Family interactions of schizophrenic and schizoaffective patients: determinants of relatives' negativity

PSYCHIATRY RESEARCH Psychiatry Research 56 ( 1995) 12I - I34

ELSEVIER

Family interactions of schizophrenic and schizoaffective patients: determinants of relatives’ negativity Steven L. Sayers*a, Alan S. Bellack”, Kim T. Mueserb, Ann M. Tierneya, Julie H. Wadea, Randall L. Morrison” aMedicol Co!!ege of Pennsybonio 01 Eastern Pennsyivonio Psychiatric InsMute, 3200 Henry Avenue, Philadelphia, PA 19129, USA bNew Hampshire-Dartmouth Psychiatric Research Center, 105 Pleosonf Street. Main Building. Concord, NH 03301. USA ‘American Medical Associorion, Chicago. IL 606 IO, USA

Received 26 July 1993; revision received 4 May 1994; accepted 21 June 1994

Abstract

Videotaped family problem-solving interactions of 57 schizophrenic or schizoaffective patients and their relatives were examined for predictors of negativity of their communication behavior. Ratings of patients’ behaviors and independent assessments of patients’ symptomatology were used to predict the negativity of relatives in the videotaped interaction. The results indicated that severity of symptomatology was not related to relatives’ negativity. Patients’ social skill, as independently assessed by a role-play test, also was not associated with relatives’ negativity. The regression results suggest that with both members of a patient-relative dyad, the quality of communication in a discussion is related to the other participant’s level of negativity. Keywork

Expressed emotion; Social skills; Communication

1. Introduction There is considerable evidence that negative family attitudes and behaviors play a key role in the relapses of schizophrenic patients. A recent review of 12 studies has reported that high expressed emotion (EE), or high levels of critical family attitudes and emotional overinvolvement, are linked to relapse in the 9-month period after the * Corresponding author, Tel.: + I 2 I5 842 4568; Fax: + I 2 15 843 3341. e-mail: [email protected].

deviance; Prognosis

patient’s discharge from the hospital (see Parker and Hadzi-Pavlovic, 1990). This finding is reasonably robust even when other important factors are examined. For example, several studies have examined clinical characteristics (e.g., patient’s mental status at discharge) and shown that they do not account for the association between high-EE ratings and elevated relapse rates (Brown et al., 1972; Vaughn and Leff, 1976; Miklowitz et al., 1983; Vaughn et al., 1984; Karno et al., 1987). Furthermore, medication compliance and the number of prior hospitalizations have been examined in

Ol65-1781/95/.W.50 0 1995 Elsevier Science Ireland Ltd. All rights reserved SSDI 0165-1781(95)02517-Z

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the context of these EE findings, but these other factors provide independent contributions to the prediction of relapse. The EE index is usually assessed by the Camber-well Family Interview (CFI), a lengthy semistructured interview of key relatives of the patient. It has been assumed that the attitudes expressed in the interview are reflected in day-to-day interactions in the family. To test this assumption, several studies have used videotaped family problem-solving discussions recorded in the period following an exacerbation of the patient’s illness to sample the quality of relative-patient communication (Hahlweg et al., 1989; Miklowitz et al., 1983, 1989). Although not entirely consistent, the findings generally support the notion that relatives classified as high EE are more negative and express more intrusive and invasive statements than lowEE relatives, Thus, these studies have pointed to the importance of a negative affective climate to the course of schizophrenia; however, little research has examined the contribution of patient characteristics to this negativity. Traditionally, the highversus low-EE distinction has been seen as representing relatively enduring characteristics of the relatives (Vaughn and Leff, 1981). Recently, investigators have suggested that high EE in relatives may be the result of an interactive process wherein both the patient and the patient’s relatives contribute to a negative family climate (Hahlweg et al., 1989; Strachan et al., 1989). There are several patient characteristics that may contribute to increased negative affect from family members. The patient’s symptomatology may play a significant role as relatives react and adjust to the patient’s illness. Hooley (1985) suggested that family members may use increased criticisms in an attempt to exert control over the patient’s behaviors. Runions and Prudo (1983) found that the most frequent problems reported by family members concerned negative symptoms. What is often seen by family members as laziness or lack of motivation may be due to these symptoms. Therefore, high EE could result from family members attempting to “motivate” an ill relative with prominent negative symptoms. Patients who exhibit greater negative symptoms would engender more negative affect from their relatives in day-to-

