Schizophrenia and Social Work: Interview with Shaun Eack, Ph.D.

[Episode 45] In today's podcast, I speak with Shaun Eack about schizophrenia and social work. We talk about some basic information that social workers need to know about the diagnosis of schizophrenia; Shaun identifies and describes the positive, negative and cognitive symptoms that are often present in people with schizophrenia. Around 13 minutes into the conversation we switch the focus from diagnosis to the role of the social worker in working with people with schizophrenia. We end our conversation with a discussion of treatment approaches, including a new approach that addresses cognitive content.


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According to the National Institute of Mental Health, schizophrenia is a chronic, severe and disabling brain disorder that affects 1.1% of the population over the age of 18. The term “schizophrenia” was coined by Eugene Bleuler from the Greek roots schizein (σχίζειν, "to split") and phrēn, phren- (φρήν, φρεν-, "mind"). Schizophrenia literally means "split mind." But, because of the etymology of the word, schizophrenia is commonly misrepresented as a split personality, or in clinical terms - Dissociative Identity Disorder (APA, 2000). The confusion between these two disorders is commonly found in the popular press, and is perpetuated in jokes, such as in this parody of a popular children's rhyme:

Roses are red
Violets are blue
I'm schizophrenic
And so am I

This children's rhyme makes schizophrenia sound like a simple confusion or perhaps a funny condition. Far from funny, schizophrenia is a severely disabling disorder. The symptoms of schizophrenia fall into three broad categories: positive, negative, and cognitive.

Positive symptoms: the presence of sensations, beliefs, and behaviors that would not normally occur. These are the most noticeable symptoms, and often the ones that are used to stereotype people with schizophrenia. Examples of positive symptoms include delusions (beliefs about things that are not true), hallucinations (seeing, hearing, smelling, feeling, or tasting things that others do not), slow movements or catatonia, and erratic emotions.

Negative symptoms: the lack of abilities. Examples include: lack of energy, difficulty engaging in social activities, poor motivation, difficulty making friends or functioning in psychosocial contexts.

Cognitive symptoms: There are two categories of cognitive symptoms - neuro-cognitive and social-cognitive. Neuro-cognitive deficits are problems with things like attention, memory, and executive function (the ability to engage in problem-solving). These are basic neuro-cognitive processes that people use in every day life. People with schizophrenia perform 2 standard deviations below average on test of neuro-cognitive functioning. The second category of cognitive symptoms are social cognitive deficits. These are the things that you think or do to act wisely and appropriately in social situations. One example is the ability to recognize social cues. People with schizophrenia have a profound deficit in picking up on social cues.

The combination of positive, negative, and cognitive symptoms, can make people with schizophrenia fearful and withdrawn, and cause difficulties in relationships with other.

Bio

Shaun M. Eack received his Ph.D. on November 4, 2008 from the School of Social Work at the University of Pittsburgh. He is a predoctoral fellow in the Department of Psychiatry at the University of Pittsburgh. His primary research focus is on the development, implementation, and evaluation of psychosocial treatment methodologies for persons with schizophrenia. He also studies the biopsychosocial factors that contribute to recovery and psychosocial outcomes among this population, and how the elucidation of these factors can serve to aid novel treatment development efforts. In addition, he holds a broad interest in social work education and workforce development as they relate to the provision of care for persons with schizophrenia and other severe mental illnesses. He has authored several publications under the mentorship of the late Professor Gerard E. Hogarty on the cognitive and behavioral effects of Cognitive Enhancement Therapy, a novel psychosocial treatment program for persons with schizophrenia. In addition, he has published papers on factors affecting various psychosocial outcomes among individuals with schizophrenia, particularly quality of life, as well as social work workforce development issues as they relate to serving individuals with schizophrenia. He is currently a recipient of an individual predoctoral fellowship from the National Institute of Mental Health that focuses on studying a novel domain of social cognition in schizophrenia and its implications for psychosocial treatment development.

[Note: This interview was recorded prior to Shaun's successful disseration defense.]

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Transcript 

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Jonathan Singer: So Shaun, first question, what is schizophrenia?

Shaun Eack: That’s a very good question to start on. It’s, I mean, officially defined by the DSM.

Jonathan Singer: The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, 2000, APA).

