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Schizophrenia: A Family Systems Approach


Permission graciously given by the author to reproduce this paper.

Schizophrenia: A Family Systems Approach

Rosalba Acosta
2007

Introduction

Schizophrenia is a disorder that affects both the patient and his/her family members.  Until recently, schizophrenia was treated by focusing on the identified patient only, or the person suffering from the disorder.  However, through research it has been found that schizophrenia can be better treated by including the family members in the process. This paper will underline the family systems approach as one of the methods through which schizophrenia can be treated.  It will also mention how cognitive behavioral therapy could also be used to treat the disorder and also how the media and society portray schizophrenia.  We will also mention the challenges that families face and some characteristics of the disorder including common medication, side effects and a sample vignette with differential diagnosis. 

What is Schizophrenia?

Schizophrenia is a severe and persistent mental disorder that affects 1% of the population. The disorder is marked by the distortion of experiences, thoughts, and feelings, and often weakens the ability to function in such areas as education, work, interpersonal relations, and self-care (Jennings, 1998).  It is characterized by a wide range of positive and negative symptoms. Positive symptoms are those that occur in people with schizophrenia but not in others, such as: hallucinations, delusions, disorganized thinking and bizarre behavior. Negative symptoms are those that are absent in people with schizophrenia but present in others, they include: apathy and inability to follow through on tasks, inability to experience pleasure and to enjoy relations, inability to feel and express emotions, inability to focus on activities and impoverished thought and speech (Jennings, 1998).

Schizophrenia is associated with abnormalities in brain activity, chemistry, and structure. Approximately one third of people with schizophrenia have a family history of the disorder (Galuszca,1999).   There is considerable agreement among professionals that schizophrenia involves a vulnerability (or biological predisposition) to develop certain symptoms and that a range of factors can interact with this vulnerability to affect the course of the illness.

How does schizophrenia affect families?

Schizophrenia has a devastating impact on all members of the family.   They usually need to cope with: care giving responsibilities, emotional distress, increased stress and disruption.  Many services can assist families to cope with schizophrenia. These include: short-term educational programs, which provide information about schizophrenia and its treatment, care giving and management issues; long-term psycho educational programs, which offer support, education, and skills training in stress management, communication, and problem solving; family or group therapy to help resolve illness-related concerns and deal with other family issues (Berger, 2002).

Families can play important roles in their client's treatment, rehabilitation, and recovery.  Families need to practice good communication skills because schizophrenia is associated with unusual vulnerability to stress, families can help their relative by maintaining a supportive environment and by resolving family problems in a constructive manner.  Some suggestions are: learn about schizophrenia and community resources; develop skills for coping with schizophrenia; understand the meaning of the illness; and develop realistic expectations.

Therapy from a Family Systems Perspective

This perspective had its beginnings in the 1950s when a creative group of mental health professionals began to shake up the psychiatric establishment with a new and revolutionary way of looking at mental illness.  This theory viewed the behavior of a disturbed individual as a reflection of poor family communication "Although one family member might be defined as a patient, in a sense that patient was merely a messenger, communicating to the world the problem existing in the family as a whole” (Fisher, 2002).  The communication theory believes that psychopathology results from faulty communications within the family. 

In the 1970's Salvador Minuchin's "structural theory" conceptualized relationships in terms of "units," individuals and alliances that serve some function within the group. Murray Bowen, proposed that the key to healthy functioning for a family member is the degree to which that person achieves "differentiation of self" (Prouty, 2002). 

The Family systems theory is an approach to treatment that emphasizes the interdependency of family members rather than focusing on individuals in isolation from the family (Kuipers, 2002).  It is a form of therapy that involves all the members of a family.  This approach regards the family, as a whole, as the unit of treatment, and emphasizes such factors as relationships and communication patterns rather than the symptoms in individual members. 

Family therapy began shortly after World War II, when doctors, who were treating schizophrenic patients, noticed that the patients' families communicated in disturbed ways (Prouty, 2002). These observations led to considering a family as system with its own internal rules and patterns of functioning.  Family therapy uses "systems" theory to evaluate family members in terms of their position or role within the system as a whole. Problems are treated by changing the way the system works rather than trying to fix a specific member. 

