In everyday language, the word is often used to describe a contradiction, an ambivalence or a supposed “split personality”. In the social imagination, it remains associated with dangerousness, strangeness, the incomprehensible. In certain theoretical traditions, it has also been reduced to a family causality, as if psychosis could be explained by a few pathogenic interactions or by a mother’s responsibility. Conversely, in other approaches, it has sometimes been reduced to a brain disorder, as if life circumstances, relationships, precarity, trauma or stigmatisation did not count.

None of these reductions is satisfactory.

Schizophrenia is a complex, heterogeneous, often severe psychotic disorder, but one whose trajectories are highly diverse. It affects perception, the interpretation of the world, thought, emotion, vital drive, cognition, relationships and sometimes the very sense of inhabiting a shared reality. The World Health Organization notes that it can have a considerable impact on personal, family, social, educational and professional life, but also that effective care exists and that a significant proportion of people can achieve complete remission of symptoms.

The challenge is therefore twofold:

Schizophrenia is not a split personality

The first misunderstanding must be cleared up plainly: schizophrenia is not dissociative identity disorder. Dissociative identity disorder, formerly known as “multiple personality”, involves a discontinuity of identity, memory and the sense of agency. Schizophrenia, for its part, belongs to the field of psychotic disorders. The central problem is not the existence of several personalities, but an alteration of the relationship to shared reality. The National Institute of Mental Health explicitly distinguishes these two disorders and points out that schizophrenia is not a “split personality”.

In schizophrenia, the person may hear voices, hold delusional beliefs, feel persecuted, watched, influenced or manipulated. They may attribute an intense personal meaning to ordinary events. They may also present disorganisation of speech, thought or behaviour.

Cognitive difficulties must also be emphasised. They are less visible than hallucinations and less spectacular than delusions, but they can be massively disabling: difficulties with attention, memory, planning, concentration, processing speed, the organisation of action. Inserm stresses that the most striking symptoms are not necessarily the most disabling, as cognitive difficulties and social withdrawal can weigh heavily on daily life. Recent work on cognition in schizophrenia indeed describes it as a central dimension of the disorder, contributing substantially to functional difficulties.

A plurality of trajectories, not a single essence

Speaking of “schizophrenia” in the singular is convenient, but clinically insufficient. Some people experience an acute psychotic episode and then recover substantially. Others go through several episodes. Others live with persistent symptoms. Some pursue studies, work, create, start a family. Others encounter intense suffering, lasting disorganisation, social precarity, repeated hospitalisations or a loss of autonomy.

This diversity calls for caution in language. Saying “schizophrenics are…” is almost always a mistake. It is better to speak of people living with a diagnosis of schizophrenia, or of people affected by schizophrenic disorders. This lexical choice is not merely moral or political. It has clinical significance: it reminds us that the disorder does not contain the whole person.

French data from Santé publique France show, for example, that in 2014:

These figures point to a significant public health issue, but by themselves they say nothing about the singularity of individual trajectories.

Schizophrenia is not synonymous with violence

The other major cliché concerns dangerousness. Media portrayals of psychosis often dwell on news stories, spectacular acts, crisis situations. This produces a distorted image: as if the psychotic person were necessarily threatening.

The available data invite a far more nuanced reading. The NIMH points out that most people living with schizophrenia are not violent, and that they are more often at risk of being harmed by others than people not affected by the disorder. The risks of violence towards oneself or others increase above all when the disorder goes untreated or when there is associated alcohol or substance use.

This clarification is fundamental. It does not deny that certain clinical situations can be dangerous, particularly during acute episodes, severe disorganisation, addictive behaviour or disengagement from care. But it refuses the conflation of diagnosis and threat. Stigmatisation delays access to care, isolates families, deepens patients’ shame and can worsen trajectories. The WHO stresses, moreover, that people affected by schizophrenia are frequently exposed to stigmatisation, discrimination, exclusion and violations of their rights.

A multifactorial causality: neither “all biology” nor “all family”

Contemporary research does not support a single cause of schizophrenia. Current models speak instead of interactions between genetic vulnerabilities, brain development, environmental factors, stress, substances, life events, social conditions and relational trajectories. The WHO clearly states that no single cause has been identified and that the interaction between genes, environment and psychosocial factors must be taken into account.