Shaun Eack: Yes that’s right, you’ll have to excuse me for all acronyms I may be using.

Jonathan Singer: Well, I might jump in so we get some clarification for our listeners.

Shaun Eack: Please do, please do. So anyways, it’s officially defined as a collection of symptoms, like all of the mental disorders that we work with in social work. It’s really just a constellation of signs and symptoms. Now in schizophrenia there are symptoms that are very specific, it’s a class of what’s known as the psychotic disorders, which you know used to be these things were grouped into disorders of psychosis and disorders of neurosis, where neurosis had to do with depression, anxiety, and psychosis had to do with disorders that sort of represent kind of a break with reality, interpretation of stimuli that isn’t there, or severe confusion and difficulty using language, and formal thought disorder. Schizophrenia is under that broad framework, it has some specific symptoms that people use to diagnose the disease, I won’t go over every single one of them, you know but the hallmark symptoms of schizophrenia really are what’s know as the positive category of symptoms, the hallucinations and delusions. A hallucination is really sort of the brains interpretation of some sort of stimuli that isn’t actually there in the external, sort of shared reality of everybody else. This is most frequently experienced by people hearing voices, there’s many different types of voices you can hear in schizophrenia, sometimes they comment on each other, sometimes they comment on you, sometimes they tell you what to do, sometimes they are just passive and they don’t really make sense, and so it’s a broad array of voices people could possibly hear that could be indicative of someone having schizophrenia. There are also hallucinations associated with every other sensory modality, from sight to touch, but by far the most common are auditory hallucinations, second behind that are visual hallucinations.

Jonathan Singer: Well it’s interesting because I think in the popular media, it’s the visual hallucinations that seem to get all the play.

Shaun Eack: Yes

Jonathan Singer: People are like “oh I am seeing...” What was it - Robin Williams in the Fisher King - and you know seeing someone on a horse riding towards him.

Shaun Eack: Hollywood has a tendency to over dramatize what it’s like to have schizophrenia, and paint a somewhat unreal picture of even what visual hallucinations might be like. So often times I think our patients report them being much less diffuse than sort of concrete picture of something doing something to you, like a person riding in on a horse, they’re usually much more nebulous than that. Not to say that that’s completely impossible or never happened.

Jonathan Singer: But it’s certainly more compelling in a blockbuster moving to have somebody riding towards you on a horse.

Shaun Eack: Yes, it does make for interesting story telling.

Jonathan Singer: (Laughs) Now you mentioned positive symptoms, I just want to say that when you say positive symptoms, does that mean it’s something that’s good?

Shaun Eack: That, it does not mean good. As anyone who has experienced them will tell you, it does not mean that they’re good. Now some people with schizophrenia have hallucinations that are less aversive and even they may come to depend on and enjoy, but for the most part people will agree that their hallucinations are at the very least annoying, at the most, very detrimental to their lives. Positive is just kind of a misnomer, and just refers to an excess in function. In this case, an excess in the brain responding to something that is not there. That’s why they call it a positive symptom, because it represents more than what sort of you have normally. To contrast that, schizophrenia is not only marked by quote unquote positive symptoms, but also what’s known as negative symptoms. We name things pretty simply in schizophrenia research, positive and negative, even though they may not make a whole lot of sense. As positive symptoms represent sort of an excess in sort of sensory function, negative symptoms represent some sort of inhibition or digress in function. These are usually characterized, I mean they can become very severe in many cases, but they’re usually characterized by symptoms sort of flat affect, so speaking with sort of very little affect in your voice, presenting with very little affect in your facial expressions, individuals it’s called sort of affect of flatting or affective, blunting of affect, there’s also a severe lack of motivation that’s characteristic of what we call negative symptoms, there’s also problems with poverty of speech, so not being able to produce language as fluently as other people, and you see this category as a little more easy to understand, than the positive symptoms, just in terms of its name. All of these represent really kind of a loss of function, whether it has to do with a lowering of speech, a lowering of affect, interpretation, or expression, and so on.

Jonathan Singer: So those are the positive and negative symptoms, are there any other characteristics of schizophrenia?

Shaun Eack: Those are the big two, schizophrenia is a remarkably heterogeneous disorder.

