The Etiology of Schizophrenia the Hypo Thesis of Cognitionn Just Like a Dream You Entering This1

8/3/2019 The Etiology of Schizophrenia the Hypo Thesis of Cognitionn Just Like a Dream You Entering This1

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BritishJournalof Psychiatry1992),161,20 1210

A Comparison of A cadem ic and Lay Theories of SchizophreniaA. FURNHAM and P. B OWER

This study investigatedlay subjects ' theoriesof schizophrenia.A questionnaireexaminingthefivedentified ainac adem ictheo rie sfschiz ophr enia medical, oralbehavioural,ocial,psychoanalytic, ndconspiratorial) longvari ousimensi onsaetio logy , ehav iou r,rea tmen t,functionof the hospital,andthe rightsanddutiesof bothpatientsandsociety)was constructedforuseinthestudy.The resultsrom 106 layrespond entshowed thatno singleodelwasfavo uredexcl usi vely utseemed to pointto a synthes isfsev eralcademictheorie s.helay subjectsstressedthe importanceof patientenvironmentin the aetiologyof schizophreniara therhan a physiological alfuncti on,ut tendedto stressthe persona lrights f theschizophrenic .The differencesbetween lay and the current lydominantpsychiatricmodelsarediscuss edntermsoft hefunc tionhesemodelss erveforeach group.

At tempt s to in teg ra t ehe menta ll y il li n to thecommunity willundoubtedlybe affectedto somedeg re e by the r ec ep tion soc ie ty accord s th e menta llyill, whic h is in tu rn d ep en de nt o n popula r a ttitu de sand belie fs . I t is , th er ef or e, impor tant t o under st andlay theories of schizophren ia and other men tali llnesses . Farina & Fisher (1982) have d is tingu ishedbet wee nthepu bli c'stti tud es subjective eelings)a nd b elie fs (o bje ctiv ely v erifia ble k now le dg e), a sresearch has show n them to have m any differentproperties, the m ost im portant being that w hileatti tudes avea rath ereakrelat ionsh ip obehaviour,the rela tionsh ip between belie f and behav iour ismuch more c ompre he nsib le , u se fu l, a nd p romisin g(Furnham, 1988).There is an ex tensive but d iffu se litera tu re on

a tt itudes towards menta l d isorder (Sarbin & Mancuso ,1971, 1978; C rocetti et a l, 1971 , 1972 ;No rman &Malla , 1983;P r in s, 1984;Eker, 1985;Ma l la & Shaw,1 98 7). O ne o f th e most exh au stiv e an d im po rtan tr ev iews was that o f Nunnall y ( 1961 ), who found tha tthe mentally ill are regardedwith ear,istrustandd islik e across so cial g rou ps, w ith o nly a littlevar iat ionithage ,sex ,or edu cat ion .Nunnal ly ( 1961 ) f ac to r ana ly sed que st ionnai re s

concerning w hat the general public knew aboutmental i llness(containing statements such as nervousbreakdowns seldom have a phys ical o riginand heinsane laugh more than normal people) andfound ten interpre table factors , suggest ing fa ir lycomplex b eliefs. In con trast to the attitud inal

findings, there weremarkeddifferences between thebelie fs o f o lder and younger people , and betweenth e more an d less ed ucated , bu t la y perso ns' v iew swereno t very d iffe rent from those of the experts',a finding which may be interpretedeither positivelyor negatively.

Rabkin (1972 ) r ev iewed s tudie s o f th e US pub lic 'sa ttitu des toward s m en tal he alth an d fo un d sim ila rrejecting attitudes in the m ajority of cases. A nexample of these closedanks' was found byCumming & Cumming (1 957), who trie d to p romo temore accepting att itudes towards the menta lly ill .They found tha t peop le agreed wi th two propos it ions:tha t th e ran ge o f n orm al b eh av io ur is w ide an d th atdeviant behaviouris not random but has a cause andthus can be understood and modif ied. However, ther esponden ts to ta lly r eje cted t he id ea th at norma l andabnormal behaviour l ie on a continuum and are notquali ta tively different.Attitudes to the mentally ill are related to

d emog raph ic and p sy ch ograp hic fa cto rs. C lark &B inks (1966) found th at th e younger and b ettereducated responden ts in the ir survey had more l ibe ra lattitudes towards the mentally ill. In a cross-culturalc on te xt, S hu rk a (1 983) su rv ey ed Isra eli A ra bs a ndreplica ted both th e gener al findings o f negativeattitudes to the mentally ill and the general lesseningof stigmatisationwithgreatereducation.F urthermore,t he f ac t th at th es e a ttit udes a re r ela ted in some way tobelief systemswas demonstratedby Christianrespondents who showed lessnega tive a tt itudes than the o therreligious groups tested. However, in a test of theatt itudes of Swedishuniversitystudents Am etal(l971)f ound f ew p re judi ced a ttit udes , aga in showing a linkbetw een education and m ore positive opinions. T heyalso discovered more posit ive att itudes among women,polit ical adicals, nd tho sewit ha fam ily ist oryf

menta l d isorder. Psych ia tr ic t ra in ing a lso led to morebenevolent att itudes, with an increase in toleranceand a r educ tion in soc ia l d is tance. Ge lfand & Ullman(1961) also found that psychiatric training led to amore lib era l, human ita rian ou tlook , w ith moreemphasis on treatment than control.

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202 FU RNHAM & BOWER

A difficulty arises in the interpretation of som eof the studies described above in that the beliefsstudied are those about m ental illness in gen eral,ins tead of a part icu la r d isorder. I t seems unlike ly tha tbeliefs about such distinctdisordersas schizophrenia,d ep ression, and neu ro sis wou ld be h ighly homogeneous. Therefore,som e researchershave investigateda ttitu de s a nd b elie fs c on ce rn in g a s in gle d iso rd er,su ch a s de pressio n, w hile ig no rin g o th ers, su ch asschizophrenia.R ip pere (19 77 , 19 81 ) lo ok ed at common -sense

