Hopelessness and its impact on rehabilitation outcome in schizophrenia –an exploratory study

Schizophrenia Research 43 (2000) 147–158 www.elsevier.com/locate/schres

Hopelessness and its impact on rehabilitation outcome in schizophrenia – an exploratory study Holger Hoffmann *, Zeno Kupper, Barbara Kunz University Psychiatric Services Bern, Mid and West Sectors, Laupenstrasse 49, CH-3010 Bern, Switzerland Received 16 October 1998; accepted 20 July 1999

Abstract The primary focus in contemporary psychiatry on symptoms and their neurobiological basis, although fundamentally important, is nevertheless incomplete. The long-term course and outcome of schizophrenia are determined not only by the disorder, but also by the interaction between the person and the disorder. Not only psychopathological symptoms but also cognitive variables such as negative self-concepts, low expectations and external loci of control can influence the patient’s coping strategies and may lead to hopelessness and chronicity. Hopelessness here refers to a cognitive-affective state in which the patient perceives the disorder and its consequences to be beyond his control, feels helpless and has given up expecting to influence its course positively, thereby abandoning responsibility and active coping strategies. In a prospective study, we examined these relationships by using logistic regression in data from 46 schizophrenic outpatients who were participating in a vocational rehabilitation program. Negative selfconcepts, external loci of control, and depression correlated to a higher extent with depressive-resigned coping strategies than did schizophrenic symptoms. Thus, poor rehabilitation outcome may be predicted to a high degree by the presence of external loci of control, pessimistic outcome expectancies, negative symptoms, and depressive-resigned coping strategies. After having eliminated the influence of negative symptoms, external control beliefs still had significant predictive value for the outcome. Rehabilitation outcome in schizophrenic patients can be only partially predicted by negative symptoms; the other predictive factor is whether the patient has already given up or not. © 2000 Elsevier Science B.V. All rights reserved. Keywords: Coping; Hopelessness; Locus of control; Negative symptoms; Outcome expectancies; Rehabilitation outcome; Schizophrenia

1. Introduction Recent studies on rehabilitation in schizophrenia have revealed that outcome is determined to a major extent by negative symptoms (Solinski et al., 1992; Lysaker and Bell, 1995; Hoffmann and Kupper, 1997). It is now widely accepted that * Corresponding author. Tel: +41-31-387-6111; fax: +41-31-382-9020. E-mail address: [email protected] (H. Hoffmann)

negative symptoms are the typical and enduring characteristic features in the long-term course of schizophrenia (Pogue-Geile and Harrow, 1984; Fenton and McGlashan, 1994) and that prominent negative symptoms are accompanied by a distinctly unfavorable course (Andreasen, 1982; Crow, 1985; Carpenter et al., 1988). However, this long-term course and outcome are determined not only by the disorder’s process itself but also by the interaction between the person and the disorder. These interactions involve the patient’s feelings, cogni-

0920-9964/00/$ - see front matter © 2000 Elsevier Science B.V. All rights reserved. PII: S0 9 2 0 -9 9 6 4 ( 9 9 ) 0 0 14 8 - 6

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tions, and actions. They influence phases of the disorder and have a major impact on psychological control mechanisms that guide the evolution of these phases (Strauss, 1987, 1989). The primary focus that mainstream psychiatry places on symptoms and their neurobiological basis, although important, is incomplete. An alternative view conceptualizes adaptive functioning as influenced by an individual’s organizational status, reflected by his or her beliefs, selfconcepts, and expectations. Bleuler (1911) noted that deterioration and improvement in the longterm course of schizophrenia often depend on the patient’s self. Strauss (1989) and Breier and Strauss (1983) suggest centering more attention on the patient’s self, personal goals, life trajectories, and active role in regulating one’s own life and psychopathology. Such an approach, based on the stressvulnerability concept ( Zubin and Spring, 1977) and the coping model of Lazarus and Folkman (1984), would seem instrumental in explaining either the presence or lack of adaptive functioning and coping strategies in the long-term course (Bo¨ker, 1987; Bo¨ker et al., 1992). Chronicity as a consequence of maladaptive interactions with the person’s self, the environment, and the disorder, plus the resultant coping behavior often characterizes the long-term course of schizophrenia. One contributing factor to chronicity may be hopelessness, i.e. when the patient perceives the disorder and its consequences to be beyond his control, feels helpless, and has given up expecting to influence its course positively, thereby abandoning responsibility and active coping strategies. Cognitions indicating hopelessness may strongly influence the patient’s behavior, especially manifested in secondary negative symptoms and impaired psychosocial functioning, even after partial or full remission of symptoms. Thus, once established, hopelessness may become a central limiting factor in the efficacy of treatment and rehabilitation. Hopelessness has been operationalized by Beck et al. (1974) in a relatively short ‘Hopelessness Scale’. This questionnaire mainly focuses on negative expectations about the future and on depressive ideation, neglecting other theoretical constructs that are helpful in characterizing hope-