A family systems perspective encompasses an assessment of the attitudes and behaviors of the patient and of the treatment interventions that are used. Central to this framework is the concept of triangling (Berger, 2002). This is a process in which two family members lower the tension level between them by drawing in a third member.  This theory maintains that whenever any two persons in the family system have problems with each other, they will "triangle in" a third member as a way of stabilizing their own relationship. The triangles in a family system usually maintain the family homeostasis. Each person in the system influences and is impacted by every member of the system so, each person's construction of his or her shared reality is extremely important, and it is vital that each individual have an opportunity to tell his or her story in his or her own terms in a therapeutic environment.

A Marriage and Family Therapist can assist families to identify the needs and to make choices about the use of services. In addition, a therapist can offer consultation, education about mental illness, and skills training. All of these services can assist family members to gain insight into the meaning of schizophrenia for themselves and their families, to learn more effective methods of coping, to reduce their level of distress and to obtain support in creating a more fulfilling life.

Treatments for Schizophrenia

Many people with schizophrenia and their families find it helpful to talk about their feelings and experiences and to get support in coping with the illness.  Counseling and psychotherapy are mostly used alongside drug treatment for people with schizophrenia. Support and self-help groups can also help ease feelings of isolation and provide a place for people to talk about their feelings and share information.

Many effective treatments are now available for schizophrenia. These treatments can result in reduced symptoms, decreased relapses and hospitalizations, improved quality of life, and increased ability to function in home, school, work, and leisure settings. Some effective treatments for schizophrenia include:

• A new generation of antipsychotic medications that have fewer unpleasant side effects and that are more effective in treating the positive and negative symptoms of schizophrenia.

• Family interventions designed to reduce the client's risk of relapse and re-hospitalization, and to address the needs of families themselves.

Treatment for people with schizophrenia almost always involves drug therapy. It aims to stabilize psychotic symptoms and reduce their chances of relapse.  Drugs (antipsychotics or neuroleptics) can relieve some symptoms for some people, but there is a need for more effective drugs (Wickham, 2002).  Some of the common medications are: 
 
Classification Trade Name Generic Name Oral Depot Recommended Daily
Dose
Phenothiazines
I. Aliphatic compounds
II. Piperidines
III. Piperazines
Largactil

Melleril

Fentazin
 

chlorpromazine

thioridazine

perphenazine
 

Yes

Yes

Yes
 

Yes

No

No
 

75-300, max 1000

150-600

12-24
 

Thioxanthines Depixol
Clopixol
flupenthixol
zuclopenthixol
Yes
Yes
Yes
Yes
3-18
20-50 (max 150)
Butyrophenones Haldol
Droleptan
haloperidol
droperidol
Yes
Yes
Yes
Yes
3-15 (max 30)
15-80 (adults)
Substituted benzamides Dolmatil sulpiride Yes No 200-1200
Atypical antipsychotics Clozaril
Risperdal
Seroquel
Zyprexa
clozapine
risperidone
quetiapine
olanzapine
Yes
Yes
Yes
Yes
No
No
No
No
12.5-900
2-16
50-750
10

Antipsychotic side effects

Specific side effects of typical antipsychotics are severe movement disorders, called extrapyramidal side effects. These usually affect about one person in three and include:

• Muscle spasms - often in the head and neck after a first dose or a change in dose.
• Unusual involuntary body movements -  (pseudoparkinsonism) similar to the  symptoms of Parkinson's disease. 
• Severe movement disorders -  (tardive dyskinesia) repetitive movements of the face, tongue and neck.  Extrapyramidal side effects are a source of stigma, with the common misconception that movement disorders are part of the disease.  Some of the more common side effects are: 
• Feelings of drowsiness, sedation and apathy 
• Blurred vision and dizziness 
• Breast enlargement (male and female) 
• Reduced sexual desire 
• Weight-gain (olanzapine and clozapine)

Further research may bring new and better antipsychotics.  According to The American Journal of Psychiatry, more than 50% of service users are not consulted about their treatment options and about half of them are not given any written information about the side effects of medication. Research like this suggests treatments will have more success if people with schizophrenia are more involved in their own care. <>Cognitive