not ions of depress ion and found that there is muchunderstand ing and consen su s a s to th e cause andtreatment of depress ion. This is presumably due tothe w idespread nature of the disorder and theincreased ability of lay persons to empathise w ithth ose su fferin g d epression , h av in g ex perience dsim ilar problem s at som e point in the past. If thisrea son ing is cor rect, th en sim ila r resear ch in tos ch izophr en ia is unlik ely to fmd any such consensus ,since the disorder is less common and less unders tood . Fumnham & Rees (1988 ) su rveyed lay theo rie sof schizophrenia (both beliefs about schizophreniaand cau sa l exp lana tions ) and found a mis concep tionabout what the disease actually was, most of th erespondents adher ing to the view that it meant thatthe patient was suffe ring from splitersonality'.Four factors emerged from the belief questionnaire,the first concerning the dangerousness of thesc hiz op hren ic, esp ecially th e u np red ic ta ble n atu re o fthe disorder. The other three factors dealt with theamorality,gocentricity, nd vagrantnatureofthe schizophrenic. The factor analysis of thequestionnaire dealing w ith causes revealed im plicit

theories which show ed a link between explicitacademic and lay theo rie s. Fac to rs emerged a lludi ngto attentional defici ts , stress, biology, genetics, andbrain damage. Supporting the views of Sarbin &Mancuso (1971, 1972), subjects tended to adhere toa psychosoc ia l model ocia l s tr esses and familyconflicts w ere seen as the causes rather than theo rgan ic d isorde rs pos tu la ted by the medic al mode l.However, the s tudy was limited to inves tigat ion ofo nly th e m ed ic al (o r o rg an ic) a nd so cia l e xp la na torymodels.I twas the purpose of this study to extend previous

research and investigate the public acceptance of theful l range of academic theor ies cur ren tly pu t forwardto explain the schizophrenic disorder. In their paper

Mode lsf madnes s ,S iegle r & Osmond (1966 )a tt empted to sor t the p le thora of theories categori sings ch izophr en ia in to mode ls , d es cr ib ed a long severa ld imensions which cou ld then be compared . Whatthese m odels provide is a summary of modemsc ientific theorie s o f sch izophren ia , and they are

descr ib ed b rie fly below, u sing t he S iegl er & Osmond(1 966) d imen sio ns mos t re le va nt to th e stu dy o f la ytheories. It should not be assum ed that thoseplanning the treatment of schizophrenics alwaysadhere to a single model and that models aremutual ly exclusive.

Academic models of schizophrenia

The medical modelThis is th e d om in an t o rg anic co ncep tua l m od el fo rthe understanding of the somatic illness , and has asim ilar although less m arked dom inance in thet reatment of mental ifiness. Schizophrenic personsare in most cases called patients',eside in ospitals ' ,ndare iagnosed' , ivena rogno sis',and reated',ll a reflection of th is dominance .

Ae tio logy. The medic al mode l re ga rd s menta lm alfunction such as that found in the schizop hre nic p atie nt a s a c on se qu en ce o f p hy sic al a ndchem ical changes, prim arily in the brain. T heaetiology fschizophrenia sunk now natprese nt,but there has been much researchduring the pasthalf-century, i thmodernworkerssing varietyof brain-imagingtechniquessuch as computerisedtomography (CT), regional cerebral blood flow(rCBF),and positronemissiontomography(PET). Twin (Gottesman & Shield, 1972) andadopt iontudie sKety ta!, 968) aveconvi ncedmost rese arc hers th at a g en etic fac to r is in vo lv ed .Other researchers have concentra ted on brainb io chem istry, an d th ere is eviden ce th at e xcess

dopam ine (a neurotransm itter w hich plays animport an t ro le in a rous al and r ein fo rc ement) maycau se sch izo phren ic symptom s (M iller, 1 984 ;McKenna, 1987).Finally, some researchers hypothesise th e existence in sch izoph ren ics o f b ra ina bnorma li ti es s uc h a s e nl arge d c er eb ra l v en tr ic le s(Waddin gto n, 1 98 5), p oss ib ly c au se d by a v iru s(Machon e t a !, 1983).Behaviour. The behaviour of schizophrenics is asymptom of their illness, and it has no realinterpretative alu e xce ptsa rou ghind exofth es ever ity o f th e d isorder.Treatment . Treatment consis tsprimari ly ofmed ical an d su rg ical p ro ced ures, such as use ofneuroleptic drugs.

Func tion of the hosp it al.The func tion of thehosp ital is to p rovid e an environment whichfacilitates the ca re a nd cu re o f tho se sufferin gfrom th e d is ea se .Righ ts and dutie s o f th e p atie nt. The s ch iz ophrenic has the right to the sick'ole, an


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20 3CADEM IC AND LAY THEOR IE S OF SCHIZOPHRENIA

ancient and respectable role. The full load ofa du lt re sp on sib ility is re du ce d a nd p atie nts a rer egarded with sympathy, as the condition is no

fault of their own. Equally schizophrenics havethe duty to cooperate with the staff (takingmedicat ion and repor ting to the psych ia tr is t whenrequ ired) in working tow ards the goal of theirown improvement.Rightsand dutiesof society.Soc ietyhasthe rightto re stra in th os e s uffe rin g from s ch iz op hre niawho may be temporarily dangerous, but it isthe duty of society to be sym pathetic to theschizophrenic.

The moralbehaviouralmodelTh e moral-behavioural model is best known in thetreatmen t of p hob ias an d oth er n eu rotic d isord ersand is most concerned w ith the overt b ehaviour of

the schizophrenic.Schizophrenicsareseen as sufferingfor their sinful'ehaviour in the pas t.Aetiology.The aetiologyof schizophrenias tobe found in the process o f learning from other swith s im ila r b eh av io ur, o r o th er in ap pro pria telearning experiences.Behaviour. Al l schizophrenicbehaviour is to betaken at face value, and requires evaluationinstead of in terpre ta tion. Much schizophrenicbehaviour contravenes moral or legal principles,and th is is the key to both understan din g andcur ing the d isorde r.Trea tment. Trea tment i s by far the most importan ta spec t o f th e mora l- behaviou ra l mode l. Whethe rbehav iour is s een a s s in fu l, ir re sponsib le , s imp lymaladjustive, rsocially ev ia nt ,hecr uc ia l hingis to change it so a s to make it socially a cceptable.The methods used range from simple moralexhortations to complex behaviouraltechniques,such as token econom ies, verbal control ofbehaviour, and social-skil ls t ra ining (Turner eta!,1981).Functionof the hospital .The hospitalactsas acorrectional nsti tution, iffering roma pr i sononly in that the patient has broken soc ia l rule srather than laws. Ins ide, the atmosphere may beone of a otalnsti tution' that facil itates thechanging of behaviour.Rightsanddutiesof thepatient. Schizophrenicshave the right to be released as soon as their

behaviour is acceptable to society, but areexpectedto cooperate with the treatmentand takeresponsibili ty for their actions: there is no sick'role.Rightsandd utiesof society.Soc ietyhastherigh tto impose such sanct ions as incarce ra tion on those

whose behaviourviolates currentsocialrules, andthe duty to provide p laces fo r the tr ea tmen t o fsuch deviance.

