1. Schizophrenia and Consensus Reality 

Language describing schizophrenia as a “break from reality” is widespread. It seems this phrase has become a shorthand for the experience of hallucinations, delusions and other altered perceptions often present in psychosis. It conveys a distinction between the individual’s experience and the objective truth. Recently, another phrasing has gained traction: schizophrenia as a “break from consensus reality”. This shift may be representative of a new lens from which to view this condition, one that views schizophrenia as a disconnect between the perception of the individual and what is generally agreed upon by ‘the collective’. This framework, in which schizophrenia can be understood as a misalignment between the patient and others, broadens the aperture to consider its impact on the community. 

2. Misconnection (How does this show up and why?)

Recognizing the relationship between schizophrenia and the social world is by no means novel. In clinical contexts, social difficulties and isolation are understood as features of the condition. The impact of these social difficulties is evident in the experience of families, where disconnection can lead to caregiver burn out, frustration and hopelessness in the home. Awareness of these challenges has led to the development of family member-focused resources including the British Columbia Schizophrenia Society Strengthening Families Together and Family Support Groups programs.

Research has also examined the factors that may contribute to this disconnect. Individuals with schizophrenia frequently experience difficulties with ‘social cognition’ (the mental processes that support social interactions). In fact, these challenges often precede the onset of psychosis and persist after standard treatment. In a review of 156 studies published in 2022, researchers Weinreb and colleagues reported that people with schizophrenia had poorer performance across all measures of social cognition including challenges with emotion perception and the ability to infer the mental state of others (ex. understanding that person A has different experiences from their own and responding accordingly). These difficulties may manifest in everyday interactions as missed social cues or misinterpreted intentions behind comments or actions. Despite this, social difficulties are often conceptualized as secondary to overt symptoms of psychosis, a perspective that may underestimate their significant impact for the individual and their community.

3. From the Individual to the System

In health care, diagnosis and treatment of schizophrenia typically focuses on a single person. The first line of care entails pharmacological treatments targeting biochemical imbalances associated with acute psychotic episodes, usually interventions that regulate dopamine and serotonin chemical receptors in the brain. Still, taking research on treatment from the lab bench to real-world application is not a one-size fits all. Beyond selecting the appropriate medical intervention, treatment planning means addressing the logistics of participating in daily life. It includes considerations like how to support treatment adherence, return to work, comfort at home and in relationships. As the closest contacts to the patient, family members are often invaluable in this process, and their input can be especially helpful for understanding the complete clinical picture. As such, caregivers may find themselves in the position of negotiators between the person with schizophrenia and their medical care team. Including community members in patient care reflects the reality that schizophrenia does not occur in isolation.

From the perspective of Family/Systems Theory of human behaviour, the individual and their community is a unit and the relationship between which is bi-directional. In other words, an individual is impacted by their environment and vice versa. In a Family/Systems approach, one can consider how schizophrenia affects the patient but also the family, including how the condition changes patterns of communication and interaction between them. Caregiver burden is an example of how schizophrenia can affect family members; less obvious but also present is the impact of family dynamics on the patient themselves. In 1998, a foundational paper on this topic by researchers Butzlaff and Hooley reviewed 27 studies on the relationship between Expressed Emotion (an adverse family environment and/or negative caregiver attitude towards patient) and outcomes for schizophrenia. The results showed Expressed Emotion increased probability of relapse. The reverse is also supported: Jambawo and colleagues (2024) showed that peer support had a positive impact on recovery and empowerment in people with schizophrenia. In light of these findings, family-focused interventions have been explored and continue to be assessed. 

4. Where do we go from here?

Why consider Schizophrenia from a systems perspective? Because the distinction between treating the individual and their social environment may be less separable than conventional approaches of care suggest. The effect of schizophrenia includes how the patient interacts with their community. Where functional impairment is a central target of treatment, it could also be suggested that functional impairment is inherently social. One’s ability to engage in work, for example, requires the coordination of complex social skills and dynamics that extend beyond those directly impacted by the ‘primary symptoms’ of schizophrenia. It is also true that, as the closest contact point with the patient, family members may notice changes before they become clinically apparent, offering information that is otherwise unavailable in a single clinical encounter. This may open avenues for improved care and even earlier identification. Family interventions are one example of what becomes possible when these relationships are treated as relevant. While these are most definitely not a substitute for individual treatment, research on schizophrenia and its social impact may point to a need for a more comprehensive view of care.