Behavioral Therapy and Schizophrenia

Schizophrenia can be a devastating and debilitating illness.  It can create enormous personal distress and disability in individuals suffering from it.  Despite the benefits of new and advanced antipsychotic drugs in its treatment, for some individuals the negative as well as the positive symptoms of the illness remain resistant to pharmacological treatment.  However, current treatment approaches that integrate drug and psychosocial treatment such as Cognitive-Behavioral Therapy (CBT) have been found to be useful in alleviating this problem (Tarrier, Beckett, Harwood, Baker, Yusupoff & Ugarteburu, 1993; Garety, Kuipers, Fowler, Chamberlain and Dunn, 1994).  According to Tarrier’s ( Tarrier, Yusupoff, Kinney, McCarthy, Gledhill, Haddock, and Morris, 1998) study, the addition of CBT as an adjunct to drug therapy in the treatment of patients with chronic schizophrenia, resulted in a greater reduction of psychotic symptoms than did the use of routine care alone.  Their results indicated that patients who received CBT in combination with drug treatment, were nearly eight times more likely to have a 50% or higher improvement than those who received only drug therapy.  Furthermore, the effectiveness of CBT can be seen when compared with other forms of psychotherapy.  In a study conducted by Sensky (Sensky, Turkington, Kingdon, Scott, Scott, Siddle, O’Carroll and Barnes, 2000) in which CBT was compared in its efficacy in the treatment of schizophrenia to a nonspecific befriending intervention, it was found that in the nine-month follow-up evaluation, patients who had received CBT continued to improve, while those in the befriending group did not. However, despite overwhelming evidence of the positive effects of CBT in the treatment of schizophrenia, it is important to note that CBT may not work with every patient who is afflicted with the illness. 

This is due to various individual differences, two of which are the individual’s level of insight and cognitive functioning.  According to some researchers (Sensky et al., 2000), it works best with patients who have some insight into their condition and who possess mild cognitive deficiencies.

In addition to supportive psychotherapy and drug treatment, cognitive behavioral therapy can be useful for patients with hallucinations and delusions that persist even when they take medications.  CBT with a special emphasis on delusions and hallucinations and with the help of problem-solving and coping skills training, has encouraged patients with schizophrenia to evaluate the evidence for their beliefs and experiences and consider other explanations for such experiences (Tarrier et al., 1998).  The methods are the same as those used in cognitive therapy for depression and anxiety- correction of erroneous thoughts and perceptions. In terms of hallucinations, Beck (1998) states that because people with hallucinations are likely to mistake printed words for speech or misidentify garbled sounds as words, common techniques of cognitive therapy can be used specifically for correcting such automatic thoughts and errors in perception. For example, the therapist would question the patient about the nature and basis of the hallucinations, suggests other explanations, and asks them to assess the evidence.   Also, If the patient hears threatening and abusive voices, the therapist finds out when and where the voices surface, how often and for how long, what makes them come and go, who is speaking, and what feelings they incite .The patient can then be shown how to turn the voices off, perhaps by listening to music with a headset, engaging in conversation, or simply by shadowing (repeating what the voices say).  The therapist then teaches the patient that the commands from the voices can be safely ignored due to the fact that they are generated by the patient’s own brain and not for example, by malevolent external entities.   The methods used to prove this are explanations of brain functioning and Socratic questioning (Beck and Rector, 1998):  “Can others hear the voices? Why not? Why are you able to turn them on and off?”  In addition, according to Beck and Rector (1998), patients can be shown how the voices reflect their own thoughts and attitudes or their beliefs about what other people are thinking. When the patient learns how to respond and manage the voices, he or she finds relief from feelings of despair and helplessness. In their study, Chadwick and Birchwood (1994) found this to be true.  They found that cognitive elaboration, questioning and testing of the origin of hallucinations lessened the frequency of the voices and in turn, lessened distress in patients. 