The psychoanalytic modelThe psychoanalytic model of schizophrenia differsfrom the others in that it is in terpre ta tive , t reat ingthe patientas an agent capable of meaningfulaction.Ratherthan seeing patients as actedn ' by var iousforces (both biological and environmenta l) whichcause them to behave in cer ta in ways, the psychoanalytic concept ion of schizophrenia is concernedw ith patien ts' in ten tions, motiv es, and rea son s(Ingleby, 1981).

Aetiology .Unu sualor traumaticearlyexperienc eso r th e fa ilu re to negotia te some critica l stageof emotional developm ent are the cause of

schizophrenia.Behaviour.The behaviourof the schizophrenicis to be interpreted symbolically; it is thetherapist 's task to decode it. This interpretativeapp roach attaches meanin g to the patient'sbehaviour.Treatm ent.Long-term ,one-to-on etherap ywitha trained sychoan alyststheprimarytreatmentoffe red by th is model.Functionof theh ospital.The hospitalisus edtofac il it ate recovery through maximal con tac t wi ththe psychotherapist, and also to remove thesch izophren ic f rom the home envi ronment, wherethe problems originated.Rightsanddutiesof thepatient. Schizophrenics

have the r ight to be spared moral judgement fortheir actions and to be treated sympathetically,but have the duty to coopera te with the analyst .Rightsand dutiesof society.Soc ietyhasthe dutyto provide servicesto deal with the schizophrenicand to show sympa thy to th e su fferers.

The soc ia l modelAll socialmodels in psychiatryhave the fundamentalpremise that the widerinfluence of social forces aremore important than other influences as causes orprecipitantsof mental disorder(Rack, 1982).Mentalillness is seenas a symptom of a sick'ociety, othersbeing a h igh d ivorce rate , juvenile delinquency,increased drug addic tion, and so on. The pressureso f the modern wor ld fa ll more heavily on the poorand d isadvan taged , and thus th ey seem to su ffermore o f w hat is d escribe d as lln ess'.

Aetiology.Sc hizophrenicpatientsare driventotheir fo rm of madness by the socia l, economic ,


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and fam ilial p ressures on them . F or example,Vaughn & Leff ( 1976 ) f ound that r elaps e in s ch izophrenicswas higher in families where therewas ahigh degree of expressed emot ion ( i.e. negat ive,cri tical att itudes and emotion-laden statementsdirected towards the schizophrenic).Behaviour.he behaviourftheschizophrenicis a symp tom of th e w ider p rob lems of society.Treatment.There is no individualtreatmentinthe social model. Insteadwhat is requiredis largescale social change to reduce th e stresses onindiv idua ls and thus reduce th e in cid ence ofmental illness.Function of the hospital .The socialmodelseesth e h osp ital as a dump inground ' fo r th e poo rand o thers unable to live in th e world outsid e.Th is is r ef le ct ed in th e p ra ctic es o f some hospit alsthat seem to be orientated lessto providing a curethan to providing shelter.R igh ts an d dutie s of the patie nt. T he schizophren ic has the r ight to sympathy.Rightsand dutiesof society.Soc ietymu stchangeso as to reduce the s tresseson people and therebyprovide a cure fo r men ta l illness.

The conspiratorial modelThe conspirator ia l theory, in the form put forwardby Szasz (1987), is perhaps the most radicalconceptual model of schizophrenia in that it deniesthe existence of mentalillness(as a physicaldisorder)and standsin directopposition to the medicalmodel.

Aetio lo gy. S in ce th ere is n o p hy sica l dise ase, th ere

is no physical cause. M ental illness is notsomethingomeone has,ut somethingomeone does or is. P sych iatric diagnoses arestigmatising labels app lied to person s whosebehaviour offends or annoys others, and are usedto control eccentric,radical,or politicallyh armfulactivity.Behaviour.The behaviourof the schizophrenicis a direc tconsequence of the way the person hasbeen treated by others.Treatment.The conspiratorialmodelden iesany reatment'r cure'n the normal sense . To dealproperly with schizophrenics, one must respecttheir r ight to behave as they wish (with in lega ll imits). If the individualseeks help, then it should

be p rovided , but th ere shou ld be no coercion.Func tion of the hosp it al. Desp it e it s ou twardappearance, the hosp ital servesas an estab li shmentto im prison and control persons dangerous tosociety.Rightsand dutiesof thepatient.The schizo phren ic

has the r ight to privacy, personal f reedom, andtre atmen t s uita ble fo r a re sp on sib le a du lt.Rightsand dutiesof society.Soc ietymu strespectthe r ights of the schizophrenic individual.The d im en si on so f a ny s in gl emod el a re n ot

in depe nd en t b ut in ter-relate d, an d are n orm ally adirect consequence of the aetiological stance takenby th e model's p roponen ts. F or example, in th emed ica lmod el des cri bedbov e,theor gan ica useleads to the need for physical trea tment , behaviouris seen simply as a symptom caused by the physicalmalfunct ion, the pat ient' s r ights and duties are thesam e as th ose o f an yo ne who suffers from a som aticilln ess, an d th e righ ts of society are sim ilar to th oseapplicablein the caseof a possibly dangerousorganicd is ea se . Thus, th e model shows in te rnal coher ence.This study was therefore concerned with the

acceptance by lay people of the various acad em ic

theo ries o f schizophr en ia , th e in ter na l coher ence o fth e resp on ses of lay p eop le to th e question s d ealin gwith d imensions of the same model, and the demograp hic v ariab les su ch a s ag e, sex , an d ex perie nce(w ith s ch iz op hre nia a nd o th er men ta l illn ess ) th atm ig ht c orre la te w ith th e a cc ep ta nc e o r re je ctio n o fcer ta in models. A ques tionnai re was cons truc ted wi thitem s describing the five m odels along the eightd imensions lis ted above . Fur thermore , becauseFurn ham & Ree s (1 988) h a ve fo und th at mos t p eo ples til l b eli eve t ha t s ch izophrenia means th e pat ient h asa pl i tersonality ' , twas decidedtoin clude briefdescription of the symptoms and behaviour ofs ch iz op hre nic s in th e q ue stio nn aire s o a s to a vo idc on fu sio n w ith th e mu ltip le p ers on ality s yn drome.

