3. Theories Galore: the quest for a cause

Research into the underlying cause of schizophrenic symptoms is based on a wide variety of psychiatric theories. These theories range from hard science to non-science and the proliferation indicates a high level of confusion within the medical model. The theories essentially divide into two different types: those which assume a biological cause, and those which assume the cause is in the person's past experience, and/or past/present environment. This dichotomy between biology and experience is an echo of the old nature/nurture debate about human psychological attributes. As with the nature/nurture debate, there is also a seemingly balanced and commonsense view which assumes that both sides of the dichotomy are partly right.

Psychiatrists who support biologically based theories normally hold the view that proper treatment requires some form of physical intervention, usually drug treatment. Subscribers to the environmental/experiential theories, on the other hand, usually prefer one of the many forms of talking therapy.

But the situation is not clear cut. Sometimes it seems apparent that the two psychiatric factions have adopted their beliefs about the cause of schizophrenia simply to justify the methods of treatment they have been trained to apply. That is, the psychiatrists whose training has favoured drug therapies have simply assumed a biological cause as a convenient rationale. Similarly, psychiatrists who have undertaken training in psychoanalytic and psychotherapeutic forms of talking therapy have little choice but to assume that the cause of the problem they have been trained to talk through can be found in the past experience or environment of the patient.

However, the actual practice of psychiatry does not follow such logical patterns. In practice most psychiatrists are prepared to supervise treatment plans that mix both drugs and talk. But when psychiatrists supervise mixed treatment plans, one form of treatment is usually seen as the essential therapy while the other is a convenient supplement.

For a biopsychiatrist—that is, a psychiatrist who favours a biological theory of cause and drug treatment—the supplement of talking therapy is most likely to be found useful when it involves teaching a patient some kind of living skills. This can be a useful supplement to drugs because the efficacy of the medication in routine practice is generally measured by the ability of the patient to return to at least partial social functioning. While the drugs supposedly re-balance a patient’s brain chemistry, so that he or she wants to return to normal, supplementary therapy in the form of living skills can supposedly teach the person how to be normal. If a semblance of normality is achieved then the efficacy of the medication is confirmed and the psychiatrist can claim a successful outcome.

Similarly, a talking therapist might find medication a useful supplementary tool to calm a patient as a necessary prelude to achieving a therapeutic relationship: that is, a relationship in which the patient submits to the dominance of the therapist. However, this type of convenience is not appreciated by all talking therapists, and an argument is often mounted that no useful talking therapy can be undertaken so long as the patient is under the influence of drugs. This sort of argument is most likely to be made by therapists who are seeking the cause of the schizophrenia in the past experience of the patient, where introspection and accurate recall are important, rather than by therapists who specialise in teaching adaptation skills.

Next: Biochemical Hypotheses–and Associated Drug Treatments