Difficulties encountered in assessing family attitudes

Journal

of Psychosomatic

Research.

DIFFICULTIES

1964, Vol

8, pp. 229 to 234.

Pergamon

Press

Ltd. Printed in NorthernIreland

ENCOUNTERED IN ASSESSING FAMILY ATTITUDES E. M. GOLDBERG

I HAVE been associated with two studies in which attempts were made to assess family organisation and functioning in relation to disease. One was an intensive study of family relationships and patterns of upbringing in 32 male patients under 25 suffering from duodenal ulcer and 32 matched controls drawn from a local general practice (Goldberg, 1958). The second is an investigation of the family relationships and social circumstances, including occupational mobility, of a series of male patients under 30 admitted to two district mental hospitals, No controls were included in the latter study, but comparisons were made between within these broad diagnostic cateschizophrenic and not-schizophrenic patients; gories, the course of the disease and the social adjustment of the patient after discharge were related to characteristics of the family environment* (Goldberg and Morrison, 1963 ; Goldberg, 1960). In addition, I have been involved in monthly seminar discussions of common problems of method with the main investigators of some recent family studies in Great Britain (Bott, 1957; Brown, 1959; Howarth et al., 1962; Philp, 1963; Rapoport and Rosow, 1957; Spencer, 1964; Tizard and Grad, 1961; Willmott and Young, 1960; Young and Willmott, 1957). Some of these studies were concerned with the assessment of relationships and attitudes among families which contained known “pathology” such as the young men with duodenal ulcer, schizophrenic patients, or multiple social problems (“problem severely subnormal or maladjusted children; families”). Others in the seminar, notably Miss Bott and those connected with the Institute of Community Studies and the Bristol Social Project, were seeking to establish norms of family functioning, either in local neighbourhoods or in relation to the social networks in which the families were involved. Since most of us were trying to explore complex aspects of family relationships and organisation, the sample in all but one study was small, and material was obtained mainly by interviews with family members in their own homes. The basic difficulties that we encountered in one way or another were of three kinds : First: how to deal with problems arising from the interrelatedness of the variables. Certain variables could be isolated and measured satisfactorily: for example, the frequency of contact among relatives and extended families, or the occurrence of defined neurotic traits. Ingenious scales for the rating of attitudes towards child rearing or marriage, for instance, can be devised. But even if we succeed in measuring these discrete factors and attitudes, it is still necessary to assess how they relate to each other in the interaction of family members before one can throw any light on the aetiology of disease. * Analysis of this work is still in progress. 229

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Second:

how to evaluate information obtained in unstandardised situations, from whose ability and willingness to co-operate vary. Third: how to make comparisons valid: how useful, for example, are control groups in a field where many subtle, uncontrollable variables are bound to be involved? informants

The inter-relatedness

of cariables

This problem of course is not unique to this sector of the social medicine field. In epidemiological studies of ischaemic heart disease diet, smoking habits, physical activity and “stress” have all been postulated to play a part. It is clear that these factors are inter-related but the pattern of this inter-relationship is as yet unknown, though it may be of crucial importance in any preventive measures. Similarly, in the field of family functioning, observations and measurements of single traits or attitudes have to be seen in relation to patterns of social variables before they can be adequately interpreted. The following examples illustrate these points. Neurosis is often held to be closely associated with disturbances in inter-personal relationships. However, neurotic symptoms in the parents of the duodenal ulcer patients and the controls were not in themselves indicators of the cohesiveness of family life. Ten mothers of D.U. patients and eleven mothers of controls showed neurotic traits, and six fathers in the D.U. and five of the control sample. There was no difference in the frequency of neurosis, as defined, among the parents of both samples. Yet, almost twice as many families (13) in the control sample as in the D.U. sample (7) were rated as functioning well, according to the agreed criteria. The important variable seemed to be, how the neurotic symptoms fitted in with the spouses’ mutual needs and expectations. In the control families there were striking examples of severely neurotic couples &ho seemed to be leading satisfying lives and to be successful parents. They had managed to adapt their social roles to fit their n&rotic needs and defences (Goldberg, 1959). The amount of contact and communication between the spouses is often held to be a good indicator of the soundness of a marriage. However, lack of contact between husband and wife who have sharply segregated roles is not necessarily indicative of a pathologically split family which could endanger healthy emotional development in the children. In a family embedded in the close social network of an old established community like Bethnal Green *, it is customary for the wife to preserve close ties with her mother and other relatives and for the husband to associate with his mates. The spouses may thus share few activities and get much emotional support outside the marital relationship. In a middle class family, however, where husband and wife may have widely dispersed social networks of friends and relatives, they will need to depend more on each other for mutual support and hence to invest more in the marital relationship. In these circumstances, lack of communication and sharing of activities may be indicative of family disturbance.? I need hardly mention the fallacy of measuring and comparing situational variables without reference to the individual who is experiencing them. A fortnight away from Mum may be a shattering experience for Toddler A, while B will not turn a hair * For example,

