellowship and went to University College, Ibadan, 1955-56. In 1957 he obtained a
B.Lit., School of Anthropology and Geography, Oxford, for a thesis on 'The Social Geography of a Yoruba Township in
S.W. Nigeria.' As a medical student he won the B.M.A. Students' prize in 1959 and the Mental Health Research Fund
Students' Prize in 1961 for an essay on 'The Influence of Parental Attitudes on the Development of Child Personality.' He
also published a paper jointly with Dr. C. R. B. Joyce on 'The Objective Efficacy of Prayer: A Double-Blind Clinical Study,'
in the Journal of Chronic Diseases in April 1965.
... "As a student Ron Welldon had been concerned with the problems of the incurably ill and the dying and his continued
interest in anthropology and philosophy brought him back to this field. The titles of his two last papers were 'Living with
Death' and 'Bearing the Unbearable.' In 1968 he obtained a Sir Halley Stewart Clinical Research Fellowship to work at St.
Christopher's Hospice. Here he was directing research concerned with all the aspects of the control of pain ...
"The papers that Ron Welldon was writing on the last day of his life and which were found in his brief-case to bring to
St. Christopher's the next morning, were concerned mainly with the effect of pain on environment and community. Among
them occurred the following phrases:
'It seems extremely difficult for any given community to remain open to meaningful questioning in the sense that it is
open to change.'
'Attempting to cure without understanding and acceptance may ultimately be doomed to failure.'
People who have lived far longer lives than Ron Welldon have left much less behind them. All who have worked with him
have been stimulated to think in unusual ways for he was a truly original thinker. At the same time he had a simple and sure
touch with a patient's needs. One of our last memories of him at St. Christopher's is of his sitting quietly beside a patient
holding her hand, with the inevitable pipe in the other. When she discharged herself in a moment of homesickness he had
helped her to go with such kindness that she came back happily two days later to die peacefully. His Research Department
was a social centre for the Hospice and Ron's wit and welcome were the solace of many members of the staff... "He left
himself no reserves whatever in his concern for people and his obsessive search for truth, and this did not help his health
but he gave and found happiness in his family, in his many friends and in his work. There are many for whom Ron was
unique and irreplaceable. Perhaps the very different people who loved him can join together in the thought that he now
knows all the answers. For some people this is the end, for the rest only a beginning, but for all of us it is a challenge not to
leave humanity out of medicine or thinking and philosophy out of life."
1Scott (19) is currently investigating this watershed between the "tenable" home ituation and the "untenable" or hospitalization
alternative.
2As one of my colleagues expressed it succinctly at the time, "What? Spend all that time with one crazy familyand nothing to
show for it? You must be mad."

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