THEORIES OF FAMILY DYSFUNCTION

Many psychological theories on schizophrenia centre on dysfunctional family interactions and relationships being a causal factor. In short, the idea is that growing up in a disturbed family is at the root of a mental disorder. Several researchers have investigated this, and the following theories support this idea: Marital Schizm (Lidz), Expressed Emotion, Double Bind Theory (Batesman), and Freudian theories, all resulting in what has been termed by Fromme-Riechmann as schizophrenogenic families.

It was believed that if you belonged to a dysfunctional family, you were more likely to suffer from schizophrenia due to the dysfunction of communication within the family. According to the different psychological explanations of schizophrenia, this is because of the high emotional tension and the many secrets and close alliances that are kept in the family. Families can be confusing, conflicting mine fields essentially. More specifically, Laing believed that the family can be a cause because they argue, have favourites, and push their desires and frustrations onto their children. Laing believed that schizophrenia and most types of madness were ‘sane’ responses to insane situations. He even went further and said the so-called ‘mumbo jumbo’ and incoherent and downright weird language that schizophrenics demonstrate in their speech were understandable responses to dysfunctional pasts.

Except for expressed emotion, all the above family dysfunctional theories are psychodynamic.

PSYCHOANALYTIC EXPLANATIONS OF SCHIZOPHRENIA

At first, Freud believed that schizophrenia was not psychological in origin and that biology underpinned the condition. Freud used to examine the blood of psychotic patients for the presence of infectious agents such as spirochete. Freud later concluded that some aspects of schizophrenia could be comprehended from a psychological point of view.

Overall, psychoanalytic approaches view schizophrenia as the result of the disintegration of the ego. Fundamentally, the Ego, which operates according to the reality principle has a set of psychic functions that it uses to distinguish between fantasy and reality. For example, it organises thought, makes sense of the world and represents reason and common sense. Freud regarded the Ego as a coherent organisation of mental processes and saw its death, “Ego death” as a complete loss of subjective self-identity. In 1924, Freud wrote that in psychosis, the ego is dragged away from reality. That psychosis is triggered by a disturbance in the relationship between the ego and the external world (Freud, 1924a).  

Freud believed that schizophrenia occurs when the ego becomes overwhelmed by the demands of the id or besieged by unbearable guilt from the superego. The ego cannot cope, so it uses defence mechanisms to protect itself, which is regression. For Freud Schizophrenia was an infantile state. He stated that symptoms such as delusions of grandeur reflect this primitive state. Freud stated that hysteria, obsessional neurosis and hallucinatory confusion were three other forms of defence mechanisms. Eventually, when the schizophrenic’s fantasies become confused with reality, they give rise to hallucinations and delusions. He further thought that auditory hallucinations reflect the person’s attempt to re-establish ego control. Freud also predicted that paranoid delusions were motivated by unconscious homosexual impulses (Lester, 1975). 

Freud believed that ego damage occurs because of the patient’s inability to maintain object relations. Object relations theory is a school of thought in psychoanalytic theory centred around theories of stages of ego development. Its concerns include the relation of the psyche to others in childhood and the exploration of relationships between external people, as well as internal images and the relations found in them. Thinkers of the school maintain that the infant's relationship with the mother primarily determines the formation of its personality in adult life. Particularly attachment, as it is the bedrock of self-development. Thus, object relations theories emphasise the first years of life, ‘the pre-oedipal period when a child should develop a successful relationship with the parent of the opposite sex.

However, despite such elaborate pontificating, Freud concluded that the disorder could not be treated psychoanalytically because of the disorder’s inherent deficits in the capacity for relationships, including the therapeutically necessary development of transference to the treating person. However, Around 1907 to 1908, some of Freud’s inner circle, Harry Stack Sullivan and Frieda Fromm-Reichmann, Federn, Jung, and Abraham, began to express that psychoanalysis could be applied effectively to schizophrenia.

Harry Stack Sullivan also stressed the importance of the child’s earliest interaction with the parents and its major distorting influence as the cause of schizophrenia. He thought that mental illnesses were related to interpersonal relationships and highlighted particular characteristics in the family of schizophrenic patients, such as extreme inflexibility, incapability of communication, and mutual hostility. He felt that individuals with schizophrenia lacked basic trust; had poor ego boundaries, and a vulnerability to psychosis.

In Fromm-Reichmann’s view, schizophrenia reflected a return to early childhood forms of communication. The individual with schizophrenia has a fragile ego and is unable to handle the extreme stress of personal challenges so regresses to childish patterns of talking. Also, their difficulties in living and personality are the remains of earlier unsatisfactory relationships with their family and, in particular, the mother.  Indeed, it was in 1948 that Fromm-Reichmann suggested a 'Schizophrenogenic' mother, one who is both overprotective and hostile to her children.

A03 EVALUATION OF THE PSYCHODYNAMIC EXPLANATION OF SCHIZOPHRENIA

IS PSYCHOLOGY A SCIENCE?