see the Newbolt

‘1 See, for example,

the Brown

family family

in Miss Bott’s in the duodenal

study

pages

ulcer study

63-73. pages

29-39

Difficulties encountered

in assessing family attitudes

231

and enjoy himself hugely. The conclusions one might draw from these observations are the following: It is clearly necessary to isolate variables in the field of family functioning, whether they relate to personality, to social roles, to interpersonal relationships or to broader social factors. We need to measure the frequency or strength with which they occur. But before making any causal interpretations in relation to health or disease it is necessary to explore how they fit in with other variables in the social “space” of the family. Problems of‘ objective assessment Certain problems of assessment are peculiar to the field of psycho-social investigation. A good deal of skilled effort may be required to induce the subject to participate and the quality of the information will vary greatly with the circumstances of the interview and the degree of co-operation given. In other fields of investigation, for example screening a population by X-ray, once the subject has submitted to the X-ray the observation is complete, whatever the manner of co-operation. The instrument which is used for assessment in intensive family studies-the interview-can also be of different kinds. The more standardised and structured the interview the more reproducible and reliable are the observations made. The standardised interview tends to be so inflexible that only external facts and overt attitudes and behaviour can be studied. If we wish to explore peoples’ feelings and their human relations and experiences the rigidly controlled interview might lead to considerable distortions since there are many questions in these areas to which there is no clear cut answer or where the answer can only be reached through devious routes. On the other hand, the more prolonged, the freer, the more intensive, the interviews the more variable the material will be in depth and content. The variability of the material will depend on the type of problem being explored, and the attitudes and biases of both informant and research worker, which range from his social conditioning and resultant cultural prejudices, through his emotional conditioning and its resulting biases, to his philosophy of life and the kind of theory he holds about the development ofpersonality. If the investigator is a Jew, for example, subjects will give very different information about their attitudes to the influence of Jews in the business world than they will to a non-Jewish interviewer (Hyman, 1954). If he belongs to social class I then he may get on very much better with informants of a similar social class than with informants at the other extreme of the scale (Hollingshead and Redlich, 1958). Informants may treat the investigator as a person on whom to unburden their problems, as an intruder who has got to be kept as distant as possible, or as someone who is in need of help and co-operation. These variable elements colouring the information given make comparisons hazardous, not only because of the well known problems of observer error and bias, but also because it is very difficult to know at which “level” of human functioning the statements made by the subject are “true”. For instance, a family may appear to be functioning reasonably harmoniously. Some asides about neighbours may reveal a good deal of hostility and dissatisfaction, suggesting to the research worker that the outward “cosiness” hides antagonism and tension, but that keeping up appearances vis d vis the outside world, including the research worker, is of paramount importance. Hard facts, however, are missing. Finally, a crisis may produce conclusive evidence that the members of the

