Many Voices

From witchcraft to sorcery, Western history reveals that schizophrenia has acquired many names across the ages to persecute and execute those at odds to those in power (Read et al., 2013). Although sociopolitical reactions and vested interests regarding psychological phenomena have changed over time, stigma and distress continue to shadow a diagnosis that struggles to define diverse lived experience (Carr & McNulty, 2006). So to prevails the dominant model of mental health that locates causation within the biology of an individual despite evidence to the contrary (Read et al., 2013). As a result, the reliability and validity of schizophrenia diagnosis remain highly contentious, particularly among those whose cultural and spiritual constructions have been pathologised in mainstream psychology (NiaNia et al., 2019). This essay seeks to explore alternative perspectives to bio-genetic theories of schizophrenia with reference to cultural understandings [1]. Finally, features of psychological assessment will be discussed with respect to person-centred clinical and cultural care. 

Schizophrenia and the DSM-5

To be diagnosed with schizophrenia, the Diagnostic and Statistical Manual of Mental Disorders (5th Edition; DSM-5, American Psychiatric Association, APA, 2013) suggests that an individual demonstrate six months of marginal functioning in relation to two or more of the following: hallucinations, delusions, disorganised speech, catatonic or disorganised behaviour, and negative symptoms. Further, one of the first three symptoms must be present for diagnosis. Cultural differences in symptoms and associated explanations may lead clinicians to misinterpret the severity of presentation or give the wrong diagnosis (Alarcón et al., 1999). Indeed, voice hearing, while commonly accepted in Māori and other indigenous communities, within a western framework could be misunderstood as a symptom of schizophrenia: “For me hearing voices is like saying hello to your whānau (family) in the morning, it is nothing unusual” (Taitimu et al., 2018, p. 162). In an effort to improve cultural safety, the DSM-5 (5th Edition; DSM-5, American Psychiatric Association, APA, 2013) includes a cultural formulation guide and revised glossary of cultural concepts of distress that, to a degree, recognise the difficulties of detecting cultural syndromes (American Psychiatric Association, 2013).

The Nature of Schizophrenia

The circumstances of schizophrenia, whether sudden or insidious, have been theorised in stages (American Psychiatric Association 2013; Cooke, 2017). The prodromal phase involves transient symptoms that produce moderate disturbances to thoughts, feelings and behaviours. Extending over several months, signs of prodrome include social withdrawal and decreased initiative, preceding the emergence of psychosis (Ventriglio et al., 2016). In broad terms, the acute phase is marked by a loss of reality control in which psychotic symptoms escalate in number and intensity (Larson et al., 2010). For approximately 70% of people, delusions and hallucinations are central to the experience of first episode psychosis (Reiger, 2017). Graham (2013) revealed,

I began to think that...my blood had been poisoned by evil spirits and that I was evil, and that there were spirits around me, warping my thoughts and changing my thoughts, and that was very frightening and I didn’t know what to do with it (para. 3).

The belief of life-threatening danger (persecutory delusion), whether real or imagined, can invoke various states of psychological distress (Freeman & Garety, 2014). In a similar manner, hearing voices that instruct acts of self-harm (command hallucinations) can be considerably distressing. Upon compliance with such voices, many people are forced to contend with police, accident and emergency departments or admission to an acute psychiatric ward which is often, in itself, a traumatic experience for the individual, their families and communities (Cooke, 2017; Government Inquiry into Mental Health and Addiction, 2018). 

The Aetiology of Schizophrenia

Genetics

            According to Read et al. (2013) biological psychiatry, insists on overstating genetics as the cause of schizophrenia; a stance that is motivated by the support of the pharmaceutical industry. Some studies have reported a biological link between the shared genes of family members as evidenced by twin studies. Monozygotic twins (those who share identical genes) are more likely than dizygotic twins (50% of common genes on average) to develop symptoms of psychosis which suggests a genetic contribution (Rieger, 2017). To that end, the ‘vulnerability-stress’ model acknowledges a role of external indicators but only in people who are assumed to have genetic predisposition. That said, some have argued that increased sensitivity to stress may be a direct result of childhood trauma (Read et al. , 2014).