There has been very limited research on the psychodynamic explanation of schizophrenia mainly because many of its assumptions are incredibly hard to test scientifically. How would a scientist investigate fixations and ego defence mechanisms like regression and so on? According to Freud, the ID, Ego and Super-Ego are abstract concepts without a physical location in the brain. How does a researcher prove or not prove that the EGO has disintegrated, therefore? Even trying to prove that experiences in the first two years of life contribute to the development of schizophrenia some twenty years later would be exceptionally difficult.

More importantly, psychodynamic explanations are very underwhelming for various reasons. For instance, it is illogical to argue that schizophrenics resemble very young children as most toddlers have enormous curiosity and wonder about people and their environment. Young children are also very emotionally expressive and energetic. This doesn’t fit either with the positive or negative symptoms displayed by schizophrenic patients, e.g., lack of motivation & emotional response plus bizarre behaviours.

Also, the research and treatments are case studies (idiographic) but the theory itself is nomothetic. Make up your mind? An approach can’t combine different research rationales like this.

Determinism: although psychodynamic theories do not blame the individual’s biology or free will, the theories are still deterministic as the person has no choice about getting schizophrenia if his family is disturbed. There are positive and negative aspects to this kind of determinism. Parents getting blamed might lead to guilt and shame, but it might also lead to positive changes like expressed emotion training.

These kinds of theories are also socially sensitive because blaming parents, in particular mothers, might lead society to treat them as social pariahs. Moreover, why do mothers get continually blamed? Research has confirmed that mothers do not cause schizophrenia (Neill, 1990). The only logic behind the schizophrenogenic mother theory is that females do the bulk of child-rearing, so, therefore, they have the time to do the most damage. Psychoanalytic theories are very misogynistic and gender-biased as most mothers of schizophrenics are not harsh and withholding as Fromme-reichman assumed. Waring and Rick (1965) found that mothers of schizophrenics tended to be anxious, shy, and withdrawn - which, in turn, might be reflective of the stress of having a child with such a serious disorder.

Psychodynamic explanations are reductionist as they reduce the complexity of schizophrenia to early childhood trauma and problems with personality. There is evidence from the MZ and DZ twins that biology is a factor. Eclectic approach? See another diathesis-stress model. Also, the biological A03 on drug therapies discusses how a multi-therapy approach receives the best results.

EVALUATION AND A03 OF PSYCHOANALYSIS (TREATMENT)

Many psychodynamic theorists have very little to do with schizophrenia as it is seen as a psychotic disorder - where a person loses touch with reality. Critics believe that it would be impossible to develop a close therapeutic relationship with a patient who is unable to tell the difference between hallucinations and the real world. Moreover, symptoms such as disordered thinking and language would make psychoanalytic techniques impossible to implement. Lastly, all of the above would hinder a therapist from forming the close interpersonal relationships that are necessary for therapy to proceed.

Critics of Psychoanalysis have said it is only a treatment for the rich as it is very expensive and time-consuming. It is not, for instance, offered on the NHS.

Sullivan (1892-1949), well-known for his interpersonal theory of mental illness, is believed to have accomplished a high recovery rate in his treatment of schizophrenia during the 1920s (Wake, 2008). Indeed, Sullivan and Fromm-Reichmann claimed a massive success rate in dealing with schizophrenics. However, critics have suggested the patients that Sullivan and Fromm-Reichmann treated were not schizophrenic according to DSM or ICD criteria. Furthermore, they were not even very disturbed. Roth and Fonagy have suggested that psychodynamic therapy is not effective even when combined with drugs.

More disturbingly, research into the effectiveness of the treatments has suggested that they actually hurt patients, making them more likely to be hospitalised. Roth and Fonagy have concluded that patients, especially in the acute stage of the disorder, may be too vulnerable to withstand a therapy that is so intrusive and emotionally intense. So maybe Freud was right after all. Relevance: Some critics argue that the theory is culture-bound and has little relevance in other cultures or in modern times; for example, psychodynamic theory was popular in Europe and the USA when people were more repressed about their emotions and parenting was more punitive.

Despite the lack of scientific evidence, psychodynamic explanations of schizophrenia cannot be falsified, e.g.,disproven. Thus, if a psychoanalyst fails to uncover the dysfunctional family dynamics they believe are rooted in the development of a patient’s schizophrenia they would likely argue that the trauma was too painful to uncover from the unconscious mind. A therapist would be unlikely to acknowledge that the reason unconscious memories of abuse did not surface in therapy was because they never existed in the first place. Ultimately, this kind of logic means the theory can never be disputed or falsified.

Many psychodynamic theorists have very little to do with schizophrenia as it is seen as a psychotic disorder - where a person loses touch with reality. Critics believe that it would be impossible to develop a close therapeutic relationship with a patient who is unable to tell the difference between hallucinations and the real world. Moreover, symptoms such as disordered thinking and language would make psychoanalytic techniques impossible to implement. Lastly, all of the above would hinder a therapist from forming the close interpersonal relationships that are necessary for therapy to proceed.

Critics of Psychoanalysis have said it is only a treatment for the rich as it is very expensive and time-consuming. It is not, for instance, offered on the NHS.

Psychoanalysis treatment is difficult to test scientifically, there have been very few controlled studies investigating psychodynamic treatments.