Jonathan Singer: What do you mean when you say heterogeneous?

Shaun Eack: No two people with schizophrenia look alike, and not just in appearance, I mean in their symptom presentation. The disorder is usually made up by a constellation of different symptoms, from positive to negative symptoms, there’s also symptoms of disorganization, formal thought disorder, individuals can present with what’s been termed as salad, which is essentially speaking and all of the words are coming out, they make no coherent sense and don’t logically form sentences.

Jonathan Singer: Just to interrupt, whenever I think of the word salad, I think of something that Steve Martin once said. He said if you want to have you teach kids to speak wrong, that way when they are first grade and they want to go to the bathroom they raise their hand and say “Mambo dogface with a banana patch”.

Shaun Eack: That is word salad to a T, yes, Steve Martin hit it right.

Jonathan Singer: Hit it right, exactly.

Shaun Eack: Absolutely. I completely forgot to mention delusions of course, as an important positive symptom that you would want to know about when you are diagnosing schizophrenia. It’s frequently associated with hallucinations people do have, and delusion are really sort of beliefs, often times of unusual nature and sort of extraordinary phenomenon that have little supporting evidence or really no supporting evidence in sort of everyday life and basic reality. Individuals believing that sort of aliens have come to them in their sleep and put some sort of transmitting device in their head that sends information to the FBI or the CIA would be an example of a paranoid delusion, for example. Delusions, most often are paranoid in nature, although not always, so individuals can also have delusions that they have extraordinary powers, sort all contrary evidence kind of suggests that they probably do not, and often times these delusions are associated with the voices, or other types of hallucinations these people are experiencing, and so they kind of work hand in hand. Some interesting work has been done to try to understand why people with schizophrenia develop delusions, and it turns out such individuals seem to be prone to kind of a gross misinterpretation of kind of anomalous experiences, experiences that don’t make a lot of sense, and if you think about how you might react, just yourself, to the anomalous experience of hearing voices chatting in your head that are not your own, you would probably try to make an explanation of that, and kind of spin a story about that, and depending on what they’re telling you, your story might be very strange, and even though everybody else would tell you that your story is wrong, you still hear these things in your head, and you want to explain them. You know it seems like a lot of times delusions may in fact be sort of very related to the hallucinations these people experience as really a method to some degree to kind of cope with them and explain you know the sort of unexplainable and anomalous experiences.

Jonathan Singer: That’s really interesting because I know this idea of hearing voices is something that can be confusing when social workers first start out because we all have chatter inside our head.

Shaun Eack: Sure.

Jonathan Singer: So how do you distinguish chatter from something that’s actually problematic?

Shaun Eack: Sure, so I mean we all have kind of an internal dialogue that we keep with ourselves you know through the course of the day and you know mostly all the time. But we all kind of know it’s us to some degree and people with schizophrenia, they think it’s someone else often times and I think that’s a pretty good beginning sing that there’s a problem. Another sort kind of tell tale sign is, not only if you think maybe it’s not you but it could be someone else, but if you kind of can’t stop it. I mean most of us can have, we may not have complete volitional control over our sort of internal dialogue, but most of us could you know kind of put the breaks on it if we really needed to, and really divert our attention externally to whatever we need to focus on. Individuals with schizophrenia hear voices have a big problem trying to do that and it’s probably a good sign that you’re lapsing into probably an auditory hallucination rather than just talking to yourself. It’s interesting, some of the neuro-imaging research that’s been done in schizophrenia suggests that the same types of areas of the brain that quote unquote light up or become activated when we’re talking to ourselves and processing auditory information, are also activated when these people are hearing voices. So you know they are not just responding to stimuli they’ve made up, at a very basic biological and physical level they’re hearing information, their brain is processing some type of auditory information, and so they can’t just stop that alright, I mean it’s a hardwired process to some degree.

Jonathan Singer: So if I was working with somebody with schizophrenia and they talked about you know hearing voices, then it would be important for me to clarify what exactly that meant. Because it could be that they’re not hearing voices in the sort of psychotic sense.

Shaun Eack: Yes.

Jonathan Singer: They could just be talking about the fact that they got a lot of stuff going on and they keep thinking about, what do I need to do today, you know, blah blah blah.

