Meaning and Engagement in Schizophrenia Care
Michael D. Rosberg, Ph.D., for ASC Treatment Group
One of the harder problems in schizophrenia care is not the absence of services but the inconsistent willingness of the people we serve to participate in them. The services exist. They are clinically valid. They are staffed by people who care. And yet the person they are intended for often does not show up, or shows up briefly, or shows up in body but not in attention. The standard explanations point to the illness itself: lack of insight, motivational deficits, the negative symptoms of schizophrenia. These are real. But they do not fully account for what we see. A different framing, drawn from a recent paper in the creativity literature, suggests that part of what is missing is meaning.
Ivcevic and Kaufman (2024) argue that creativity is not adequately captured by originality alone. An idea or activity also has to be appropriate, meaning that it has to meet the demands of the context in which it appears. At the most personal level, this appropriateness comes down to meaningfulness: whether the activity is relevant to the individual, whether it supports insight or connection, whether it feels like it is for them. Something can be original and still fail this test. Something can be unoriginal, even ordinary, and pass it. This distinction has direct relevance for the engagement problem in schizophrenia care.
Clinical settings tend to emphasize structure, symptom stabilization, and adherence to prescribed interventions. These remain essential. But they do not address whether the person experiences the services on offer as meaningful, and meaningfulness, on the Ivcevic and Kaufman framing, is what determines whether participation actually takes hold. A program may be technically sound and still fail to engage, because the activities offered do not connect to anything the person finds personally relevant. This is a different problem from poor program design. It is a problem of fit.
At the personal level of creativity, where the question is whether an activity holds meaning for the individual, even modest activities can do real clinical work. Working in a garden, handling art materials, contributing to a shared project, none of these are original in any formal sense. Their value lies in whether the person experiences them as relevant. When they do, the activities support emotional regulation, cognitive engagement, and connection to other people. When they do not, the same activities sit on the schedule unused.
As engagement develops, these experiences can extend into what Ivcevic and Kaufman describe as everyday creativity, activities that meet practical demands and support daily living. Preparing meals, organizing shared spaces, contributing to the operation of a household. These too depend on meaningfulness. A person who is asked to set the table because that is on the chore list responds differently than a person who sets the table because the meal matters to them and to the people they are eating with. The activity is the same. The relationship to it is not.
The implication for clinical practice is that ideas or activities that do not meet the demands of a given context, or that fail to address the underlying need, cannot be considered effective regardless of their originality (Ivcevic & Kaufman, 2024). In our settings, this shows up in a particular way. Programs that are well-designed in theory are sometimes not experienced as useful by those participating in them. The fault, when this happens, is not necessarily in the design. It is in the gap between the activity as offered and the activity as received.
This is an argument about meaning rather than environmental design or attentional load, and the environmental and attentional arguments are developed more fully elsewhere in this collection. What this framing adds is a closer look at why some activities engage and others do not, even when the underlying program quality looks similar from the outside. The answer is that engagement requires the person to feel that what is being offered is, in some real way, theirs.
This way of thinking about engagement has practical consequences. Rather than asking clients to enter immediately into highly structured clinical interventions, we can offer activities that are easier to approach because they connect to ordinary human experience. A person who has spent years cycling through psychiatric services may be unwilling to engage with another group, another protocol, another worksheet. The same person may be willing to feed an animal, plant a seedling, prepare a meal, or contribute to something that has a visible result at the end of the day. The clinical work happens through the activity, not despite it.
The implication is straightforward. Engagement is more likely when treatment includes opportunities for participation that the person experiences as meaningful. Creativity, understood not as performance but as personal relevance and practical usefulness, is one way to support this process. When individuals can connect with what they are doing, even in small ways, the treatment experience becomes more coherent, and participation becomes more likely to last.
The harder truth this framing points to is that the disengagement we see in this population is not always a failure of the person. Sometimes it is a sign that the services on offer have not been made personally relevant to the lives they are meant to support. People living with schizophrenia have often spent years being asked to participate in things that did not feel like they were for them. Asking the question, does this activity hold meaning for this person, is a different question than asking, is this program evidence-based. Both questions matter. The collection of essays gathered here argues that the first question deserves the same kind of attention the field has long given to the second.
Reference
Ivcevic, Z., & Kaufman, J. C. (2024). Inside the box: Considering the role of appropriateness for creativity. Psychology of Aesthetics, Creativity, and the Arts. Advance online publication. https://doi.org/10.1037/aca0000703