day interactions than patients with less prominent negative symptoms. On the other hand, some researchers have suggested that affective symptoms are associated with relatives’ increased negative affect. Glynn et al. (1990) and Strachan et al. (1986) found that patients from high-EE families had greater overall levels of depressive symptomatology compared with those from low-EE families. Despite the suggestion that there is an association between increased symptomatology and the relatives’ expression of negative affect, the existing studies do not adequately test this hypothesis. The use of the CFI does not provide a direct test of the effects of the patient’s symptoms on actual patientrelative social interactions. The CFI is an individual interview conducted with the relative in the absence of the patient. There have been studies that assess relatives’ and patients’ direct communication behavior (e.g, Doane et al., 1985; Hahlweg et al., 1989); however, most of these studies did not examine whether the negative affect expressed in this behavior was a function of the patient’s symptomatology. At least one study has assessed the relationship between relatives’ negativity in problem-solving discussions with patients and patients’ symptomatology, and it did not find an association between these variables (Miklowitz et al., 1984). However, the coding system used in that study classified critical comments from written transcripts of the patient-relative interactions, which may be less sensitive to negative affect being displayed in the discussion. Thus, additional research is warranted to examine these questions. There are other patient characteristics that may contribute to the affective climate in the family that have not been examined. Gender has received little attention in the EE literature. Hogarty (1985) has argued that the existing studies only support the high-EE/relapse association for male patients. It is possible that a negative family environment operates differently for males than females. Furthermore, males may have greater negativity directed toward them because of different expectations that relatives have for male versus female patients. Because there has been a relative paucity of females in EE studies, however, more research is needed. Another important factor may be the patient’s

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social skill. Most schizophrenic patients exhibit social skill deficits as an enduring characteristic of the disorder (Bellack et al., 1990; Mueser et al., 1991). Effective social skill is an essential aspect of social performance; thus, frustration engendered by discussing problems with patients with these deficits could explain increases in relatives’ negativity. Previous studies have not examined negativity in problem-solving discussions as a function of the patient’s social skill. In the present study, the limitations of previous studies were addressed by examining the relationship between patient characteristics and negativity expressed by participants in patient-relative problem-solving discussions. The following hypotheses were tested: (1) the relatives’ negativity in face-to-face interactions is associated with the patients’ symptoseverity of schizophrenic matology; (2) the relatives’ negativity is associated with poor patient social skills; and (3) relatives express greater negativity toward male patients than toward female patients.

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subjects were receiving outpatient treatment at MCP/EPPI and either had had a relapse of psychotic symptoms during the previous 3 months or had been continuously psychotic (i.e., had a rating L 4 on at least one of the four items in the Thought Disorder subscale of the Brief Psychiatric Rating Scale). Eligibility criteria for the study included the following: ages 18-55, DSM-III-R diagnosis of schizophrenia or schizoaffective disorder (American Psychiatric Association, 1987), no evidence of organic brain syndrome, and no evidence of alcohol or drug dependence. The present data were collected in the context of two larger studies (Bellack et al., 1990, 1992; Mueser et al., 1993) that examined psychiatric patients’ social skills and perceptions. All patients were paid for their participation in the study. Diagnosis was determined by the Schedule for Affective Disorders and Schizophrenia (Endicott and Spitzer, 1978) or the Structured Clinical Interview for DSM-111-R (Spitzer and Williams, 1985). In each of the studies from which the present sample was drawn, reliability of the diagnosis was assessed by use of independent clinicians who diagnosed portions of the samples (Bellack et al., 1990, 20%; Bellack et al., 1992, 23%). Diagnostic agreement in the two studies was 100% and 94%, respectively. Table 1 provides a summary of demographic and clinical characteristics of the subjects in this study. Multivariate analysis of variance (MANOVA) indicated that there were no signifi-

2. Methods 2.1. Subjects

The subjects were 39 schizophrenic and 18 schizoaffective patients who were receiving treatment at the Medical College of Pennsylvania at Eastern Pennsylvania Psychiatric Institute (MCP/EPPI), an acute service hospital. Forty-nine of the subjects were recruited as inpatients. Eight

Table I Demographic and illness characteristics of male and female subjects Characteristics

Female (n = 18)

Age(years) Education (years) Number of previous hospitalizations Duration of current hospitalization (days) Age of first psychiatric contact (years) Nore. The racial

Male (n = 39)

Mean

SD

Mean

SD

30.1 13.0 5.9 34.4

7.5 2.7 5.5 20.5

27.7 12.4 3.9 32.0

7.5 1.8 3.5 14.9

21.2

5.9

20.2

5.0

compositionof the samplewas as follows: white - 9 females and 19 males; black - 9 females and 20 males.

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cant demographic differences between the subjects drawn from Bellack et al. (1990) and Bellack et al. (1992) (F= 1.21; df = 4, 43; NS). Demographic and illness-related characteristics based on sex and diagnostic category (schizophrenia vs. schizoaffective) were also examined. The differences between male and female patients were not significant (MANOVA: F = 1.26; df = 4, 37; NS). Comparisons were also made between schizophrenic and schizoaffective patients. A MANOVA using all of the demographic and illness-related characteristics limited the sample unacceptably, due to the pattern of missing data. (Because all variables are required to be nonmissing in a MANOVA, one missing variable for an individual patient would exclude that subject from the analysis entirely.) A series of analyses of variance on each demographic and ‘illness-related characteristic indicated almost no significant differences between the diagnostic groups (all P’s > 0.05, except one). The exception was the Alogia rating from the Scale for the Assessment of Negative Symptoms (F = 5.80; df = 1, 53; P < 0.05; schizophrenia - mean = 1.89, SD = 1.03, n = 36; schizoaffective disorder - mean = 1.17, SD = 0.38, n = 18). Thus, there were few notable differences between diagnostic groups.

