Michael D. Rosberg, Ph.D
CEO | Clinical Psychologist
People living with schizophrenia have been telling us what disables them. For the most part, the system has not been listening. Over more than four decades of direct clinical experience, we have watched outcomes diverge. Some people stabilize and rebuild, find purpose, and friendships: other cycle through the same interventions, making little lasting progress despite genuine effort on everyone’s part. What separates those trajectories is rarely the absence of effective treatments. The treatments exist. What varies is whether the environment surrounding a person in treatment is capable of supporting the gains that good clinical care makes possible. Part of that failure belongs to the system itself. Treatment for schizophrenia is imperfect. Medications work partially, have difficult, side effects, are provided inconsistently. Therapeutic relationships are disrupted. Transitions between levels of care create gaps that lead to predictable difficulty. These discontinuities are real, and their consequences fall hardest on people who are already least equipped to compensate for them. But a well-designed environment can contribute to meaningful change that equation.
When the setting is organized around safety, reduced overstimulation, is aesthetically attractive, and promotes genuine social connection, the imperfections inherent in treatment become less damaging. The person is held within a stable structure even when specific interventions fall short, change, or are interrupted. Without an interpersonal and environmental foundation, gaps in care becomes a more immediate potential crisis. When it is present, discontinuity does not disappear, but its effects can be slowed rather than compounded.
A new study from Strauss and colleagues (2026), published in Schizophrenia Research, gives that observation its clearest empirical foundation yet: when participants and caregivers describe what most disables them, they are describing conditions that environments can either worsen or address. The question is whether we choose to act on what they are telling us. The Strauss et al. study may be the first to comprehensively examine how people living with schizophrenia, and the relatives and caregivers who know them best, subjectively perceive the negative symptoms of the illness.
Negative symptoms are not the dramatic features most people associate with schizophrenia. They are the quieter: the loss of motivation, pleasure, emotional expression, and social connection. Using a disciplined research design, the investigators asked participants to define, rate, and evaluate each of the major negative symptom domains: anhedonia (the reduced ability to feel or anticipate pleasure), avolition (a loss of drive and goal-directed motivation), asociality (diminished interest in or withdrawal from social relationships), blunted affect (a flattening of outward emotional expression), and alogia (a reduction in the spontaneity and amount of speech). What participants said, in their own words, has direct bearing on how treatment environments should be designed and what they should prioritize.
The Symptoms That Matter Most: What Participants Are Saying
Both participants and caregivers rated avolition, anhedonia, and asociality as the most important negative symptoms, far more disabling in their experience than blunted affect or alogia. This is a clinical finding with direct treatment implications. It tells us where to focus.
Avolition, the experience of losing the inner drive to start or sustain activities, was rated the single most important symptom for treatment, functioning, and quality of life by participants themselves. Participants described it as aimlessness, emotional ambivalence, shame, and a sense of wasting or missing out on life. Caregivers added that avolition depletes collective family resources, increases caretaking demands, and erodes household well-being.
Anhedonia, the diminished capacity to feel pleasure or look forward to things that once mattered, was described not only as an absence of enjoyment but as something that co-occurs with active distress. Relatives also noted that anhedonia may reflect a lack of access to the resources needed to engage in pleasurable activities. That observation has an environmental implication: people may not be withdrawing from enjoyment so much as living in conditions that offer little worth engaging with.
Asociality, a pulling away from social life that goes beyond shyness or introversion, was described as relationships that lack depth, social exclusion, and an awareness of being outside the social norms that most people take for granted. Participants noted that low desire for social activity is often compounded by the behaviors of others, by impoverished social environments, and by the absence of meaningful opportunity. It is not only an internal symptom. It is shaped by external conditions.
The Environment Is Not Neutral
The Strauss et al. study substantiates this from the perspective of people living with the illness. Negative symptoms do not arise in a vacuum. They are shaped, maintained, and worsened by the environments in which people live.
Participants described how social exclusion, reduced social networks, overstimulation, stigma, and environmental deprivation all contribute to the persistence of negative symptoms. Alogia, the tendency toward sparse or halting speech, was linked not simply to an internal deficit but to situations involving strangers, sensory overload, or social contexts in which speaking did not feel safe or natural. Blunted affect, the reduced outward expression of emotion that others often notice before the person does, was experienced partly as a response to paranoia and anxiety. Participants noted that others frequently reacted to it with confusion or withdrawal, compounding isolation.
These findings reinforce what environmental design research has long suggested: the treatment environment is itself a therapeutic variable. Residential settings that feel like homes and/or campus like residential environments rather than wards, that offer sensory-friendly features, access to nature, animals, shared kitchens, creative spaces, and elements of privacy, are not simply more comfortable. They reduce the environmental conditions that maintain negative symptoms and create circumstances under which motivation, social engagement, and emotional expression can begin to emerge.
