Specification: Psychological explanations for schizophrenia: family dysfunction and cognitive explanations, including dysfunctional thought processing.

Family dysfunction explanations of schizophrenia

Family dynamics have received a lot of attention when it comes to explaining schizophrenia. These theories believe that the problems within a family contribute to onset and relapse of schizophrenia. 

Schizophrenogenic mother

Fromm-Reichmann (1948) proposed that schizophrenia comes from being reared by a cold and dominant mother who is both overprotective but rejecting. Although such a mother appears self-sacrificing, she actually uses the child to satisfy her own emotional needs. Therefore, individuals brought up with this mothering style develop schizophrenia as they are confused by their mothers overprotective but rejecting nature. 

Today this hypothesis is not taken seriously by most researchers. Although some research (Roff and Knight 1981) indicates that there is a relationship between mothering style and schizophrenia, research has also found that this mothering style is implicated in many other disorders, which is another reason why the hypothesis has largely been abandoned. 

Double-bind

Bateson (1956) proposed the double-bind hypothesis which suggested that schizophrenia is a reaction to a pathological parent presenting the child with a no win situation. This is created by contradictory communication between tone of voice and content. For example, a mother may say, ‘Come and give mummy a cuddle’, but then freezes when the child approaches, and then tells the child off for not being affectionate. This leads to a negative reaction of social withdrawal in order to escape double-bind situations. 

The theory states that children who frequently receive contradictory messages from their parents are more likely to develop schizophrenia. If a mother tells her son that she loves him, yet at the same time turns her head away in disgust, the child receives conflicting messages about their relationship on different communication levels: affection on the verbal level, hostility on the nonverbal. Bateson et al. (1956) argued that the child’s ability to respond to the mother is undermined by such contradictions because one message effectively invalidates the other. Prolonged exposure to such interactions prevents the development of an internally coherent construction of reality; in the long run, this shows itself as typically schizophrenic symptoms such as flattening affect, delusions and hallucinations, incoherent thinking and speaking, and in some cases paranoia. 

Evaluation of double-bind

A major drawback of this theory is that there is little evidence of double-bind communication in families associated with schizophrenia, and when it does occur it may well be the result of having a schizophrenic in the family, rather than be the sole cause of it. However, there is some evidence to support this account. Berger (1965) found that schizophrenics reported a higher recall of double-bind statements by their mothers than non-schizophrenics. This evidence may not, however, be reliable as patients’ recall may be affected by their illness. Nevertheless, Bateson (1956) reported a case study where a recovering schizophrenic was visited in hospital by his mother. He embraced her warmly, but she stiffened, and when he withdrew his arms she said: ‘Don’t you love me anymore?’ This gives support to the idea of double bind. Yet, critics have argued that this is weak evidence for the theory due to the use of a case study, which lacks population validity and therefore generalisability. 

However, other studies are less supportive. For example, Liem (1974) measured patterns of parental communication in families with a schizophrenic child and found no difference compared with normal families. In addition, Hall and Levin (1980) analysed data from previous studies and found no difference between families with and without a schizophrenic member in the degree to which verbal and non-verbal communication were in agreement. 

Expressed emotion

The expressed emotion explanation is where families persistently exhibit criticism, hostility and a general negative influence upon recovering schizophrenics, who when returning to their families react to the expressed emotion by relapsing and experiencing positive symptoms, such as delusions. 

Expressed emotion (EE) is a family communication style in which members of the family of a schizophrenic talk about the person in a critical or hostile manner, or in a way which indicates emotional over-involvement or overconcern. Kuipers et al. (1983) found that high EE relatives talks more and listen less. It is thought that high levels of EE are most likely to influence relapse rates - a patient returning to a family with high EE is about four times more likely to relapse than a patient whose family is low in EE. This suggests that people with schizophrenia have a lower tolerance for intense emotional situations, particularly comments and family situations. It appears that the negative emotional climate in these families arouses the patient and leads to stress beyond the patient’s coping mechanisms, therefore triggering an episode. 

