Explanations of Schizophrenia The Socio-Cultural Approach

What is the basis of the sociocultural approach to abnormality? Not concerned with biology or cognitive processes Focus on the social context of the person: abnormal behaviour may be a result of society or family interactions.

Sticky Labels Is the label of mental illness a means of controlling those whose behaviour does not conform with the ‘norm’. Remember that what is considered ‘normal’ can change depending on the context. Laing was seen as an important figure in the anti-psychiatry movement, although he never denied the value of treating mental distress. He challenged the core values of a practice of psychiatry which he thought considered mental illness as a biological phenomenon without regard for social, intellectual and cultural dimensions.

Thomas Szasz Agreed with Laing, in that he considered the labelling of a person with a mental illness was the ‘medicalisation of madness’ Psychiatrists see ‘mental disorders’ as being of physical origin.  To Szasz this is contradictory. If illness has an organic (or physical cause) then it should be classed as a disorder of the brain.  Although there are various biological models of disorders, such as schizophrenia, as yet none are proven.  As Szasz points out in the majority of cases of patients with ‘mental illness’ there is no obvious physical defect in brain structure or genetic make up. Those suffering from mental illness should be seen in an ethical and social context and not simply treated by the administration of drugs. Using terms like ‘treatment’ & ‘diagnosis’ is a form of social control.

Labelling theory… Scheff (1966) proposed the idea that schizophrenia is a learned social role that is learned through labelling. According to the theory, a person who breaks any of society’s unwritten rules (e.g. don’t talk to lamp-posts) will be given the label mentally ill. Acquiring this label becomes a self-fulfilling prophecy – the person behaves in a way that fits the label & also influences the behaviour of others towards the ‘labelled’ person. Someone with a diagnosis of mental illness may find that they cannot get a job. It becomes a cycle that cannot be broken. Their behaviour changes to suit the illness, others perceive this behaviour and change their own attitudes and behaviour which reinforces the belief that the labelled individual is ill.

There are two main sociocultural explanations of schizophrenia Labelling Szaz Scheff Receiving a psychiatric diagnosis creates stigma or mark of social disgrace. The label ‘mental illness’ creates expectations from the patient and others. As a result the behaviour of the patient may change towards those expectations. This is a way of classifying people whose behaviour is bizarre and difficult to control. ‘Mental illness’ is simply a label used to exclude and excuse people who do not conform.   It ignores compelling genetic evidence This theory does not provide any viable means of treatment for people who are disorientated, distressed and deluded. Rosenhan demonstrated labelling in a very clear way

Rosenhan (1973) Have you read the original paper What was the purpose of the study? What impact did the diagnosis have on the behaviour of the ‘patients’? How were they treated by the staff? Are there any ethical issues that need to be considered? The aim of the study was to investigate how reliable the diagnosis of mental illness is. The ‘patients’ were three psychologists, a psychiatrist, a psychology student, a paediatrician, a decorator and a housewife. They were admitted after they reported hearing voices. They were diagnosed as having schizophrenia or manic depression. Once they were admitted they started acting in a ‘normal’ fashion, however, even this normal behaviour was determined to be part of the illness. All the patients were encouraged to keep a diary – this was not seen as unusual and was noted in one ‘patients’ notes as ‘obsessive-compulsive writing behaviour’. All of the patients reported having feelings of powerlessness and fear, which compounded the opinion of the hospital staff that the ‘patients’ were mentally ill. The ‘patients’ were held for between 7 & 52 days (av 19) and were discharged as their schizophrenia was seen to be in remission. The hospitals were later informed of what had happened & were told that there may be more ‘stooges’ placed in their hospitals in the future. The hospitals then started assuming that they had ‘pseudo-patients’ in their wards when in fact they were all real! As Rosenhan points out, with physical illness it may be safer for the medical profession to play safe and risk admitting someone who is really well rather than risk missing someone who is ill.  The danger with adopting the same approach to mental illness is that a diagnosis then stays with you for life and can adversely affect your relationships, job prospects and legal standing

Evaluation of Labelling Theory As a result of the Rosenhan study the diagnostic criteria in the then DSM-III were revised to improve their reliability. The study demonstrated that the label of a diagnosis could become a self-fulfilling prophecy with a person’s behaviour & others interpretation of the behaviour conforming to that demonstrated by a person who is mentally ill. Labelling theory is useful in demonstrating how symptoms can be maintained, however, they do not explain the onset of symptoms or offer any suggestions for treatment. Ignores the evidence of a genetic cause. Criticised for trivialising what can be a very debilitating condition for some seriously ill individuals.

