Q & A: Expressed Emotion and Schizophrenia

A reader writes:

I have a friend, let's call him X, who refuses to communicate with me now because I keep telling him he should be on medication to help him with his paranoia. I'm pretty sure X hears voices and he also is quite sure that Jesus speaks to him personally. He won't go to therapy. Any advice or
insight would be welcome. Thanks!

First of all, you can't put yourself in the place of a trained mental health professional.

Be that as it may, I think from your letter that you recognize that X may suffer from schizophrenia, a disorder that drastically affects cognitive functioning. You budding therapists out there may know by now that that means we don't do any rational cognitive therapy in this case.* What it means in plain English for everyone else is that you don't try to reason with a person who has difficulty reasoning, as is often characteristic of persons with schizophrenia.

You can and should contact X's family, tell them of your suspicions, ask them to help X get help. You said he is high functioning, so they may be in denial and may have little control over X and his compliance to treatment. But you never know until you ask.

As a friend you can remain supportive and caring. That may seem like no big deal, but it is a tremendous deal, and it translates into avoiding "expressed emotion," and telling others to do that as well.

"Expressed emotion" in this context is anger. People with schizophrenia are extremely sensitive to stress, and conflict/anger is stressful. We protect loved ones who suffer from this disorder by avoiding any criticism, sarcasm, argument, loud noises, yelling, even angry facial expressions, decisions, demands, bad news when in their presence.

You can also ask X what he's thinking. If he says voices speak to him and to no one else, then ask him what the voices are saying. If the words he's hearing in his head scare or stress him, he might confide in you. It might be a relief to tell you about them. He might get to a point where he really wants help. He's scared. Then you're there to take him in to see a psychiatrist. Skip right to a medical doctor with a person who has schizophrenia if at all possible.

Being supportive and non-conflictual is the best way to help someone who says they don't want help. Persons who suffer from mental illness who are mistrustful of the health care system have a right to be afraid. It is terrifying to them. They have to trust you or someone else, like a physician or a therapist, to the degree that they will confide their fear before there is a possibility of lowering resistance. If a sick person is in enough psychic pain, he might reach out for relief.

You may be that person who gets to hear
how bad it really is for X. Then it is in your court to somehow reel him in. Until he's there, meaning until X really is in tremendous psychic pain and is willing to talk about it, all you'll get is denial and social withdrawal.

You want him to get help before he hurts himself or someone else. Not every person with schizophrenia is dangerous, but that's not your call to make. So if you really are friends with X or someone with this disorder, without seeming too invasive, hearing the thoughts is pretty important, and attending to them without being conflictual or demanding is the objective.

You want to ask him directly (gently) if he ever feels like hurting himself or anyone else.
In that case, you really have some convincing to do, and might have to bring in either the police or a mental health professional who will help you bring him to a hospital. Sometimes the police are actually well-trained for this kind of thing.

And good luck.

*Studies have shown, according to F.D., that cognitive therapies are used successfully as an adjunct when drug therapies have successfully stabilized patients with schizophrenia.

Friends, if you have any other suggestions, by all means comment below. But...
I'm not encyclopedic, certainly, and don't pretend to know everything. I just want to be helpful generally, not to advise in particular cases. These are merely guidelines. Please consult appropriate mental health and legal professionals with problems when you think they might help.



Anonymous said…
Sounds like good advice. Makes sense not to reason with a person who can't reason.
Question, is hearing Jesus talk to you always a bad thing or is it just our cultural opinion that we should not hear voices.
Seems to me like their are many prophets both dead and living that heard voices in their head and we glorified these people. Just a thought.
therapydoc said…
It's for sure a cultural bias to tune into only external, palpable(?) stimuli, you're right.

And sure, most of our religions are founded by founders who heard a voice. So who are we to judge?

It's a problem when the voice named Jesus or whomever is telling someone to do kill others or to kill themselves-- then it's a problem-- and that does happen, unfortunately.
Anonymous said…
Two other rule-outs (other explanations to consider) in a case like this are substance induced psychotic disorder and spiritual emergence/emergency.

The substance induced disorder is an important rule-out especially if X is a younger person experimenting with hallucinogens or other drugs.

