They Are Fighting a Battle You Cannot See: Understanding Schizophrenia Through a Family's Eyes

An awareness guide for families, caregivers and loved ones.

There is something we often forget when we live with someone who has schizophrenia.

We see the person sitting in front of us. We see them having breakfast, watching television, walking around the house, attending a family gathering or occasionally laughing with us. On some days, they may appear absolutely fine. They may have an intelligent conversation, remember things, express opinions and participate in everyday activities.

And then, almost without warning, something changes.

They may become withdrawn, suspicious, frightened, distracted or unusually quiet. They may respond to something nobody else can hear. They may struggle to follow a conversation or react in a way that seems disproportionate to what is happening around them.

The family wonders:

Why can't they understand something so simple?

Why are they behaving this way again?

Yesterday they were absolutely fine. Why can't they be normal today?

But here is something worth considering.

Just because you cannot see what someone is experiencing does not mean they are not experiencing it.

A person living with schizophrenia may already be trying to distinguish between what they perceive and what others perceive, manage voices or unusual sensory experiences, cope with fear, and make sense of thoughts that may not feel entirely within their control.

And while they are doing all this, the world around them continues to expect ordinary responses to ordinary situations.

This article is an attempt to help families understand the person behind the symptoms.

Not to excuse every behaviour, not to overlook the family's difficulties, but to create a little more understanding, patience and informed support.

1. First, what is schizophrenia?

Schizophrenia is a serious mental health condition that affects how a person perceives reality, processes information, thinks, experiences emotions and interacts with the world.

It can influence how someone interprets conversations, understands situations, relates to people and manages everyday responsibilities.

It is important to understand that schizophrenia is not the same as having multiple personalities. It is also not a reflection of someone's intelligence, character, upbringing or willingness to behave appropriately.

Symptoms differ from person to person. Some people experience periods of significant difficulty followed by improvement. Others experience persistent symptoms that require ongoing support.

With appropriate treatment, psychosocial support and a supportive environment, many people can improve their functioning and work towards meaningful, independent lives.

2. Understanding the DSM-5-TR diagnostic criteria

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), a diagnosis of schizophrenia involves a combination of specific symptoms, changes in functioning and duration.

A qualified mental health professional must conduct a comprehensive assessment. Having one or two symptoms does not automatically mean someone has schizophrenia.

Criterion A: Characteristic symptoms

Two or more of the following symptoms must be present for a significant portion of time during a one-month period, or for a shorter period if successfully treated.

At least one of the symptoms must be delusions, hallucinations or disorganised speech.

1. Delusions

Strongly held beliefs that persist despite evidence to the contrary.

For example, a person may believe that someone is monitoring them, that family members are conspiring against them or that television programmes contain messages specifically intended for them.

These beliefs may feel entirely real and convincing to the person experiencing them.

2. Hallucinations

Sensory experiences that occur without an external stimulus.

These may include:

• Auditory hallucinations: Hearing voices, conversations, sounds or someone calling their name when nobody is actually speaking.

• Visual hallucinations: Seeing people, figures, objects or images that others cannot see.

• Other sensory hallucinations: Experiencing smells, tastes or physical sensations without an identifiable external source.

Hearing voices is particularly common in schizophrenia.

It is important to remember that the experience can feel real to the person. Telling someone simply to stop hearing voices does not make the experience disappear.

3. Disorganised speech

Difficulty organising thoughts and expressing them coherently.

A person may jump between unrelated topics, lose the thread of a conversation, give answers that appear unrelated to the question or struggle to communicate their thoughts clearly.

4. Grossly disorganised or catatonic behaviour

Behaviour may become unpredictable, unusual or difficult to organise.

Catatonic features can involve markedly reduced movement, unusual postures, lack of responsiveness or, in some cases, excessive purposeless movement.

5. Negative symptoms

These refer to a reduction or absence of certain ordinary behaviours and expressions.

Examples include:

• Reduced emotional expression.

• Speaking very little.

• Difficulty initiating activities.

• Reduced motivation.

• Losing interest or pleasure in activities.

• Reduced social engagement.

A person may appear uninterested, unresponsive or unwilling to participate. However, what looks like a lack of interest may actually be a symptom affecting their ability to initiate or sustain activities.

Criterion B: Changes in functioning

For a significant portion of the time since symptoms began, functioning in one or more important areas must be noticeably below the person's previous level.

These areas may include:

• Work or education.

• Relationships and social interactions.

• Personal care and daily responsibilities.

Criterion C: Duration

Continuous signs of the disturbance must persist for at least six months.