Shaun Eack: You know it’s definitely important to clarify, even if someone is hearing what you are pretty sure to be an auditory hallucination, it’s always good to clarify the nature of that because they have several, they have pretty good prognostic value, different types of auditory hallucinations.

Jonathan Singer: When you say prognostic value what do you mean?

Shaun Eack: Ok, so depending on what people hear and the types of voice they’re hearing, they’ll tell you to some degree how well these people are going to be doing, and maybe even how well they might respond to some type of medicine in the future. So there are some types of, I only say that because there are some types of auditory hallucinations that we know are really particularly problematic and really tell you know kind if foretell a particularly problematic story that people with schizophrenia might experience, and these are what are known as quote unquote command hallucinations. A command hallucination is a hallucination that you have, an auditory hallucination that you have that is telling you to do something, it is giving you commands, it is telling you to do something, and often times that commands aren’t good. And we know for these individuals, while very few people with schizophrenia are violent, for the individuals that hear command hallucinations, we know that their risk for doing something violent in nature, or doing something that you know really is uncharacteristic of the general population and the population of people with schizophrenia in general is much more elevated, than the people that hear just kind of a running commentary in their head or hear an occasional you know “boo” in terms of a voice. We know that these people with command hallucinations have much more difficulty and are much more likely to have you know a severe course of the illness and problems with violent behavior in the future.

Jonathan Singer: I’m going to switch the subject, just a little bit. Why should social workers be interested in understanding schizophrenia? And a related question, what’s the role of the social worker in working with people with schizophrenia?

Shaun Eack: Sure. Well, on a very practical level, if you’re a social worker working in a community mental health center, these are who you’ll be seeing. You’ll be seeing people that are experiencing schizophrenia, that often times have been suffering from the illness for many years, and so social workers should care, if for no other reason, because these are the people that you will be helping and serving in a community mental health center. Now of course, social workers, I think, have a much more sort of noble purpose in working with people with schizophrenia beyond the fact that they’ll be seeing them in treatment, and that’s, if we talk about all the different types of people who have mental illness, and all the different mental illnesses that are out there, I think it’s probably pretty safe to say that people with schizophrenia are most in need of an advocate, they’re most in need of someone to help stand up for them, most in need of someone to support them, and they often times fall through the cracks in our systems. So we’ll see many times, as of course is a stereotype associated with homelessness and being psychotic, or having schizophrenia or hearing voices, and so social workers with their knowledge, not only of mental health treatment and diagnosis, but at a broader more system level are really in a very well equipped position to help people with schizophrenia in a number of different ways: By providing direct treatment, by advocating for better treatment, by advocating for better social services, by helping these individuals when they’re being taken advantage of which happens very often, particularly you know people with schizophrenia receive a social, of course a disability payment, and often times people will try to take advantage of them to try to coerce them to give their disability payment to them or fork it over. Family members can do that on occasion, although often time family members are nothing but helpful when it turns into working with people with schizophrenia, they can be one of your greatest allies and resources, not only for the person that experiences the illness but also for the social worker that’s really trying to help them.

Jonathan Singer: And we did a podcast earlier with Carol Anderson who developed treatment called Family Psychoeducation that really brings the family together with the family member with schizophrenia, for example, as one of the treatments.

Shaun Eack: (laughs) The grandmother of schizophrenia – Carol. Dr. Anderson is an excellent treatment researcher and schizophrenia researcher.

Jonathan Singer: What are the other treatments that are out there for schizophrenia?

