Schizophrenia is a neuropsychiatric disorder most easily defined as a distortion in thought, social behaviour and cognitive functioning. Around 1 % of the world’s population has been diagnosed with schizophrenia. There are a number of theories surrounding the onset of the disorder. Prevalent theories are steeped in the bio-medical model, while other less popular theories stem from a more psycholinguistic approach. The word “schizophrenia” comes from the Greek word “skhizein” meaning to split and “phren” meaning mind (Online Etymology Dictionary); schizophrenia therefore, can be translated as a splitting of the mind. This understanding has confused some individuals who are not necessarily familiar with the symptomatology of the disorder. It should not be confused with dissociative identity disorder, where there is a split between personalities; rather, the split that occurs in schizophrenia is a split between self and reality (how one internally conceptualizes reality).
This confusion does not end with the definition of schizophrenia. Most do not understand the presentation of symptoms, what the symptoms mean, or how to interact with these symptoms. I have witnessed many times, individuals interacting with someone with schizophrenia and not understanding just how to do so – it can be a complicated and at some times frustrating experience, when you do not fully understand the disorder. I am here to outline some major symptoms of schizophrenia, and how they present themselves, along with some ways to interact with clients while they are demonstrating these symptoms.
First, let us differentiate between positive and negative symptoms. Positive symptoms can easily be thought of as additions to a persons’ behaviour or cognition. Common examples of positive symptoms are hallucinations and delusions. Negative symptoms are subtractions from a persons’ normal range of functioning. Common examples of negative symptoms would be blunted affect and alogia.
Now that we have identified positive and negative symptoms we can assess the full range of symptoms presented in persons with schizophrenia.
Hallucinations and delusions are the most commonly known symptoms of schizophrenia, in fact, most people will not know many symptoms aside from these two.
Hallucinations can manifest in 5 different ways, these being auditory, visual, olfactory, gustatory and tactile. Visual hallucinations are things that are seen by the client which are not there, or that other people cannot see. Auditory hallucinations are characterized by hearing voices that others are unable to hear, tactile hallucinations are characterized by feeling things which are not there, or which other people do not feel. Tasting, or smelling things, which are not present, or that other people do not taste or smell characterizes the final two categories of hallucinations – gustatory and olfactory (American Psychiatric Association, 2013).
Delusions are identified as false beliefs held with strong conviction, regardless of evidence to the contrary. These can be characterized in 4 categories, which are delusions of paranoia, delusions of grandeur, somatic delusions and delusions of reference (American Psychiatric Association, 2013). Paranoid delusions are false beliefs centered on the idea that others are out to get you, or that others are doing things when there is no clear evidence. Delusions of grandeur are centered on the idea that you are important, special or significant outside of the normal realm. For instance, believing you are a religious prophet, or the reincarnation of Christ. Somatic delusions are false beliefs about your body – internally or externally. Delusions of reference are false beliefs that things in the environment are directed towards you, when they are not. For instance, a TV show or radio broadcaster is talking about a certain event, and you believe that this is directed at you specifically.
Disorganized speech, otherwise known as word salad, is characterized by derailment or incoherence in speech (American Psychiatric Association, 2013).
The final positive symptom in schizophrenia is known as catatonia, or catatonic behaviour. This behaviour is characterized by rigidity, stupor, inactivity, mania, or extreme flexibility of limbs, (American Psychiatric Association, 2013).
Negative symptoms, as mentioned before, are characterized by a lack of certain behaviour. These are as follows:
Alogia, which is characterized by a difficulty or inability to speak.
Affective flattening (or blunted affect), which is characterized blunted facial expressions, or less lively facial or bodily movements.
Lack of emotion or, the inability to enjoy activities to the same degree as before.
Social isolation, in which the individual spends most of their time away from others, or when they do, it tends to be close family only.
Low energy, in which the individual does not exert a lot of energy, spends most of their time sitting around or sleeping.
Lack of motivation, in which the individual does not have much motivation or interest in life.
Inappropriate social skills or, a lack interest in, or ability in socializing with others
and finally, inability to make friends, in which the individual finds it difficult to make new friends, or keep friends they already have. They may not care for their friends.
There is one more category of symptoms that typically gets ignored when discussing schizophrenia. These are categorized as cognitive symptoms, and refer to difficulties with concentration and thinking.
They are as follows:
- Disorganized thinking
- Slow thinking
- Difficulty understanding
- Poor concentration
- Poor memory
- Difficulty expressing thoughts, and
- Difficulty integrating thoughts feelings and behaviour
In treating and individual with schizophrenia, understanding the symptoms of the disorder is half the battle. It is not enough to simply be aware of these symptoms, you must too understand their presentation and be able to differentiate between the symptom, and the person. What I mean by this is you must have the ability to separate the person from the expression of the symptom. For instance, a woman experiencing an auditory hallucination may be feeling anxious, or aggressive. She may be feeling attacked, and may yell or swear out loud in response to the hallucination. You may think she is yelling or swearing at you, and you may involve yourself in the situation. This should be avoided. That is not to say that you are not able to communicate with her while she is experiencing these symptoms, but you should avoid centering the conversation on them. The reason I say this is because you are not experiencing the symptom, you are not aware of what exactly is being said. This is based almost entirely on whether or not you have gained the client’s trust. Do not pretend to hear the voices as well – she is able to recognize that you do not hear them. Do not pretend that you know how to make them go away – because when she realizes you are unable to do this, you lose even more trust.