Also, the research and treatments are case studies (idiographic) but the theory itself is nomothetic. Make up your mind? An approach can’t combine scientific approaches like this.

Sullivan (1892-1949), well-known for his interpersonal theory of mental illness, is believed to have accomplished a high recovery rate in his treatment of schizophrenia during the 1920s (Wake, 2008). Indeed, Sullivan and Fromm-Reichmann claimed a massive success rate in dealing with schizophrenics. However, critics have suggested the patients that Sullivan and Fromm-Reichmann treated were not schizophrenic according to DSM or ICD criteria. Furthermore, they were not even very disturbed. Roth and Fonagy have suggested that psychodynamic therapy is not effective even when combined with drugs.

More disturbingly, research into the effectiveness of the treatments has suggested that it actually hurts patients making them more likely to be hospitalised. Roth and Fonagy have concluded that patients, especially in the acute stage of the disorder, may be too vulnerable to withstand a therapy that is so intrusive and emotionally intense. So maybe Freud was right after all.

DOUBLE BIND THEORY

A01 RESEARCH

Double Bind theory accounts for the psychological onset of schizophrenia. It assumes that it does not have a biological or genetic brain origin. The double-bind theory is a psycho-dynamic theory.

Batesman and his colleagues used the term “Double Bind” to describe the contradictory verbal and non-verbal messages that children receive from three parents. . According to Batesman, parents predispose their children to schizophrenia by communicating with them in ways that place the children in a ‘no win situation’.

A double bind is technically defined as a situation where:

• If you do some Action, you'll be punished implicitly

• If you don't do that Action, you'll also be punished

• If you bring up the contradiction, you'll be punished

• You can't leave the situation 

DOUBLE BIND EXAMPLES

EXAMPLES:

1. A mother might, for example, complain about the lack of affection shown by her son whilst at the same time indicating that he is too old to hug her when he tries to be affectionate. Another instance is when a parent expresses care, e.g., tells a child she loves them but shakes her head in disgust when the child makes a mistake. An order to disobey the order; “I dare you to disobey me. You have not got the balls.”

2. A punishment that is done for love. “I am only smacking you because I love you”.

3. “A mother says to her son: "If you admit you stole my money, I will beat you. When the child admits they stole the money they are hit. If they say nothing they are hit. There seems to be no way out.” "Darling, tell me how you feel," and then when you do, you scream at me for being a liar, crazy or bad.

4. Your mother/Father finds fault in something you did. She asks you to be open and explain why you did it, and when you respond by explaining your reasons, he/she attacks you verbally, finding fault in your explanation despite having promised to be understanding, oR Your mother/Father attacks something you are doing. When you refuse to respond by explaining your reasons (because he/she said you were being ‘an idiot’ the last time this was said), he/she now tells you that you are not being open with your feelings and are being withdrawn.

5. No-win questions are questions that are going to convict and condemn you no matter how or which way you answer them. Perhaps the most often cited double-bind question is: "Have you stopped bullying your brother yet?" Clearly either a "yes" or a "no" answer will convict and condemn you. The most common double-bind or no-win questions involve the use of "don't": "Don't you love me?" "Don't you care?" "Don't you want to make something of yourself?" "Don't you want to be successful?" "Don't you want to make me happy?" "Don't you understand me?" "Don't you want to go to college?" "Don't you know better than that?" If you say "yes," then the response is to ask why you didn't or don't then do what you should if you know what to do. If you say "no," then the response is you are defective, bad, worthless, stupid, etc., for not knowing what you should do: the right thing according to their values.

6. When you are told to do two opposite things and then chastised because you did one and not the other, which is an example of “Double Bind statements”. “Double Bind statements” are a guaranteed way to control someone because you can never be right. Here is an example from an old joke: A mother gave her son two shirts. At a family gathering the son made a special effort to wear one of these to please his mother. When he arrived, his mother was angry. "Why?" he wanted to know. "Because you did not wear the other shirt, " she replied. “Double Bind statements” can happen in a variety of ways. For example, in a discussion, a parent might say two opposite things. You are led to believe that he/she changed his/her mind, and you accept the last statement as what was meant. But later in the week, when the issue comes up, he/she says, "Well, I already told you such and such" which was the first thing he/she said. In short, the discussion with you was set up so that no matter what happened, the person can say that he/she did what was agreed.

7. The classic double bind that many Christians grow up with is that God is Love and unconditional love, but he will be angry and will send you to hell for being bad. And to challenge this paradox is a sign of being sinful.

8. Statements such as "Be genuine" The idea here is to present to the person commanding this that you are the master of your true self. But the more the person tries to be genuine the phonier they are, and even the act of not trying is just another version of trying.

The double bind is often misunderstood as a simple Catch-22 situation, where two conflicting demands trap the child. While it is true that at the core of the double bind are two conflicting demands, the difference lies in the following:

• How the demands are imposed upon the victim/child.

• What the child's understanding of the situation is,

• Who imposes these demands upon the child?

A double bind situation is when a powerful person victimises a person with less power, the less powerful is unable to leave the situation, and the paradoxical comments from the powerful person leave the victim speechless and create doubt about their own perceptions.”