The genetic dimension is real, but it does not correspond to the simplistic idea of a “schizophrenia gene”. Recent genomic research describes a strongly polygenic architecture: many common variants of small effect, sometimes compounded by rarer variants of larger effect. Inserm also notes that genetics alone cannot explain the disorder: even in twins sharing the same genetic make-up, concordance is not total.

The neurodevelopmental dimension is also central. Schizophrenia frequently emerges in adolescence or early adulthood, periods of major brain reorganisation. Research has notably explored the role of synaptic pruning, that is, the progressive reorganisation of neuronal connections.

Dopamine remains a major actor in biological models of psychosis, but the contemporary hypothesis is subtler than a simple “excess of dopamine”. The theory of aberrant salience proposes that certain ordinary stimuli become abnormally important: a glance, a noise, a sentence heard on television, a coincidence. The world becomes charged with signs. Delusion can then be understood, at least in part, as an attempt to give shape to an experience that has become too intense, too personally addressed, too meaningful. The work of Howes and Kapur helped reformulate the dopamine hypothesis in this direction.

Environmental factors matter: obstetric complications, stress, early trauma, urbanicity, migration, discrimination, social isolation, precarity, cannabis use, particularly when early, frequent or high in THC. Inserm underlines the established role of stress and cannabis in the emergence of psychotic disorders in some vulnerable individuals, while insisting on the heterogeneity of effects depending on the individual, the dose, the age of exposure and the THC content.

Early adverse experiences are also associated with an increased risk of psychosis. A meta-analysis by Varese and colleagues showed a significant association between childhood adversity and psychosis, with an effect observed across different types of studies. Here again, association does not mean mechanical causation. Not all trauma produces psychosis. Not all psychoses are traumatic. But the life history must be heard.

An interesting hypothesis, at the interface of the biological and the social, is that of “social defeat”. It proposes that the chronic experience of exclusion, subordination, humiliation or non-belonging may sensitise the stress and dopamine systems, increasing psychotic vulnerability in some people. This hypothesis has notably been discussed as a way of understanding the links between psychosis, migration, urbanicity, trauma and social exclusion.

Bateson, Palo Alto and the double bind: a fertile intuition to be handled with care

Schizophrenia occupied an important place in the history of systemic thinking, notably through the work of Gregory Bateson, Don Jackson, Jay Haley and John Weakland. Their 1956 article, “Toward a Theory of Schizophrenia”, became a classic text of the Palo Alto school and of the theory of the double bind.

What interested Bateson was not only the family as a locus of causality. It was human communication, and more precisely the levels of communication. When someone speaks, they do not merely transmit content. They also transmit a metamessage: something about the relationship, about the context, about how the message is to be understood. The same sentence can be tender, ironic, threatening or absurd depending on the tone, the posture, the gaze, the moment, the relational history.

The value of this theory is to have proposed an interactional reading of confusion. Some symptoms can be understood as attempts to survive in contexts where the relational rules become unreadable:

• come closer, but do not come near;
• be autonomous, but do not leave me;
• tell the truth, but do not name what you perceive;
• love me spontaneously, but on command.

However, double bind theory was historically hardened and at times used in a blaming way. It fed the idea that schizophrenia was caused by the family, or even by the mother. This drift took a particularly harmful form with the figure of the “schizophrenogenic mother”.

This idea has now been abandoned as a general explanation of schizophrenia.

Contemporary systemic practice must therefore be rigorous: families do not “cause” schizophrenia in any linear sense. They may suffer, become exhausted, grow rigid, become clumsy, critical or overprotective. They may unwittingly take part in certain loops of escalation. But this does not mean they manufactured the disorder.

Thinking in loops rather than in single causes

A systemic reading does not only look for the origin of the disorder. It observes the interactions surrounding it: what aggravates, what maintains, what soothes, what rigidifies, what restores room for manoeuvre.

Imagine a person who sleeps less, becomes anxious, feels watched, interprets certain signs as threatening. Those close to her worry. They ask more questions, check her medication, correct what she says, try to reason with her or, on the contrary, avoid the subject entirely for fear of triggering a crisis. The person may experience these reactions as surveillance, invalidation or abandonment. The more she withdraws, the more her family worry. The more they worry, the more intrusive they become. The more intrusive they become, the more wary she grows. The more wary she grows, the more they panic.

The systemic gaze makes it possible precisely to step out of moral judgement. A critical relative is sometimes an exhausted relative. An intrusive relative is sometimes a terrified relative. A person who withdraws is sometimes simply trying to reduce a relational or perceptual overload. A family that controls is sometimes trying to prevent a relapse. The problem is not only the symptom; it also lies in the way the system tries to solve it.