Childhood Trauma

Research has indicated that childhood trauma is common in people who later develop schizophrenia (Davis et al., 2016; Seaman, 2010), even when accounting for mediating factors, such as familial psychopathology. In a study of over 4000 individuals, Janssen et al. (2004) found that increased levels of exposure to trauma were associated with increased risk of subsequent psychotic symptoms. Notably, participants who were severely abused demonstrated 48 times greater risk of psychosis compared to participants who were without abuse. In Pete’s (2013) experience:

We used to have a childminder that would come round on a Friday evening and look after us, and after a period of time I started to experience sick sexual and physical abuse off this woman from the age of five up to about the age of thirteen. I would say about, when I was about seven year old that’s when I first started to hear voices (para. 1)

Cultural Understandings

In addition to developmental adversity, several social determinants are risk factors for schizophrenia: poverty, unemployment, abuse, violence, cultural alienation and social isolation. Further, ethnic minorities, immigrants, and indigenous communities are more likely to be diagnosed with schizophrenia, explained by prejudice, discrimination and the ongoing impacts of colonisation (Cooke, 2017; Government Inquiry into Mental Health and Addiction, 2018; Read et al., 2013). In Chondol’s (2012) words: “My views and beliefs were wrongly interpreted as an illness. If the professionals concerned had taken the trouble to consult with people from my own cultural background the facts would have been perfectly clear to them” (para. 1).

The pathways from poverty and ethnicity to schizophrenia are complex. Nevertheless, research suggests that inequality and deprivation, viewed through their social and personal meanings, are important causal factors (Demarchi et al., 2012; Petrović-van der Deen et al., 2020). To illustrate, Sadowsky (2003) found that the content of delusions in African patients in Southwest Nigeria were expressed as a result of the socio-political landscape in experiences of war and colonisation. Therefore, better understanding may arise from assessing the extent to which an individual’s histories, thoughts, beliefs, social and economic circumstances relate to schizophrenia (Reiger, 2017).  

Assessment

Engagement

Respect and meaningful connection can assist in uncovering the client’s needs and values: "I've learned to manage with the help of the people I trust." (Lampshire, 2011, Aucklander section). Therefore, the expression of warmth and empathy are important, especially when clients are facing high levels of distress. In these circumstances, clinicians should create a calm environment with particular sensitivity to the effect of any discussion (Kuipers et al., 2006; Voss & Das, 2020). Further, Kleinman and Benson (2006) noted that to improve clinical rapport and engagement: “Speaking the language of the patient,” in terms of linguistics, concepts and metaphors, can result in greater engagement, improve assessment discussion, and strengthen therapeutic alliance. In Longden’s (2010) words: “He didn’t talk about auditory hallucinations; he talked about hearing voices, and unusual beliefs rather than delusions. He didn’t use this terrible mechanistic, clinical language; he just couched it in normal language and normal experience” (p. 256). This process, at least in practice, can be difficult to navigate depending on culture, context and how symptomatic the individual presents. As such, clinicians may find it helpful to adjust their approach according to the client's readiness to engage.

Assessment Measures

With respect to the client, the clinician may find it helpful to carry out a mental state examination. Domains of observation can include appearance, behaviour, motor activity, speech, mood, thought content, perceptual disturbances, cognition, and insight. Additional measures such as the Psychotic Symptom Rating Scales (PSYRATS) or Cultural Formulation Interview can be prescribed for richer contextual information (American Psychiatry Association, 2013; Reiger, 2017). Assessments generally concentrate on the severity or frequency of clinical features and are normally based on interviews rather than self-report, on the assumption that lack of insight (anosognosia) is seen to be central to schizophrenia. As such, measures include both items rated from the information obtained from the client, and others rated on observations made during the interview.

Collaboration

According to Kuipers et al. (2006), the two most important areas for working with clients are the distressing experiences they bring to the assessment, and the sense they make of them. Therefore, an important aspect of collaboration is listening. Further, Cooke (2017) cautioned that not everyone finds their experiences distressing or understands them as symptoms. As such, it is important that clinicians are open to different ways of understanding experiences beyond the assumption that all difficulties align with illness. Similarly, Reid et al. (2013) explained that it is important to recognise that clients may want to be active participants of assessment rather than passive recipients of the practitioner model. Nicholls (2007) revealed, “We are tired of being categorised and feared, worn down by being voices in the wilderness...voices that cry out for a humane and holistic understanding of who we are, that embraces physical and spiritual as well as psychological and emotional wellbeing” (p. 103).