Shaun Eack: I mean if we just have to divide them broadly, you know because there’s a lot of them. They fall into two groups, one is a pharmacological approach, medicine, particularly anti-psychotic medication, so of which there’s lots of different kinds of course, and then the other one, which is the one that social workers provide, not that they should not know anything about psychopharmacology, of course it’s very important to know something about that, but the other type of treatment is psychosocial treatment, which ranges from therapy to family psychoeducation, which is as I am sure Carol explained kind of a misnomer, it’s education about the illness, it’s not sort of psychoeducation or whatever, there’s also sort of more systemic models like sort of community treatment, which was a very interesting approach developed by a social worker, a psychosocial approach to help people with schizophrenia live outside of the hospital. Particularly the people that had been in state hospitals for many years, rather than making them stay in the hospital, it’s let them live in the community and sort of bring the hospital to them, so they called it hospital without walls, which was a very effective approach, it’s been disseminated in a number of places now. There are several individual therapeutic approaches, one that we’ve been working on here at the University of Pittsburgh that focuses on improving cognitions in schizophrenia, and you know it’s one of the symptoms that we didn’t really talk about much, and it’s a symptom that actually most people don’t talk about much when they think of schizophrenia. I highlighted the two biggies, the positive and the negative symptoms, but we’ve recently turned our attention to these cognitive symptoms, and I’ve been trying to develop treatments for them for a number of reasons. Perhaps the most important, is even if we completely reduce or remove a persons positive symptoms, hallucinations and delusions, which anti-psychotic medications can be very effective at doing, many individuals with schizophrenia still experience great disability, and which was I think to some degree puzzling to people some years ago, that really kind of the hallmark of psychosis would be remitted, but these individuals would still have difficulty getting a job and maintaining friends, and sort of building the quality of life that most of us would consider to be even minimally sufficient. Some people started looking at the various aspects of schizophrenia and discovered that the disease really was characterized kind of by a core deficit in thinking, in cognition, that really kind of fell across two different domains, and that really helped us understand why these individuals are continuing to have difficulty and struggling in life, even after positive symptoms have gone away. And the two dimension of cognitive problems that people with schizophrenia tend to experience are, one area is called neuro-cognition, which is kind of the area of cognition that you think about when you think about thinking problems in general, problems with attention, problems with memory, problems with the quote unquote executive functions, which is really being able to solve problems, and so these are all kind of basic neuro-cognitive processes that people need to get on with their everyday life, to remember a phone number, to pay attention to a conversation, so on and so forth. And so it turns out that that’s a big problem in schizophrenia, people with schizophrenia perform on average two standard deviations below the mean of healthy individuals, right so that’s very poorly, and this has nothing to do with their intellect, it’s not to say that people with schizophrenia are not smart, many of them have above average IQ’s, these have to do with basic cognitive processes that you need to get on with your daily life, and that you need to put one foot in front of the other, and be able to make sense of the world and engage in complex problem-solving and information processing.

Jonathan Singer: So you’re suggesting that if somebody with schizophrenia is walking down the street and somebody says “Hey how are you doing?” and they have a hard time responding, it might not be because they’re actively hallucinating or they have paranoid delusions, or something else, you’re suggesting that there is some cognitive deficits going on that are separate from these other cluster of symptoms that we’ve been talking about that might prevent them from interacting or engaging with someone on the street?

Shaun Eack: Absolutely, so that’s not to say that auditory hallucinations will not keep you from engaging with people on the street, I mean those are certainly big barriers, but when we get those taken care of or largely under control, you’ll still see problems. And people with schizophrenia will still tell you, “I’m still having trouble sort of concentrating and focusing, and remembering what I’m supposed to do everyday” and what not. So there is a basic core deficit in cognition in schizophrenia, one is this domain of neuro-cognition, there is another domain that’s very recently become a major area of study in schizophrenia research, called social cognition, and these are the kind of things that you do or think about to be able to act wisely in social situations, they’re the kind of mental processes that you’ll engage in to be able to interact with others effectively, and process social information. For example, all of us has the ability to recognize various social cues, most often in peoples faces to let us know how they’re doing and how they’re responding to whatever we’re interacting with them and however we’re talking with them, and people with schizophrenia have a profound deficit in being able to pick up these kind of cues, which you can only imagine, I mean look if you have difficulty remembering and keeping track of things in a conversation, and you can’t kind of tell how a person is reacting to it because you’re having difficulty judging their facial expressions of emotion, then that puts you at a great disadvantage for building relationships, for interacting effectively, and being able to act wisely in social situations. So these have become strong predictors of how people with schizophrenia are going to do, and how people with schizophrenia are doing currently, and they’re even stronger than the positive symptoms of the disorder, right, so those things are very important, and will certainly limit your ability to get along with others and function. But after it’s all said and done and you get some good medicine and you get those taken care of, these are some of the residual symptoms that are left that we need to focus on in order to help these guys build a good quality of life and eventually recover from the disease, so that’s a nice long digression to what we’ve been up to here in Pittsburgh, working on a therapy to improve cognition in schizophrenia. It’s a psychosocial treatment developed by a social worker by the name of Jerry Hogarty, who has developed, he’s the king of psychosocial treatments in schizophrenia, has developed these treatments for many many years, his latest and kind of culmination of his work is Cognitive Enhancement Therapy, which as the name suggests is a therapy designed to work on improving or enhancing cognition in schizophrenia.