How does a double bind make a child develop SZ?

A01 DESCRIPTION

The double bind was originally presented as a situation that could lead to schizophrenia if imposed upon young children, or simply those with unstable and weak personalities. Creating a situation where the child could not make any comment or statements about their dilemma would, in theory, escalate their state of mental anxiety. Bateson maintained that in the case of the schizophrenic, the double bind is presented continually and routinely within the family context. By the time the child is old enough to have identified the double bind situation, it has already been adopted, and the child is unable to confront it. The solution, then, is to create an escape from the conflicting illogical demands of the double bind in the world of the delusional system.

“For example, this means that the child will become confused as the messages they are given are conflicting; one message effectively invalidates the other. As a result, the child is left with self-doubt and eventual withdrawal. Children who experience such double binds may begin to lose their grip on reality and see their feelings, perceptions knowledge and so on as being unreliable indications of reality.

Occurrences such as these are said to cause SZ as they prevent the development of an internally coherent construction of reality, e.g. they don’t know what is real because the messages they receive are contradictory. They may also develop mental health issues because there is no clear template of a loving relationship; instead, the child is always unsure if they have done something wrong due to the conflicting messages they are given. In the end, they are likely to experience SZ-type symptoms such as delusions and hallucinations and, in some cases, paranoia.

 A01 RESEARCH STUDIES THAT SUPPORT DOUBLE BIND THEORY

Some researchers have argued that it would be a confirmation of the double-blind theory if it could be demonstrated that double-bind interactions occur more often in families with a schizophrenic member than in families without a schizophrenic member.

PROSPECTIVE STUDIES: prospective studies are also longitudinal studies because they follow cohorts of individuals or case studies for extended periods into the future.

Goldstein and Rodick (1975) studied adolescents with behavioural problems and their families over five years. Several developed schizophrenia and related disorders during this period and abnormal communication did seem to predict the later onset of schizophrenia. A03: However, the parents of manic patients also displayed deviant communication. So the results cannot be applied to a specific causal factor in schizophrenia.

Blotchky et al. observed 15 families who had a child enrolled in a short-term residential treatment programme. They found that mothers communicated a larger proportion of messages, in which verbal content was rated as being conflicting with nonverbal expression, to the symptom-bearing child (71%) than to other family members, whereas the father did not send more conflicting messages to the symptom-bearing child than to the other family members. Mothers also contributed more to the total of conflicting messages exchanged in these interactional episodes than other family members. A03: Most of the studies have no information on individual differences between the 15 different family groups,

A03: PROSPECTIVE STUDIES

UNSCIENTIFIC RESEARCH METHODS

The trouble with all the psychological theories, including double-bind and psychodynamic theories, is that the research process is very problematic, and any results gained are scorned by the scientific community because trying to prove that experiences in the first few years of life cause schizophrenia, some twenty years later is extremely problematic.

Firstly, getting families to participate in prospective research on schizophrenia is very problematic; who would want to be studied like this? The researcher must be truthful about the hypothesis, but this would then create demand characteristics and social desirability bias; it is doubtful many mothers would behave naturally if they thought the result was them getting the blame for their child’s disorder.

Moreover, the next problem after finding willing participants is finding willing participants with the same set of family dynamics, e.g., the same number of siblings and sibling age gaps, birth order, environment, income, religion, and type of Schizophrenia displayed. Then how does a researcher rate what they see? Can the researcher be objective? How often would they observe? Research budgets dictate this.

Thus, a major criticism of the Double Bind theory is the inability to replicate findings across studies because of uncontrollable variables. Thus, studies such as those outlined above have too many individual differences and an inability to control family dynamics.  As a result, many researchers have found conflicting results.

Secondly, if a researcher wanted to prove that schizophrenia was caused entirely by psychological factors then they would have to find samples that had no history of schizophrenia in the family. Seems relatively straightforward until you remember that the general risk for developing schizophrenia is 1% and that children don’t get schizophrenia until at least 15.. This means the research team must study at least 2000 families for at least fifteen years to get data from approximately 20 participants to enable them to establish whether family communication is causal in the development of schizophrenia, and that’s before you consider things like the internal validity of the observer’s ratings and the participant’s behaviour.

RESEARCHER OBJECTIVITY AND VALIDITY OF BEHAVIOURS:

• It is assumed that schizophrenics and family members continuously talk in double binds, will talk in double binds when third parties are present, and that outsiders can detect double binds without fully appreciating the context in which the interaction occurs (Bateson, 1969/1972).

• Klebanoff has suggested that family patterns that are correlated with schizophrenia actually constitute a reasonable response to an unusual child. Thus children who are brain-damaged and retarded often have mothers who are more possessive and controlling than mothers of non-disturbed children. But this is a response to the unusual child rather than a cause of it.

• An additional criticism is the fact that the Hawthorne effect, demand characteristics, and social desirability bias might have occurred. In observations of families, there is no proof that the parents or children will act as they normally do; therefore, the validity of the results is reduced as the results might not show a true picture of how families with schizophrenic children behave.