Evaluation of expressed emotion

Hooley et al. (1998) conducted a meta-analysis of 26 studies and found that schizophrenics returning to a family environment of high EE experienced more than twice the average rate of relapse. This was supported by Kavanagh (1992) who also conducted a meta-analysis, finding that the relapse rate for schizophrenics who returned to live with high EE families was 48% compared with 21% for those who went to live with low EE families. These studies support the claim that EE could be responsible for a patient’s relapse. 

However, not all patients who live in high EE families relapse and not all patients who live in low EE homes avoid relapse and individual differences appear to play a role in how people respond to EE. Altorfer et al. (1988) found that one-quarter of the patients they studied showed no physiological responses to stressful comments from their relatives. Consequently, the vulnerability to the influence of high EE may be psychologically based. Lebell et al. (1993) suggests that how patients appraise the behaviour of their relatives is important. In cases where high EE behaviours are not perceived as being negative/stressful, they can do well regardless of how the family environment is objectively rated. This is showing that not all patients are equally vulnerable to high levels of expressed emotion and there are clear individual differences. Overall though, the general approach is supported by the fact that therapies successfully focusing on reducing expressed emotions within families have low relapse rates compared with other therapies. 

Evaluation of family dysfunction theories

Having a schizophrenic within a family can be problematic and extremely stressful. Therefore, it is possible that rather than dysfunctions within families causing schizophrenia, it could be that having a schizophrenic within a family leads to these dysfunctions. For example, it may be an effect of living with a schizophrenic rather than the initial cause. There is a general lack of support for family dysfunction as a causal factor, if anything it is more likely to be a maintenance factor. 

A problem with all of the theories involving the family is that they fail to explain why some children in such dysfunctional families often do not go on to develop schizophrenia. If family dynamics were the sole cause of schizophrenia, then all children raised in similar environments should be schizophrenic. As this is not the case family dysfunctions cannot be the sole cause of the illness. It is more likely that the schizophrenic has a biological predisposition to the disorder and that the unhealthy family environment combines with the biological vulnerability to cause the illness, like the diathesis-stress model proposes. One element of nurture is most probably not enough alone to cause the illness. 

Cognitive explanations of schizophrenia

Cognitive approaches examine mental processes i.e. how people think and how they process information. Schizophrenia is associated with several abnormal cognitive processes and cognitive explanations focus on these as the cause of schizophrenia. 

Cognitive deficits

Cognitive deficits occur when sufferers experience problems with attention, communication and information overload. Schizophrenics are unable to deal with inappropriate thoughts, such as misperceiving voices in their head as people actually trying to speak to them, rather than perceiving them more sensibly as ‘inner speech’, which most people experience. There is evidence that people diagnosed as schizophrenic have difficulties in processing visual and auditory information. Schizophrenics have difficulties in understanding other people’s behaviour might explain some of the experiences of those diagnosed as schizophrenic. Social behaviour depends, in part, on using other people’s actions as clues for understanding what they might be thinking. Some people who have been diagnosed as schizophrenic appear to have difficulties with this skill. Cognitive deficits have been suggested as possible explanations for a range of behaviours associated with schizophrenia. These include reduced levels of emotional expression, disorganised speech and delusions. 

Cognitive biases

Cognitive biases refer to selective attention. The idea of cognitive biases has been used to explain some of the behaviours, which have been traditionally regarded as symptoms of schizophrenia. 

• Delusions: The most common delusion that people diagnosed with schizophrenia report is that others are trying to harm or kill them (delusions of persecution). These delusions are associated with specific biases in reasoning about social situations. Many people who experience feelings of persecution have a general tendency to assume that other people cause the things that go wrong with their lives. 

• Auditory hallucinations: There is evidence (Bentall 1990) that auditory hallucinations (hearing voices where none exist) are related to cognitive biases. To some extent, people see themselves in terms of their social relationships. Some people tend to see themselves as powerless compared to other, more powerful individuals in their social network. This bias can lead them to see themselves as worthless, useless and incompetent. Most people experience an inner voice when thinking in words – for example, when deciding what to do or when struggling with a problem. There is evidence that some people who experience auditory hallucinations mistake their inner voice for speech from an external source. Those who see themselves as powerless sometimes hear voices saying ’he’s useless’. The status and power gap they see between themselves and others in their social network is mirrored in the relationship they have with the ‘voice’. The bigger gap, the more powerful the ‘voice’ and the more control it has. 