Method

A total o f 106 sub ject s comple ted the ques tionna ire, o fwhom 59 were female (55.7%). There were 36 full -t imeuniversitystudents , 16 student nurses , 40 people in fullt ime occupat ion, and 14 unemployed people . They werep art o f a u niv ersity s ub jec t p an el o f v olu nteers . A ges ra ng edf rom 18to 60, withan averageof 23; 33% of responden tswerein the age range 1720,nd 33% in the range2130.T hirty-one of the sam ple claim ed to have som e experienceof anymen talllness.Itshou ldbe recognisedhatthesamplewas probablyskewedtowardspeoplewithsomepreviousknow ledgeof mentalillness.Thisw asneithera representativenor a large sample; however, checks were carried out todeterm ine w hether the resu lts m ight be atypical because o fthis.

E ntitle d Commonb eli efs a bo ut s ch iz op hre nia , th equestionnaire consisted of a description of the mainc ha ra cte ris ti cs o f t he d is or de r f oll owed by 72 que st io ns ,ea ch to b e an sw ered o n a sev en -p oin t scale (see A pp en dix ).I t wasdesignedby both authorsand basedon previousmeasures. Extensive pilot work ensured that it w as


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ModelsDimensionMedicalMoral-behaviouralPsychoanalyticSocialConspiratorialAetiology3.332.203.603.432.94Behaviour3.59

ofospital5.264.034.504.103.33Patientrights5.585.675.565.475.37Patientduty4.663.934.66-3.19Societyrights3.722.84Society

duties5.796.085.795.495.69

20 5CADEMIC AND LAY THEORIES OF SCHIZOPHRENIA

Table 1Meanson the eightdimensionsor the f ive models1

1. Scale: True 7 6 543 2 1 False.2. No useof thedimensionn thedescript ionof the model.

unambiguousand interpretable.These descriptionsof thedisorder and the questions per ta ining to each dimensionof thefivemodelsbeingtestedwerederivedfromtextbooksandjournals,especiallytheSiegler&Osmond(1966)andFurnham & Ree s ( 1988 ) p a pe rs . I n s ome c as es th er e wer etwo or morequestionsdealingwitheach dimension,andsomemodelsweredescribedusingfewerthan the fulleightdimensions . Where necessary, the ques tions were adaptedto lay languagefor ease of understanding.Whenall 72questionshad beengathered,theorder wasrandomisedonthe questionnaire, except that questions pertainingto thesame model neverappeared consecutively.The questionna ire h ad b oth fac e a nd c onte nt v alid ity.The firstpageof thequestionnaireontain eda descr iption

of themaincharacteristicsf schizophrenia.tincludedtemsdescribing thought disorder (delusions and hallucinations),speech (w ith an ex am ple of schizo phrenic discourse), andbehaviour,togetherwitha noteexplainingthatthe disorderwasnot a caseof splitpersonality.Itcouldbe arguedthatthis information, to some extent, guided the respondents'responsesin a particulardirection;however,it wasthoughtnecessaryin order to ensurethat lay peoplewereactual lyconsidering chizophrenia tself ath erhansom eot hermenta l i llness .Most sub ject s f il led out t he quest ionnai re s in the ir own

tim e an d retu rn ed th em to th e research er b y h and o rthroughthe post.The dataw erecollectedin 1989/90.Fewerth an 5% failed to respond or handed in incompletequestionnaires.

ResultsThe m ean scores on the seven-point scale of all 72quest ionnai re i tems a re g iven in the Append ix . The sco re sf rom ques tions descr ib ing the same dimension of eachmodel were averaged,and the mean values for eachdimension for all five models are given in Table 1.In themedicalmodel,the highestmeanvaluewas for

items describing the patient's right to sympathy and the dutyof societyinca ringfortheschizophrenic.However,subjectstendedto disagreewith this aetiologydimensionin themedicalmodel(mean scoreof 3.33).The moral-behaviouralmodel was th e one w ith which subjects had mostdisagreement.The mean scores for the behaviourand

treatmentdimensionswereonly 2.67 and 2.73, respectively,and the largestmeanvalueswerefor itemsp ertainingtothe r ights of the schizophrenic and the duty of society toprovideplacesfor treatment.

A ll th e m ean v alu es o f th e s ev en d im en sio ns o f th e p sy ch oanalyticmodelw ereabovemidpointexceptaetiology,whichhad a mean score of 3 .60, the highes tmeanvalue foraetio lo gy o f all fiv e m od els . T he h ig hes t v alu es co ncern edth e righ t of p atien ts to b e sp ared moral ju dgemen tsregardingtheirconditionand to be accordedsympathy,andthe d uty of society to show sympathy and respect tosufferers.Of the six dimensionsused to describethe socialmodel,four had meanvaluesabovemidpoint,withtheh ig hes t ag ain co ncern in g th e rig hts o f p atie nts to symp ath yandrespect,andthe dutiesof societyto respectheserights.S ev en d im en sio ns w ere u sed to d esc rib e th e co ns pirato rialmodel , and three mean values were rated above the midpoint, those referring to schizophrenics' r ight to propert reatment ( i. e. to be a llowedto run the ir own l ives)andsociety 's duty to r espec t th ese righ ts. The aetio logyd imen sion h ad a mean valu e of on ly 2.94, in dicatin gdisagreement.To test whetherthe respondentsreplied to the question

n aire it em s c on ce rn in g o ne p ar ti cu la r th eo ry a s a n i nte rn all ycoherent odel,orrelations erecom put edetw eenhescores of each m odel's dim ensions. Of the 28 intercorrelations fth eva ri ou s imensions fth emed ica lod el ,nin e(32%)wer esta tis tic all y ignificant P