Risk Assessment

            Across the lifetime, an estimated 10% of people diagnosed with schizophrenia will commit suicide and 30% will attempt it (Kuipers et al., 2006; Sher & Khan, 2019). As such, early assessment and initiatives are crucial in reducing risk (Laursen et al., 2014). In addition, it is important to assess if the client has any other medical conditions or if they are engaging in alcohol and substance use. This information can be useful for differential diagnoses of drug-induced psychosis or comorbid depression which is an important contributor to suicide risk in patients with schizophrenia (Sher & Khan, 2019).

Where appropriate, clinicians should take measure of the client’s psychosocial history including ongoing areas of trauma and conflict (Read et al., 2013). Bearing in mind that control and criticism (high expressed emotion) from family and carers can lead to increased risk of relapse, clinicians may find it beneficial to explore relevant aspects of the client’s home environment (Kuipers et al., 2006; Rieger, 2017).

Cultural Considerations

NiaNia et al. (2019) explained that, “Good clinical care requires sensitivity to the tensions between pathologising culture and culturally rationalising genuine psychological issues. Navigating this territory appropriately involves both careful clinical assessment and cultural knowledge” (p. 347). This interaction is significant, particularly for clients who maintain a strong cultural identity. With the inclusion of a cultural formulation interview in the DSM-5 (5th Edition; DSM-5, American Psychiatric Association, APA, 2013), clinicians can be guided in eliciting culture-specific information. (American Psychiatric Association, 2013). However, in practice, symptom assessment methodologies need to be tailored, and prescribed assessment tools may not be appropriate, given their reliance on Eurocentric understandings (Demarchi et al., 2012).

In many cultures, spiritual explanations are expected in the natural course of healing (Moskowitz et al., 2011). Among Māori, the most common belief for understanding supernatural experiences such as hearing voices, is a spiritual one, including matakite (seer), mākutu (curse), mate Māori (spiritual disorders) and communication from ancestors (Durie, 1994; Kidd et al., 2018; Sanders et al., 2011): “They come to me when things are about to get bad. I used to think them coming meant I was going crazy again but now I realise that when times were tough, they were there to help me through” (Taitimu et al., 2018, p. 162).

Durie (1994) recommended that clinicians consider a holistic approach to assessment with regards to the interconnected nature of individual and family across mental, emotional, physical and spiritual domains. Therefore, collaboration between psychologists, whānau (family), Tohunga (Māori healers) and other kaumātua (elders), can produce relevant psychological assessment for Māori, particularly when spiritual experiences are suspected. Accordingly, assessment may involve the use of karakia (prayer), mātauranga Māori (Māori knowledge), and tikanga (Māori customs) (Valentine, 2016).

Pōwhiri Assessment Tool

In Māori culture, the pōwhiri ritual is a traditional welcoming ceremony that can be regarded as a guide to conducting appropriate engagement (Drury, 2007). As such, the Pōwhiri assessment model is designed to be used from the first contact with client and family. The process intends to reduce formal barriers of assessment that can, at times, overwhelm the client. Consistent with the mental status examination, the pōwhiri tool covers nine dimensions that form a multi-dimensional assessment tool. Domains include: karanga (invitation) in which appearance and gait can be measured; mihimihi (introductions) in which speech and thought content can be assessed; and whanaungatanga (connections) in which history and therapeutic relationship can be formed (Valentine, 2016; Williams, 2019). While the tool aims to deliver a comprehensive assessment, it also embodies the strengths and abilities of the clinician while taking into account the diverse needs of the client and their family (Williams, 2019).

Conclusion

The origins and impacts of schizophrenia have been extensively researched and theorised across disciplines. However broad and contested the definition, nothing can be more defining than the lives of those who experience such a phenomena. Consequently, many researchers and professionals have located schizophrenia within the body and minds of those diagnosed. Yet, beyond the individual, an excess of causal factors exist across cultural,  environmental, social and spiritual domains. This is especially relevant to those whose voices have been silenced or marginalised in the wider conversation. Therefore, assessment can afford the opportunity for those voices to be heard. A person-centred approach can inspire the therapeutic relationship whereby all parties are encouraged to explore the diverse understandings of experiences associated with schizophrenia. Subsequently, the pathologising approach to assessment can be replaced with new lines of inquiry. In Longden’s (2013) words, “the relevant question...shouldn’t be what’s wrong with you, but what happened to you?” (10:40).

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[1] Testimonies have been included throughout the essay to illustrate the lived experience and different points of view from people of all cultures.