In terms of delusions, CBT has been found to help patients modify and cope with delusional beliefs.  For instance in Kingdon’s study ( Kingdon, Turkington and Carolyn, 1994) patients with fixed delusions were asked to relate the history of their delusional thinking (without labeling it as such) and their experiences supporting the validity of their delusions.  According to Kingdon et al. (1994), once a positive relationship has been established, the therapist can then gently question the patient’s evidence, offer alternative explanations to account for the evidence, challenge the patient to consider his or her belief in light of hypothetical contradictions to the delusional belief, and otherwise use a combination of questions and reality testing to help the patient consider alternative views.  For example, suppose a patient claims that he knows there is a conspiracy against him because his mail arrived late, loud lawn mower noises woke him from his sleep and he couldn’t find his keys.  The therapist might ask:  Is it clear that these inconveniences are due to a conspiracy?  What other possible explanations are there?  Also, if the patient believes he can read other people’s minds, the therapist may ask how it is done and question the patient’s speculations.  In their study, Kingdon et al. (1994) found that patients who over a series of sessions were encouraged to systematically review the start of their delusions and then question them in detail to identify faulty reasoning learned to monitor them and to develop coping strategies.  Such coping strategies included changing attention, relaxation techniques and modifying behaviors that may exasperate the delusions.  Furthermore, according to Beck and Rector (1998), another way to break the hold of delusions is focusing.  The patient is encouraged to relate specific characteristics (that could be observed by a trusted outsider like the therapist) of the mysterious persecutors.  In effect, the more the patient tries, unsuccessfully, to appropriate clear features to these indistinguishable figures, the less real they appear. 

Even when the most prominent and troublesome symptoms such as psychotic hallucinations and delusions are chemically controlled, the so-called negative symptoms of apathy, withdrawal, emotional unresponsiveness, inexpressive speech and impoverished thinking usually persist. Patients with these negative symptoms struggle with lingering deficits in areas such as attention, concentration, short-term memory, motivation, decision-making and sense of pleasure.  Such patents often display chronic disabilities in self-care, social relatedness and work capacity (Kane and McGlashan, 1995).  According to Beck and Rector (1998), because these negative symptoms of schizophrenia have two important causes one of which is depression and the other is fear and confusion which are stirred by the hallucinations and delusions, they respond well to standard cognitive techniques and behavior therapy (engaging the patient in  real-life activities, exciting interest in projects, improving social and vocational skills).

Based on the information and studies available on CBT and schizophrenia it is clear that CBT can serve in the treatment of residual positive and negative symptoms of schizophrenia to enhance the effectiveness of medication. CBT builds a positive interpersonal relationship of “collaborative empiricism” between patient and therapist that helps the patient to better manage positive and negative symptoms by strengthening his or her capacities for normal thinking and feeling. 

In summary, patients with schizophrenia require far more than drug treatment; they require a system of care, the basis of which includes both pharmacological and psychosocial treatment approaches such as CBT.  Resources permitting, this clinical advance in the treatment and management of schizophrenia might eventually become the standard treatment of schizophrenia.  In the years to come, not only may it be integrated more and more into routine clinical practice but it may also be incorporated into the training of health care professionals.  This would be an important clinical development in the treatment of schizophrenia as any improvement in symptoms that are resistant to pharmacological treatment will be of significant gain to the patient and in the long term, it may also lessen the cost of care. The media and the portrayal of schizophrenia

After reviewing the journals, movies and various other sources, the research overwhelmingly indicates that the portrayal of the mentally ill, especially schizophrenia, in news media and film is mostly negative.  Schizophrenics are stigmatized as violent or criminal individuals.  Moreover, when they are not portrayed as such, they are instead seen as figures of fun to be laughed at.  Thus the stigma is harmful to schizophrenics in a myriad of ways and the psychiatric terms used to describe and characterize them only reinforces the public’s negative perception about schizophrenia.  This leaves the public misinformed and confused about schizophrenia, in general.