You can ask the client what the voices are saying. I believe that by doing this, you are demonstrating to them that you care, and it opens a window to strengthen the trust that is already there. You can also ask the client if they believe what the voices are saying. If they are able to, ask them to challenge the voices. You can re-direct the negativity into positivity.
Albert Ellis proposed rational emotive behaviour therapy (REBT) in 1955, which is the pioneering cognitive behaviour therapy. The goal of REBT is to challenge thoughts in order to avoid certain behaviours. He proposed an ABCDE model, with A meaning action (activating event) B meaning belief system, C meaning emotional consequence, D meaning disputing and E meaning cognitive/emotional effects of revised beliefs. In a situation such as the one outlined above, we can easily apply this model to the clients’ hallucination. The beauty of REBT is that it involves rationalizing the situation prior to the onset of behaviour. By asking the client to challenge the thought, voice, hallucination, or delusion, we are going straight to the disputing stage of our model. It is perfectly all right for a client to dispute their delusions or hallucinations. In fact, it should be encouraged. By ignoring or trying to avoid the symptoms, we end up encouraging repression, which means that the symptoms will likely return.
You should avoid invalidating their symptoms because though they may not be real to you, they are very real to your client. Invalidating their experience breaks down trust, and creates a divide between you and them.
While interacting with someone with schizophrenia we should always be mindful of our own attitudes and behaviors, specifically while they are being symptomatic. You should avoid teasing or mocking the client’s behaviour. I have witnessed caregivers laugh at a client’s word salad, or mock their catatonic behaviour. There is a misconception that because these individuals are experiencing things outside of the realm of normalcy that they do not understand our behaviour, or do not notice it. This is not true, and you should always be aware of your attitudes, language use, tone, and behaviour.
Experiencing schizophrenic symptoms puts the client in a very vulnerable state. There is a need for trust, without the ability to trust. Not only, will a client with schizophrenia find it more difficult to trust you due to their illness, they will also find it difficult to trust you because they have been taken advantage of so many times before. With that in mind, their delusions hold some truth. It is difficult to give your entire trust to someone else, to give up your power and to rely on someone else’s.
There are better ways we could and should be interacting with these clients. It may sound obvious, but the two most important traits are patience and kindness. Due to the combination of cognitive delays and positive/negative symptoms experienced by the client, it is sometimes difficult to make it through a conversation with them. This should not discourage you; in fact, you should seek out any opportunity you have to share a conversation with them. This not only builds trust, but it helps you understand the client more, so that in the future you may be able to differentiate between symptomatic expression and non-symptomatic expression.
Empathy is the most important thing we can offer the client. Carl Rogers explains the importance of empathy in understanding our clients, and in aiding them in their healing process (Rogers, 1951, 1959, 1961, 1974). To be empathetic is also to demonstrate unconditional positive regard, also identified by Rogers as a key factor in successful therapy/treatment (Rogers, 1951, 1959, 1961, 1974).
When communicating with a client with schizophrenia, you should be mindful to communicate with them the same way you would with any other client. Attempt to include them in social activities – they may say they do not want to each time, which is fine, but eventually they may change their mind. What matters, however, is that you made the offer; this shows them that you care.
Understanding schizophrenia is a difficult task, however it is far more difficult to live with it. By attempting to understand, show empathy, and build trust with our clients, we are helping them heal. We are helping them make it through a very difficult disorder. The key to understanding schizophrenia is education and the ability to listen.
American Personnel and Guidance Association. (1974). Carl Rogers’s 1974 lecture on empathy. Retrieved from https://www.youtube.com/watch?v=iMi7uY83z-U&feature=share&list=PL9w3l7GkGUr1yxU4s2PiggyCbOO3XfpRf
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Ellis, Albert. (1957). How To Live with a Neurotic. Oxford, England: Crown Publishers, 1957.
Rogers, Carl. (1951). Client-Centered Therapy: Its Current Practice, Implications and Theory. London: Constable
Rogers, Carl. (1959). A Theory of Therapy, Personality and Interpersonal Relationships as Developed in the Client-centered Framework. In (ed.) S. Koch,Psychology: A Study of a Science. Vol. 3: Formulations of the Person and the Social Context. New York: McGraw Hill.
Rogers, Carl. (1961). On Becoming a Person: A Therapist’s View of Psychotherapy. London: Constable.
Schizophrenia. (n.d). Online Etymology Dictionary. Retrieved from http://www.etymonline.com/index.php?term=schizophrenia
 It should be noted that not every individual diagnosed with schizophrenia would present all or the same symptoms.