This is where family interventions take on their full meaning. Not because the family is responsible for the disorder, but because it is often on the front line. NICE recommends that the families of adults living with psychosis or schizophrenia be offered family interventions, notably because they can improve coping abilities and relapse rates.

Schizophrenia as a crisis of context

One systemic way of thinking about schizophrenia is to consider it as a crisis of context. Not merely a “loss of contact with reality”, a classic formula but sometimes too vague; rather a difficulty in stabilising the frames that make it possible to know what is going on.

In ordinary life, we contextualise constantly. We distinguish a joke from an insult, a coincidence from a message, a thought from a perception, a fear from a proof, a metaphor from a fact, a memory from a present event. Most of the time, we know which frame we are in.

In psychosis, this compass of context can become deregulated. Details become signs. Chance events become messages. Glances become threats. Thoughts become alien. Inner or ambiguous voices may be experienced as external. The world is not empty of meaning; it can become too full of meaning. Too charged. Too personal. Too personally addressed.

Delusion can then be understood as an attempt at recontextualisation. It seeks to order an experience that has become chaotic. It gives an explanation for the intensity. It builds a coherence. But that coherence can become imprisoning, persecutory, dangerous for autonomy and for relationships.

Articulating the levels of care

Antipsychotics can be essential, notably to reduce hallucinations, delusions, agitation or the risk of relapse. But they are not always enough. They can have side effects, be difficult to accept, and they do not by themselves address the cognitive, family, traumatic, social, occupational or existential dimensions of the disorder.

Conversely, psychotherapy, the family or the social sphere do not replace psychiatric treatment when it is needed. The opposition between biology and relationship is a dead end.

Contemporary recommendations insist instead on comprehensive care, combining pharmacological treatments, psychoeducation, therapies, family interventions, psychosocial rehabilitation, supported employment, community support and attention to the person’s preferences. The WHO explicitly mentions medication, psychoeducation, family interventions, cognitive behavioural therapy and psychosocial rehabilitation as care options. The American Psychiatric Association likewise recommends comprehensive, person-centred treatment plans, articulating pharmacological and non-pharmacological interventions, notably for first psychotic episodes.

A contemporary systemic approach does not, therefore, replace psychiatry. It broadens it. It compels us to ask:

• Which systems support this person?
• Which systems crush them?
• Which systems invalidate them?
• Which systems can become habitable again?

The system, here, is not limited to the family. It includes the hospital, the caregivers, school, work, housing, neighbours, social rights, the media, institutions, diagnoses, the words used, the cultural images of psychosis.

Restoring narrative dignity

One of the most destructive effects of the diagnosis is sometimes narrative. The person becomes “a schizophrenic” before being a brother, a sister, a parent, a friend, a student, an artist, a colleague, someone who loves, who thinks, who hopes, who struggles, who sometimes understands very well what is happening to them and sometimes less so.

The diagnosis can help to name, organise and orient care. But it can also crush identity if it becomes the only story available. Stigmatisation then adds a second suffering to the psychotic suffering: that of being seen as dangerous, incomprehensible, beyond recovery or shameful.

Restoring narrative dignity means allowing the person not to be confused with their symptoms. It means being able to say: “I hear voices” without being reduced to a monster. “I am not sure what is real” without being abandoned. “I am afraid” without being humiliated. “I need help” without losing all autonomy.

It also means helping families not to be reduced to the role of culprits, controllers or victims. Families can become places of exhaustion, but also places of stabilisation. They can be caught in harmful loops, but they can also help rebuild context, rhythm, safety and trust.

Conclusion: making reality habitable again

• Schizophrenia is not a split personality.
• It is not synonymous with violence.
• It is not simply caused by the family.
• It is not reducible to an excess of dopamine.
• It is not an absolute condemnation.

It is a psychotic disorder involving biological, genetic, neurodevelopmental, cognitive, psychological, relational and social dimensions. The great mistake would be to look for a single cause. The great richness of the systemic approach is to think in levels, in contexts, in loops and in relationships.

Psychosis can be understood as a moment when the compass of context becomes deregulated. The world becomes unstable, sometimes too meaningful, too threatening, too personal. Care then consists in rebuilding reference points. Not merely saying “what you are experiencing is false”, but creating the conditions for a shared reality to become habitable again.