lessness as a cognitive-affective construct and in defining its interaction with the disorder of schizophrenia. These theories include locus of control and related theories of perceived control, the role of depression and loss of optimism, the patient’s outcome expectancies and self-concepts, and the type of coping strategies chosen to handle stressful situations. These constructs, though in part closely related to one another, represent different aspects of hopelessness and function on different behavioral levels. As it was our intention to investigate (1) the interaction between the different aspects of hopelessness, and (2) to identify the factors that have the highest impact on rehabilitation outcome, the following constructs and related measurements were included in the study. 1.1. Locus of control construct The belief in internal versus external control of reinforcement concerns the degree to which an individual perceives life events as being contingent upon his or her own behavior, which is assumed to be more or less consistent across a variety of situations. Rotter first conceptualized this with the locus of control (LOC ) construct (Rotter, 1966). Other constructs of perceived control, such as ‘causal attributions’ ( Weiner, 1988), the ‘learned helplessness’ of Seligman (1975) and Abramson et al. (1978) and the ‘self-efficacy’ of Bandura (1977), although based on different theoretical backgrounds, are closely related to LOC (Strickland, 1989; Skinner, 1995). In contrast to personality traits, these belief sets are constructed by the individual; hence, they can be influenced and altered by new experiences (Skinner, 1995). Perceived control seems in part to reflect the individual’s generalized sense of confidence and experience of self as either a hopeful, causal agent in the world or as a despairing victim who is acted upon ( White, 1965). Rotter’s dichotomic locus of control was reconceptualized by Levenson (1972), who split the external locus into: (1) a scale of control by powerful others, and (2) one of control by chance or fate. These two external loci of control, which represent the tendency to believe in the efficacy of environmental rather than personal forces in understanding the

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causes of life outcomes, can be interpreted as fatalism ( Wheaton, 1983) and as contributing to hopelessness. This widely studied cognitive construct was previously found to be related to schizophrenia, psychopathology, and general adjustment. Numerous studies have reported schizophrenics to have a higher external score on LOC than other diagnostic groups (Seeman and Evans, 1962; Harrow and Ferrante, 1969; Cash and Stack, 1973; Varkey and Sathyavathi, 1984; Goodman et al., 1994) and mentally healthy persons (Cromwell et al., 1961; Duke and Mullens, 1973; Kraemer and Schikor, 1991). The finding that persons suffering from a chronic disease report a significantly higher external locus of control has been replicated several times (Strickland, 1978; Wallston and Wallston, 1981, 1982), as have the relationships of external locus of control with the acceptance of the diagnosis ( Warner et al., 1989; Birchwood et al., 1993). However, an internal locus of control proved to be important for good outcome in psychotic patients ( Warner et al., 1989).

1.2. Depression and loss of optimism Previous research has revealed that fatalistic externality is highly related to depression and to feelings of hopelessness (Beck, 1967; Beck et al., 1974; Prociuk et al., 1976; Benassi et al., 1981; Brown and Siegel, 1988). Birchwood et al. (1993) demonstrated that in schizophrenia, the patient’s perception of the uncontrollability of his illness correlates highly with depression. For Birchwood et al., depression in schizophrenia may be — apart from other forms and etiologies — in part a psychological response to an apparently uncontrollable life event, namely the illness and its disabilities. Seligman (1975) interpreted depression as an obvious response to problems in coping — a highly likely consequence of ‘giving up’. The loss of optimism, as occurs when people are demoralized or depressive, engenders hopelessness and strongly influences the interaction between the person and the disorder, thereby leading to a poor outcome (Aguilar et al., 1997).

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1.3. Outcome expectancies Both the motivation to do something or not and the ensuing, observable behavior are determined not only by the experiences of the past and by present control beliefs and affects, but to a substantial degree also by expectations of the future. The importance of future expectations in the rehabilitation of chronic schizophrenics has been demonstrated by Ciompi et al. (1979) and Dauwalder et al. (1984). According to Bandura (1977, 1982), outcome expectancies must be differentiated from efficacy expectancies because an individual can believe that a particular course of action will produce a positive outcome, but if he has serious doubts about whether he can perform the necessary activities, his behavior will not change in the expected direction, and he experiences helplessness. If both expectations are low, hopelessness and passivity will be the result.