For the issues outlined above, researchers soon turned towards another way of studying how families might contribute to SZ. This second research method involved studying families retrospectively, e.g., asking them questions about past family communication during the schizophrenic’s childhood.

RETROSPECTIVE STUDIES

• Berger (1965) investigated families retrospectively by administering a questionnaire consisting of thirty double-bind statements, which subjects were asked to rate on a four-point scale regarding how frequently they recalled their mothers using such statements. There were four groups: one consisting of schizophrenic participants, and three consisting of non-schizophrenic participants. The schizophrenic group consistently reported a higher incidence of DOUBLE BIND statements than one of the comparison groups (college students)

  A03: Results were not significantly higher than the other comparison groups with medical or psychiatric conditions. As with any retrospective study, the interpretability of findings is limited by the fact that recall may be unequally biased in the schizophrenic group because of patients with paranoia and thought control delusions.

• Blumenthal et al. found that a greater number of mothers in families with disturbed members (referred by schools because of chronic behaviour and emotional problems) produced messages which were conflicting along the verbal-nonverbal spectrum than mothers in families without disturbed members during a 5-minute interactional sequence in which families were asked to discuss family related issues.

  A03: Bugenthal’s findings do not rule out differences between the two groups for example nine out of twenty of the disturbed families in his study were single-parent families, whereas all non-disturbed families were two-parent families; it is not clear to what degree these difference may affect the likelihood of double binds occurring but single mothers often have to play dual roles of both mother and father so the observations of Bugenthall may have been unfairly critical.

• Beavers, Blumberg, Timken and Weiner (1965) investigated the meta-communicative ability of schizophrenic families. They found that mothers of schizophrenic children more often respond evasively to interview questions about their children than mothers of non-schizophrenic members, suggesting a difference in interactive style concerning the degree of indirectness. Furthermore, the mother appears to be engaged more often in the exchange of contradictory messages involving children than other adults. This finding would be consistent with Bateson et al.'s condition that discrimination of messages needs to be vital for double bind interactions to have a pathogenic effect.

  A03:

• Wynn and colleagues (1977) and Bateson (1956) found similar results.

• Laing and Esterson (1964) case studies of 11 patients and their families found similar results.

• However, Beakel and Mehrabian (1969) found no differences between those parents ranked by clinical observers as having higher levels of psychopathology and those rated as having lower levels for Double bind statements.

• Some researchers only included problem families.

Evidence suggests that attachment styles may influence subclinical psychosis phenotypes (schizotypy) and affective disorders and may play a part in the association between psychosis and childhood adversity (Russo et al, 2017). Social attachment is a biological and affective need (Trémeau et al., 2016). In the later years, Pinto, Ashworth and Jones (2008) hypothesized that the risk of developing schizophrenia can increase in particular types of deprived childhood environments. Although schizophrenia is primarily genetic the social environment cannot be ignored. Studies show that the social environment can increase the 1% schizophrenia average by a factor of ten (Pinto et al., 2008). In addition, Rajkumar (2014) indicates that disturbed childhood attachment leads to core psychological and neurochemical abnormalities, which are implicated in the genesis of schizophrenia and also affect its outcome.

Most of the above studies appear to indicate that within the family, the symptom bearer is more often engaged in contradictory interactional sequences than other family members.

 A03 SPECIFIC TO RETROSPECTIVE STUDIES

There are said to be problems as it is called a retrospective recall, as the data is unreliable (participants may have poor memories, lie about memories they are uncomfortable with, or repress painful memories). Also as most of the memories were from childhood, researchers would not be able to go back in time to assess the validity of the recollections.

Another problem is that schizophrenics may be unreliable participants, for example, if they are delusional they may be recalling things that didn’t happen, e.g. that their parents gave them conflicting messages.

The families were studied retrospectively; this means they were studied long after the mental disorder may have affected the family system. This means that various family routines will have been disrupted so you will be unable to see how the family acted before a child developed SZ. This is because living with someone with SZ is difficult and distressing for all the family as it has an impact on everyone, not just the patient of SZ. Who says that Schizophrenia is the result of bad parenting? It may be that having a Schizophrenic child causes parents to act strangely and causes massive disruption in the family, giving up work, etc. Chicken and Egg?

OVERALL A03:

Many of the studies blame the mother. The view that mother–child interactions play a causal role in the development of Schizophrenia lacks scientific support, and such approaches have difficulty in explaining why abnormal patterns develop in some rather than all of the children in a family or why some children suffer similar situations and do not develop the disorder.

Plus, theories that blame the mother are personally damaging. How would this make a mother of a schizophrenic child feel? It is socially sensitive as other people will view mothers of schizophrenics negatively.

Such theories are also incredibly gender biased and misogynistic (hateful towards females and motherhood. Mothers have been falsely blamed for most mental illnesses.

However, some researchers contend that since mothers spend far more time caring for children than fathers (who account for much of the abuse), their role may be critical in this regard. There is now a vast body of evidence that early infantile deprivation and erratic or unresponsive care as a toddler make adults more vulnerable to depression and personality disorder (a close diagnostic relative to schizophrenia. Maternal deprivation may create a vulnerability to schizophrenia if there is subsequent abuse. Children with schizophrenic mothers are twice as likely to develop the illness as those with an afflicted father. This could be because disturbing mothers are a major factor. Counter argument: Equally, it could be due to gender-linked genetic inheritance or problems when pregnant.

