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Working with schizophrenia
World Mental Health Day earlier this month had the theme of living with schizophrenia. I thought I would write something this week to discuss some of the thoughts that people have about this diagnosis, and some ideas about working with people who have schizophrenia. To celebrate World Mental Health Day, the World Mental Health Federation have produced a report on living with schizophrenia worldwide, and this includes a number of articles from different perspectives, all of which acknowledge schizophrenia is a serious disorder, with no cure, that affects 26 million people worldwide. The report describes plenty of ways of treating and working with it.
First of all I should say that the term schizophrenia is a relatively new one – it was coined in 1950. That’s not to say that people did not have schizophrenia before that, rather that the behaviours and thoughts that are associated with it were given different diagnoses. The second important thing to note is that it is a controversial diagnosis, partly because there a number of negative connotations about schizophrenia which I’ll explore later. There are many people who dispute the term schizophrenia. That is not to say people don’t recognize some of the thoughts and behaviours, rather that they think it is wrong to apply a label. This alternative view is that these are not symptoms of an illness, but are rational responses to an increasingly stressful and chaotic modern world.
Different models of mental disorder
So what can the ordinary person in the street make of this, or even the health and social care worker? Well, it is very difficult but it probably makes sense to at least acknowledge there are different views on this, and you don’t have to fall on one side of the fence or another – is it a biological illness, or just an artificial label that is used to suppress people? Most modern thinking in the field of mental health work recognises there are different approaches to working with people with symptoms of schizophrenia that might include some biological approaches (medicine) as well as psychological, or educational, approaches that promote the idea of the person being in charge of their own path to recovery. So, let’s look behind the label at some of the thoughts and behaviours that might lead clinicians to say someone was experiencing schizophrenia. It is characterised by a number of thoughts and behaviours that might include hearing voices, experiencing visual hallucinations, or the thoughts of other people being inserted into their minds. There are some other behaviours such as lack of motivation, lacking self-care, and getting up in the night and sleeping in the day. The first of these are called positive symptoms, and the second group negative symptoms. That doesn’t mean that one group is good and the other group is bad, but that the positive group are active symptoms, and the negative group indicates the absence of usual responses and behaviours.
Breaking down stigma
The issue that was highlighted on World Mental Health Day this month was the stigma surrounding schizophrenia. I think there are two main reasons for this, the first being the word itself. Let’s go back to some of the thinking that has contributed to the stigma of schizophrenia. Firstly, the name is derived from Greek words meaning split and mind. Well, some people interpret that as meaning split personality, like Jekyll and Hyde. This is not what schizophrenia is about.
The other thinking that has promoted stigma is really a product of portrayals in TV, newspapers and books. Lurid headlines like ‘Dad killer schizo is in Broadmoor’ fuel the idea that this is a disorder associated with violence, and this only serves to frighten people. In fact it can be unhelpful to talk about people being ‘schizophrenic’ as though that defines everything about them. It can be less stigmatizing to talk about someone ‘having schizophrenia’ or ‘living with schizophrenia’.
Getting in early
So what helps in working with people with schizophrenia? First of all early intervention. Modern thinking and research suggests that if symptoms of schizophrenia can be identified at a young age, typically late teenage, then chances of a good recovery are much improved. This can be difficult, when you look again at some of the ‘negative’ symptoms of the disorder; these could well be typical behaviours of a teenage boy.
The stress-vulnerability model
Secondly, what helps is education, of both the service user and their family. Often families are crying out for some information beyond the diagnosis, in terms of signs and symptoms to look out for, and what does and doesn’t help. Often, families have worked out their own ways of coping with behaviours and symptoms but would still benefit from outside support. Exploring coping strategies (e.g. being able to deal with the experience of hearing voices) and problem-solving can help. These can help reduce the stress of day-to-day living that can sometimes contribute to a relapse in the person’s mental health problem. Practitioners sometimes use the analogy of a bucket of water, whereby the size of the bucket indicates the capacity of the person to cope with stress (see Brabban, A. & Turkington, D. (2002) The search for meaning in Morrison, A. (ed.), A Casebook of Cognitive Therapy). This model takes the view that people with schizophrenia are more vulnerable to the stresses and strains of life, such as major life events (losing a job, bereavement etc.) and day-to-day stresses (such as managing bills, or other daily tasks). These can sometimes cumulate to the level where the person’s ability to cope is lost, and a relapse can occur. The ‘bucket’ analogy describes these stresses as amounts of water being poured into a bucket until the bucket overflows – that is breaking point. It can be very difficult to remove all stresses from someone’s life so often the work to be done is about increasing the person’s ability to cope – making the bucket bigger! Medication can be one way of helping someone cope.
The QCS Schizophrenia Policy and Procedure CC42 describes this and other models of thinking and ways of working. To support World Mental Health Day, the Mental Health Foundation has produced a short, free factsheet on schizophrenia explaining some of the common misconceptions about schizophrenia, and a charter for improving services.