2.2. Measures of symptomatology The Brief Psychiatric Rating Scale (BPRS; Overall and Gorham, 1962) and the Scale for the Assessment of Negative Symptoms (SANS; Andreasen, 1981) were administered in structured interviews to assess the severity of symptoms of each patient. The BPRS yields five subscales on the following dimensions: Anxiety-Depression, Anergia, Activation, Hostility, and Thought Disorder. The SANS yields five global ratings: Blunting, Alogia, Apathy, Asociality, and Inattention. ’ Reliability of the interviews was examined by an independent rater on a subset of the audiotaped or videotaped interviews and was found to be high (interclass correlations [ICCs] ranged from 0.64 to 0.94) with the exception of the Activation subscale on the BPRS from Bellack et al. (1990; ICC = 0.44).

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2.3. Independent assessment of social skill -

role-

play test

The subjects participated in a role-play test that is a variation of a commonly used procedure to assess social skills (Bellack et al., 1990). The test was administered in a videotape studio arranged in a living room format. The patient was in a chair at a 90” angle from a research assistant who portrayed an interpersonal partner, such as a friend or relative. A second assistant coordinated the test and served as narrator. The narrator first explained the procedure and then gave the subject an index card that contained a description of a common social situation. The subject was requested to read the description and was given 30 s to try to imagine being in such a situation. If the subject had difficulty reading the card, the narrator read it aloud and indicated the correct parameters. When the subject indicated that he or she could imagine being in such a situation, the narrator read the scene description aloud, and the research assistant portraying the specified role presented a prompt to initiate the interaction. Subjects enacted two practice scenes to orient them to the task; corrective feedback was provided when necessary (e.g., if the subject spoke to the narrator instead of to the research assistant portraying the specified role described in the scenario). The role-play test proper consisted of situations previously used in our laboratory that were determined to have high relevance and moderate difficulty for this population. For the role-play test conducted with the subjects drawn from the Bellack et al. (1990) study, the 12 scenes included in the test represented social encounters from three ’ The SANS was updated between the data collection for the first study and the second; thus, the version used within each study differed slightly. The version used in Bellack et al. (1990) required ratings of each symptom on a scale as follows: 0 = none, 1 = questionable, 2 = mild, 3 = moderate, 4 = marked, and 5 = severe. The anchors of the version used in Bellack et al. (1992) were as follows: 1= not at all, 2 = mild, 3 = moderate, 4 = marked, and 5 = severe. Because the anchors from 2 to 5 in the two versions are identical, slight changes were made in the ratings on the earlier version to make the ratings from the two studies comparable. Thus, ratings of 0 and 1 from the earlier study were considered to be I for the data analysis.

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response domains: initiating conversations, resisting unfair treatment (negative assertion), and expressing positive feelings for something an interpersonal partner said or did (positive assertion). An example of a negative assertion scene includes the scenario that the subject is home watching television and someone walks in and changes the channel. After the scenario is described, a research assistant leads in by saying, “Let’s watch this instead.” If the subject demurs, the research assistant says, “You always get to watch your show. Now let’s watch mine instead.” If the subject complies with the original prompts, the research assistant says, “Movies are really much better.” The role-play test conducted with the patients from the Bellack et al. (1992) study consisted of six scenes reflecting common sources of conflict or disagreement in this population (e.g., the patient oversleeps and is late for an appointment). The research assistant in each of these scenes is to exhibit benign expressions of disappointment or disagreement. For example, in one scenario, the patient is to have, by accident, broken a vase belonging to a roommate. After the general scenario is described, the research assistant leads in with the prompt, “Did you break my vase?” After each response from the patient, the research assistant responds, “How did it [could that] happen?” and “Please try to be more careful.” There were content differences between the role plays used in each study, which represented different kinds of social challenges. There was also variability between scenes within each study, however, so that a reasonable range of situations was covered. All of the scenes were designed to represent moderate difficulty. Each role-play test interaction consisted of three verbal interchanges (e.g., the subject was required to make responses to three prompts). Research assistants were trained to deliver their prompts in a standardized manner with neutral, but appropriate affect. The initial prompt in each scenario was the same for every subject for that role play. The second and third prompt varied somewhat according to the subject’s response. The role-play test is available from the authors upon request. The role-play test enactments were videotaped

