The Wisdom of Silvano Arieti, Pioneer in Schizophrenia

Silvano Arieti's book Interpretation of Schizophrenia was awarded the 1975 U.S. National Book Award in the Science category. More than 40 years later, it remains the most significant contribution to the psychological understanding of schizophrenia since Kraepelin and Bleuler. Contemporary psychiatrists and psychotherapists would be wise to review Arieti's vast contributions to the field.

Silvano Arieti, M.D. (1914-1981).

Source: Public domain

In the tradition of other pioneering Italian psychiatrists like Gaetano Benedetti, Arieti maintained throughout his career chief interest in understanding the problem of schizophrenia. It is perhaps his conceptualization of this disease, as well as his broader theoretical contributions regarding the nature of mental illness, for which he will be most remembered.

Trained initially as a psychiatrist and then as a psychoanalyst, Arieti placed great importance on understanding the psychological significance of psychotic symptoms. At a time when most psychiatrists dismissed the psychoanalytic approach in favor of neuroleptic treatment for schizophrenia, Arieti saw the illness through a comprehensive biopsychosocial lens, insisting that schizophrenia, at least in its earlier stages, could be helped by a psychotherapeutically-oriented treatment. With therapy, Arieti contended, the patient could begin to understand how he concretized abstract ideas, wishes, and conflicts into psychotic symptoms. He also submitted that the development of basic trust is the foundation upon which any effective psychotherapeutic work is undertaken.

Describing the psychodynamic mechanisms underlying first-episode psychosis, Arieti (1974) writes in Interpretation of Schizophrenia:

[When the patient] cannot change the unbearable situation of himself any longer, he has to change reality. . . . His defenses become increasingly inadequate. . . . The patient finally succumbs, and the break with reality occurs.

Despite his lifelong dedication to the psychotherapy of schizophrenia, Arieti never discounted the importance of biological research, nor did he shun treatment with psychiatric medication. In his brilliance, Arieti realized that the biological and the psychodynamic are not competing paradigms but rather complementary ones. Biological findings do not lose meaning when psychoanalytic explanations are detailed, and the psychoanalytic does not lose its value when biological mechanisms are described. In Interpretation of Schizophrenia, he devotes four chapters to biology, including "The Biochemistry of Schizophrenia" and "The Central Nervous System in Schizophrenia."

A first-issue Italian stamp featuring Silvano Arieti on display in my office, sent to me graciously by his son, David.

Source: Mark L. Ruffalo, D.Psa., L.C.S.W.

Writing beautifully in his American Handbook of Psychiatry, first published in 1959, Arieti summarizes his views on psychiatric treatment:

My own marked preference, in the average case, is psychotherapy. . . . My "bias" is based on the belief that physical therapies, as far as we know or can infer, produce only a symptomatic improvement, whereas psychotherapy tends to: (1) remove the basic conflicts that led to the disorder (2) correct the psychopathologic patterns and (3) permit the regenerative psychological powers of the organism to regain lost ground. These assertions, however, should not be considered a condemnation of physical therapies. On the contrary, I have found physical therapies, with the exception of psychosurgery, useful, at times, in a variety of situations.

Arieti was a longtime professor of psychiatry at New York Medical College and was also a training analyst in the Division of Psychoanalysis at the William Alanson White Institute in New York City. Born in Pisa in 1914, he left Italy soon after medical school due to increasing political tensions under Benito Mussolini. The Italian government issued a stamp in 2014 to mark the 100th anniversary of his birth. Arieti died in New York in 1981.

In the preface of Interpretation of Schizophrenia, Arieti writes:

The present book . . . is the work of one man. . . . Be lenient, reader, but not too much; for I was not alone in this thirty-three year work. Always with me was the sufferer, who sooner or later gave me the gift of trust.

Silvano Arieti is remembered as one of history's foremost authorities on the most complex condition known to afflict mankind: schizophrenia. His devotion, care, and love is demonstrated throughout his abundant writings. At a time when the most that could be done for those with schizophrenia was long-term institutionalization in the back wards of state mental hospitals, Arieti attempted—and succeeded—at developing meaningful, human relationships with his patients.

Yet, it is perhaps Arieti's appreciation for both the biological and the psychoanalytic that reflects his greatest and most enduring contribution to contemporary psychiatry.