This period must include at least one month of active-phase symptoms meeting Criterion A, unless successfully treated. The remaining period may include earlier or residual symptoms.

Criterion D: Other mood-related conditions

Schizoaffective disorder and depressive or bipolar disorder with psychotic features must be appropriately ruled out.

Criterion E: Other medical or substance-related causes

The symptoms must not be attributable to the physiological effects of a substance, medication or another medical condition.

Criterion F: Developmental history

If there is a history of autism spectrum disorder or a childhood-onset communication disorder, additional specific conditions apply before schizophrenia can be diagnosed.

Important: These criteria are provided for awareness and education, not self-diagnosis. Only an appropriately qualified professional can make a diagnosis following a comprehensive assessment.

3. What might be happening inside their mind?

This is perhaps the most important section for families to understand.

Imagine being at home with your family. Everyone is having a normal conversation. Someone asks you what you would like for dinner.

But you are also hearing a voice commenting on everything you do.

Perhaps it is criticising you. Perhaps it is frightening you. Perhaps it is telling you that someone in the room intends to hurt you.

You are trying to listen to your family, but your attention is divided.

Now imagine someone becoming irritated because you are not responding appropriately.

For the family, it may be a simple dinner conversation.

For the person experiencing hallucinations, it may be an emotionally exhausting situation.

This is why we need to understand that the person is not necessarily ignoring you, disrespecting you or deliberately refusing to participate.

They may be dealing with an experience that you cannot see or hear.

Some people experience hallucinations alongside delusions. Others experience changes in thought organisation, concentration, perception and their ability to interpret what is happening around them.

Their experience of reality may be very different from yours at that moment.

And sometimes, even when the hallucinations are less noticeable, the emotional and cognitive effects can continue.

4. Where are they emotionally?

Not everyone with schizophrenia experiences the same emotions. However, several emotional experiences may be particularly important for families to recognise.

Fear and anxiety

Hearing voices or believing that someone is watching, following or threatening you can be frightening.

Even when the family knows that there is no danger, the person may genuinely feel unsafe.

Confusion

When internal experiences and external events become difficult to distinguish, understanding what is happening can become exhausting.

The person may struggle to explain what they are experiencing, particularly when they do not have the words to describe it.

Frustration

Imagine wanting to communicate something but being unable to organise your thoughts clearly.

Imagine trying to concentrate while experiencing distracting voices.

The frustration of not being understood can sometimes appear as irritability or withdrawal.

Loneliness

A person may gradually withdraw from social interactions because conversations become difficult, relationships feel overwhelming or they fear being judged.

They may also become aware that others treat them differently.

Emotional blunting

Some people experience reduced emotional expression. They may not smile, cry, react or show excitement in ways their family expects.

This does not necessarily mean they do not love their family, care about others or experience emotions internally.

Their ability to express emotion may be affected.

Loss of confidence

Repeated difficulties with relationships, education, employment and everyday decisions can affect self-esteem.

They may become increasingly dependent on others, not necessarily because they want to be, but because certain everyday tasks have become difficult.

Families should remember that the absence of visible emotional expression is not proof of the absence of emotional experience.

5. What can we expect socially from someone living with schizophrenia?

This is where family expectations often need to be reconsidered.

Social interaction involves several abilities working together: listening, interpreting facial expressions, understanding tone, remembering what someone said, responding appropriately and managing one's own emotions.

Some of these abilities may be affected in schizophrenia.

Let's consider a few everyday situations.

At family gatherings

You may expect the person to greet everyone, participate in conversations, answer questions and remain present throughout the event.

But a crowded environment, multiple conversations, unfamiliar people and sensory stimulation may become overwhelming.

They may choose to sit alone, leave early or avoid attending altogether.

It does not automatically mean they dislike the family.

During conversations

They may lose track of what someone is saying, repeat themselves, misunderstand a statement or respond to something that seems unrelated.

Sometimes their attention may be occupied by internal experiences.

Give them time. Avoid turning every conversation into a test of their understanding.

In relationships

They may struggle to maintain friendships, interpret someone's intentions or manage disagreements.

Some may become suspicious of people they previously trusted. Others may become socially withdrawn.

This does not mean that meaningful relationships are impossible.

It means relationships may need more patience, clarity and consistency.

In everyday responsibilities

Tasks that appear simple to others, such as organising the day, managing appointments, remembering instructions or completing household activities, may require additional effort.

Try breaking responsibilities into smaller, manageable steps rather than expecting everything to happen at once.

In public spaces

People may notice unusual behaviour, reduced social engagement or conversations with someone who is not visibly present.

Unfortunately, stigma can make these experiences even more isolating.