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could be split into tw o subm odels form ing coherentmod els in th em se lv es. T he first d ea ls w ith ae tio lo gy,b eha viou r, an d treatm en t, an d th e seco nd w ith th esick'o le and its a ttendant rights and duties. Inth e c as e o f soma ti c il ln es s, th es e two submodels f orma comple te guide to the pathogenes is and managementof the disorder,yeti t seemsthe lay respondentsw ished to con fer th e benefits o f th e sick'o le onthe schizophrenicpatientwithout necessarilyagreeingth at th e d is ord er h as a n o rg an ic o rig in .The mean values of the dimensions of the moral

behavioural m odel show ed that the respondentsd isa gre ed w ith th e a etio lo gy, b eh av io ur, a nd tre atment dimensions,but agreedwith those items dealingwi thth edu ti esfs oc ie tynprov id in gla ce sode alwith schizophrenics. The cleares t s ta tement of therespondents' dissatisfaction with this model was theh igh mean r esponse g iven to th e i tem sugge st ing thatsch izo pb ren ic s sh ould n ot b e jud ge d mora lly fo r th eirac tio ns (q ue stio n 5 2), a su gg estion whic h is c on tra rytothefundamenta lr oposalsfthismodel.The highmean value accorded to the hospital-function dimension may seem incongruent with the sick'olefactor describedabove, since the moral-behaviouralmodel sees the hospital as a kind of prison, butana lysis o f the scores fo r the indiv idua l hosp ita lfunction questions showed that 73lof respondentstotal ly d isagreed wi th the conten tion tha t the hosp itals hould be a cor re ctiona l in st itu tion and that t he h ighm ean value w as m ainly due to the other questionsper ta in ing to the hosp ita l func tion of th is model,suchasthose oncer nedithfacil itati on frecovery.In general, the psychoanalytic model received a

favourable reception from the subjects in this study.Subjects agreed that schizophrenic behaviour hadsome meaning and was neither random nor s implya symptom of an illness (Cumming & Cumming,1957). They a lso though t that psychotherapy wasmore likely to help these patients than any treatmento ffe re d b y th e o th er mod els . Items p erta in in g to th epsy cho an aly tic m ode l load ed o n b oth facto r 2 (th esicko le ') and facto r 1 , which dea lt with s tr ess asa causal agent and accounted for more variancethanany o ther fa cto r. The two items with th e h ighestmean v alu es o n th is fa cto r were th e p sy ch oa na ly ticexplanation of the cause of schizophrenia astraum atic ex perien ces in child ho od and th e in terpre ta tion of the behav iour o f schizophren ics as insome way symbolic o f their p roblem.

Only six dim ensions w ere used to describe thesocial m odel, and analysis of the m ean values show edthat subjectsmost agreedwith items dealingwith ther igh t of sch izophren ics to sympathe ti c t reatment andthe duty of society to reducesocial pressureson thesepatients. The socia l aet io logy was corre la ted with

The aetiology dimension was significantly correlatedwithall the dimensionsexceptsocietalduty.A factoranalysiswas performedn orderto investigate

theunderlyingstructureof thelay beliefsexaminedin thiss tudy. By the scree tes t, f ive factors emergedwhichaccounted for over 38% of the var iance. The first factorto emergefromthe analysis(factor1)accountedfor 11.6%of the variance,and containeditemsreferringto stressasa causal fac tor in the pathogenesisof schizophrenia ,in childhood development(questions18, 25, and 37),interpersonalrelations(questions44, 55, 60, and 64), oreverydaysociallife (questions21,52, and69).Thehighestmean value was for que stion 18Traumaticxperiencesin early childhood can cause schizophrenia. Factor 2accounted for 9.7 % of the variance and w as concerned w iththerightof schizophrenicatientsto beaccordedsympathyforthe condition (questions 12and 46 concerning this hadthehighestmeanvalues,6.09 and 5.64), to be providedwithproper care, and to be spared moral judgement for theiractions(question52).Factor3, whichaccountedfor6.4% of thevariance,dealt

withthe schizophrenic'sightto respect(questions5 and45)and personalfreedom(questions6,8, 50,and 70).Thehighestmean value (5.82)was for question 8, Schizophrenicshavethe rightto personalfreedomif theydo notbreakthelaw.actor4 wasconcernedwithwhatmaybe calledthehidden'unctionof thehospital,in thatthe itemsloadingon this factordealtwithusesof thehospitalthatmaybedifferentfrom the professedaims of the institution.Therewere i tems a llud ing to the use of the menta lhosp it al as ashelterfor the poor ratherthan a medicalinstitution(questions 11 and 26), as a place to punish society's deviants

(ques tions34, 48, and 65), and as a degrading otalinstitution' (question39).T he highestmean valuewas forquestion11,Whateverhe aimof thementalhospital,itoften endsup becominga dumpinggroundfor the poorand disadvantaged.The final factor(factor5) accountedfor 4.9% of the

varianceand was concernedwith the sort of treatmentsuggestedby the moral-behaviouralmodel, with itemsdea li ng wi th the r ight o f soc ie ty to pun ish o ff ending sch izop hr en ic s (q ue sti on 5 9) i n c or re ct io na l in st it uti on s ( qu es tio n22),andpunishmentbeingassumedto bean effectiveformof treatmentquestion14).Thehighestmeanvaluewasjust1 .95for ques tion 59 ,and the mode responsefor a ll threeques tions was 1 .A seriesof one-wayANOVAswascomputedtembyitem

in order to see whetherany of the threedemographicvar iable s ( sex, age , and p revi ou s exper ience w ith t hemen ta lly il l in g en er al a nd s ch iz op hr en ic s i n p ar ti cu la r) w eres ignif icant determinants of responses to the ques tionnai re .Therewereno more significantdifferencesin any of thevar iables than would have been expectedby chance,indicatingthat the subjectdemographicand experiencefactorsin thissampledid not relatesystematicallyo theschizophreniaquestions.