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and later rated on overall social skill, a general measure of the patient’s social competence, including apparent comfort and confidence in the situation as well as verbal, nonverbal, and paralinguistic elements. Overall social skill was rated on a Spoint Likert scale, with high scores reflecting greater skill. Coders were unaware of the subjects’ diagnoses. Previous studies in our laboratory have demonstrated that overall social skill as assessed by the role-play test is stable over time, can be rated reliably (ICCs range from 0.72 to 0.76), and is highly related to other measures of social competence such as social adjustment. Ratings of overall social skill on the role-play test from both Bellack et al. (1990) and Bellack et al. (1992) indicate that schizophrenic patients are consistently less skillful than nonpatient control subjects; patients with major affective disorders have social skills at an intermediate level between those two groups. 2.4. Family problem-solving task All subjects were requested to identify a relative with whom they had the greatest regular contact outside of the hospital. The relatives were then invited to participate in a structured problemsolving discussion and were paid for taking part in the study.* The following relatives participated in the problem-solving interaction (listed with frequency): mother (38), father (5), sister (3), brother (3) grandmother (2), husband (l), wife (2), ’ A reader noted that EE studies typically involve as many family members as are available to rate EE. No previous studies evaluated the merits of assessing the relative with the most contact with the patient, as we have done. It is conceivable, however, that the inclusion of more than one relative would lead to different dynamics in our problem-solving assessments as compared with including only one. Indeed, this concern led US to include only one relative. We knew that we would not be able to engage more than one family member in the interactions for many or most of the patients (many patients were in contact with only one parent or had sufficiently chaotic families that engagement would have been difftcult). Thus, the cases in which we would have been able to involve more than one relative were too few to allow a systematic evaluation of this factor. We decided that to ensure comparability across the sample, in each case only the family member with the greatest contact with the patient would be included.

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daughter (1), and aunt (2). Brief separate interviews were performed with each member of the family dyad to identify two conflictual issues that could be the locus of the problem discussions. The interviewer used either the participants’ responses to the Areas of Change Questionnaire (Weiss, 1980) or the Social Adjustment Scale-II (Schooler et al., 1979) to determine areas of conflict between the patient and relative. The family problem-solving task was divided into three segments: a warm-up exercise and two IO-min discussions dealing with problem issues. For the warm-up exercise, the patient and the relative were given a list of incomplete sentences about their family and multiple-choice responses to complete each statement (e.g, “Our family likes to: (a) watch TV, (b) go for a walk, (c)...“). The dyad was instructed to arrive at a consensus for the answer to each question. Following the instructions, the research assistant left the room for 10 min while the family completed the exercise. After the warmup exercise, the research assistant described one problem area that had been identified by the preliminary interviews, instructed the dyad to discuss this issue for 10 min, and then left the room. For Bellack et al. (1990), these problem areas were drawn from the Areas of Change Questionnaire, while for Bellack et al. (1992; see also Mueser et al., 1993), they were drawn from the Social Adjustment Scale-II. Both studies required a brief discussion with the participants to clarify the disagreement so that essentially the same procedure was used to obtain a sample of interactional behavior from the participants. After the discussion of the problem area, the research assistant identified a second area of disagreement, provided the same instructions, and left the room for another 10 min. Examples of topics discussed in the interactions include the following: (1) “[the relative] thinks [the patient] does not socialize enough”; (2) “[the relative] wants [the patient] to help more with chores”; (3) “[the patient] thinks that her mother is always trying to tell her what to do.” The two IO-min problem-solving discussions were videotaped. The patients’ and relatives’ behavior was rated by trained coders who were unaware of the diagnosis of the patients. Ratings

Research 56 (1995) 121-134

were made on 5-point Likert scales every 2.5 min of the discussion for the following domains: Quality of Communication (the overall effectiveness of the speaker, reflecting his or her believability, impressiveness, or presence), Quality of Problem Solving (the ability to remain focused on the problem, task-oriented in detining it and identifying means for solving it, and open to other’s opinion), Gaze (appropriateness of eye contact), Length (appropriateness of length of utterances), and Negative Valence (degree of expression of negative feelings toward the partner, including verbal, nonverbal, and paralinguistic elements). Reliability was assessed on a substantial proportion of the tapes from each study (32% from Bellack et al., 1990; 20% from Mueser et al., 1993). ICCs generally ranged from 0.67 to 0.87, indicating satisfactory reliability between raters. (The exceptions were ICCs = 0.51 for both Quality of Communication and Quality of Problem Solving.) The ratings for each 2.5-min period were averaged within each problem discussion and across the two discussions, yielding one average global rating score for each patient and his or her relative. (See Bellack et al. [1990] and Muescr et al. [1993] for more information on the measurement of these dimensions of interactional behavior.) 2.5. Procedures The clinical records of new admissions to MCP/EPPI were reviewed by research staff for potential participants, and appropriate patients were then interviewed to determine diagnoses approximately 2 weeks after admission. All subjects provided informed consent and were paid for their participation in the study. The testing of the patients began after the research team and the attending physician agreed that acute symptoms had been stabilized and medication had been titrated. Assessments (i.e., role-play test, BPRS, SANS, and family problem-solving task) were carried out at similar time points in both studies (Bellack et al., 1990, 1992), except for the family problemsolving task (see Table 2 for the assessment schedules). Although the SANS was administered somewhat later for some patients than for others, data from Mueser et al. (1991) suggest that nega-

