This confusion would have been intolerable for him, creating disorganized patterns of thought. Out of this disorganization developed delusion. The boy came to imagine that the father killed the mother.
Another way cognitive (and psychodynamic) approaches explain the genesis of schizophrenia is by reference to childhood trauma. Things such as abuse, divorce, a domineering mother, or witnessing murder are seen as major factors in schizophrenic development (Koehler & Silver, 2009, p. 225). Traumatic events lead to dissociation from parents and from reality. Other related factors are stress, fear, anxiety, and social isolation that lead to schizophrenia. In other words, it is how the person is embedded in extreme and dysfunctional social relations that may shape their development. Here Spider's malady would be discussed in terms of intense family strife. There is evidence for severe marital tension in the film, exemplified by the man's having an affair. Combined with poor family communication and confusion, this could easily have lead to perceived trauma. The boy may have interpreted this as catastrophic and thus developed delusions and schizophrenic symptoms, including murderous impulses.
Cognitive psychology, then, interprets the development of childhood schizophrenia by linking traumatic or catastrophic family circumstances with resulting thought patterns and delusional belief systems. These delusions are understood as cognitive distortions and dysfunctional beliefs. Cognitive errors -- such as taking things too personally or out of context, jumping to conclusions, all-or-nothing thinking and overgeneralizing -- are central in this view to the creation of delusions (Kingdon & Turkington, 2005, p. 102). In terms of therapy, the goal is to understand the initial events that led to the delusional belief. Hallucinations arise, in the cognitive viewpoints, when the person attributes internal experiences (thoughts) to an external source. They are often accompanied by obsessions and compulsions (Kingdon & Turkington, 2005, p. 8). Spider is clearly obsessive-compulsive when he writes in his notebook and collects objects from the road. His hallucinations are distortions of real perception. His delusions can easily be seen to have arisen out of his past in which he interpreted his parental environment as traumatic and confusing. He also has irrational reactions to the smell of gas, which is an olfactory hallucination that relates to his past murder of his mother.
This cognitive paradigm has the advantage of considering the social environment in which schizophrenia arises. It is valuable as well in showing how important thought processes are in influencing maladaptive behavior and emotion. It explains the persistence of Spider's symptoms through an inability to adjust his thoughts and beliefs to more real conditions. This is perhaps out of shame and guilt at his past act, which has irrevocably damaged him and his esteem. More simply, it could be out of the pain of trauma. Spider's symptoms persist also in this view because he was unable as a child to challenge his interpretations of events. The confusion of his family situation is so entrenched that it makes it impossible for him to organize his thoughts, or to see the past in a different way. The whole film is about him trying to reconstruct his identity, through delusory hallucinations. He is trapped in a repetitive cycle. He is unable to realize that his father did not kill his mother, as he believes. In all the years, he still has not put the shattered pieces back together to form a coherent narrative based on the truth. It is why his speech is so disorganized. The cognitive approach would point to this and say that he needs teaching so that he can form a rational system. The therapist would work with him to reexamine the origin of the delusion about his parents and point subtly toward alternative interpretations of the same events. Combined with this would be social skills training, coping methods, and the attempt to do reality testing which reinforces behaviorally the cognitive changes.
One of the disadvantages of the cognitive approach is its over-emphasis on thoughts. Somehow it seems to presume that changing Spider's interpretation will undo the trauma that he feels he experienced. In looking primarily toward future reconstruction of thought patterns, it does not necessarily do justice to the psychological depth of the felt catastrophe. It is possible that the emotions are primary here, rather than thoughts. If one does not deal with emotions first, then the thoughts may not change. This would explain why Spider, and schizophrenics in general, is very hard to treat.
It is hard to work with schizophrenics. They rarely want to deal with the causing trauma. Often they are silent and withdrawn, along with having a hard time communicating their thoughts in an intelligible way. Most come to therapy through the initiation of the family, rather than by personal choice even when they are severely distressed. In Spider's case, his family seems to be absent. He has no family left -- perhaps because his father has abandoned him for killing his mother -- and therefore there is no one to engage in family therapy with him. He is under the control of the state. The state ultimately takes him back to the institution from which he came to the halfway house. This is because he demonstrated suicidal urges (with the stolen piece of glass), theft (of keys), and most important a threat to the caretaker's life.
Does Spider have hope of recovery without family help? The film ends on a depressing note for sure. All the family therapy methods that cognitive therapists have devised for working with schizophrenics cannot be applied to Spider's case. He is too internalized, alone, and isolated. He has no family to dialogue with, which might help him overcome his childhood ambivalence and construct new ways of communicating (see Chavez, 2009). Other cognitive approaches use coaching and role playing to develop specific social skills like conversation skills, conflict management skills, assertiveness skills, community living skills, medication management skills, friendship skills, and work skills (Bellack et al., 1997). Here the therapist is a teacher trying to encourage skill-building. This could help Spider gain more control over his life. Combined with normalization and psychoeducation, Spider could come to understand his illness more, stop blaming himself, and stop catastrophizing. Perhaps even his delusions would vanish and he could learn to speak more clearly.
However, the general trend is toward pessimistic outcomes for schizophrenics, with or without pharmaceuticals. Beck et al. (2009) says, "The available evidence warrants the conclusion that a significant proportion of individuals diagnosed with schizophrenia achieve poor outcomes" (p. 21). These scholars are more optimistic, however, when cognitive therapy is combined with behavioral skills training and some form of medication. A more positive appraisal of hope for schizophrenics could be imagined than the one that ends Spider.
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