Psychological Explanation: Family Dysfunction & Family Therapy

Psychological Explanations: Family Dysfunction

The double-bind and schizophrenic mother explanation suggests that abnormal functioning within families can cause schizophrenia. However, the Expressed Emotion (EE) Family is an explanation which explains how schizophrenic episodes can be triggered! Therefore, in your exams, please DO NOT say that the EE causes schizophrenia, as this would be incorrect.

You have the option to watch this video, or you can read and makes notes 🙂

Double-Bind Theory: Casual Theory

Bateson (1956) argues that a double-bind is a situation in which a person receives: Two (or more) conflicting messages e.g. verbally positive, but non-verbally negative. If the child questions this inconsistency: They may be criticised or punished, reinforcing their confusion.

As a result, the child feels constantly worried about doing the wrong thing. When they ‘get it wrong’ (which is often) the child is punished by the withdrawal of love. This leaves the child to understand the world as dangerous, confusing and unpredictable.

This dysfunctional family environment leads to certain schizophrenic symptoms. For example, Paranoid delusions could occur, this is because the child finds it very difficult to predict the world around them, this makes them feel paranoid and unsure of when the next negative conflict or situation will happen. This makes the child feel on edge and cautious.

The child may also develop disorganised thinking or behaviour. This is a disturbance in the way a person organises, connects, and expresses their thoughts. This is typically seen through disorganised speech where a person can shift from one topic to another with no clear link.

In summary: The child learns that communication is confusing and unreliable. They struggle to interpret meaning correctly. Over time, this may lead to:

• Difficulty distinguishing reality from contradiction – which feed into delusions.
• Disorganised thinking/speech

Schizophrenic Mother – Psychodynamic Explanation – Casual Theory

A common misconception of this theory, is that the mother has schizophrenia, and genetically passes it on to the child. This is not the case. The context of the theory was the belief that early mother-child interactions exerted a primary and determining effect on schizophrenia. The theory is called schizophrenic mother, but actually, it would be more appropriate to call it the ‘schizophrenia causing mother’. 

This theory is based on accounts that Fromm-Reichman had heard from patients. She describes the mother is described as cold, rejecting and controlling. The environment is tense and full of secrecy.

This relationship leads the child to feel distrust that could later develop into paranoid delusions. The child may constantly feel that they are being victimized and this could magnify into the child believing that other people are out to get them too.

Over time, this parenting style may lead to disorganised thinking and the development of schizophrenia. The key idea is that it creates chronic confusion and insecurity, which disrupts how a child learns to think, interpret, and organise information.

IMPORTANT NOTE: Both the Double-Bind theory and Schizophrenic Mother when taking a Modern view: Are not accepted as a sole cause (better as a risk factor). This is because there is no strong evidence that these family dysfunctions alone causes schizophrenia. It is now more reasonable to interpret it as: Part of the diathesis–stress model, or a possible environmental risk factor.

Expressed Emotion (EE) – RISK TO TRIGGERING RELAPSE

This is a family communication style of: criticism, hostility and over-involvement. They tend to talk more and listen less. It is important to recognise that this theory only claims to explain how someone with a genetic vulnerability can be triggered to develop schizophrenia OR it can cause a RELAPSE in someone who already has schizophrenia. 

It appears that the negative emotional climate in these families, leads to high levels of stress. This stress mounts on top of their already impaired coping mechanisms, thus triggering a schizophrenic episode.

Remember:

• Criticism = Insulting behaviour
• Hostility = Hostility isn’t about shouting or threatening — it’s about treating the person like they are the problem
• Emotional over-involvement = Overprotective or excessively self-sacrificing behaviour. Intrusive and controlling.

Evaluation: Family dysfunction

• Useful Applications – Point: A further strength of the family dysfunction explanation is its practical application, as it has led to the development of effective treatments such as family therapy. Evidence: For example, Pharoah et al. reviewed 53 studies and found that family therapy reduces relapse rates and improves quality of life for individuals with schizophrenia and their families. Explain: This provides support for the role of family environment, as modifying dysfunctional communication patterns appears to have a positive effect on outcomes. However, the effectiveness of family therapy is only moderate, suggesting that family dysfunction cannot be the sole explanation for schizophrenia. Consequence: As a result, it suggests that family dysfunction may not be the primary cause, because targeting it would be expected to have a consistently strong effect. Challenge: Furthermore, this suggests that other factors, particularly biological influences such as genetic vulnerability, are likely to play a more significant role. Therefore, while family dysfunction may contribute as an environmental stressor, the evidence indicates that it is only one part of a more complex, multifactorial explanation.
• Point: One strength of the family dysfunction explanation is that there is some research which suggests dysfunctional communication may contribute to schizophrenia. Evidence: For example, Bateson (1956) described a case in which a patient received conflicting verbal and non-verbal messages from their mother, demonstrating a potential double-bind situation. Explain: This may contribute to confusion in thinking, which could be linked to schizophrenia symptoms. However, this evidence is based on clinical observations and case studies, which lack objectivity and scientific control, meaning they cannot establish cause and effect. Consequence: As a result, it is unclear whether the dysfunctional communication caused the schizophrenia, or whether the mother’s behaviour was a response to the individual’s symptoms.
• Social Sensitivity: Furthermore, this family explanation has been criticised for parent-blaming, which is socially sensitive and reduces the credibility of the theory, particularly given that biological explanations, such as genetic evidence, provide more robust empirical support.
• Causality Issues: Family dysfunction explanations is that they do not provide a clear causal account of schizophrenia. For example, the double-bind theory suggests that exposure to conflicting communication may increase the likelihood of developing schizophrenia, but it is better understood as a risk factor rather than a direct cause.
• Alternate explanations: Gottesman (2010) found that the risk of mental illness was much greater for children who had two parents with a diagnosis of bipolar or schizophrenia: 67.5% of offspring who had both parents diagnosed with schizophrenia, had developed a mental health issue by the age of 52. This weakens the family dysfunction explanation because it demonstrates that schizophrenia can develop in the absence of dysfunctional family environments, suggesting that such factors are not necessary causes.