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GOLDBERG

family are disunited and full of hostility. It is clear by then that excessive conformity held them together under favourable external conditions, but that under stress each person will pursue his own ends, irrespective of the needs of the other members of the family. On the other hand, a marital situation may appear hopeless during the first interview. The partners quarrel violently and accuse each other of grave faults. suggesting that their home is in danger of breaking up. Yet below this disturbed surface, strong positive drives may be at work. The distress of the couple may be so intense just because they are aware of their destructive behaviour and afraid of the damage they might do to each other. It is possible that the first family, functioning more harmoniously on the surface contains greater pathogenic factors than the second openly disunited family. How can one ensure not to assess as well-functioning those families who keep up appearances at all costs, and to label as pathological those who present with the urgency of their problems? Training, and the development of insight into the nature of defences and the forces at work in the interview situation, is one There are also ways of checking the consistency of the material. valuable safeguard. For example, how the behaviour in the interview situation tallies with attitudes and values the informant professes to hold in relation to other experiences. Finally, one hopes that growing knowledge and sophistication in the designing of psychological tests will enable investigators to validate clinical observations by using more objective and penetrating measuring devices. For example, in the study of D.U. of mother-child relationships patients and their families, certain typical patterns emerged which are also reflected in Card 6 (the mother-son card) of the Thematic Apperception Test (Murray, 1943). Hazelton and Kanter (who report their work in this volume) show that it is possible to objectify this test still further. Making valid comparisons

Encouraged by the success of field trials many maintain that properly selected control groups will solve the problems of making valid comparisons in psycho-social research; but three kinds of difficulties arise here. 1. Samplingproblems. In our study of duodenal ulcer patients a carefully selected control group was used and, so far as we could contrive, subjected to the same procedures as the patients in the experimental group. In the absence of any knowledge of norms of family behaviour in this particular sub-culture, however, we have no means of knowing how representative this small control group of 32 families was. 2. ControZgroupps will not overcome the problems of bias, personal, cultural, as well as theoretical, which most observers have, however highly trained they may be. Such bias may be built into observations of both control and experimental group. Are there any means of ascertaining an observer’s bias before or during his investigations in the field? Group discussions among investigators with a knowledgeable supervisor may help. 3. Dgerences in motivation between patients and control subjects may invalidate results. It is often argued that patients and their families who have therapeutic needs are more likely to reveal painful experiences to outsiders; while control families, approached because they are thought to be healthy and representative of the ordinary run of people are less likely to talk about their difficulties. The conscious motives of the controls to co-operate are altruistic, while the experimental group hope to obtain help. Experiences in the D.U. study were encouraging in this respect; such

Difficulties encountered

in assessing family attitudes

233

differences between the two groups did not appear to affect the information to any great extent. In both samples there were some families with severe problems who openly wanted help and who revealed a great deal about themselves. In both samples the majority of families, however, managed their lives independently. Though they might have some problems (like everybody else) they did not expect the investigator to give them any specific help, and they discussed many aspects of their lives freely. There was a minority in both samples who were much on the defensive and scarcely co-operated. Once the interviewer got “below the surface”, the relationship between her and the controls was not essentially different from that with the ulcer families though there was bound to be a certain unavoidable bias in knowing which group had the disease and which group was “well”. Differences in motivation between the groups were less important than differences in co-operation within the groups. It may be helpful therefore to divide informants according to the type of co-operation given. This may range from an eagerness to communicate, allowing a great deal of self revelation, to defensiveness and concealment. Like would be more easily compared with like if willing co-operators were compared on the one hand and defensive informants on the other. Some have suggested that because of these unsolved difficulties of differing motivations and levels of co-operation it is misleading to investigate random samples of families, and that we can only learn anything valuable from the co-operation of volunteers. But those who have undergone some form of psycho-analysis as part of their training will know that even in these favourable circumstances where volunteers want to understand themselves and co-operate with their therapists, the forces of resistance may be formidable. Prospective studies based on predictive hypotheses avoid the difficult problem of unrepresentative control groups in small studies. The studies undertaken by Brown and Wing of discharged schizophrenic patients are a case in point (Brown et a/., 1962). Here the family ratings were made before the patients’ behaviour after discharge was known. Similarly, in a study of family life in relation to delinquency in South London, the family circumstances of a sample of school children are assessed before these children can officially start on a delinquent career. Significant associations, found between certain family characteristics and deterioration in the clinical condition of the schizophrenic patients or the appearance of delinquency in the children of South London, will be more convincing than the same associations found as a result of retrospective studies based on experimental and control samples. Approaches

