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Paul Eugen Bleuler ( ; "Bleuler". Random House Webster's Unabridged Dictionary. ; 30 April 1857 – 15 July 1939) was a Swiss psychiatry and eugenicist most notable for his influence on modern concepts of mental illness. He coined several psychiatric terms including "schizophrenia", "schizoid",Details recorded in: "autism",Peter Gay, Freud: A Life for Our Time (1989) p. 198 depth psychology and what Sigmund Freud called "Bleuler's happily chosen term ambivalence".Sigmund Freud, Three Essays on the Theory of Sexuality, p. 65. Bleuler remains a controversial figure in psychiatric history for his racism, sanism, and ableism beliefs, as well as his implementation of eugenic practises in psychiatry based on these beliefs, most notably at the Burghölzli clinic in Zurich.
Bleuler became the director of a psychiatric clinic in Rheinau, a hospital located in an old monastery on an island in the Rhine. At the time, the clinic was known for being functionally backward and largely ineffective. Because of this, Bleuler set about improving conditions for the patients residing there.
In the year 1898, Bleuler returned to the Burghölzli and became a psychiatry professor at Burghölzli, the same university hospital at which he completed his residency. He was also appointed director of the mental asylum in Rheinau. He served as the director from the years 1898 to 1927. While working at this asylum, Bleuler cared for long-term psychiatric patients. He also implemented both psychoanalytic treatment and research, and was influenced by Sigmund Freud.
During his time as the director of psychiatry at Burghölzli, Bleuler made great contributions to the field of psychiatry and psychology that made him known today. Given these findings, Bleuler has been described as one of the most influential Swiss psychiatrists.
Like Freud, Bleuler believed that complex mental processes could be unconscious. He encouraged his staff at the Burghölzli to study unconscious and psychotic mental phenomena. Influenced by Bleuler, Carl Jung and Franz Riklin used word association tests to integrate Freud's theory of repression with empirical psychological findings. As a series of letters demonstrates, Bleuler performed a self-analysis with Freud, beginning in 1905. Bleuler laid the foundation for a less fatalistic view of the course and outcome of psychotic disorders along with C. G. Jung, who further used Bleuler's theory of ambivalence and association experiments to diagnose neurotic illnesses.
Bleuler found Freud's movement to be overly dogmatic and resigned from the International Psychoanalytic Association in 1911, writing to Freud that "this 'all or nothing' is in my opinion necessary for religious communities and useful for political parties...but for science I consider it harmful".Quoted in Gay, p. 215 Bleuler remained interested in Freud's work, citing him favorably, for example, in his often reprinted Textbook of Psychiatry (1916). He also supported the nomination of Freud for the Nobel Prize in the late twenties.Gay, p. 456 and p. 486
Bleuler distinguished between positive and negative symptoms of schizophrenia. Positive symptoms include symptoms not found in unaffected people, such as hallucinations or delusions. Negative symptoms describe the absence of typical experiences such as social withdrawal or lack of pleasure. Bleuler also distinguished between basic and accessory symptoms as well as primary and secondary symptoms. Basic symptoms are those that are present in every case of schizophrenia, whereas accessory symptoms vary depending on the patient. Bleuler defined primary symptoms as those that are directly related to neurobiological processes. He defined secondary symptoms as behavioral reactions to primary symptoms. Differentiating these symptoms contributed to an increased understanding of schizophrenia in general.
Like Kraepelin, Bleuler argued that dementia praecox, or "the schizophrenias", was a physical disease process characterized by exacerbations and remissions. He argued that no one was ever completely "cured" of schizophrenia; there was always some sort of lasting cognitive weakness or defect that was manifest in behavior. Unlike Kraepelin, Bleuler believed that the overall prognosis was not uniformly grim. He believed "dementia" was a secondary symptom not directly caused by the underlying biological process. There were three other "fundamental symptoms" that included deficits in associations, affectivity, and ambivalence. He believed the biological disease was much more prevalent in the population due to its "simple" and "latent" forms.
Bleuler's changes to Kraepelin's dementia praecox were accepted by countries such as Switzerland and Britain. However, some countries, such as Germany, did not accept these changes at first. Bleuler's concept of schizophrenia was pushed aside due to its similarities to Kraepelin's dementia praecox. It was only widely accepted after Kraepelin's disease classification did not have direct evidence nor was it directly expressed in his patients.
In 1911, Bleuler wrote, "When the disease process flares up, it is more correct, in my view, to talk in terms of deteriorating attacks, rather than its recurrence. Of course the term recurrence is more comforting to a patient and his relatives than the notion of progressively deteriorating attacks". The eugenic sterilization of persons diagnosed with (and viewed as predisposed to) schizophrenia was advocated by Bleuler. He argued that racial deterioration would result from the propagation of "mental and physical cripples" In his Textbook of Psychiatry, Bleuler states, See:
In 1917, Bleuler discussed the heredity involved in schizophrenia after psychiatrist Ernst Rudin published his findings. Bleuler agreed with Rudin that having a family member with schizophrenia increases an individual's chance of also having the disease. However, Bleuler found that Rudin's study did not use sufficient sampling methods, threatening the integrity of the study. While researching further, Bleuler made several conclusions that differed from Rudin's. First, that the schizophrenic gene was not a dominant trait. Second, the disease involves a dihybrid, complex gene and does not include a monohybrid gene. Bleuler also said that there may be a polymorphic aspect to schizophrenia, meaning it presents itself in different forms.