Discussion

This study dealt with lay beliefs about schizophrenia.The results indicate that the complete medical model


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207CADEM IC AND LAY THEOR IE S OF SCHIZOPHRENIA

behaviour, treatment, hospital function, and dutiesof socie ty, showing that the subjects responded tothese items as a rela tively coheren t model. Soc ia litems were a lso con ta ined in the str es s facto r andfacto r 4 , which dea lt with the hidden'unction ofthe hospital.Th e dimensions th at received most p ositive

responses in the conspi ra to rial model were concernedw ith th e tre atmen t a nd rig hts o f th e s ch iz op hre nic .Although some of these items were included in thesickole' factor, th ey mad e up a significan tp roportion of facto r 3 , which dea lt with the r ightto personalfreedom of schizopbrenics.The item withthe h ighest mean value in facto r 3 was that dea lingwith the wrongfulness of commitment to an asylumwhen a patien t h ad not committed a crime. Itemsfrom the conspiratorialaetiology were also includedin factor 1 , rela ting to interpersonal s tress, and infacto r 4 , dea ling with the func tion of the hospita la s a p ris on for dev iants and o ther unwanted member sof socie ty. Correla tions between the aet io logy ando ther d imensions y ie lded s ignifican t resu lts fo rbehaviour, treatment, hospital function, and rightsand duties of the pat ient, showing that the subjectsresponded to this as an internally coherent model.It is clear from the results that the subjects'

r esponses d id not confo rm nea tly to any one of theacademic models, but the resu lts can be used to seewha t so rt o f model was favou red by the subjects.Th e aetiology dimen sion d ealt w ith b y factor 1,which was made up of items from the social,ps ych oan aly tic, an d c ons pirato ria l m od els, sh ow edthat stress in childhood, stress at the interper sona l leve l, and s tr ess from life s ituations a reall seen by lay people as important causal agents. I tis unc lea r wha t th e most e ffec tiv e tr ea tmen t is in th islay model. Analysis of the means shows thatone-toone psychotherapyis regardedmost favourably, andany reduction in the s tresses would presumably beseen to help th e su ffere rs (Furnham & Ward ley,1990).Factor 3 is concerned w ith civil liberties and

showed thatschizophrenicsshould be accordedbasichuman rights and freedoms despite their condit ion,and th is c an be in te rp re ted a s a re je ction o f soc ie ty 'sr ight to commit schizophrenic pat ients when theyhave b roken no law. The function o f th e hosp ita lis dealtwith by factor 4, which indicates that peopleareawareof the fact that mental hospitals can often

be u sed in ways th at h ave little to do with ca re andcure , even if t he se a re th e p ro fe ss ed and cor re ct a ims .Thus, sub jects in th is study seemed to hold a v iewc lose to that o f the consp irato ria l theorist, Szasz(1987). Finally, the remainderof the dimensions ofthis lay model seems to be summed up in factor 2

as the sickole', which in the form found in thisstudy is importan t to some degree in all modelsexcept the moralbehavioural .Sub jec ts had s trongbeli ef s th at th er e should be l ittle d iff er ence betweenthe treatmentof schizophrenicsand people sufferingfrom somatic disorders.The lay m odel appears to defy reduction or

classification into any one of the five m ain academ icmode ls . The vocabula ry used to desc ribe schizophrenia is almost entirely medical , yet lay people donot seem to unders tand the academic implicat ionsof this and are not aware of the incongruenceb etw een th eir lab els a nd implicit th eo ries . H ow ev er,some everyday expressions about the causes ofmental illness (drivingme mad ') a re not med ica lexpressions. If a lay person uses a term such as llness'o descr ibe a psychological d iso rder, thedefini tion of i llness appears to inc lude such semantica tt ribu tions as self-centredness',harmful', mpair

ment ', undesirable',nd unexpected'Furnham,1988) w ithou t an y belief that th e cau se has to bephys i ca l . hi s suggest sthat t he use o f medicalla ng ua ge is s imply co nv en ie nt a nd stems fromexperience of expert usage rather than any implicitagreementwith the medica l model.Possib ly, the popula rity o f the proposa ls o f the

psychoanalytic model is due to the fact that they aresimila r to the fo rms of under stand ing used by laypeople . Exp lana tions of human behav iour o ftenproceed by showing that the behav iour is rationa lin light o f t he sub je ct's b eli efs and des ire s, s o it s eemsthat th e psychoanalytic app roach is closest toeveryday theories in its understanding of individualbehaviour and thus is rated as most useful (Ingleby,1981). Yet, lay people are often perp lexed andrepelled by som e psychoanalytic interpretations oftheir behaviour which go beyond people's ownunderstanding of themselves (through so-calleddepthermeneutics') to provide explanations of theobs erv ed b eh av io ur. What is b ein g h ypoth es ise d isthat both lay and psychoanalytic approaches use thesame method o f in terp re ta tion and that th is mayaccount fo r the rela tive popula rity o f the psychoanalytic model as a key to understandingschizophrenia.I t seems that lay people have not been converted

to the m edical view and prefer psychosocialexplanations. H owever, it also seem s that thesubjects in this study accorded the schizophrenic the

sicko le ' desp ite the socia l aetio logy. One of themain a ims of the proponents o f the medical modelwas to see th at the men tally ill receive the samesym pathetic treatm ent as the physically ill, and thehope was that a belief in a physical aetiology wouldfac il it ate thi s. However, in t ry ing to equa te the r igh ts


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208 FU RNHAM & BOWER

of the physically and mentally ill, it looks as thoughthe proponents of the medical model may have beenpushing throu gh an open door.

Therema y be consider ableesistan ceocha ngingthepublic'seliefsboutthenatur eof thedisorder.If the hypothesis about the relat ionship between thefunction of lay beliefs and theircontent given abovei s t rue, then the re may wel l be problems in convert ingthep ubl ic'siewstoa med ical -mod elper spec tivefthe new beliefs are less useful to the lay person inord eri ngndm aki ngsen sefth ebeh avi ourfothe rsin the soc ia l wor ld .Clearly, there are many other issues to in

vestigate in this area. For instance, one couldinvestigate how the public develops its beliefsabout the nature of schizophrenia (and otherd iso rders), o r, more specifica lly, how d ifferen tthe results of this study would have been if onewas investigating a neurotic, as opposed to apsychotic, disorder.

Appendix

Q ue st io nn aire it em s

1. Schizophrenias causedby havingbloodrelativeswho are schizophrenic.

2 . S ch izo ph ren lc s h av e th e rig ht to b e left alo neaslongastheydo notbreakthelaw.

3. Menta lhospi ta lsare best used to removeschizophrenicsfrom stressfulhomesto quietersettings.

4. Societyhas the r ight to protec t i t s peoplef romschizophrenics.

5 . Schi zoph renic sh ave t h e r ight t o be t re at ed a sresponsible adults .6 . Thebest way to t reat s ch izophren ic s s to r espect

th eir lib erty an d rig ht to lead th eir o wn life.7 . T he re a re more s ch iz op hre nic s i n s om e c ul tu re s

a nd coun tr ie s t ha n o th er s.8 . Sch izophremcs have the r ight to persona l

freedom if they do not break the law .9 . T he d uty o f so ciety is to c ha ng e a nd re du ce th e

stresses and strains on schizophrenics andothers.