Dr. Thomas Insel, former Director of the National Institute of Mental Health, has argued that we already possess the knowledge needed to substantially reduce the burden of mental illness, if we commit to applying it (Insel, 2022). The Strauss et al. study adds weight to that point: people living with schizophrenia know what is disabling them, and they want it to change. Our obligation is to build environments where the change afforded by best practices becomes possible, and consequently more sustainable..
Adherence as Social Participation
Treatment engagement is not simply a matter of individual compliance. We see it is also directly impacted by social context. When people are surrounded by peers who are active in their own recovery, participation becomes normalized, inviting and even expected. The rhythms of a well-structured community create behavioral momentum that can stay with a participant during interruptions in necessary care.
The Strauss et al. findings support this framing. Caregivers rated asociality as particularly important, which reflects their close-range experience of its effects: withdrawal from family gatherings, strained relationships, the accumulating sense of isolation. In group living environments, asociality is not merely an internal state. It becomes visible and consequential for others. And its opposite, engagement and connection, becomes visible in the same way.
When someone who has long withdrawn from social contact begins attending a shared meal, working alongside peers in a garden, or contributing to a collaborative project, something more than activity is occurring. Social cognition is being practiced. Emotional regulation is being exercised. Motivation is being activated through the low-stakes, structured demands of ordinary community life. The environment functions as a form of cognitive remediation, not through computerized exercises, but through the lived experience of a coherent daily life.
What Meaningful Improvement Actually Looks Like
The Strauss et al. study asked participants what level of symptom change would constitute meaningful improvement. Their answers were consistent: a modest reduction in symptom severity, roughly one to two points on a standard clinical scale, was sufficient to represent a meaningful difference in quality of life. Participants and caregivers did not demand the elimination of symptoms. They asked for movement, for some degree of relief. The study emphasizes that the subjective experience of isolation and the absence satisfying social experiences is more important to them, then the more attended to aspects of their illnesses.
This kind of incremental progress is visible in residential treatment settings organized around these principles. Someone who previously cycled in and out of hospitals achieves several months of stability. Someone who had withdrawn entirely from social contact begins attending group meals. A person who described their days as aimless starts taking responsibility for a shared task within the community and may be more comfortable in the company of others. These are not dramatic changes by clinical trial standards, but they are the kind of changes that participants themselves identify as worthwhile reasons for treatment adherence.
Shared decision-making follows directly from this. When individuals participate actively in defining their own treatment goals, and when those goals reflect what they actually experience as most disabling, engagement improves. When someone identifies what most diminishes their quality of life, the clinical response should be oriented accordingly: toward structured activity, toward opportunities for goal-directed behavior, toward environments that support motivation rather than simply requiring it.
A Call Toward Person-Centered Implementation
The Strauss et al. study concludes with a call for more person-centered approaches to negative symptom assessment and treatment. What it contributes, beyond its clinical findings, is rigorous empirical backing for an approach that takes the lived experience of participants as its starting point rather than an afterthought.
People living with schizophrenia understand their own illness. They can articulate what disables them, what constitutes meaningful improvement, and what these symptoms feel like from the inside. They are not passive recipients of treatment. They are active participants in a recovery process, and that process depends substantially on the quality of the environments built around them.
What remains is implementation: designing residential environments that reduce the conditions that maintain negative symptoms, building cultures of engagement and participation, centering shared decision-making in clinical practice, and treating the environment itself as the therapeutic variable it has always been. The evidence supports it. The people we serve are asking for it.
References
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Gonzalez, M. T., & Kirkevold, M. (2014). Benefits of sensory garden and horticultural activities in dementia care: A modified scoping review. Journal of Clinical Nursing, 23(19-20), 2698-2715.
Insel, T. R. (2022). Healing: Our path from mental illness to mental health. Penguin Press.
Leckey, J. (2011). The therapeutic effectiveness of creative activities on mental well-being: A systematic review. Journal of Psychiatric and Mental Health Nursing, 18(6), 501-509.
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press.
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Strauss, G. P., Zhang, Z., Arnold, L. E., Hutcheson, A. L., Barolette, J. T., Luck, J. E., Carter, Z. A., Knippenberg, A. R., Allen, D. N., & Kirkpatrick, B. (2026). Subjective perceptions of negative symptoms among outpatients with schizophrenia and their relatives or caregivers: Definitions, importance, measurement, and desired improvement. Schizophrenia Research, 295, 61-71.