In the last section, we discussed three topics regarding diagnosis. The three topics we discussed are Schneider’s Guidelines for Suspicion of Schizophrenia, symptoms of schizophrenia, and subtypes of schizophrenia.
In the next two sections, we will discuss negative symptoms or the absence of normal behavior for the client diagnosed with schizophrenia. Positive symptoms are the presence of a behavior, for example, hallucinations. As stated in section one, there are five common negative symptoms or absences of normal behavior for the schizophrenic client. These five negative symptoms are apathy, incongruous emotional responses, reductions in speech, social withdrawal, and reduced social performance.
This section will discuss three of the five symptoms. The three negative symptoms covered in this section are apathy, incongruous emotional responses, reductions in speech. The focus of this section is to provide examples of negative symptoms and applicable techniques that schizophrenic clients can use to cope with or reduce those symptoms. While listening to this section, you might consider how to implement the techniques with your client.
5 Negative Symptoms of Schizophrenia (#1-#3)
♦ Symptom #1 - Apathy
First let’s look at apathy. As you know, apathy can affect clients in different ways. Certainly clients have told you that they don’t feel like doing anything or that they are tired all the time. Such was the case with Gloria a schizophrenic client, age 33. Gloria stated, "I’m always tired. I don’t have the motivation to get out of bed a lot of the time. And you know what? I really don’t care. I’d almost rather stay in bed all the time." Think of your Gloria. Does his or her apathy manifest as lethargy or indifference? If your client is apathetic, you might consider the Energizer technique.
♦ "Energizer" Technique, 4 Steps
To help minimize Gloria’s level of apathy and perhaps boost her energy level, I asked her to try the Energizer technique.
Step 1: First, I stated, "Feeling tired may be a negative symptom, or it may be caused by your medication." Do you agree that when clients are aware of symptoms, they can benefit themselves by informing their therapist of any symptomatic occurrences or relapses? It was productive that Gloria let me know she felt tired. When clients inform therapists of specific symptoms, therapists can add to or adjust medications, if necessary.
Step 2: Second, I asked Gloria to force herself out of bed in the morning. I stated, "If you need to, place your alarm clock away from your bed so you have to get up to turn it off." Gloria implemented this second step by allowing herself no more than 8½ hours of sleep. She indicated that, for her, 8½ hours was the cutoff for feeling well rested verses feeling tired.
Step 3: In addition to identifying the symptom and getting out of bed, the third step in the Energizer technique was for Gloria to stay out of bed. Gloria was asked not to get back into bed once she was up. The fourth step of the Energizer technique is generally helpful to implement the third step.
Step 4: The fourth step is exercise. Gloria stated in a later session, "My energy level is still low, but I’ve realized that any kind of activity where I’m moving around helps bring my energy up a little." Gloria benefited from the Energizer technique by limiting her susceptibility to apathy. I have found that, like Gloria, schizophrenic clients with apathy can reduce the symptom by limiting its affect on their behavior. Do you agree?
♦ Symptom #2 - Incongruous Emotional Responses
The second negative symptom of schizophrenia that we will discuss is incongruous emotional responses. This is a symptom characterized by conflicting behavior. For example, one client may not appear to react to happy or sad news. Conversely, another client may laugh at sad news and cry when hearing good news.
Do you remember Tyler from the last section? Tyler displayed an incongruous emotional response when his uncle died. Tyler had had a close relationship with his uncle. However, when Tyler’s uncle was diagnosed with prostrate cancer and was scheduled to undergo surgery, Tyler’s mother reported that Tyler appeared not to react. How about your client? Does he or she present incongruous emotional responses? What coping strategies have you found to reduce this symptom?
♦ Symptom #3 - Reductions in Speech
In addition to apathy and incongruous emotional responses, the third negative symptom that we will examine is reductions in speech. Gloria, who presented apathy as a symptom, also presented reductions in speech. Gloria grew less responsive in conversations and often failed to initiate conversations.
Gloria explained why she thought she experienced reductions in speech when she stated, "Sometimes I have a hard time concentrating, but not always. I can be following along perfectly and then whoever I’m talking to will stop, and I know what they said. I know they expect me to talk, but I can’t come up with any words to say!" Are you treating a client like Gloria who experiences reductions in speech? If so, you might consider the Communication Skills Building technique.
♦ "Communication Skills Building" Technique, 4 Steps
To help reduce the negative symptom of reductions in speech, I implemented the Communication Skills Building technique. This four step technique can help a client to increase his or her ability to communicate. However, as I explained to Gloria, schizophrenic clients may find the technique strange at first, but gradually it will come more naturally.
--a. In the first step, Gloria practiced listening to people when they spoke. Unlike other schizophrenic clients I have treated, Gloria did not experience difficulty concentrating. Therefore this step came easily to her. However, if your client experiences auditory or visual hallucinations, he or she may find it very difficult to concentrate on listening to people. If this is the case, more time may have to be used to focus on this first step.
--b. The second step of the Communication Skills Building technique was for Gloria to repeat. I stated, "Repeat back to people what you hear." For example, while talking to someone on the bus, that person stated to Gloria, "I am bored by my life." Gloria stated, "I heard you say you were bored."
--c. In addition to listening and repeating, the third step in the Communication Skills Building technique is follow-up questioning. Gloria followed up with the person on the bus by asking, "So why are you bored with your life?" In a later session, Gloria stated, "It sort of works. When I use the steps, I can think of some things to say. At least I don’t feel like an outsider when I can respond to what other people are saying."
--d. The fourth step expanded on what Gloria had already begun to learn. I stated, "When you find yourself not knowing what to ask, remember who, what, when, where, how, and why. These are six words that will help you in most situations when you don’t know what to say. Choose one to ask your question."
Because Gloria implemented the Communication Skills Building technique successfully by making a special effort to be curious about people and things, she benefited from this technique. Think of your schizophrenic client. Could he or she increase interaction and interest through the Communication Skills Building technique?
In this section, we discussed three of five common negative symptoms of schizophrenia. The three negative symptoms that we discussed were apathy, incongruous emotional responses and reductions in speech.
In the next section, we will continue to discuss negative symptoms of schizophrenia. We will discuss two additional negative symptoms. They are social withdrawal and reduced social performance.
Peer-Reviewed Journal Article References:
Diamond, D. (2018). Changes in object relations in psychotherapy with schizophrenic patients: Commentary on Carsky and Rand (2018). Psychoanalytic Psychology, 35(4), 410–413.
Hallford, D. J., Farrell, H., & Lynch, E. (2020). Increasing anticipated and anticipatory pleasure through episodic thinking. Emotion. Advance online publication.
Holzman, M. S., & Forman, V. P. (1966). A multidimensional content-analysis system applied to the analysis of therapeutic technique in psychotherapy with schizophrenic patients. Psychological Bulletin, 66(4), 263–281.
Igra, L., Roe, D., Lavi-Rotenberg, A., Lysaker, P. H., & Hasson-Ohayon, I. (2021). “Making sense of my diagnosis”: Assimilating psychoeducation into metacognitive psychotherapy for individuals with schizophrenia. Journal of Psychotherapy Integration, 31(3), 277–290.
Leventhal, D. B., & Shemberg, K. M. (1977). Treatment failures and technique modifications in the out-patient psychotherapy of schizophrenic college students. Psychotherapy: Theory, Research & Practice, 14(1), 49–51.
What are three of five common negative symptoms of schizophrenia?