10. Schizophrenicbehaviour is so odd i t showshowillthey are.

11. W hatev er th e aim o f a m en tal h osp ital, it o ftenend s up becoming a dump ing g round fo r t hepoor and d isadvantaged.

12. Sch izophren ics have the r ight to be t reatedsympathetically.

13. Schizophreniais causedby learningstrangeand

b iz ar re b eh av io ur f rom o th er s.14. Sch izophren ics can be t reated by pun ishing the irbad behav iou r.

1 5. S ch iz op hr en ic b eh av io ur i s s ymbo lic o f t heproblems encountered by the individual.

16. Making schizophrenics more responsible for theirbehav iour i s the bes t way of t reat ing them.

Appendix (continued)

Meanscore'

17. Mentalhospitalsare usedto keepschizophrenicsawayfrom society and have little interest in cure. 3.36

18. Tra umat ic ex pe rie nc es in e ar ly ch ild ho od c an ca useschizophrenia. 4.05

19. S chizoph ren ics hav e th e righ t to be released w hentheir b ehaviour is acceptableto society. 5.66

20. Schizophrenicscan be treatedby makingthema ct properly'y using rewards. 2.82

21. S tr es sf ul li fe event s s uch a s lo sing one 's job canlead to schizophrenic behaviour. 3.53

22. Mentalhospitalsshouldact like correctionalinstitutions (prisons). 1 .55

23. The behaviourof schizophrenicss relatedmeaningfully to their problems. 3.99

24. The bes t way to t re at s ch izophr en ic s i s w ith d rugs . 3 .2825. The cause of sch izophren ia i s unusual ear ly

experience. 3.2626. Mental hospi ta ls sometimes end up s imply

providing she lt er for the poor and o theru nfo rt un at es a nd d o l it tl e t o g et th es e p eo pleout of the hospital and back into society. 4.43

27. Schizophrenicbehaviour is a wayof deal ingwith the problems in the modern world. 3.11

2 8. S ch iz op hre ni a is c au se d b y a c hemi ca l im ba la nc ein the body. 4.50

Mean 2 9. It is s ociety 's d uty to p ro vid e p eo ple a nd p laces t o treatscore' schizophrenics. 6.07

30. Thebehaviourof schizophrenicss an indicationof adiseasedmind. 3.30

2 .86 31. Themos t e ff ec ti ve way o f hel ping s ch izophr en ic sis tocreate a society truly fit for them to live in. 4.10

4.96 32. T he schizophrenic individual m ust coop erate fullywith those t reating him/her. 4.66

33. It is possibleto help schizophrenicswith long-termtherapy with a trained counsellor. 5.52

34. Whatever the reason for the buildingof menta lhospitals, theyare often usedto punishpeople

who do not fo llowthe rulesof society.3 5. A ca use o f sch izo ph ren ia is b rain d am ag e d ue toa v irus .

36. Schizophrenicehaviours nearlyalwaysbadandwrong.

37. The ca use o f sc hiz op hr en ia is p ro blem s in emotio na ldevelopments a child.

38. I t is possibleto help schizophrenicsby simplytalkingto them about thei r problems.

3 9. A m en tal h osp ita l is a k in d o f co ncen tratio n cam p,wherepeopleare subduedand degradedin orderto makethemeasierto control.

4 0. I t i s p os si ble to t re at s ch iz op hre ni cs b y s ur ge ry.41. The schizophrenic has the duty to take responsibi li ty

for his /her actions and their outcomes.42. I t i s t he r ight o f t he sch izophren icto be cared

for by society.43. Producinga morecomfor tableand lesss t ressfu l

s oc ie ty i s t he b es t way t o t re at s ch iz ophr en ic s.

4 4. S ch iz op hr en ic b eh av io ur i s c au se d b y h ars h a ndunsympathetictreatmentby others.4 5. P riv ac y i s t he rig ht o f a ll s ch iz op hre nic s.4 6. S ociety h as th e d uty to sh ow sympath y to

schizophrenics.47. Thebestwayto treatschizophrenicssto respecttheir

ri gh t to l ea d th ei r own li ve s.

3.44

3.71

5.37

4.74

4.06

5.82

4.012.63

2.45

3.47

3.79

5.31

3.11

5.34

6.08

1.831.77

3.90

3.58

3.222.38

3.18

5.63

4.22

3.075.33

5.63

4.35


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209

Append ix ( cont in ue d) Caocirrr i, G. , Spixo, H. & SiAssi , I . (1971)Are the ranksclosed?Att itudinal, socia l dis tance and mental i l lness. American Journal

Mean 0 /P sy ch ia try,1 27 ,112 1 1127 .score' LEMXAY,., et a! (1972)Multiplemodelsand

men ta l il ln es s: a re jo in de r t o Failuref a mor al e nt erp ris e:401 a ttitu des o f th e p ub lic towa rd smen ta l i llne ss y T. R . S arb in228 & J .C . Mancuso. J ou rnal of Consu lti ngand C lin ic alP sychology,

39 , 15.565 CUMMING, E. & Cur.os1No, J. (1957) Closed Ranks. Cambridge,

MA: Ha rv ar d Un iv er si ty P re ss .5 65 E Ic IR ,D . (1985) The e ffe cts o f four a etio logi es on j udgement so f

men ta l il ln es s, s oc ia l d is ta nc e a nd p ro gn os is . In te rn at io na lJournal/Socialsychiatry, 1,243251.

FARINA, A. & Fisuni, J. (1982) Beliefs about mental disorders.

F in din gs an d im plic atio ns . In ln te gra tio n o f C lin ica l an d S ocia lP sy ch olo gy (e ds C . Wea ry & A . M ire ls), p p. 3 7-6 4. L on do n:Oxfo rd Unive rs it y P res s.

FURNNAM,A . ( 19 88 ) L ay T heo ries . O xfo rd : P erg am on . & REES, .1. (1988) Lay theories o f schizophrenia. International

Journa l o f Soc ia l Psych Ia try, 34, 212 -220 . & WARDLEY, Z. (1990) Lay theories of psychotherapy. I.

Attitudes toward, and beliefs about, psychotherapy andtherapist . Journal of Clinical Psychology, 46, 878-890.