to problems

of measurement

Finally, a word on the problems of measurement in relation to the family data in We adopted both a quantitative and a descriptive approach the two studies mentioned. within a statistical frame. The pilot study in the D.U. investigation had led to the formulation ofcertain hypotheses about characteristic family relationships and patterns of upbringing in families of D.U. patients. Rating scales were designed, based on operational criteria arising from the field material. The scales were used for comparing the ulcer and control samples in relation to the formulated hypotheses. These comparisons were continually illustrated with excerpts from case histories. Variables were gradually linked together into patterns. For example, the mothers’ personalities with their attitudes to child rearing and their children’s reactions to them; variables

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E. M. GOLDBERG

relating to the mothers’ and fathers’ personalities, backgrounds and upbiinging were linked into patterns of marital interaction. Finally, an attempt was made to assess the functioning of the family as a whole according to certain defined criteria. In addition, three detailed case histories were given illustrating three typical patterns of family interaction found among the ulcer families. Similarly, in the study of schizophrenic patients and their families, statistical and factors descriptive methods are being used in a complementary way. Six unfavourable in the family environment of schizophrenic patients were defined and their absence or presence recorded in each family. An independent observer assessed the case material separately; agreement between the two observers was around 90%. The absence or presence of these unfavourable factors was then related to such variables as length of stay in hospital, number of readmissions, and the patients’ ability to work after discharge. Secondly, an attempt was made to describe typical patterns of family interaction found among families who presented no unfavourable factors and families with two or more unfavourable factors. REFERENCES BOOT E. BROWN G. W. BROWN G. W., MONCK E. M., CARSTAIRSG. M. and WING J. K. GOLDBERGE. M.

1957 1959 1962

Family and Social Network, Tavistock, London. Millbank Memorial Fund Quarterly 27, 2. Brit. J. Prec. Sot. Med. 16, 55.

1958

Family Influences and Psychosomatic Illness, Tavistock, London. Social Work 16, 2. Brit. J Psych. Sot. Work 5, 2--I 2. Brit. J. Psych. 109, 785. Social Class and Mental Illness. New York.

GOLDBERGE. M. GOLDBERG E. M. GOLDBERGE. M. and MORRISONS. L. HOLLINGSHEADA. B. and REDLICH F. C. HOWARTH E. et al.

1959 1960 1963 1958

HYMAN H. H.

1954

MURRAY H. A.

1943

PHILP A. F. RAPOPORTR. and Rosow 1. SPENCERJ.

1963 1957 1964

TIZARD J. and GRAD J. C.

1961

WILLMOTT P. and YOUNG M.

1960

YOUNG M. and WILLMOPT P.

1957

1962

The Canford Families. The Sociological Review Monograph No. 6., University of Keele. Interciewiq in Social Research. University of Chicago Press. 162. Thematic Apperception Test Mamral. Harvard University Press, Cambridge, Mass. Familv Failure, Faber, London. Hum& Relations 10,209. Stress and Relief in an Urban &are. Tavistock, London. The Mentally Handicapped and their Families: A Social Sarory. Oxford University Press. Family and Class in a London Suburb. Routledge and Kegan Paul, London. FamiiJ and Kinship in East London. Routledge and Kegan Paul, London.