The family can play an important role in protecting the person's dignity rather than making them feel embarrassed or ashamed.

6. Can schizophrenia affect judgment and decision-making?

Yes, it can. But this needs to be understood carefully.

Schizophrenia can affect cognitive functions such as:

• Attention and concentration.

• Working memory.

• Processing speed.

• Planning and organisation.

• Problem-solving.

• Interpreting social situations.

• Evaluating information and considering consequences.

Some people may also have difficulty recognising that certain experiences are symptoms of an illness. This is sometimes described as reduced insight.

How much these abilities are affected varies considerably.

For example, a person may be able to decide what they want to eat, what clothes they prefer or which activity they enjoy, but struggle with a complicated financial decision or a situation involving conflicting information.

Another person may be able to manage most responsibilities independently but experience significant difficulty during periods of active symptoms.

The important distinction: A diagnosis does not automatically take away someone's ability to make decisions.

Families should not assume that every decision made by the person is irrational or that they need someone else to make all their choices.

Instead, consider:

• Is the person able to understand the information being discussed?

• Can they consider the available options?

• Do they understand the possible consequences?

• Are their current symptoms interfering with their ability to evaluate the situation?

• Would additional time, simpler explanations or professional support help?

Where possible, involve the person in decisions that affect their life.

Supporting someone does not mean taking ownership of their life away from them.

7. What should families stop expecting?

This is not about lowering expectations or treating someone as incapable.

It is about recognising that expectations need to be realistic and responsive to the person's present abilities.

Here are some expectations worth reconsidering.

Stop expecting every day to look the same.

Someone may have a relatively good day followed by a difficult one. Improvement does not necessarily mean every symptom has disappeared.

Stop expecting them to simply ignore the voices.

For someone experiencing auditory hallucinations, the voices may be intrusive, distracting or frightening. Asking them to ignore something they experience as real may not be helpful.

Stop expecting immediate responses.

They may need additional time to process information, organise thoughts and respond.

Stop interpreting every withdrawal as rejection.

Sometimes the person needs less stimulation, more rest or space to manage their experiences.

Stop expecting them to understand every social cue.

Tone, sarcasm, indirect communication and complicated interpersonal situations may be difficult to interpret.

Stop assuming that a good day means they are completely well.

A person can participate in everyday life while still experiencing symptoms that are not visible to others.

Most importantly, stop making every interaction about their diagnosis.

They are still an individual with preferences, interests, memories, relationships, ambitions and the right to enjoy ordinary life.

8. How can family members actually help?

Understanding is a beginning. But families also need practical ways to respond.

Here are some things that can make a meaningful difference.

1. Listen without arguing about their experience

If someone tells you they are hearing voices, avoid immediately saying, "Nobody is there. Stop imagining things."

You do not have to agree with their perception to acknowledge their distress.

You could say:

"I understand that you are hearing something that is upsetting you. I cannot hear it myself, but I can see that it is affecting you. Would you like me to sit with you?"

This communicates care without reinforcing the hallucination.

2. Do not challenge every unusual belief

Arguing repeatedly about a delusion may increase distress and damage trust.

Instead of trying to prove the person wrong, acknowledge their feelings.

For example:

"I can understand why that would make you feel unsafe. I don't see the situation in the same way, but I want to understand what is worrying you."

Keep your response calm and grounded.

3. Communicate clearly and simply

Avoid giving several instructions at once.

Use short sentences. Allow time for responses. If something is important, repeat it calmly without expressing frustration.

For example, instead of saying:

"Why haven't you got ready? We have told you several times that we need to leave, and now everyone is waiting."

Try:

"We are leaving in 30 minutes. Would you like to get ready now? I can help if you need me."

Small changes in communication can reduce unnecessary pressure.

4. Create predictable routines

A relatively consistent daily routine can provide structure.

Regular sleeping and waking times, meals, personal care, medication schedules, manageable activities and appointments may help create a sense of stability.

Avoid overwhelming the person with too many changes at once.

5. Encourage independence without withdrawing support

Allow the person to do what they can independently.

If they can manage certain activities, encourage them to continue.

If they need help with others, offer assistance without making them feel incapable.

The goal is not to do everything for them. It is to help them retain and develop their abilities.

6. Support treatment and professional follow-up

Schizophrenia requires appropriate professional care.

Treatment may include antipsychotic medication, psychological interventions, family interventions and psychosocial rehabilitation, depending on the person's needs.

Families can help by supporting appointments, encouraging treatment adherence and communicating observed changes to the treating professional.

Never independently stop or change prescribed medication.

7. Learn the person's early warning signs

Families who spend time with the person may notice changes before a significant deterioration occurs.