GELFAND, S. & Uw@tari, L. P. (1961) Change in attitudes aboutment al i ll ne ss a ss oc ia te d w it h p sy ch ia tr ic c le rk sh ip t ra in in g.International ournalfSocialsychiatry, ,292-298.

410 I. I. & Swaiis, J. (1972) 77@EpigeneticP uz zle . N ew York : A ca demic P re ss.

ING LEBY , D . (1981) Critical Psychiatry. London: Penguin.KEr r, S . S ., R os ar inw, D ., Wari@e it,P. H ., e t a l( l9 68 ) T he t yp esand prevalenceof mental i llnessin the biological and adoptivefami li es o f a do pt ed s ch iz op hr en ic s. I n T he Tra nsmi ss io n o fSch izophrenia (eds D . R osenthal & S. S. K ety). N ew York:Pe rgamon Pres s.

M ACNO N, R., M EDNICK, S. & SCHULSINGER, F. (1983) Thein teractio n o f seas on ality , p lace o f b irth , g en etic risk an dsubsequen t sch i zophren i a in a h igh -r isk sample . Br it ish Journalof Psychiatry,143,383388.

MAL LA , A . & S HAw, T . (1987) A ttitudes tow ard s m ental illness:the influence of educationand experience.InternationalJournalof SocialPsychiatry,33, 3341.

McKENr4A, P. J. (1987) Pathology, phenomenology and the

dopamine hypothesi s o f sch izophren ia . Bri ti sh Journal o fPsychiat ry, 151, 288301.Miuia, R. (1984) Major psychosis and dopasnine:controversial

featuresand song suggesions.PsychoiogIca!Mediciiie,14,779-789.No ju s@r i,R . & MALLA ,A . ( 1983 ) Adol es ce nt s' a tt it ud es t owar dmen ta l il ln es s: r el ati on sh ip between components and s exd i ff er ences . Soci al Psych ia try, 18 , 45 -50 .

NUNNALLY, J. C. (1961) Popular Conceptions of Mental Health.

New Yor k: H olt , R in eh art a nd Win st on .P iu ri s, H . (1984) A tt it udes t oward t he men ta ll y d is or de red.

Med ic in e, S ci en ce a nd Law, 24, 1 81 191 .R ,@s iu ri ,J . ( 1972 ) Op in io ns a bout ment al i ll ne ss : a r ev iew o f t he

l itera ture . PsychologIcal Bulle tin, 77, 153171.RAcK, P. ( 19 82 ) R ac e, C ul tu re a nd Men ta l D is ord er . L on do n:

Tavistock.RIPPERE, V . (1977) Common-sense beliefs about depression and

ant idepress ive behaviour. A study of social consensus. BehaviourResearch and Therapy, 15,465 -473 .

(1981) How depressing: ano ther cognitive dimension of

c ommo n-s en se k no wled ge. B eh av io ur R es ea rc h an d T he rap y, 1 9,169181.

SARBIN , T. R. & MAricuso, J. C. (1970) Failure of a moralen te rp r is e : a tt it udes o f the publ ic towards mental i ll ne s s. Journa lof Consultingnd Clinical sycho logy,5,159 17 3.

& (1972) Paradigms and moral judgements:

improper conduct i s not d isease . Journal o f Consul ting andClini ca l Psychology, 39, 68.

4 8. M en tal h osp itals are o ften u sed to rem ov etroublemakersfrom society.

49 . The behaviourof schizophrenicss of ten s inful .50. Society has the duty to respect the rights of the

schizophrenic individual .51. Thebehaviourof schizophrenicssa symptomof their

illness.52. Schizophrenicsshould notbe judged moral lyfor their

a ct io ns , s in ce t he y h av e l it tl e c on tro l o ve r w ha tthey do. 5.23

53. Schizophreniais causedby nothingmore thanproblems in daily living. 2.51

54. Themainfunctionof thementalhospitalisto providean atmosphere for care a nd cure. 5 .53

55. Schizophrenicbehaviouris a resultof dreadfultreatment by other people. 2.78

56. Soc ie ty has the duty to prov ide p laceswhere sch izophrenics can go for help with their problems. 6.04

57. The most e ffec tive way of t reat ing sch izophren icsi s to imp rovehe soci et yn wh ichheyl iv e. 4 .1858. Menta lhospi ta lsshouldbe used to teach schizop hren ics to act resp on sib ly so th ey can fit inwith society.

59. Societyhastherightto punishorimprisonthose,l ikesch i zophren i cs , whose behav iou r b reaks mora lstandards even if they don't break the law . 1.95

6 0. T reatin g p eo ple in an u np leasa nt m an ner can leadto schizophrenicehaviour. 3.02

61. The way sch izophren icsac t i s a code'hich tel ls usabout the w ay they a re f eeling. 4.18

62. People a re cal led sch izophren ic when those a roundthemcannolongercopewiththewaytheybehave. 3.21

63. Schizophrenic behaviour often violates the moralrules by which we live. 3 .53

6 4. If lo ts o f p eo ple trea t so me on e b ad ly , th at p erso noften displays schizophrenic behaviour. 3 .12

65. Thefunct ionof the hospital is to r id societyof thosewho threaten it. 2.06

6 6. M ost o f th e b eh av io ur o f s ch izo ph ren ics is immo ral. 2 .0 067. Schizophreniais caused by learning from others withsimilar behaviour. 2.00

68. A one-to-one relationship w ith a skilled therapist isthe best w ay to treat schizophrenics. 4.96

6 9. T he cau se o f sch izo ph ren ia is th e sick'oc ie ty inwhich we live. 2.69

70. Soc ie ty has th e duty to r espect th e lib er ty o f th eschizophrenic. 5 .35

71. T he fu nctio n o f th e men ta l h o spita l is to mak e t herecovery of schizophrenics quicker. 4.99

72. Schizophreniascausedbya person'sfeelingguiltyforhis/her past actions. 2.76

1. Scale7completelyrue to 1completelyalse.

ReferencesA sri, L ., O rro soM, J . & P EIJU S, C . (1 97 1) A ttitu des to ward s

m ental disorder and m ental care in university students.In te rna tiona l Journal o f Soci a l Psych ia t ry, 17 , 270-274 .

C LA RK , A. & B IN IC 5,N . M . (1966 ) R elation of age and educationto attitudestoward mental illness.PsychologicalReports, 19,649650.

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