Spiritual emergence or spiritual emergency is possible whether drugs are involved or not. The idea of spiritual emergency is an increasingly recognized mental health diagnosis, largely due to the work of Lukoff. Check out the Spiritual Competency Resource Center and Lukoff's description of his own psychotic episode (complete with messages from Jesus and other spiritual figures) by clicking on the Shamanic Initiatory Crisis PDF link on this page.

All of this said, I think paranoia and direct messages from Jesus are, in the great majority of cases, probably indicative of schizophrenia.
Anonymous said…
If so-called prophets hear the voice of God, isn't it then possible that they were actually just high-functioning schizophrenics? If it matters, all religions/relationships with God/Jesus that preach intolerance needs to be scrutinized a little bit more.
Anonymous said…
I have a question I am very curious about. I am a budding therapist (psychology student) and wondered about your thoughts regarding the amount of self-disclosure you are making available to your patients via this blog. I know from my own therapy that 1) I am endlessly curious about my therapist's personal life and obsess about it sometimes while 2) it is much better for me therapeutically NOT to know too much. I think I would feel uncomfortable as a patient having access to so much of my therapist's personhood via a blog, and I imagine that as a therapist I would be worried about being so transparent to patients. Any thoughts? Do you ever worry about affecting your patients adversely because of your blogging?
Many thanks,
a loyal reader in PA
therapydoc said…
Thank you Jonathan, great input. I'll check it out.
therapydoc said…
Boogaloo, I'm working up a post for you on this. Great question.
Must be so frustrating, I know from my clients how frustrating it is when I try to help and they won't take the help.
therapydoc said…
SWFM, and this fellow actually lost a friend.
jeanie said…
Thanks for a good post, TD.

I once knew someone who died due to (his own) schizophrenia and I know how hard it is to get past the paranoia when trying to help - it must be doubly so when wearing the medical hat.

I think that the more "information" is out there about this disease and therefore the less room for prejudice should be encouraged.

My friend was, to all intents and purposes, mainly a danger to himself, but I was greatly concerned what steps he may take to "save" our family from perceived threats from the voices.
Anonymous said…
TherapyDoc: I am very much looking forward to your reply to Boogaloo's question. I've started to think through my own position on this issue on the disclaimer section of my blog, but I want to dig deeper. I am sure your own thoughts will encourage me to do so!
therapydoc said…
Jon, coming right up, just have to edit.
I'm glad I can say I knew ye when you were out of the closet. ;)
therapydoc said…
chana, i was hoping someone would say that.
Anonymous said…
Mind you, Hearing from God is not a sign of schizophenia...people...sigh.
Usually, in most cases, if it is God it involves repenting or helping others or doing something to benefit yourself or others- they had a "call" to help the homeless. Of course, sometimes people with schizophenia who are also religious (christian) sometimes mistake their symtoms or visions to be from God and then worry in real life that the "voices" or other figures will harm or hurt their friends and their friends are like no, the visions of bad things wont happen to me so dont worry...

In anwsering the spirit question, most intelligent christian workers in that field of deliverance and healing ask all those who would want their services to go get a check up and examined by a doctor to rule out mental illness, minal definceities, or other normal problems before you look for spirits (who may be there).
There is a saying in medicine-when you hear hoofbeats, think horses not zebras....
therapydoc said…
Thanks, lovely comment. The voices I worry about are the ones that worry the client, those that tell the client to hurt self or others, negative stuff like that. You're right on to say, Rule out. . .before labeling anyone anything. Think first. Jumping to a dx is usually a bad idea, if irresistible.

A little knowledge, a dangerous thing, a big concern when I post things on this blog.
Anonymous said…
It concerns me that the reader has decided that her friend needs medication. I don't see that her friend is expressing a concern about his experiences and if he's happy with it, who does it harm?

It disturbs me that so many people in our culture take it upon themselves to decide what is best for other people or determine what is "normal". I don't read anything from the reader that says her friend is harming himself or others, so why can't he be this way if he likes?

I worked with a schizophrenic who was also an artist a few years ago. He consciously decided not to take his medications for very good reasons. It's too lengthy to go into here, but you can read the story on my blog, The Schizophrenic Artist. I believed at the time he was right to do so and I still believe he was right.

Life isn't always as black or white as we want it to be. And other people sometimes make decisions based on things we don't know about, like art.
therapydoc said…
Thanks Kellen, for your thoughts. I'll get to that website soon. I look forward to the story and you're so right, life is never in black and white.

Popular Posts