According to a professional advisor to the National Schizophrenia Fellowship in Great Britain, “ schizophrenia is the last great stigma “ ( Reveley, 1997 ).  The press, for example, has consistently distorted people’s views of the mentally ill through recycling of such terms as psycho, mania, and schizo.  Some organizations and special forums have been established to fight the misinformation and unfair reporting in the papers and television news about people who suffer from the schizophrenic disorder.  Often they are described in the papers as “ dangerous time bombs waiting to explode “ or “ armed and dangerous “ ( Ferriman, 2000 ), when the reality concerning schizophrenics paints a different picture.  They are more likely to harm themselves and only some, of the 1% who are schizophrenic, are involved in substance abused criminal behavior (Torrey, Mullen, Burgess and Soyka, 2000 ).  One study reported in the Lancet (Sartorius, 1998 ) reported that there was no evidence of increasing criminal behavior in schizophrenics first admitted in community based services from 1985-1994 versus those whose first admission were hospital based between 1975-1984.  Thus concluding that criminal behavior among those with schizophrenia is not associated with deinstitutionalization and, more importantly, schizophrenics involved in criminal behavior is often the result of failing to take medication and lack community services.  Other reasons for violence are varied and include factors like male sex, more severe psychopathology, early onset of psychosis, a primary antisocial personality, poor social integration, and non-compliance to treatment ( Torrey, Mullen, Burgess, and Soyka, 2000 ).   Unfortunately, there are no spokespersons that come out on behalf of the mentally ill when a sensationalist story of a violent act is reported.  For example, as an airline spokesperson says it is safe to continue flying after a tragic crash is reported in the papers.

In New Zealand, however, a study conducted left the relationship of mental illness to violence unclear.  The study links elevated violence rates in young adults to the presence of at least one of three psychiatric ailments—alcohol dependence, marijuana dependence and a range of psychotic experiences and beliefs called schizophrenic-spectrum disorder.  In short, people with schizophrenic-spectrum disorder displayed an increased risk of violence that was independent of the effects of substance abuse.  Contributing to their acts of violence was an excessive perceived threat in their surroundings.  Other studies in the United States, which they point out, suggest no increased violence among schizophrenics.  It is suggested that more violence occurs in the U.S. and that more violence in New Zealand is attributable to mental illness ( Bower, 2000 ). 

Some of the reasons why newspapers and television report these sensationalist stories on the mentally ill are twofold.  First, papers sell more when reports reinforce the reader’s view instead of challenging them.  The media feels like they are on the public’s side and understand their fears when they report how local institutions seem to have gone wrong in servicing the mentally ill.  ( Ferriman, 2000 ). Secondly, there is the profit motive.  Papers, novels, television shows and movies sell more whenever good drama is portrayed.  Unfortunately, schizophrenics and the mentally ill are often involved in such stories and movies, which leads to another source of misinformation about schizophrenia. 

Hollywood has been one of the main suspects to inaccuracy, misinformation and unfair depictions of people suffering from schizophrenia.  For example, most cinematic films coming out of Hollywood have depicted schizophrenics as dangerous or violent killers or laughable figures of fun.  Moreover, adding insult to injury, they often confuse psychiatric terms with schizophrenia.  For example, dissociative identity disorder or multiple personalities with its “ split personality “ characteristic is often portrayed in the movies as being schizophrenic.  Most films that portray schizophrenics and the mentally ill confuse their disorders with dissociative identity disorder, which is quite rare and controversial ( Byrne, 2001 ).  This is where a person assumes the role of another and is usually out of control, as typically seen in many motion pictures. 

The definitive movie that accelerated the trend of a split personality character that hides dark secrets and kills is Psycho ( 1960 ).  This movie reinforced the public’s perception that schizophrenics are violent people to be feared.  It also mixed up the notion that schizophrenics can change into another personality and be taken over by the dominant personality.  Sometimes, on the other hand, Hollywood can get it right when depicting schizophrenia.  For example, A Beautiful Mind ( 2002 ) accurately portrays the life of a paranoid schizophrenic with visions and voices that haunt the main character.  It also demonstrates how schizophrenia is a severe disturbance of the brain’s functioning that prevents a person from not knowing what is real and what is not, unlike the typical description of a split personality with violent tendencies.  However, the film does have its critics.  One argument against the films portrayal of schizophrenia is that one cannot conquer the disorder by sheer willpower with the support of family and friends as the movie implied ( Nassal, 2002 ).  Another criticism of the film is the portrayal of the main character recovering from schizophrenia by taking newer anti-psychotic medication.  The argument being that a schizophrenic can recover or improve without the use of medication ( Napoli, 2002 ).  These criticisms by those professionals that concern themselves with schizophrenics demonstrate that even in an accurate portrayal of schizophrenia in a movie, there are still disagreements. 