These could include:

• Changes in sleeping patterns.

• Increasing social withdrawal.

• Increased suspiciousness.

• Becoming unusually preoccupied.

• Changes in communication.

• Reduced self-care.

• Increasing distress related to voices.

Discuss these observations with the treating professional and develop a plan for responding to them.

8. Avoid humiliation, criticism and constant correction

Correcting someone's behaviour in front of others, mocking unusual statements or repeatedly reminding them of their diagnosis can damage trust.

Preserve their dignity.

Address difficult behaviour privately and calmly whenever possible.

9. Encourage meaningful social participation

Do not force the person into every family gathering or social activity.

Instead, explore what they enjoy.

Perhaps it is a short walk, a familiar friend, gardening, cooking, listening to music or spending time with one family member.

Small, comfortable interactions can be more valuable than overwhelming social expectations.

10. Take care of yourself, too

Being a caregiver can be emotionally demanding.

Families may experience exhaustion, helplessness, frustration, guilt and uncertainty.

You are allowed to have difficult days, seek support and establish healthy boundaries.

You do not have to become the person's therapist.

You are a family member, and you deserve support as well.

9. What if the person is having a difficult episode?

During periods of significant symptoms, the person's ability to process conversations and manage their environment may be reduced.

A few things can help:

• Speak slowly and calmly.

• Reduce unnecessary noise and stimulation.

• Avoid crowding or surrounding the person.

• Do not argue, threaten or physically confront them.

• Give them personal space while maintaining appropriate safety.

• Ask what would help them feel safer.

• Contact their treating psychiatrist or mental health professional.

If they are expressing intentions to harm themselves or someone else, experiencing dangerous command hallucinations, becoming severely agitated or unable to meet essential safety and self-care needs, seek urgent professional or emergency assistance.

Families should have a crisis plan prepared in advance, including professional contacts, emergency arrangements and information about the person's treatment.

10. What about the family? Who supports the supporter?

We often focus entirely on the person who has received the diagnosis.

But what about the mother who has not slept properly because she is worried about her son?

What about the spouse who is trying to understand why their partner's behaviour changes?

What about the sibling who feels guilty for wanting to have a life of their own?

What about the daughter who constantly wonders whether they are doing enough?

Families can experience their own emotional struggles while supporting someone with schizophrenia.

They may become overprotective, controlling, anxious or emotionally exhausted. Sometimes, fear makes them monitor every action. Sometimes, frustration makes them withdraw.

Neither response necessarily comes from a lack of love. Often, families simply do not know what to do.

This is where family therapy and psychoeducation can help.

Family interventions can provide a space to:

• Understand schizophrenia and its symptoms.

• Recognise the difference between symptoms and intentional behaviour.

• Improve communication.

• Develop realistic expectations.

• Learn how to manage difficult situations.

• Work through caregiver stress.

• Establish boundaries and responsibilities.

• Develop a collaborative plan for ongoing support.

Family therapy is not about finding someone to blame.

It is about helping everyone understand their role in creating a more supportive environment.

11. A final thought: They are more than their diagnosis

Someone living with schizophrenia is not just a collection of symptoms.

They are not simply the person who hears voices, withdraws from conversations, forgets appointments or sometimes struggles to make decisions.

They are individuals who may want friendships, meaningful relationships, independence, respect, affection, purpose and opportunities to participate in life.

Some days, they may need more support. On other days, they may surprise you with how much they can manage independently.

The challenge for families is learning to recognise the difference without constantly judging, correcting or controlling.

You may not be able to experience what they experience. You may not always understand their reactions. And there may be days when you feel that your patience is running out.

But you can still learn to respond differently.

You can listen without agreeing with everything. You can offer support without taking over. You can establish boundaries without withdrawing affection.

And perhaps most importantly, you can allow the person to have a life beyond their diagnosis.

They are already trying to make sense of a world that may not always make sense to them. They should not also have to spend every day proving to their family that they are trying.

At SEVEE CARE, we believe that meaningful support begins with understanding. Family therapy can help families learn how to support a loved one while also recognising their own emotional needs, responsibilities and boundaries.

You do not have to understand everything to be supportive. Sometimes, the first step is simply learning to see things from a different perspective.

You can stand beside someone without expecting them to experience the world exactly as you do.

A note for families

This article is intended for mental health awareness and psychoeducation. It does not replace psychiatric assessment, diagnosis or treatment. Schizophrenia is a complex condition, and every individual's experiences, abilities and support requirements are different.

Professional guidance should be sought for concerns about symptoms, treatment, safety or changes in functioning.