PSYB3: Mood Disorders and Schizophrenia There are two main sociocultural explanations of schizophrenia 2. Family Dysfunction The importance of family relationships has been put forward as a possible explanation for schizophrenia. Schizogenic mother Double bind This is someone who is cold, dominant and created conflict. These mothers are rejecting, overprotective, self-sacrificing, moralistic about sex and fearful of intimacy A parent verbally gives one message and non-verbally conveys the opposite message E.g. A parent might ask for a hug and then push the child away, telling them they are too old for cuddles. Schizophrenia emerges in the child as a result of these behaviours towards them. This theory suggests that children will become confused and lose their grip on reality. Negative symptoms of social withdrawal and flat affect may be an appropriate and logical response to double bind situations

‘Double Bind’ Bateson (1904 – 1980) was a British anthropologist and social scientist & was one of the first researchers to look at the family dynamic of those people suffering from schizophrenia. He stated that if children receive mixed messages from parents e.g. being asked for a hug & then being pushed away, then they learn that they cannot trust the messages they receive from others. As a result they do not trust their own feelings & perceptions. This contradictory information was termed ‘double bind’ the children are ‘punished’ for doing what was asked (giving a hug, then being pushed away) & then punished again when the parent gives no reason for pushing them away. Just as a matter of interest – his first wife was Margaret Mead – the researcher who went to New Guinea to study the gender roles of different tribes. Anthropologist: studies humankind through changes in culture, physical characteristics etc (like in Bones!)

Family Socialisation Theory Families do not always provide a stable & supportive environments or appropriate role models for their children (Lidz et al, 1957). The parents do not act in role appropriate ways. Schismatic Families: conflict and division between the parents, where one is always trying to undermine the other & they are competing to win the affection of other family members. Skewed families: the balance of power within the family is biased towards a dominant parent & the children are encouraged to follow that parents direction. The other parent is submissive. Conflict between family members causes stress and the schizophrenia develops as a way to deal with the conflict. Socialisation: the process that teaches children to adopt certain values & roles Schism – a division or split Skew – reminder of research methods in AS Behaviour and interactions between family members will be observed and absorbed by the children. This in turn will influence their cognitive & social development.

Evaluation of Early Studies of Family Patterns & Styles. While there is a correlation between family patterns and schizophrenia there is no proof of cause & effect. It is possible that it is difficult behaviour from the child that influences the family behaviour patterns rather than the other way round.

Supporting evidence for family dysfunction theory Tienari (1987) Children with a biological mother with schizophrenia adopted by non-schizophrenic families However, the schizophrenic gene only seemed to develop amongst those individuals whose adoptive family was psychologically disturbed in some way This seems to suggest that the individual may have a schizophrenic gene but the family that brings them up have an impact on whether or not that gene is activated.

Expressed Emotion (EE) Expressed emotion or emotional over-involvement e.g. Expression of positive and negative emotion; Hostility; Critical comments through both tone & content. If these factors were high then the risk of a relapse was high.

Supporting evidence for family dysfunction theory Brown (1966) Expressed emotion (EE): families where communications are commonly to do with criticism, hostility and disapproval are said to have high EE People recovering from schizophrenia and discharged from hospital were followed up over a 9-month period. Interviews with family members were conducted to determine the level of expressed emotion PSYB3

Families where expressed emotion (EE) levels were high resulted in 58% of people with schizophrenia returning to hospital for further treatment, compared to only 10% of those from low expressed emotion families Family relationships can affect the degree of recovery rates of people with schizophrenia. Klebanoff (1959) has argued that strained family communication may be the result of dealing with an already unusual child.   PSYB3

Bebbington & Kuipers (1994) Performed a meta-analysis of studies from a variety of countries from 1958 – 1990 which were investigating the risk of relapse in patients returning to high EE families compared with low EE families. The studies were analysed to determine: (i) the proportion of high & low EE families (ii) the relapse rate of patients returning to these families. They found the following chances of remission: 52% of families were deemed high EE 50% when returning to a high EE family 21% when returning to a low EE family Bebbington & Kuipers concluded that returning to a high EE family was a significant risk factor in relapse. However, this does not determine cause & effect…

Evaluation of the EE Explanation Strengths Weaknesses It is possible to predict the relapse rate of patients for up to six months after discharge using the measure of EE within the family. It is uncertain whether EE is a cause of relapse or simply a reaction to the patients behaviour. If a sufferer starts to deteriorate into a relapse of schizophrenic symptoms then family involvement is going to increase in an attempt to help the situation. High EE patterns are not specific to schizophrenia, they have also been found in the families of sufferers with other disorders such as depression. They are also more common in Western families. Only one interview is used to measure levels of EE. This may not be enough to provide an accurate picture of family interaction.

Summary of explanation Sociocultural explanations look to the person’s environment to explain schizophrenia Families can influence both the onset (through socialisation) and the maintenance (through high EE) of schizophrenia The diathesis-stress model of schizophrenia is where biological factors cause a predisposition to develop schizophrenia the stress factors in the environment may well be to do with family dysfunction and expressed emotion

Outline & Evaluate… A common essay question would be to ‘outline & evaluate’ different explanations for schizophrenia. Outline: you need to provide a summary of the theories used by each approach to explain schizophrenia. Evaluate: strengths and weaknesses of the approach – this is where you need to compare with another approach. Make sure that you refer to any research/studies. Practise writing out the main points associated with each theory.

Essay question Discuss sociocultural explanations of schizophrenia (12 marks)