What do these negative media and cinematic portrayals of schizophrenics mean to those that suffer from the disorder?  First, the stigma created by these stereotypical depictions creates more discrimination and a lack of societal understanding and commitment to mental health care.  Second, the stigma of schizophrenia effects the chances for employment, marriage, finding an apartment, or receiving support from neighbors or the community.  Lastly, the family members of schizophrenics are affected when society makes it harder to be treated or trusted.  There needs to be more education on schizophrenia given to the public.  In addition, more accuracy in media and films need to be supported and encouraged.  Government funding should go out to those groups that fight on behalf of the mentally ill.  The research should focus on how other cultures portray their mentally ill persons suffering from schizophrenia so that we may learn from their values and concerns.  How do the French or Scandinavians or Japanese approach the disorder in media and film?  Future research should concentrate on the effects of stigma has created for schizophrenics.  Also, future research should concentrate on the successful stories of people suffering from schizophrenia.  There needs to be a positive face placed onto the public consciousness if there is to be any hope of destigmatizing schizophrenia.

Case Vignette of a client diagnosed with schizophrenia

Andrea is a 25-year-old client who works as a nurse and was referred to therapy by a social worker from her child’s school, as he was seen crying at school.  When the child was interviewed by the social worker, the child disclosed that he feels alone, as mom is not there when he gets home from school.  After the social worker visits the home, she refers Andrea to therapy.  When Andrea arrives to the therapist she discloses that she recently separated from her abusive husband and is going through a legal custody battle and divorce.  She reports that she has not been able to sleep due to the ongoing problems.

She discloses that her husband was very controlling and threatened to send a detective to spy on her.  She further discloses that she believes he’s installed cameras in the apartment where they used to live as he still has access to it.  She further discloses that she is hearing voices through the wall, but she can’t tell what they say.  Andrea seems to worry more about the cameras her husband has installed in the apartment as she feels that this information can be used against her in court.  She reports that she is not paying as much attention to the voices, because she does not know what they are saying, but sometimes she can distinguish that they tell her to be careful as her husband is planning to kill her.  Andrea appears to be anxious and agitated.

Andrea works in hospital where she takes care of elderly and reports that she had been seen by a psychologist before, but has stopped taking her medication as she can’t afford the treatment, due to the recent divorce procedure and as the attorney costs have been given priority. 

Andrea reports a history of panic attacks that usually precipitated after the abuse she was subjected to. The symptoms that are currently noticed are; Delusions, hallucinations, severe anxiety and agitation, flat affect, anhedonia, low self-esteem, social isolation and incoherent speech at times.

The treatment of choice will be an antipsychotic: olanzipine 2.5 mg,  if tolerated this will be increased to 5 mg.  After two weeks, Andrea reports that she’s been sleeping better and her anxiety level has decreased.  However, the auditory hallucinations have not stopped.  After six weeks of treatment, client reports that the hallucinations have stopped; however she remains socially isolated and emotionally empty. Treatment is continued for 12 months including the prescription of haloperidol, which is reduced gradually in a period of 8 weeks.  Andreas seems to be stable and psychotic episodes have decreased.  Follow up appointments are schedule to monitor progress closely and provide support.

Schizophrenia and family treatment

Schizophrenia is a devastating illness that affects cognitive and emotional functioning.  The treatment of schizophrenia is the focus of current research in the hopes of finding improved medication that target both positive and negative symptoms.  Positive symptoms include hallucinations, delusions, disorganized speech and behavior.  Negative symptoms that are often exacerbated by neuroleptic medications are restrictive affect, fluency and productivity of thought, speech and lack of goal directed behavior ( Sturmey & Gabatz, 2003). Evidence suggests that lack of insight into having a psychotic illness is also a manifestation of the illness. Medication compliance is essential, however, other factors such as family support, and community involvement are critical in assisting with medication compliance and relapse prevention.  Studies indicate that patients with family involvement and support and access to community services are less likely to be hospitalized after the first psychotic episode ( Barker, Lavender & Morant, 2001). Social awareness is also instrumental in effective treatment of schizophrenia.