Bleuler found that in order for schizophrenia to present itself in patients, several elements must come together. He found that there are a wide variety of symptoms associated with schizophrenia that can lead to a potential diagnosis. Bleuler concluded that several aspects of the disease are not genetically inherited. These tend to be behavioral aspects and positive symptoms, including hallucinations, delusions, and strange ideas.
He believed the disease's central characteristics were the product of splitting between the emotional and the intellectual functions of the personality. He favored early discharge from hospital into a community environment to avoid institutionalization.
Bleuler was known for his clinical observation and willingness to let symptoms speak for themselves. He was also known for his skillful expository writings. Bleuler has never been credited with healing his patients. Like Sigmund Freud he experimented on patients in his care; many were sterilised and many committed suicide.L. L. Hvens/S. N. Ghaemi, Psychiatric Movements (2004) p. 334 and p. 353.
Later in his life, Bleuler studied and published works on psychoids. He defined the psychoid as the capacity to respond and adapt to stimuli, creating permanent changes in the brain and shaping future reactions. Bleuler believed the psychoid to be a cause of psychic development. He also proposed that social, mental, and physical aspects of life are not separate from each other but instead are seen as aspects of a sole life principle. These ideas were not particularly popular among the scientific community and did not receive a great deal of attention.
In his seminal 1911 work, Dementia Praecox, or the Group of Schizophrenias, Bleuler wrote: "Castration, of course, is of no benefit to the patients themselves. However, it is to be hoped that sterilization will soon be employed on a larger scale... for eugenic reasons." These practices were part of a broader movement in early 20th-century psychiatry that endorsed eugenic policies, influencing Bleuler’s implementation of such practices in psychiatric care.
Bleuler's advocacy for eugenic sterilization significantly contributed to the widespread adoption of these practices in psychiatric institutions, most notably at the Burghölzli Clinic.
This paradox is particularly striking given that Bleuler expanded on Emil Kraepelin concept of dementia praecox while rejecting its strictly degenerative prognosis. Although he acknowledged some variability in outcomes, he still framed schizophrenia as a disorder characterized by a "split" from reality that could not be fundamentally reversed. This perspective played a significant role in the medicalization of psychiatric conditions, contributing to a framework that justified eugenic interventions—such as sterilization—rather than treatments focused on recovery. By framing schizophrenia as an irreversible condition, Bleuler reinforced a medical model that prioritized control and segregation over healing and reintegration.
In this same vein, he developed what he called 'Udenotherapy (also spelled Oudenotherapy, from the ancient Greek οὐδεν (ouden) meaning “nothing” and θεραπεία (therapeia) meaning “service, care, healing”). This term reflected his belief that illnesses should not be treated with immediate, active intervention but rather by allowing their natural course to unfold, observing passively their decline, with the hope that recovery could occur. However, waiting for symptoms to resolve without intervention risks being viewed as neglect rather than compassionate care.
Institutional therapy under his direction was primarily based on work and occupational engagement. Patients were trained in self-discipline, and in severe cases, subjected to behavioral conditioning. Discharge required suppressing and controlling disruptive secondary symptoms, a process Bleuler and his successors referred to as "socialization".
By defining schizophrenia as a fixed biological defect rather than a dynamic condition with potential for improvement, Bleuler helped shape psychiatric practices with severe consequences for patients:
• Involuntary commitment and Institutionalization – His theories justified the long-term confinement of individuals with schizophrenia in asylums rather than efforts to reintegrate them into society.
• Eugenics and Sterilization – Framing schizophrenia as a hereditary, incurable illness provided justification for sterilization and other eugenic measures, which Bleuler supported.
• Shifting Focus from Recovery to Management – Instead of prioritizing treatment aimed at healing, the medical model of schizophrenia focused on long-term management, often through coercive and experimental methods. Many patients committed suicide as a result.L. L. Hvens/S. N. Ghaemi, Psychiatric Movements (2004) p. 334 and p. 353.
As a doctor, Bleuler was expected to seek cures rather than create a framework that solidified schizophrenia as an unhealable disorder. His approach aligned more with eugenics and social control than with the hypocratic oath, making his legacy philosophically and ethically questionable to this day.
The revision of the textbook after the war—removing references to eugenics and replacing them with methods like lobotomy and neuroleptics—can be interpreted as an attempt to distance the field of psychiatry from its eugenic past, but also raise questions about the ethics of covering up problematic history. The introduction of lobotomy and neuroleptics after the war, while possibly aiming to reflect a shift in psychiatric treatments, also have contributed to harmful practices. Lobotomies, as well as Neuroleptics were deeply controversial despite their widespread use, and would later become subjects of ethical scrutiny due to concerns over their overuse, side effects, and questionable application in treating vulnerable patients.
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