Schizophrenia in the South African context

“I have schizophrenia. I am not schizophrenia. I am not my mental illness. My illness is a part of me” (Living with Schizophrenia, 2020). This paper provides an understanding of the features and symptoms associated with the personality disorder of schizophrenia. Literature relating to the treatment models used in the treatment of schizophrenia will be discussed. Further to this, the South African context will be explored relating to the intersection between culture, mental illness and the concept of family and stigma. The cultural aspects will be considered in relation to schizophrenia and family therapy. Finally, the preferred treatment model will be proposed whilst elaborating on its background, core concepts and ethical considerations.

 Schizophrenia   

Schizophrenia is a personality disorder, which is complex with the symptoms of psychosis at its core (Nolen-Hoeksema, 2014). The author explains that the five domains of psychotic symptoms comprise of four symptoms which are deemed positive symptoms: 1) delusions, 2) hallucinations, 3) disorganised thought (speech), 4) disorganised or abnormal motor behaviour, and one negative symptom such as restricted emotional expression. In order to be diagnosed with schizophrenia, two or more of the symptoms listed must be present for a significant portion of time during one month. In addition, for six months they must have experienced some of the symptoms which have resulted in social or occupational impairment. To summarise, individuals with this disorder experience visual and auditory hallucinations, they may also have fixed beliefs (delusions) which are out of touch with reality, and they may speak incoherently and act unpredictably. Schizophrenia can be experienced as mild to severe, and has, therefore, been placed on a continuum (Nolen-Hoeksema, 2014). The continuum mentioned herein is representative of what the DSM-5 refers to as the schizophrenia spectrum, which is a set of psychotic disorders that share similar traits with schizophrenia but are not as severe or persistent (Nolen-Hoeksema, 2014). Clinicians refer to the diagnostic criteria set out in the DSM-5 (APA, 2013) when assessing patients for schizophrenia. 

Schizophrenia can be explained as a disease of the brain, which manifests clinically as a disease of the mind (Jarvis et al., 2020). Nolen-Hoeksema (2014) explains that the causes of schizophrenia can be rooted in genetics, structural and functional brain abnormalities, neurotransmitters, and psychosocial causes. 

Schizophrenia has various treatment options. The use of medication is one such option which includes typical antipsychotic drugs and atypical antipsychotics. Although medications do assist in relieving the psychotic symptoms of schizophrenia, individuals still struggle to control the negative symptoms and, therefore, commonly struggle with social interactions and motivation (Nolen-Hoeksema, 2014). 

Literature 

The literature sets out to explore the most suitable treatment modality for a schizophrenic client within the South African context, and will be explored using relevant evidence, research and theory. Firstly, the below literature will give a brief background of the modalities used for the treatment of schizophrenia worldwide and then, secondly, in the South African context. Gottdiener (2006) set out to provide empirical evidence by conducting a review to support the use of practising individual psychodynamic psychotherapy to treat individuals with schizophrenia. He states that in recent decades there has been a decline in the use of psychoanalysis to treat schizophrenia. This was attributed to a pessimistic view held by mainstream clinical psychiatry and psychology that it had not rendered improvements. The conclusion of this review states that there is evidence which supports the use of psychotherapy but that the procedures used are not consistent with the schizophrenia treatment guidelines of the APA (2004).   

Louise et al., (2018) review the use of mindfulness-and-acceptance-based interventions for psychotic individuals.  As therapies for psychosis have advanced, one of the outcomes has been to apply “third wave” cognitive behavioural therapies (CBT). The focus is on mindfulness and acceptance as a way of experiencing the symptoms and resisting the urge to change them. This theory foregrounds an approach of empathy towards self, non-judgement, and acceptance of experiences and symptoms. The results showed that the third-wave interventions are effective in the treatment of depressive and psychotic symptoms. Leff et al., (2014)  developed a novel computerised therapy, namely Avatar Therapy, which enables the patient to create a human or non-human entity which links to their hallucinations or persecutory thoughts. This entity can be created to fit the visual description they experience, and it is referred to as an avatar. In therapy, the client is encouraged to enter into dialogue with the avatar (in the presence of the therapist) so that they can change the power dynamic they experience with the avatar. An example of this is where the client initially experiences the avatar (entity) as abusive; they may be able to alter this to a more supportive experience. This treatment was effective with patients who had not responded well to medical treatment. It also highlighted the importance of patients having a relationship with their ‘voices”. Bucci et al., (2016) state that family interventions are the recommended psychological intervention worldwide for treating schizophrenia.  It is further stated that psychiatric specialist organisations in the United Kingdom, Australia and New Zealand recommend family interventions as the first-line of treatment for all stages of psychosis. In reviewing the evidence to substantiate these claims, the emotional atmosphere of families became a central focus. 