So far the psychological theories that have been looked at are quite outlandish - from the psychodynamic theory about regression to escape unemotional mothering to Batesman’s double=bind statements. Can these things really cause schizophrenia? There are a multitude of theories that are far more plausible and certainly a lot easier to test. Alternative psychological theories centre around, marital schism, abuse, neglect, trauma and bullying and have much evidence to support them. For example, the Finish adoption study by Tienari (1991) showed that adopted children of schizophrenic mothers were more likely to develop schizophrenia if their adoptive families were disturbed.

Importantly, neither psychodynamic theory nor Double-Bind theory can explain why negative symptoms occur. This is a major disadvantage of the theories as they can account for a large proportion of people who have hypodopamine systems.

EXPRESSED EMOTION

A01 THEORY OF EXPRESSED EMOTION (EE)

Expressed Emotion theory (EE) was developed in the late 1970s.

Because proving psychological theories about the cause is problematic, researchers started looking at how families might contribute to the course of a schizophrenic’s illness rather than the cause of it. Therefore, this theory does not look at childhood or any past living conditions, rather it looks at how families affect the progression of the illness after treatment success. However, findings from EE can be extrapolated to theories about what causes schizophrenia as it shows that schizophrenia is affected by psychological factors such as hostile and critical communication. But be careful how you introduce this theory though and link to cause explicitly.

To understand the origins of the concept of “Expressed Emotion,” one has to go back to the 1950s for the influential research by George Brown. In 1956, George Brown joined the Social Psychiatry (MRCSP) Unit of London, which was established in 1948. When George Brown joined the MRCSP unit, the antipsychotic drug chlorpromazine was widely used to treat schizophrenia patients, which led to the discharge of long-stay patients after they became symptomatically stable and recovered functionally. However, many of these patients were to be readmitted soon after discharge due to symptom relapse. To understand the basis for the symptom relapse, a study was initiated by George Brown and his colleagues with 229 men discharged from psychiatric hospitals, 156 of them with a diagnosis of schizophrenia.

From the study, it was observed that the strongest link between relapse and readmission was the type of home to which patients were discharged. Surprisingly, the patients who were discharged from the hospital to stay with their parents or wives were more likely to relapse and need readmission than those who lived in lodgings or with their siblings. It was also found that patients staying with their mothers had a reduced risk of relapse and readmission if patients and/or their mothers went out to work. It suggested that relapse was probably due to the adverse influence of prolonged contact of patients with their family members.

Theoretically, then, a high level of EE in the home can worsen the prognosis in patients with Schizophrenia (Brown et al., 1962, 1972) or act as a potential risk factor for the development of psychiatric disease.

COMPONENTS OF EXPRESSED EMOTION

The five components of Expressed Emotion are

• Critical Comments

• Hostility

• Emotional Over involvement

• Warmth

• Positive Regard.

• High Expressed Emotion

• Family members with highly expressed emotions are hostile, very critical and not tolerant of the patient. They feel like they are helping by having this attitude. They criticise not only behaviours relating to the disorder but also other behaviours that are unique to the patient's personality. High-expressed emotion is more likely to cause a relapse than low-expressed emotion.

HIGH EXPRESSED EMOTION

• HOSTILITY: Hostility is a negative attitude directed at the patient because the family feels that the disorder is controllable and that the patient is choosing not to get better. Problems in the family are often blamed on the patient, and the patient has trouble problem-solving in the family. The family believes that the cause of many of the family’s problems is the patient’s mental illness, whether they are or not.

• EMOTIONAL OVER-INVOLVEMENT: Emotional over-involvement reflects a set of feelings and behaviours of a family member towards the patient, indicating evidence of over-protectiveness or self-sacrifice, excessive use of praise or blame, preconceptions and statements of attitude. Family members who show high emotional involvement tend to be more intrusive. Therefore, families with high emotional involvement may believe that patients cannot help themselves. Thus high involvement will lead to strategies of taking control and doing things for the patients. In addition, patients may feel very anxious and frustrated when interacting with family caregivers with high emotional involvement due to such high intrusiveness and emotional display towards them. Overall, families with high EE appear to be poorer communicators with their ill relatives as they might talk more and listen less effectively.

• CRITICAL COMMENTS: Careful observations of direct communications between patients and caregivers prove that critical caregivers get involved in angry exchanges with the patient whom they seem unable to prevent or to step away from. These potentially lead to physical violence, and it is the nature of some families with high EE. Patients who are unable to get up in the morning, who fail to wash regularly, or who do not participate in household tasks are criticised for being lazy and selfish; unfortunately, in this context, the caregivers fail to understand that these could be potential manifestations of negative symptoms of schizophrenia or any other psychotic disorder. By contrast, low EE caregivers are more capable of recognizing aspects of the patient’s behaviour that manifest the illness. Examples: Family caregivers may express in an increased tone, tempo, and volume that the patient frustrates them, deliberately causes problems for them, family members feel the burden of the patient, living with him is harder, commenting that the patient is ignoring or not following their advice.