Family involvement is critical in treating schizophrenia.  Because of the nature of the illness, cognitive functioning is affected.  Memory, psychomotor abilities and attention are impaired and as a result, difficulty in daily functioning as well as psychosocial rehabilitation can occur. Many people suffering from schizophrenia have difficulty providing the basic needs of food and shelter for themselves.  Severe depression can follow and statistics show that 10% of people suffering from depression as opposed to 1 % of the general population commit suicide.  Sustained employment is difficult, thus a lowered standard of living can occur. Impairment in communicating and feeling understood can lead to social isolation.   Social networks are particularly important in assisting people with schizophrenia to adapt to life in a community because they play an important part in providing information, support and practical assistance during times of stress.  Findings show that people with schizophrenia with larger and more supportive social networks are admitted less frequently to hospitals (Bustillo, Horan & Lauriello, 2001). Without the assistance of a strong and supportive family, adjusting to the illness can be overwhelming.

Families also have difficulty in adjusting when a relative is diagnosed with schizophrenia.  In a study conducted in Great Britain of eight families with a relative diagnosed with schizophrenia, all discussed their family life in terms of before the onset of the illness and after the diagnosis was confirmed, suggesting that the dynamics within the family changed dramatically.  Misinformation about the illness, lack of support by medical professionals, guilt, fear and loss were reported by all families (Barker, Lavender & Morant, 2001).  Research also suggests that people suffering from schizophrenia who live in families with high expressed emotion, have a higher rate of relapse ( Bellack, Haas & Long, 2002).   For this reason, interventions for families, such as cognitive behavior therapy, are helpful in dealing with hostility and criticism in the home ( Teschinsky, 2000). Living with a person with schizophrenia can be extremely challenging for family members.  Due to the thought disorder, altered sense of self and bizarre behavior, the family members must develop adequate coping skills to be able to care for their ill family member. Individual cognitive behavior therapy has been shown to be effective in alleviating symptoms associated with anxiety and depression. It assists in improving coping strategies of family members by targeting negative perceptions and automatic thoughts and teaching behavioral techniques that result in improved functioning.  Caregivers utilize coping strategies such as involvement in activities away from the home, belonging to a support group, accepting the illness, setting behavioral limits for the ill person and emotionally distancing themselves from the situation. Educating families on identifying signs of relapse can assist in early intervention thus reducing the need for hospitalization. 

Families and patients with schizophrenia must also face the stigma of mental illness.  Schizophrenia remains a disease that is not well understood and frequently feared in society.  The stigma often spreads to the whole family and may cause them to avoid talking about how they are feeling or to deem themselves social outcasts for having this illness in their family, potentially creating a barrier between them and mental health professionals ( Teschinsky, 2001) . 

Community services can offer psychosocial support and facilitate job training, which can translate into more adaptive functioning in the community (Bustillo, Horan & Lauriello, 2001).  Patients with schizophrenia are often ill prepared to find and maintain the multiple services they need to function in the community.  Case managers act as brokers of services and assist patients in contacting the appropriate providers.  Community programs provide assistance in social skills training, using learning theory principles to improve social functioning.  Vocational rehabilitation and employment programs have shown a high degree of success in improved community functioning.  With a large majority of schizophrenic patients living in the community and hospital stays becoming progressively shorter as a result of managed care, community interventions will be necessary for a large proportion of patients (Bustillo, Horan & Lauriello, 2001). 

There are no exact statistics, but approximately 150,000 individuals with schizophrenia are homeless.  There are more people with untreated psychiatric illnesses living on America's streets, than are receiving care in hospitals (Treatment Advisory Center, 2003). The New York Times recently reported that in Berkley, California, " on any given night, there are 1,000 to 1200 people sleeping on the streets.  Half of them are deinstitutionalized mentally ill people." With the closure of hospitals, the reduction of beds in psychiatric facilities and cuts in federal and state budgets, the mentally ill are not receiving adequate treatment.  Availability of single room occupancy hotels and other low rent housing has dramatically declined as urban redevelopment has begun to thrive.  The result is a growing number of people suffering from schizophrenia that are homeless or in jail (Treatment Advisory Center, 2003). 

Family involvement, community intervention and social awareness are essential in addressing the needs of people with schizophrenia.  Better communication between medical facilities and community services and staff will assist in improved treatment compliance for the patient suffering from schizophrenia. Access to services that can assist with housing and vocational needs and support will alleviate some of the burden of family members in caring for their loved one.  Lastly, social awareness can bring about change so that as a society we begin to address the needs of the homeless who are suffering from schizophrenia.  Instead of ignoring them, we take action to end their plight. 

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