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Table 2 Schedule of assessments for Bellack et al. (1990) and Bellack et al. (1992)

Diagnostic interview

BPRS Role-play test SANS Family problem-solving task

Bellack et al. (1990)

Bellack et al. (1992)

- 2 weeks after admission

- 2 weeks after admission

Number of weeks after diagnostic interview l-2 1-2 1-2 1-2 l-2 l-4

1

6

Note. BPRS, Brief Psychiatric Rating Scale; SANS, Scale For the Assessment of Negative Symptoms.

tive symptoms as assessed by the SANS are somewhat more stable than positive symptoms. Thus, the results of the present study are not likely to be highly sensitive to slight variations in assessment time. The difference in the time of administration of the family problem-solving task reflected practical design considerations and did not result from differences between patients or relatives involved in each of the investigations (e.g., motivation, chronicity). As discussed above, all of the patients were considered to be stabilized by their attending physicians before they entered the study. 2.6. Data-analytic strategy We examined the following hypotheses based on the priorities of the study: (1) the relatives’ negativity in face-to-face problem-solving discussions would be associated with the severity of the patients’ symptomatology, (Za) the degree of relatives’ negativity would be associated with poor patient social skill, (2b) negativity from both patients and relatives would be associated with poorer interactional skills exhibited in the problem-solving discussions, and (3) the patients’ relatives would express more negativity toward male patients than toward female patients. The following approaches were used to explore study hypotheses: (1) zero-order correlations and (2) hi-

erarchical classes of relatives’ ratings in

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regression, testing the associations of variables as blocks in the prediction of negativity (e.g., all the SANS global a single block).3

3. Results Zero-order correlations were computed as an initial test of the hypothesis that the level of symptomatology in the patient and the relative global interactional characteristics of the patient-relative dyad contribute to the negativity of the problemsolving interaction. Zero-order correlations were computed for the BPRS, the SANS, overall social skill, and the global ratings of the patient and the relative during the problem-solving assessment (see Table 3). Independent ratings of patients’ hostility on the BPRS were found to be related to the Negative Valence of the patients during a problem discussion. However, these ratings of patients’ hostility were not related to relatives’ negativity during the interaction. With the exception of hostility, no other symptom or skill variable rated independently of the family interaction was associated with the Negative Valence ratings from the interaction. Ratings of patients’ and relatives’ behavior made during the family problem-solving interaction were associated with the Negative Valence ratings during the interaction (see Table 3). The ratings of thepatients' Quality of Communication, Quality of Problem Solving, Appropriateness of Gaze, and Appropriateness of Length of Utterances were inversely associated with the relatives’ Negative Valence. Similarly, the ratings of the relatives’ Quality of Communication and Problem Solving (but not the Appropriateness of Gaze and Length ratings) were inversely associated with patients’ Negative Valence. Thus, the negativity of each of the participants seems to be related to the quality of the interactionalpartner’s 3 We considered analyzing data From the Bellack et al. (1990) and Bellack et al. (1992) investigations separately. However,

the smallnumber of subjects would have resulted in inadequate power to test important effects such as gender within each study group.Specifically, there were IO female patients in the study of flellack et al. (1990) and 8 female patients in Bellack et at. (1992) who also had data From the patient-relative interactional assessment.

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Table 3 Zero-order correlations of symptomatology measures with patients’ and relatives’ interactional variables Patients’ negative valence

Relatives’ negative valence

Paiients’ symptomatology BPRS Hostility Anxiety-depression Thought disorder Activation Anergia SANS Blunting Alogia Apathy Asociality Inattention

0.4F 0.12 0.15 0.22 -0.06

-0.12 -0.16 0.10 0.08 0.17

-0.06 -0.12 -0.08 0.16 0.04

0.17 0.01 -0.08 0.10 0.06

Patients’ overall social skill

-0.21

-0.02

Patients’ interactional variables Quality of communi-0.08 cation -0.09 Quality of problem solving 0.00 Appropriateness of gaze 0.00 Appropriateness of length of utterances Relatives’ interactional variables -0.50a Quality of communication Quality of problem -0.35b solving -0.18 Appropriateness of gaze Appropriateness of 0.05 length of utterances

-0.41 a -0.418 -0.3lb -0.2F

-0.14 -0.19 -0.06 -0.18

Note. BPRS, Brief Psychiatric Rating Scale; SANS, Scale for the Assessment of Negative Symptoms. aP < 0.001; bP < 0.01; cP < 0.05.