LOW EXPRESSED EMOTION: Low expressed emotion is when the family members are more reserved with their criticism. The family members feel that the patient doesn't have control over the disorder. When the family is more educated they are more likely to have low expressed emotion.

• WARMTH: It is assessed based on kindness, concern, and empathy expressed by the caregiver while talking about the patient. It depends greatly on vocal qualities with smiling being a common accompaniment, which often conveys an empathic attitude by the relative.  Warmth is a significant characteristic of the low EE family. Examples: Caregivers state that the patient tries to get along with everyone, he makes a lot of sense, he is easy to get along with, and it is good to have him around; the patient’s behaviour is appropriate since it is not his/her pre-morbid self.

• POSITIVE REGARD: Positive regard comprises statements that express appreciation or support for the patient’s behaviour and verbal/nonverbal reinforcement by the caregiver. Examples: Family states that they feel very close to the patient, they appreciate the patient’s little efforts or initiation in his day-to-day functioning, they state that they can cope with the patient and enjoy being with him/her.

HOW DO YOU MEASURE EE?

Expressed emotion (EE), is a measure of the family environment that is based on how the relatives of a Schizophrenic patient spontaneously talk about the patient. It is a psychological term specifically applied to psychiatric patients.

• Typically, it is determined whether a person or family has high-expressed emotion or low-expressed emotions through a taped interview known as the Camberwell Family Interview (CFI). Answers to questions and non-verbal cues are used to determine if someone has highly expressed emotion.

• There is another measurement that is taken from the view of the patient. It rates the patient's perception of how his family feels about him and the disorder. If the patient feels that the parents are too protective or not caring the patient feels that his parents don't care about his independence or trust his judgement. This attitude may cause the patient to relapse, and patients who rate their parents poorly in this test have a harder time coping with their illness if too much time is spent with the parent.

• An alternative measure of expressed emotion is the Five Minutes Speech Sample (FMSS), where the relatives are asked to talk about the patient for five uninterrupted minutes. Although this measure requires more training, it becomes a quicker assessment form than the former method.

A01 RESEARCH EXPRESSED EMOTION

• It is well established that high family levels of Expressed Emotion are consistently associated with higher rates of relapse in patients with schizophrenia. The first study to undertake the EE measure and connect it to the course of schizophrenia was investigated by Brown et al., where the patients were followed up for nine months after they were discharged and sent to their home from the hospital. It was found that prolonged contact with patients with critical caregivers determines the relapse in schizophrenia.

• Btzlaff and Hooley (1998) meta-analysis

• Kavanagh reviewed 26 studies on EE and found that the mean relapse rate was 48% for patients residing with high EE families and 21% for those in low EE families.

• A comprehensive analysis by Bebbington and Kuipers of data from 1,346 patients established the relationship between family caregiver’s EE and relapse, and also the protective factor of reduced face-to-face contact for patients in high EE families.

• These studies have been supported by Linszen who found relapse to be four times more likely in high EE homes. This study suggests that a high level of emotion in the family environment plays a role in the SZ patients’ disorder becoming worse.

• There is also support for this explanation from Vaughn and Leff who also found that the level of expressed emotion had an effect on relapse rates amongst discharged patients. However, they also studied the amount of face-to-face contact patients had with relatives after discharge, and they found an increase in relapse rates as face-to-face contact increased, and even more so with higher levels of expressed emotion. This study suggests that the more time an SZ patient spends with a family with high levels of EE the more likely they are to relapse.

• Kalafi and Torabi (1996) studied expressed emotion within families in an Iranian culture. They found a higher prevalence of expressed emotion was one of the main causes of relapse, this suggests that a mixture of emotions from parents in the Iranian culture plays a role in the SZ patient relapsing.

A03: EVALUATION OF EXPRESSED EMOTION

There are several strengths to this theory. For example, there is a lot of supporting research conducted to make the theory more valid. The EE is a well-established “maintenance” model of SZ and many prospective studies have been conducted which support the EE hypothesis across many cultures, therefore the theory is also applicable cross-culturally.

The EE model has become widely accepted, and research is now focussing on relatives of those with SZ in order to understand better which aspects of high and low EE relate to relapse. For example, there is evidence to support that the family members do not display High EE when their relative displays positive symptoms such as hallucinations and delusions as they think these are part of their relative’s mental illness. They cannot control them through free will. On the other hand, there is also evidence that family members attribute negative symptoms, for example, social withdrawal, to the person’s personality characteristics, and it has been observed that they become over-critical in an attempt to change those behaviours. In other words, family members think negative symptoms are thought to be due to the free will of the schizophrenic. As a result, family members will display high EE to get their relatives to stop behaving with negative symptomology.

Which EE variable is the most damaging? Overall, it was concluded by Lopez that families characterised by negative affect (criticism) have much higher relapse rates in comparison to those with positive affect (warmth).

Another criticism of this theory in general, is that many patients with SZ are either estranged from their families or have minimal contact. Yet, there is no evidence that such people are less prone to relapse. Therefore it is unclear whether there is an impact.

