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Schizophrenia: Psychiatry vs psychology

In the genesis of schizophrenia, which is decisive — nature or nurture? In other words, does schizophrenia have a biological (i.e. genetic) cause, or is it the result of a "bad upbringing" or a "bad experience"? And how should it be treated — by a psychiatrist or a psychologist?

To a large extent, your reply to these questions will be determined by your concept of schizophrenia, which is based on what you have read or been told about it.

If you believe it is an illness, and believe it has a biological cause, you will almost certainly believe it is something to be dealt with by psychiatry — the "branch of medicine concerned with the study, diagnosis, treatment, and prevention of mental illness" (Webster's New College Dictionary). If, however, you do not believe it is an illness, and do not believe it has a biological cause, you will almost certainly believe the solution to it is to be found in the realm of psychology — "the science of mental processes and behavior" (Webster's).

Psychiatrists, being doctors, treat their "schizophrenic" patients with drugs that are designed to eliminate the psychosis — the "complete or partial withdrawal from reality" (Webster's) — that is a salient feature of schizophrenia. In the case of my family member who has schizophrenia, the antipsychotic medication prescribed is flupenthixol. This is administered once a month by "depot injection" — "an injection, usually subcutaneous or intramuscular, of a pharmacological agent which releases its active compound in a consistent way over a long period of time" (Wikipedia).

Psychologists, on the other hand, treat their patients with "talk therapy" in a relaxed setting in which, they believe, the patients will be able to "work through" their problems, and come to terms with the presumed "bad experiences" that caused their psychoses. Psychologists are often passionately opposed to psychiatric practice, which they sometimes describe as an assault upon the integrity of the person — especially when it is imposed by a court order.

From time to time, I receive emails, with "Stop forced drugging!" in the subject field, from people who go on to cite such "authorities" as R D Laing, Thomas Szasz and Loren Mosher in defense of their position. Generally, I don't argue with such people, as they are ideologically committed and as impervious to reason as religious fanatics.

On the one occasion I did enter a debate with a psychologist, I asked him a simple question: "In the absence of compulsion, how do you keep the patient in the room?" I pointed out that many people diagnosed with schizophrenia are, like my family member, so paranoid that they never stay more than a day or two in the same place. "She would be off to the other side of town, the next town, or even the next country, before you even knew what was happening," I added.

Of course, he couldn't answer my question.

I don't think it can be stated too strongly that the choice, in cases like that of my family member, is not between compulsory treatment and voluntary treatment. It is between compulsory treatment and no treatment at all. As a matter of fact, my relative did check into some "retreats" and "half-way houses" during her months of itinerant destitution. But she never stayed. She would take off after a couple of days, often after accusing other residents of stealing from her or of being in league with her "enemies". Sometimes the police were involved, and things became unpleasant.

I have no regrets about taking the actions that eventually resulted in my family member being committed to the psychiatric ward of a public hospital. The medication she received there, and which she has since received in reduced doses, put her on the road to a remarkable recovery. This has seen her gain a second university degree, find a good job, and buy a fabulous house.

That is not to say that medication is the be all and end all of treatment in a case of schizophrenia. Also crucial, during the long recovery, are family support, good nutrition, plenty of rest, and a program under which the patient sets, and achieves, a succession of goals, while painstakingly building on each advance.

Looking back, I realize that the cause of my family member's schizo-
phrenia was both biological and environmental. Although she had a happy, successful childhood and adolescence, and seemed destined for a brilliant career in science, her final year of study for an honors degree, plus an involvement in highly competitive sport, proved too much for her.

She didn't have a "bad experience". (My hunt for a possible rapist was a wild-goose chase!) What she had at university was actually an ordinary experience, and one that, if she had not been predisposed to slide into psychosis while under stress, she would have been able to take in her stride. When she eventually returned to her studies, she took things more slowly and was careful to restrict her commitments.

Written in July 2011 for Triond.