Psychological Treatment: Family Therapy

Families can play an important role in helping a person with schizophrenia recover and stay well. Family intervention in the treatment of schizophrenia has developed as a result of studies of the family environment and its possible role in affecting the course of schizophrenia. Research has consistently shown that the long-term outcome for an individual with schizophrenia has much to do with the relationship between the individual and those who care for them. Poor relationships tend to result in poor outcomes, i.e. a greater chance of relapse. The main aim of family therapy is to provide support for carers in an attempt to make family life less stressful and so reduce re-hospitalisation.

How does it work?

By reducing levels of expressed emotion and stress, and by increasing the capacity of relatives to solve related problems, family therapy attempts to reduce the incidence of relapse for the person with schizophrenia. Families are taught to have weekly family meetings solving problems on family and individual goals, resolve conflict between members, and pinpoint stressors. The main steps for family therapy are:

Identify: Through interviews and observation the therapist identifies strengths and weaknesses of family members and identifies problem behaviours.

Educate: teaching the patient and the family the actual facts about the illness, it’s causes, the influence of drug abuse, and the effect of stress and guilt.

Communicate: training the family in skills that help them to communicate more effectively with each other. 

Pharoah et al (2010) recommends a number of strategies. I have developed the memory strategy UNITES to help you remember the key strategies of family therapy. Pharoah didn’t come up with this, so please feel free to use this as part of revision. But don’t say in your exams that Pharoah uses a UNITES therapy. 

UNITES

Unity in caring for the individual with schizophrenia

Negative emotion and stress reduction

Irritation and guilt reduction

Teaching boundaries

Educating relatives about schizophrenia

Solve and anticipate problems

Evaluation of Family Therapy:

• • Research to support the effectiveness of Family Therapy: Pharoah et al. developed a type of family therapy and then reviewed 53 studies in order to understand the effectiveness of it for families of schizophrenia sufferers. They concluded that there is moderate evidence to show that family therapy significantly reduces hospital readmission over the course of a year, improves medication compliance and improves quality of life for patients and their families.
  • Research to oppose/question the effectiveness of Family therapy: Pharoah et al. research shows mixed results. They concluded that there is moderate evidence to show that family therapy significantly reduces hospital readmission over the course of a year, improves medication compliance and improves quality of life for patients and their families. Firstly, the evidence is described as ‘moderate’, which implies that there is mixed findings in terms of how effective it is. Secondly, it could be suggested that the main reason for its effectiveness is more to do with the fact that it increases medication compliance. Patients are more likely to reap the benefits of medication because they’re more likely to comply with their medication. This casts doubt on the effectiveness of family therapy alone. Therefore, we must be cautious in drawing the conclusion that family therapy is effective in treating schizophrenia as it is difficult to establish a cause and effect when considering the research by Pharoah.
  • Freewill is encouraged in Family therapy – Family therapy teaches the family strategies and this encourages freewill as it helps them to understand that they can make active and conscious choices to change their family dynamic. This could be why Pharoah found success rates in terms of long-term effectiveness. This is because family therapy allows the family to solve and anticipate issues themselves and therefore they do not need to rely on medical and health resources on a regular basis. This could make family therapy more useful because it helps to reduce the cost of care by training the family to be effective carers.
  • Free will issues in Family therapy – The fact that family therapy encourage a sense a freewill and works on the basis that the patient has to make a conscious choice to be committed to the treatment causes some issues. Family therapy in particular requires the commitment of not just one member, but several. This may not be possible, as some members of the family may not be want to participate as they find it too painful. In addition, the negative symptoms such as avolition and emotional flattening can lead to a reluctance to participate and an inability to engage and therefore act as a deterministic factor.
  • Usefulness Family therapy – FT could be deemed more useful in the sense that it doesn’t cause any physical side effects in comparison to anti-psychotic drugs. Use evidence from studies in biological treatments for schizophrenia.
  • Practical Issues – Usefulness of Family Therapy- However, could be deemed less useful because therapies are expensive and can be very time consuming. This means that it can be difficult to offer therapy on a mass scale (especially when it is the most common psychotic disorder), and it could lead to drop out rates, especially when a patient in going through a severe episode. The individual and the family must be committed and attend regular sessions in order for it to be successful. 
  • Idiographic approach/Individual differences –Family therapy targets and improves the unique deficits of each individual. Unlike drug therapies that provide a one fits all approach.