What is not yet clear is exactly how to interpret the effects of EE. Is EE causal, or does it reflect a reaction to the patient’s behaviour? It should be remembered that relationships within the family work both ways and that there is some evidence that certain aspects of High EE behaviour are now associated with the abnormalities in the patient. For example, if the condition of a patient with schizophrenia begins to deteriorate, a family member’s concern and involvement might increase. Indeed disorganised or dangerous behaviour by the patient would warrant limit setting and other family efforts that could raise the level of EE.

There has also been an argument about whether the EE model is a cause or an effect of SZ. Indeed, it has been found that high EE is less common in the families of first-episode patients than in those of first-symptom patients. This suggests that High EE may well develop as a response to the burden of living with a Schizophrenic.

A03: ALL PSYCHOLOGICAL EXPLANATIONS

DETERMINISM VERSUS FREE WILL

All psychological theories are deterministic and suggest that you have no free will against developing or personally overcoming Schizophrenia. There are negative and positive aspects to this. On the negative side, parents will be blamed for causing Schizophrenia.  Family and theories are unconstructive as they blame the parents and families for a child developing SZ. Suggesting that a parent has caused SZ is at least unhelpful and, at most, highly destructive, as they not only have to cope with living with someone with SZ but are then told that it is their fault, which will lead them to feel guilty and hurt as they are blamed for a poor upbringing.

On the positive side, your family may see it worthwhile in trying to change their behaviour and individuals will not be perceived to be at fault as their illness is a result of their upbringing. Matthijs Koopmans of City University in New York states: "There is a very persistent misconception that models connecting family processes to schizophrenic symptomatology in effect blame the parents for their children's ills, rather than recognising the potential of such models to empower parents and caretakers to modify their interactive patterns to better accommodate the identified patient, and perhaps even prevent dysfunctional patterns of interaction from occurring in the first place."

NATURE VERSUS NURTURE (DIATHESIS STRESS MODEL).

Psychological theories are nurture yet nurture cannot be the only answer as MZ twins have a 48% concordance rate and DZ twins have a 17% concordance rate. If it was purely psychological then MZ and same-sex DZ twins would have the same rate. This means nature must play a role too. Indeed, current thinking now believes that both nature and nurture play a role in the aetiology of Schizophrenia, e.g. that individuals are born with a genetic predisposition or biological trigger but may not develop the disorder unless they are exposed to an environmental or psychological trigger. These triggers can be Psychological factors that include disturbing family dynamics and stress. This is known as the Diathesis Stress Model (DSM). Tienari’s ‘Finnish adoption study’ supported the DSM as only children of schizophrenic mothers developed schizophrenia themselves if their adopted family was disturbed. Genes alone did not cause the illness. However, if there was a high genetic risk and it was combined with mystifying care during upbringing or abuse, the likelihood was greater. This suggests that genes can be implicated, but only if the family environment is of the kind that fulfils schizophrenic genetic potential.

ALTERNATIVE THEORY: The fact that some two-thirds of people diagnosed as schizophrenic have suffered physical or sexual abuse is shown to be a major cause of the illness.

John Read (2004) collected 40 studies that reveal childhood or adulthood sexual or physical abuse in the history of the majority of psychiatric patients (see also Read's book, Models of Madness). A review of 13 studies of schizophrenics found rates varying from 51% at the lowest to 97% at the highest. Importantly, psychiatric patients or schizophrenics who report abuse are much more likely to experience hallucinations. Read believes the content of these often relates directly to the trauma suffered. At their simplest, they involve flashbacks to abusive events which have become generalised to the whole of their experience. For example, an incest survivor believed that her body was covered with sperm. The visual hallucinations or voices often scare and belittle the patients, just as their tormentors did in reality, creating a paranoid universe in which people/family/friends cannot be trusted.

JOINT A03 DEBATES:  IS PSYCHOLOGY A SCIENCE? CLASSIFICATION ISSUES

Theories that are psychologically based have not gained much support, for they are considered to be less scientific, for example, poorly controlled studies, no controls, retrospective data, internally invalid, and not the same results when replicated.

Family studies are harder to conduct experimental procedures less possible because real-life/individual family dynamics are difficult to control. Cause and effect conclusions are not possible then; therefore, psychological research is often correlational.

What really clouds the validity and reliability of any of the psychological theories is the fact that many researchers (Bentall, 1990, Rosenhan) believe that Schizophrenia is an impossible illness to classify. Since 1911, when the illness was first described, there has been great controversy concerning what symptom and description should be used to define the illness. Indeed, DSM IVR and ICD 10 have different criteria for the diagnosis and classification of Schizophrenia. Moreover, the last few years have been particularly important in the evolving definition of Schizophrenia as the criteria for the illness have slimmed down considerably. Not only have two distant subtypes emerged, type one and type two (which incidentally have had psychologists arguing that two very different illnesses may exist and not one!), but the condition has many categories, e.g. Paranoid and Hebephrenic. If we cannot rely on what the ever-changing definition of schizophrenia is, then how can research test its prevalence? Especially research conducted in the 1960s when the definition bore little resemblance to what the illness translates to today.