Dysfunctional thought processing

Frith et al. (1992) has identified two kinds of dysfunctional thought processing: 

• Metarepresentation is our ability to reflect on thoughts and behaviour and it allows us to identify our goals and intentions, as well as allowing us to interpret the actions of others. Dysfunction in this area would disturb out ability to recognise our own actions and thoughts as being ours and carried out by ourselves, rather than being carried out by someone else. This therefore can explain hallucinations as the inner voice is experienced as coming from an external source. 

• Central control is our ability to suppress automatic responses while we perform deliberate actions instead. Having disorganised speech could be due to an inability to suppress automatic thoughts and speech triggered by other thoughts. Many schizophrenics experienced derailment of thoughts and spoken words/sentences because each word triggers an associations and the schizophrenic cannot stop the automatic responses to these associations. 

Evaluation

There is evidence that suggests that information is processed differently in the mind of a schizophrenic. Stirling at al. (2006) compared 30 patients with schizophrenia with 18 controls on a range of cognitive tasks including the Stroop Test. In the Stroop Tests participants have to name the ink colours of colour words, therefore suppressing the impulse to read the words in order to do the task. The schizophrenic patients took twice as long to name the ink colours as the control group, indicating that they were struggling to have central control and suppress the automatic associations. 

Sarin and Wallin (2014) reviewed recent research relating to the role of cognitive biases and found supporting evidence for the claim that the positive symptoms of schizophrenia have their origin in faulty cognition. Delusional patients were found to show various biases in their informational processing, such as jumping to conclusions and lack of reality testing. Also patients with hallucinations were found to have impaired self-monitoring and tended to experience their own thoughts as voices. This research illustrates that schizophrenia sufferers have cognitive biases not present in normal controls. 

One weakness of the cognitive explanation is that there are problems with cause and effect. Cognitive approaches do not explain the causes of cognitive deficits i.e. where the dysfunction comes from in the first place. Are the cognitive deficits causing the schizophrenic behaviour or is the schizophrenia the cause of the cognitive deficits? Links between symptoms and faulty cognitions are clear however, it is not possible to know the origin of those cognitions, therefore it is not possible to be certain that cognitive dysfunctions are the cause of the illness and not just an effect. 

A strength of the cognitive explanations is that it provides many practical applications. Yellowless et al. (2002) developed a machine that produced virtual hallucinations, such as hearing the television telling you to kill yourself or one person’s face morphing into another’s. The intention was to show schizophrenics that their hallucinations are not real. This suggests that understanding the effects of cognitive deficits allows psychologists to create new initiatives for schizophrenics and improve the quality of their lives and allows for the design of effective treatments. This is reinforced by the success of cognitive-based therapies like CBT. The effectiveness of this approach was shown by a meta-analysis conducted by NICE (2014). They found consistent evidence that when compared with antipsychotic medication, CBT was more effective in reducing symptoms and improving levels of social functioning. The fact that a treatment based on the explanation is effective provides support for the role of cognitions as a cause of schizophrenia. 

Possible exam questions

1. Briefly discuss the family dysfunction explanation of schizophrenia. (6 marks)

2. Explain how family dysfunction might be involved in schizophrenia. Refer to one or more types of family dysfunction in your answer. (4 marks)

3. Outline at least two ways in which a cognitive psychologist might explain schizophrenia. (4 marks)

4. Outline one psychological explanation of schizophrenia. (4 marks)

5. Evaluate psychological explanations of schizophrenia. (10 marks)

6. Anthony, aged 24 years, has recently been diagnosed with schizophrenia. Two of his Aunts have been treated for schizophrenia. When asked about his parents, he says they did not get on well. His mother was harsh, demanding and difficult to talk to. His father was hardly ever at home. Discuss at least two explanations for schizophrenia. Refer to Anthony’s case in your answer. (16 marks)

7. Describe and discuss cognitive explanations for schizophrenia. (16 marks)

8. Describe and evaluate family dysfunction explanations of schizophrenia. (16 marks)