In the 1950s, research was conducted on the emotional atmosphere of families with schizophrenia, which led to the development and understanding of the term “expressed emotion” (EE) (Brown & Rutter’, 1966). Nolen-Hoeksema (2014) states that the one factor relating to family interaction which also correlates with multiple episodes of schizophrenia is high levels of expressed emotions (EE). EE refers to high levels of emotions relating to being overly involved in a family member’s life, being overly protective, or hostile, resentful and critical. This behaviour stems from a lack of understanding about the disorder whereby family members believe the schizophrenic family member can control their symptoms. Research shows a link between high levels of EE within the family environment and the relapse or outcome of a schizophrenic family member (Alvarez-Jimenez et al., 2012) . Cross-culturally, research shows that the absence of warmth within the family has appeared to be the strongest predictor of possible relapse, more so than aggression and disapproving behaviours (Nolen-Hoeksema, 2014). 

Research shows that positive family interventions may reduce the number of times a patient will relapse or return for hospital admission (Haddock & Lewis, 2005) which, therefore, led to the development and recommendation of using family interventions in treating schizophrenia (Bucci et al., 2016).   

Bucci et al., (2016) express concerns that, in practice, family interventions are not being implemented as frequently in the treatment of schizophrenia treatment as they should be, and the most prominent reason for this is the lack of training available for health professionals in using family interventions.  

Corey (2015) states that the use of family systems therapy in the multicultural framework is one of the main strengths of its approach in that many ethnic and cultural groups place a high value on the extended family. Within this approach, if a therapist is working with an individual from a cultural background, with emphasis on including the extended family in the treatment, it is clear that family interventions have an advantage over individual therapy. This is relevant to treating schizophrenia in the South African context with the majority of the population having a collectivist view of self, which means they see themselves as part of a more extensive family system and community. Mafumbate (2019) states “The extended family system in Africa emphasises the principle of ‘living together’ and the sense of ‘community of brothers and sisters’’ (p.10). This further affirms the African philosophy of Ubuntu which refers to interconnectedness wherein “a person is a person because of others”(Nussbaum, 2003, p. 2). 

South African Context

Kritzinger and Swartz (2009) researched the challenges and pathways of implementing family therapy to treat schizophrenia within South Africa. The authors confirm the link between EE experiences within families and relapse rates, showing higher relapse rates when engaging in family therapy where there is conflict as opposed to individual therapy. It is suggested that a method of psycho-educating the family about the illness could assist them in gaining an understanding of the condition and the potential for relapse, and also learning coping strategies to ensure that the family environment is supportive of the schizophrenic patient. The authors state that although there is evidence that family interventions are more effective than standard care, they are calling for more research to conclude whether single or multiple family treatment is more effective. Jarvis et al., (2020) state that there is a substantial relationship between culture and psychotic disorders such as schizophrenia. This is further confirmed by Asmal et al., (2011) who proposes family therapy as an effective intervention for schizophrenia as it lends itself to being culturally sensitive. 

The intersection between culture, interpretation of mental illness and concept of family 