communication. However, Negative Valence ratings were not associated with each individual participant’s own quality and appropriateness ratings in the interaction.

a problem-solving discussion (Hahlweg et al., 1989), it was necessary to evaluate this association in the present study. The patient’s global Negative Valence within the problem-solving interaction was used to predict the relative’s Negative Valence in the interaction. As shown in Table 4, this model was not significant, so that it was not necessary to retain this variable in the analyses of other patient in predicting negativity in characteristics relatives.4 Regression models were used as a supplement to the zero-order correlations for two reasons: (1) to test the hypothesis that severity of patients’ symptoms as a whole was associated with relatives’ negativity, and (2) to evaluate whether specific symptoms had a unique association with relatives’ negativity after adjustments had been made for the other symptoms. The BPRS symptom measures were added to the regression model in a block to assess whether the variables explained a significant portion of variance in the relatives’ Negative Valence ratings in the interaction. In the first test, the following positive and affective symptom ratings were entered into the equation as one block: Hostility, Anxiety-Depression, Thought Disorder, and Activation. This block of predictors did not provide a significant increase in R2 values (see Table 4). Negative symptoms were tested in a similar manner to assess the contribution of negative symptoms to relatives’ negativity. The following subscale ratings were entered into the equation as a single block: Blunting, Alogia, Apathy, Asociality, Inattention (all from the SANS), and Anergia (from the BPRS). Again, this block of symptom ratings did not account for significantly more variance in relatives’ negativity (see Table 4). Thus, contrary to expectations, these data provided no evidence that the severity of patients’ positive/affective or negative symptoms was associated with relatives’ negativity in the interaction. 3.2. Relatives’ negativity and patients’ social skill and gender

Independent ratings of overall social skill from 3.1. Symptomatology and relatives’ negativity Because previous research had suggested that patients’ and relatives’ level of negativity covary in

4The findings for the models discussed below were the same with or without the patients’ global Negative Valence ratings included.

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Table 4 Predictors of relatives’ and patients’ negativity Total R2

F (dfi

Standardized @

Patients’ negative valence

0.04

0.12

I.831 (I, 49) 1.62 (4, 46)

-

Positive/affective syrnptomatology

Relatives’negative valence(dependent variables) Patients’ predictors (independent variables)

-

Hostility Anxiety-depression Thought disorder Activation

-

Negative symptomatology

0.09

0.70 (6, 44)

-

Blunting Alogia Apathy Asociality Inattention Anergia Overall social skill (OSS) ass

and gender

0.04

0.72 (3, 47) -

-

Gender OSS x gender Patients’ interactional variables

0.20

2.93” (4, 46) -1.15 -0.39 -0.0 I -0.37

Quality of Communication Quality of Problem Solving Appropriateness of Gaze Appropriateness of Length Patients’ negative valence (dependent variable) Relatives’ interactional variables

0.29

4.75b (4, 46)

(independent variables)

Quality of Communication Quality of Problem Solving Appropriateness of Gaze Appropriateness of Length

-2.90b 0.96 0.34 0.51

Note. Total R* refers to the total variance accounted for by the corresponding model in the table, and as described in the text. For any given model, blocks of variables from previous steps that were not significant were not retained in that model. “P < 0.05; bP < 0.01.

the role-play assessments were examined to explore the association between other patient characteristics and relatives’ negativity. Gender was considered in the examination of overall social skill because of the generally poorer social skills and social functioning of male patients and the potential importance of these factors in social interactions with their relatives (Mueser et al., 1990). Relatives’ negativity was predicted in this regression model from gender (dummy-coded 0 = female, 1 = male), overall social skill, and the interaction term (overall social skill x gender). As

shown in Table 4, the omnibus test of the model was not significant; furthermore, the overall social skill x gender interaction and the overall social skill and gender main effects also were not significant.5 Thus, contrary to expectations, the social skillfulness of patients in the role-play assessments was not related to relatives’ negativity. - 5The test of the model with overall social skill and gender was not significant even after the overall social skifi X gender interaction was removed from the model: F = I .07;. df= 2, 48; P = 0.35.

