This article was published in Scientific American’s former blog network and reflects the views of the author, not necessarily those of Scientific American
Schizophrenia can seriously impair the ability to relate to people, but with effort, a degree of normalcy can be attained.
As someone who lives with schizophrenia, this is glaringly obvious to me.
When you have schizophrenia, the overarching plot of the experience is the inability to tell whether the things you are thinking are actually taking place in reality.
On supporting science journalism
If you're enjoying this article, consider supporting our award-winning journalism by subscribing. By purchasing a subscription you are helping to ensure the future of impactful stories about the discoveries and ideas shaping our world today.
For instance, in a normal interaction with anyone from my parents to a friend I’m thinking things like “Was that inflection in your voice a signal that I should be more friendly or more reserved?” or “Was that laughter I heard over my shoulder about me or something totally innocuous?” or “What are you thinking about the way I’ve smiled at you today? Does it indicate that I’m weak or that I’m crazy?”
Simply put, when someone has schizophrenia or schizoaffective disorder, interacting with the world in a meaningful and socially cognitive way is more than difficult.
There’s a distinct apathy and flatness that result when you lose control of your mind. In essence you’re trying so hard to get a grip on reality that things like social aptitude, interactive conversation and even general hygiene go by the wayside and this apathy is only heightened by the shock of a mental illness diagnosis, delusions and paranoia, and powerful antipsychotic medications.
I’ve lived with schizophrenia coming up on eight years now and though I have been symptomatically stable for years, with a few periods of uncertainty, the desire to adequately relate to others has been a driving force for me. Shortly after I was diagnosed I was essentially dead socially. I couldn’t even go into a grocery store because I was so paranoid what people thought of me. By contrast, I can remember being pretty popular in high school and having friends from every different clique, every group and every grade. The ability to connect with people seemed so effortless then and it’s a goal that I’ve been striving to re-attain for the last eight years.
Part and parcel of my experience interacting with others is the analysis that goes on both during and after any interaction. After every interaction–even those as minor as greeting the pizza delivery guy or the gas station attendant–this analysis goes on for hours or days. Unbeknownst to me, that hyper consciousness and hyper analysis was my own form of social cognitive conditioning which, in addition to my meds and therapy for helping me accept myself, has offered no less than an a reawakening.
Interestingly, I recently learned of a formal technique that seems to parallel my self-therapy. Called Cognitive Enhancement Therapy (CET), it is a recovery phase intervention for symptomatically stable persons with severe mental illness, who nonetheless remain socially and vocationally disabled. The Center for Cognition and Recovery says CET works by helping individuals develop and enhance the mental capacities that produce the awareness for self-directed social interactions that are wise, appropriate, and effective using a combination of software training in attention, memory and problem solving along with social cognitive group exercises.
According to a CET Cleveland document called“CET, Cognitive Enhancement Therapy – An Overview of the Evidence-Based Practice”, patients use a process called secondary socialization to improve social cognition. “Socialization is the process of learning from other people (e.g., parents, other caregivers, relatives, peers, etc.) the informal rules of interacting wisely and effectively. After primary socialization in childhood, individuals undergo secondary socialization in adolescence and young-adulthood where they learn how to detect, evaluate, test and finally utilize the unwritten and unspoken rules of social interaction with peers and adults. In other words, individuals learn what is right (acceptable) and wrong (unacceptable or inappropriate) actions in many different social settings with feedback from many different people.”
Essentially, CET recapitulates the process by which individuals learn how to “get it” socially, to get the gist of an interaction without getting hung up on details.
I had not heard of CET until earlier this morning when I was researching schizophrenia and social impairment. However, and unknowingly, in the years since my diagnosis I have been engaging in a project resembling at least some aspects of CET with myself, analyzing my social interactions with a special kind of ferocity.
Such extensive analysis may not be healthy in socialized individuals. But for people with schizophrenia, over-analysis may be an important tool for social cognition. It has been for me. I am in an unending dialogue with myself over social awareness that has led to not only a deep understanding of who I am, but also an acute social consciousness of everyone and everything around me. At times I’m so distracted with the dialogue that I can’t perform accurately in the interaction I am in, and a performance is essentially what social interaction boils down to for me.
When I do it right, successfully connecting with another human being, I feel giddy. But if something goes wrong and the execution wasn’t perfect, the tinge of regret will stay with me until I focus my mind elsewhere. Occasionally, an interaction feels so horribly catastrophic to me that I’ll be thinking about my mistakes for hours or days and the only thing I want to do is curl up in my bed and flip a bird to the world. But even in those cases, I learn from my mistakes.
Since 2004, the SAMHSA-recognized CET program out of Cleveland has run 138 CET groups. All of them reported an 85 percent graduation rate with significantly improved social cognition. Graduates went from having a flat affect with little or no social reciprocity or ability to converse appropriately (i.e. respond sympathetically, use a proper tone of voice, and so on) to displaying relative social competence. A similar improvement has characterized my own recovery. As they say, practice makes perfect.
Paranoia about what people think of me has been with me since I broke, and I imagine it will continue to be until I’m an old man. Still, it’s provided me with a rich, multi-faceted concept of myself that others would have a hard time even imagining. After eight years of practice in social conditioning, anyone, even schizophrenics, can attain a level of normalcy in their interactions. They can begin to get on the right track forming meaningful relationships and contributing to society.