This section highlights the importance of the structure and content of interventions and the emphasis on how they should be adapted for people living in a cultural and diverse setting such as South Africa (Asmal et al., 2011). Each culture will have a different way of defining family and interpreting mental illness. Individuals in rural areas may be more inclined to see mental illness as caused by external malevolent spiritual forces and seek care from traditional healers (shamans) (Stretzler, 2001). Contrary to this, those based in urban areas are more likely to believe that mental illness originated from an internal factor such as the grief emanating from the loss of loved ones (Asmal et al., 2011). Niehaus et al., (2004) state that diagnosis in African indigenous healing requires an understanding of the context as it does not follow the classification of symptoms but rather relates more to theories of causation. The “culture-bound” syndromes fall outside of the Western diagnostic categories; indigenous groups consider these patterns to be illnesses which have local names that require further understanding when treating schizophrenic patients in South Africa. “Ukuthwasa” is explained as a calling by the ancestors, which is deemed to be a privilege, and to conform to this calling is to acknowledge special powers but to resist this calling can lead to illness. “Amafufunyana” is described as behaviour which is characterised by hysteria and talking in strange and muffled tones. This is believed to be induced by sorcery and being possessed by multiple spirits. Asmal et al., (2011) state that, in the South African context, schizophrenia is understood within the explanatory models of bewitchment, jealousy and ancestral callings. Family members may encourage that, in addition to medication or psychiatric treatment, the schizophrenic family member also seeks help from indigenous healers. The concept of a person within the western medical framework is understood from an individualistic perspective with an emphasis on autonomy. In contrast, the African culture has a collectivistic perspective which has an emphasis on the individual’s role in the broader family system. An awareness of these differences is essential when implementing a family intervention successfully within the South African context. 

Austin et al., (2014) state that in South Africa, clinical symptoms of schizophrenia can be further complicated by the use of substances (mandrax, alcohol and cannabis) which are used in a variety of combinations. A further consideration is South Africa’s under-resourced mental health system which impacts the patient’s ability to receive treatment and gives rise to the revolving door policy, which results in patients being frequently hospitalised. 

Stigma, schizophrenia and culture 

Mbanga et al., (2002) state that culture is pivotal when determining the level of stigma relating to a mental illness. This has been confirmed in several studies in South Africa whereby family members attributed the diagnosis of schizophrenia to being witchcraft or spirit possession. Kritzinger & Swartz, (2009), note that the concerns around the stigma was not only on the emotional well-being of the individual but also on the impact it had on their successful treatment. Findings revealed that there was a higher mortality rate of individuals with schizophrenia in instances where they did not adhere to their treatment. Kakuma et al., (2010) confirmed this, stating that these individuals are often victimised and mistreated by their family, friends and the community, and can also face discrimination in the workplace and stand to lose their jobs. This hostile environment threatens to negatively impact their mental health condition. (Austin et al., 2014). 

Culture mediating the relationship between family therapy and schizophrenia 

Rosenfarb et al., (2006), state that research shows that culture has an impact on the EE. The role of culture is immersed in the therapeutic environment whereby a clinician could unknowingly focus on reducing what may be perceived as critical or intrusive behaviours; however, they are experienced within the culture as adaptive. Further misconceptions that can take place in the South Africa cultural context is the use of eye contact or the concept of personal space which could result in misunderstanding non-verbal behaviour. Asmal et al., (2011) state “Theoretically, the attribution of psychotic symptoms to spiritual forces may lead to relatives being more accepting of untoward behaviour since it is believed that the patient is not fully in control of their actions thereby creating a natural “low-EE” environment”” (p. 369). This demonstrates one aspect of the complicated family dynamic of schizophrenia.

Treatment model – Family Systems Therapy 

Family systems therapy has been empirically tested and recommended as an effective intervention for the treatment of schizophrenia (Bucci et al., 2016; Corey, 2015; Kritzinger & Swartz, 2009; Nichols & Davey, 2017), particularly in a multicultural setting such as South Africa (Asmal et al., 2011; Austin et al., 2014; Corey, 2015). 

Background

Nichols and Davey (2017) state that Gregory Bateson was one of the pioneers of family therapy whilst working on the schizophrenia project in Palo Alto, California, in 1952. Bateson studied communication where he introduced the concept of meta-communication and a double bind as a way of understanding the two-levels of communication that occurs. He also spoke about regulating behaviour within the family, terming it homeostasis. Corey (2015) states that Murray Bowen was another one of the founders of mainstream family therapy. His theory evolved from psychoanalytic principles and practices and is now a theoretical and clinical model. Bowen is known for his multi-generational approach and his approach to the treatment of schizophrenia. His two colleagues, Betty Carter and Monica McGoldrick, initiated a multicultural perspective in family therapy. 