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The association between patients’ interactional skill level during the family interactions and relatives’ negativity was examined in a regression model to test whether the skills as a whole were predictive of negativity and to evaluate whether specific skills had a unique association with relatives’ negativity. The global measures of Quality of Communication and Quality of Problem Solving, Appropriateness of Gaze, and Appropriateness of Length of Utterances were tested as a block in a regression model predicting the ratings of relatives’ Negative Valence. As predicted, these variables were significantly related to ratings of during the interaction relatives’ negativity (R2 = 0.20) (see Table 4). None of the t tests corresponding to the individual B weights were significant, suggesting that none of the variables were uniquely associated with relatives’ negativity. However, the direction of the /3 weights was consistent with the zero-order correlations, which indicated that low skill and appropriateness ratings of the patients were associated with high negativity from the relatives. The initial zero-order correlations indicated that there was a pattern of association between relatives’ interactional skill and patients’ negativity that was parallel to the one described above. To test this hypothesis, regression analyses were used to predict patients’ Negative Valence ratings with the global ratings of relatives’ Quality of Communication and Quality of Problem Solving, Appropriateness of Gaze, and Appropriateness of Length of Utterances. As shown in Table 4, this block of variables was significantly associated with patients’ Negative Valence during the interaction. Tests of the individual /3 weights for each variable indicated that only the relatives’ Quality of Communication was uniquely associated with patients’ negativity. Thus, it is suggested that patients who exhibited lower levels of negativity were interacting with relatives with greater communication skill (and vice versa).6 The results described above raise the question of whether the patients’ hostility ratings were still im6The findings for the model discussed above were the same with or without the relatives’ global Negative Valence ratings included.

portant in predicting patients’ Negative Valence once the relatives’ interactional variables had been taken into account.’ In an exploratory analysis, we added the patients’ BPRS Hostility score to the model predicting patients’ Negative Valence from relatives’ interactional variables (the last model in Table 4). The omnibus test of the model was significant (F= 5.47; df= 5,49; P < 0.05), as were the tests of the @weights for Hostility (partial r = 0.28, P < 0.05) and Relatives’ Quality of Communication (partial r = -0.38, P < 0.01). These results suggest that relatives’ Negative Valence and patients’ BPRS Hostility levels have significant unique associations with patients’ Negative Valence during the family problem-solving task. 4. Discussion Much of the previous research examining the role of EE in families with a schizophrenic patient has examined only the predictive value of EE level as an indicator of the patient’s future functioning. The present study examined the correlates of negativity in a family problem discussion to explore possible determinants of negativity. The results suggest that with both members of a patient-relative dyad, the quality of communication in a discussion is related to the other participant’s level of negativity. The negativity ratings did not simply reflect the skill of the individual; indeed, ratings of communication quality and communication appropriateness were not significantly related to negativity ratings within an individual. In addition, communication quality was still important even when the patient’s hostility level was taken into account. Thus, the patient’s negativity is associated with both his or her symptomatology and the relative’s communication behavior. These findings lend support to family intervention approaches that are focused on improving the communication skills of patients and relatives as a way to decrease conflict in the family (see Falloon and Liberman, 1983). Future studies should examine the degree to which quality of communications of patients and relatives might cause the level of negativity in the interaction, as well as how ’ We thank an anonymous reviewer for this suggestion.

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negativity might in turn determine the quality of the interaction. This area of research holds great potential because of the well-documented role of negative affectivity in increasing schizophrenic patients’ risk of relapse. It is of interest that the patients’ levels of appropriateness in gaze and length of statements were associated with relatives’ negativity, while the relatives’ appropriateness ratings were not similarly related. This likely reflects many schizophrenic patients’ deficits in these aspects of social skill as demonstrated amply by previous research (see Bellack et al., 1990). Because the relatives were largely appropriate in their gaze and the length of their statements, these characteristics were not relevant to the patients’ negativity. The ratio of male to female patients was approximately 2: 1, which may have led to our inability to find the gender differences among schizophrenic patients that have been noted in previous studies (see Mueser et al., 1990), because of the resulting diminished power associated with the low N of the female subgroup. This may be particularly important since Hogarty (1985) has argued that the extant literature supports the high EE/relapse association only for male patients. Future studies should address this issue within the constraints of the other questions examined. Similarly, in the present study, most of the relatives included in the interactions were female, usually mothers. This may be the source of any sex differences in the relationship of the relative to the patient. In the present study, we were constrained by the decision to use the relative with the most contact with the patient. Thus, we could not address this interesting question. However, it might be useful in future studies to examine whether patients are at particularly high risk with relatives of one type who may tend to be more negative (e.g., fathers; see Hogarty, 1985). The results of the present study suggest that it will be fruitful to explore how the verbalizations of patients affect their relatives (and vice versa) on a more detailed level. For example, Strachan et al. (1989) reported that patients in families with negative styles of interaction tend to exhibit primarily self-denigrating and countercritical styles of interaction (instead of using statements that display