Jonathan Singer: So there are a couple of things, one this idea that cognitive symptoms are perhaps more important than positive or negative symptoms, or maybe that’s overstating it.

Shaun Eack: I think that probably is a little bit, I don’t’ want to paint the picture that positive symptoms are not important. They are very important, the good thing about them is their generally responsive to treatment, which means now that we can help people with those, we need to start working on the things that we haven’t been able to help them with.

Jonathan Singer: So because we have medications that can address these positive symptoms, what you’re talking about is really the next step in the treatment of schizophrenia and, so if I were a social workers out there, and I said “Oh, ok, great, everything’s great, my client’s doing well, taking her medication, and she’s not hearing voices, the paranoia is under control, everything is good to go”, you’re suggesting “No”.

Shaun Eack: I would certainly argue with that, I think the challenge for us as social workers is to not stop at, oh they’re taking their meds, you know they haven’t gotten in trouble lately, they’re not hearing voices, they don’t close the blinds all the time because they think the CIA’s after them, you know for many years that was like doing great for people with schizophrenia, and the challenge for us is to begin to step beyond that because you know if all that we are doing is helping these people take their medicine, and helping these people feel a little less you know influenced by their delusions, I think we’re not doing enough. I think the people that we serve would say “You know, I want a little something more than stability, I want a life.”

Jonathan Singer: So one of the ways to do that, that sounds like you guys have been working on here in Pittsburgh is this treatment called Cognitive Enhancement Therapy and I think that would be a great podcast to follow up on. Thanks so much for coming here and talking about schizophrenia and really sort of unpacking this idea, this disorder that as you mentioned before, looks different in everybody.

Shaun Eack: It does.

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References and resources

@Health.com. (2008, October 15). Schizophrenia. http://www.athealth.com/Practitioner/Newsletter/FPN_12_10.html

Anderson, C. M., Reiss, D. J., & Hogarty, G. E. (1986). Schizophrenia and the family. New York: Guilford.

Hogarty, G. E. (2002). Personal Therapy for schizophrenia and related disorders: A guide to individualized treatment. New York: Guilford.

Keshavan, M. S., Tandon, R., Boutros, N. N., & Nasrallah, H. A. (in press). Schizophrenia, "Just the facts": What we know in 2008 Part 3: Neurobiology. Schizophrenia Research. Available at: http://dx.doi.org/10.1016/j.schres.2008.07.020

Mueser, K. T., & McGurk, S. R. (2004). Schizophrenia. Lancet, 363(9426), 2063-2072.

National Institute of Mental Health. Schizophrenia. Available at:
http://www.nimh.nih.gov/health/publications/schizophrenia/complete-publication.shtml
Bethesda, MD: Author.

Tandon, R., Keshavan, M. S., & Nasrallah, H. A. (2008). Schizophrenia, "Just the Facts" What we know in 2008 Part 1: Overview. Schizophria Research, 100(1-3), 4-19. doi:10.1016/j.schres.2008.01.022

Tandon, R., Keshavan, M. S., & Nasrallah, H. A. (2008). Schizophrenia, "Just the Facts": What we know in 2008. 2. Epidemiology and etiology. Schizophrenia Research, 102(1-3), 1-18. doi:10.1016/j.schres.2008.04.011

Tunner, T. (n.d.). Schizophrenia - how social workers help. Help Starts Here. Retrieved on April 24, 2008 from http://www.helpstartshere.org/Default.aspx?PageID=520

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APA (6th ed) citation for this podcast:

Singer, J. B. (Producer). (2008, November 17). #45 - Schizophrenia and social work: Interview with Shaun Eack, Ph.D. [Episode 45]. Social Work Podcast [Audio podcast]. Retrieved from http://www.socialworkpodcast.com/2008/11/schizophrenia-and-social-work-interview.html