Nichols and Davey (2017) state that the “emotional client” has been established as an essential factor in relapse with schizophrenic patients. Researchers have used the findings relating to EE and developed psychoeducational family interventions which facilitate the recovery of the patient whilst supporting family members. The education component of the program provides a description of what EE is and how it triggers symptoms and how family members can assist in reducing relapse. 

Corey (2015) is cited below to explain the family systems model of therapy proposed by Bowen. The central assumption of family systems therapy is to view the individual as part of the family system. The individual’s behaviour extends out of the interactions which take place within the family as well as the broader community and societal systems. Family systems therapy views the individual as a system embedded in many other systems, thus bringing a new perspective to treatment. The therapist will use a multi-layered approach to family therapy which aims to be collaborative whilst focussing on mutual caring, respect and empathy. The therapist will focus on building a strong therapeutic relationship with the client from the outset that is engaging, open and warm. The therapist should not focus on the content of issues but rather on ways of relating within the family system. The therapist will aim to be supportive and encouraging towards all member of the family as a way to gain co-operation and achieve successful outcomes. This process should encourage empowerment. During family therapy, special attention should be given to ensuring that individuals within the family are not singled out or blamed for any shortcomings of the family unit. The interventions and techniques employed in therapy will be dependent on the specific dynamics of each case and the goals identified in the initial assessment. The therapeutic approach for schizophrenic individuals in the family system may take the role of psychoeducation and provide a platform to provide support, empathy and care to the individual and the family unit. Flexibility and a multi-layered approach will be crucial to the success of the intervention.

Ethical considerations 

The family systems therapy should be implemented by a registered professional who is guided by the ethical standards as set out by the Health Professions Council of South Africa (HPCSA, 2004) as its use within the South African context may give rise to unforeseen ethical dilemmas. As a precaution, the client and their extended family will need to be informed of the professional’s limitations concerning confidentiality, and all participating members will be required to provide informed consent. The following are examples of possible ethical considerations. Statutory vs voluntary bodies: it is essential to understand the difference between a statutory body (determined by law) and a voluntary body (not determined by law) when faced with an ethical dilemma. Professionals must ensure that the HPCSA guidelines are used to guide treatment. Competency limits: when working with a family and in multicultural settings, the professional must not be working outside the realms of their knowledge. This includes language barriers, and the use of a translator should it be required. Boundary violations: within the multicultural setting, boundary crossing would include imposing your own set of values or beliefs onto your client, or responding in such a way that is racist, sexist or discriminatory. This would also be violating the ethical code of “not harm”. Barter with clients: providing therapy within the family setting and in South Africa with the complex socio-economic realities, the likelihood of being faced with an offer of services in exchange for psychological services is probable, the guidelines will need to be adhered to in this regard and ensure that any such exchange was not unprofessional or exploitative. Couples or family therapy:  the professional must clarify at the outset which individual is deemed to be the client and clarify the role and relationship with all members of the group. If conflicting roles occur the professional must attempt to clarify these or withdraw from the appropriately (HPCSA, 2004; Naidu, 2016).

Conclusion  

This paper has explained the mental illness of schizophrenia with the symptoms of psychosis, making up the core of the disorder. Individuals living with this disorder may experience hallucinations and delusions, which present them as being out of touch with reality. Genetics, brain abnormalities and psychosocial causes all play a part in developing this disorder. The treatment using medication is briefly mentioned whilst a more extensive focus has been on reviewing the psychological treatments used such as psychodynamic psychotherapy, mindfulness-and-acceptance-based interventions and avatar therapy. Family interventions were deemed to be the therapy of choice in several countries when treating schizophrenia and the additional advantage was its multicultural framework which was pertinent to its effectiveness in the South African context. The considerations that need to be factored in were discussed in detail regarding the expressed emotion within families linking to relapse rates, as well as the consideration of cultural beliefs and traditional culture when treating a disorder such as schizophrenia in South Africa. 

Further to this is the consideration of the collectivist view in the African culture and the importance of the family as part of the focus of treatment. In concluding, Family systems therapy has been deemed the therapy of choice whilst outlining the concepts of the approach as proposed by Bowen, and this therapy appears well suited to the treatment of this illness in the multicultural society of South Africa.     

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