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autonomy). Future research might evaluate whether relatives’ criticisms lead to greater selfdenigration, whether patients’ denigration leads to greater criticism on the part of the relatives, or whether the behaviors are reciprocally determined. Furthermore, comparisons with families who do not have a schizophrenic patient would help determine whether the observed patterns are specific to families in which a schizophrenic patient is present. Studies using event-based coding of interactional behavior are needed to examine the sequential relationship of the behaviors to answer these questions. Previous studies analyzing sequences of behavior have focused primarily on the valence of the behavior in patient-relative discussions instead of on the valence and the content of the behaviors (e.g., Hahlweg et al., 1989). Contrary to our predictions, independent ratings of symptomatology were not significantly associated with relatives’ negativity toward the patient in the problem-solving interactions. Past studies have found a relationship between EE and symptomatology (e.g., Glynn et al., 1990) but it appears that when interactional style is assessed through direct observation, the severity levels of positive or negative symptoms do not predict the degree of relatives’ negativity. Individual differences among relatives of schizophrenic patients may explain why some relatives respond negatively to the patients’ symptomatology. For example, attributions that relatives have about the patients’ symptoms may mediate between the severity of the symptoms and the relatives’ affective response (see Brewin et al., 1991). Individual differences in relatives’ responses to patients’ symptomatology are potentially useful in understanding this phenomenon. It is unclear why patients’ independently rated social skill was not associated with the intensity of relatives’ negativity. Determinants of negativity from within the patient-relative problem-solving interactions appeared to be much more important than the level of skills assessed independently in the role-play test. This finding may stem from ingrained patterns of communication that had developed over time between the relative and patient. As suggested above, it may be essential to look at specific kinds of behavior occurring within

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an interaction to evaluate what processes lead to greater negativity from relatives. For example, we recently reported that specific ineffective strategies of avoidance and withdrawal (i.e., lying or denying errors to escape criticism) are particularly characteristic of schizophrenic patients, and we suggested that these findings deserved more attention (Bellack et al., 1992). The mean ratings for patients’ and relatives’ global negativity were not correlated in the present study, although superficially the results of previous studies suggest that overall levels of patients’ and relatives’ negativity should be correlated (e.g., Hahlweg et al., 1989; Strachan et al., 1989). However, instead of using globally rated negativity, these studies used counts of statements during family interactions that were classified as negative on the basis of their content or nonverbal factors (Hahlweg et al., 1989; Strachan et al., 1989). Furthermore, the association between patients’ and relatives’ negativity in Hahlweg et al. (1989) was based on the sequential probability of negativity rather than overall levels. Thus, the lack of a significant association between relatives’ and patients’ overall levels of negativity does not necessarily imply that there are not important sequential associations between the participants’ negative statements. Studies are needed to evaluate the relative benefits of both methods of assessing the associations between patients’ and relatives’ negativity. Other explanations for the present findings and limitations of the present study must be acknowledged. First, the Quality of Communication and Quality of Problem Solving ratings had the lowest reliability but were seemingly the most important in predicting global Negative Valence ratings. This is notable given that variables with lower reliability are most likely to result in an underestimation of relationships among the variables. However, to support this interpretation, improving the reliability of the ratings in any replication would be essential. Second, some of the family-interaction assessments were conducted an average of 5-6 weeks after the symptomatology ratings were made (6 weeks after the diagnostic interview). This could have minimized the observed relationship between the level of symptomatology

and behavior exhibited in the videotaped family discussion (family problem-solving task). On the other hand, none of the patients participated in the assessment procedures until they were considered to be stabilized; therefore, it is quite likely that the symptom ratings were good estimates of the patients’ level of symptomatology at the time of the family problem-solving task. In a related vein, the question remains as to whether the findings would be the same if the patients and their relatives had been assessed a significant period of time after leaving the hospital (e.g., a year later). This is an issue that is being addressed in an ongoing study. Furthermore, common method variance also should be considered as an explanation for the consistent association between Negative Valence and the other global ratings of the participants’ communication behavior. However, the fact that these associations were across the patient-relative dyad, and not within each participant, mitigates this concern. Another limitation of the present study is that the family interaction occurred in the laboratory with only one other family member. Although an attempt was made to engage the relative who had the most contact with the patient, it is possible that this assessment does not reflect a home environment where other relatives are present. Last, the independent assessment of overall social skill involved role-play scenarios that differed across the two studies from which the subjects were drawn. We believe that these content differences had limited effects on the ratings of overall social skill given that previous results were the same across the two studies (Bellack et al., 1990, 1992). It is still possible, however, that content differences reduced the ability of the present design to detect a relationship between independently assessed social skill and relatives’ negative affect. There are many questions remaining about the determinants of the level of negativity in a household that has a patient with schizophrenia. Research has just begun to examine relatives’ and patients’ characteristics that may contribute to this negativity. It is clear that studies will need to examine more detailed questions about the family environments of schizophrenic patients instead of relying solely on the EE construct to achieve a

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greater understanding of interactional patterns (see Koenigsberg and Handley, 1986; Halford, 1991). One approach might be to develop better strategies of measuring in-home family interaction. Drawbacks of laboratory samples of interactional behavior include potentially significant reactivity of the participants and the need to standardize the procedure across families. Obtaining a sample of in-home behavior in an unobtrusive way is a significant challenge. The positive aspects of family interactions are also considerably important, especially the extent to which family members work together to resolve ongoing conflicts and stressors within the family. Only by understanding these processes fully can we best design interventions that will facilitate the functioning of schizophrenic patients who live with family members. Acknowledgements

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