Family Dysfunction

Psychological Explanations of Schizophrenia: Family Dysfunction

Whilst biological explanations focus on genes and neurochemistry, psychological approaches have proposed that abnormal family environments — particularly disordered patterns of communication and relationship — contribute to the development and course of schizophrenia. The most evidence-based of these is the concept of expressed emotion, which continues to influence clinical practice. Earlier theories (the schizophrenogenic mother; double bind) are historically important but now largely discredited.

The Schizophrenogenic Mother (Fromm-Reichmann, 1948)

Frieda Fromm-Reichmann proposed that schizophrenia could be caused by a cold, overprotective, and rejecting mother — the 'schizophrenogenic mother' — whose contradictory communications and failure to nurture caused the child to retreat into psychosis. This psychoanalytic account was widely influential in the mid-20th century but is now rejected: there is no evidence that any particular parenting style causes schizophrenia, and the concept placed enormous and unjustified blame on mothers. It was damaging both clinically and personally to the families of people with schizophrenia.

Double Bind Theory (Bateson et al., 1956)

Gregory Bateson and colleagues proposed that schizophrenia arises from a pattern of communication called the double bind: the child is repeatedly placed in situations where two contradictory messages are communicated simultaneously, and the child cannot respond correctly to either without violating the other, and cannot escape or comment on the contradiction. For example, a mother who says 'come and give me a hug' in a cold, rejecting tone places the child in an impossible bind: approaching invites physical rejection; withdrawing disobeys the verbal instruction. Bateson proposed that chronic double-bind communication prevents the child from developing a coherent model of reality, potentially leading to psychosis.

Double bind theory has not been empirically supported as a causal account of schizophrenia. The original evidence was anecdotal case studies; systematic research has not found that families of people with schizophrenia use double-bind communication more than other families. The theory is now considered of historical interest but not of clinical utility as a causal explanation.

Expressed Emotion (Brown et al., 1962; Vaughn and Leff, 1976)

Expressed emotion (EE) refers to three components measurable in the speech of relatives of people with schizophrenia: criticism (number of critical comments about the patient), hostility (generalised negative attitude), and emotional over-involvement (excessive worry, over-protectiveness, self-sacrificial behaviour). Brown et al. (1962) initially found that patients returning to live with high-EE families relapsed more quickly than those returning to low-EE environments. Vaughn and Leff (1976) replicated and extended this finding: patients in high-EE households had a 51% relapse rate at nine months, compared with 13% in low-EE households. The association between high EE and relapse is one of the most replicated findings in schizophrenia research — meta-analyses across multiple countries find consistent EE-relapse relationships (Butzlaff and Hooley, 1998).

EE is not proposed as a cause of schizophrenia — it is proposed as a maintenance factor and relapse precipitant. High-EE family environments create a chronic psychological stressor that may trigger relapse in biologically vulnerable individuals. This is consistent with the diathesis-stress model (B1561).

Clinical implications: EE measurement (using the Camberwell Family Interview) has become a standard part of schizophrenia assessment. Reducing EE through family therapy — psychoeducation about schizophrenia, communication skills training, reducing criticism — is associated with reduced relapse rates. Pharoah et al. (2010) found that family intervention reduced relapse significantly compared with standard care.