1.4. Self-concepts Another important influence on behavior are the individual’s self-concepts. Positive self-concepts can be associated with ego-strength (Deusinger, 1986), while negative self-evaluation is, according to cognitive theories, a major component of depression. Deusinger (1986) demonstrated that the self-concept of patients with schizophrenia is significantly more negative than that of normals, but more positive than the selfconcept of depressive patients. Of all self-concept dimensions, self-esteem is most often discussed in the literature. The studies of Tennen and Herzberger (1987) and of Tennen et al. (1987) revealed that self-esteem is a more powerful predictor of failure attribution than depression, which itself highly correlates with low self-esteem (Battle, 1978; Wilson and Kane, 1980). Other studies have proven low self-esteem to be highly related to schizophrenia (Grinker and Holzman, 1973; Kendler and Hays, 1982), to the severity of schizophrenic symptoms (Brekke et al., 1993), and to the severity of disturbance for both depressives and schizophrenics (Goodman et al., 1994).

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1.5. Stress and coping strategies In the stress-vulnerability models of Zubin and Spring (1977), Nuechterlein and Dawson (1984), and Liberman (1986), personal coping resources are said to have a protecting effect against stress. There is some evidence that perceived control, optimism or pessimism, as well as expectancies and self-concepts are part of the coping resources and therefore mediate coping behavior ( Wheaton, 1983; Lazarus and Folkman, 1984; Beutel, 1989; Bo¨ker et al., 1989). Thus, the effect of stress depends on the individual’s belief as to whether a stressful event is controllable or not. According to the learned helplessness model, we may hypothesize that people with perceived external control have limited access to their coping potential in stressful situations. If a situation is perceived as uncontrollable, not only patients with negative self-concepts but also those with an optimistic outlook tend to choose a depressive-resigned coping strategy rather than an active, problemfocused approach. Vocational rehabilitation that aims at reintegration into competitive employment can be very demanding and stressful for patients with schizophrenia. Sufficient coping resources and functional coping strategies are needed to achieve a favorable outcome. Although schizophrenics generally seem to have fewer coping resources than normal controls, it can be assumed that they differ among themselves not only in symptomatology but also in their coping resources, which are mediated by the individual extent of hopelessness as characterized by the interplay of the different constructs discussed above. 1.6. Study questions The review of the pertinent literature leads us to assume that all the cognitive variables indicating hopelessness are closely inter-related as well as strongly related to symptomatology and coping behavior. The distinct impact of each of these variables on hopelessness and on the long-term course and rehabilitation of schizophrenia, however, cannot yet be clearly determined, as these constructs are still underestimated in schizophrenia

research. Thus, owing to the complex relations among the different aspects of hopelessness, it is not surprising that a clearly operationalized model of hopelessness in the long-term course of schizophrenia does not yet exist. The purpose of the present study was to explore the impact of different cognitive variables indicating hopelessness on the prediction of rehabilitation outcome and specifically to examine: (1) the interaction among the cognitive variables indicating hopelessness and their interaction with schizophrenic symptomatology and the patient’s coping strategies; (2) which of these variables are predictive for outcome in a vocational rehabilitation program; and (3) whether outcome can be predicted by these cognitive variables, statistically independently from the influence of negative symptoms. The last question was included as it may be hypothesized that some variables are significantly related to negative symptoms, which have already been proven to be highly predictive for the outcome of this program (cf. Hoffmann and Kupper, 1997).

2. Subjects and methods 2.1. Background The rehabilitation program for vocational reintegration into competitive full-time employment developed at the University Psychiatric Services Bern has been described in detail elsewhere (Dauwalder and Hoffmann, 1992). Patients attend a five-phase program for a maximum of 18 months. Phase 1 is the assessment phase and lasts for 2 weeks, at the end of which time patients demonstrating less than 40–50% of ordinary work performance are excluded. Other exclusion criteria include a high level of manifest psychotic symptoms or insufficient motivation. Phase 2 takes place in a program-integrated workshop, with a capacity for 15 participants. After approximately 6 months, during phases 3 and 4, the patients begin working on training jobs in local companies. Phase 5 is the aftercare phase. From the third phase onward, a mobile rehabilitation team supports not only the patients in their training jobs, but also their

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co-workers and supervisors. Other significant aspects of the program are the social skills training group, which meets twice weekly, and the participation of people from the relevant environment in the form of monthly systemic family therapy. 2.2. Study group To date, 46 patients, meeting DSM-IV criteria for schizophrenia, have been enrolled in the program. The average age was 27.6 years (s.d. 4.9). Sixteen participants were female (=35%). Four patients were married, six separated, divorced or widowed, and the rest single. The mean duration of mental disorder was 5.6 years (s.d. 5.0) during which time the patients had been hospitalized an average of 2.6 times (s.d. 2.2). Thirty-one (=67%) had completed vocational training, five (=11%) had failed to pass their final examination, and only 10 (=22%) were unskilled. The mean duration of unemployment before entering the program was 14.0 months (s.d. 12.7). On the Global Assessment of Functioning Scale (GAF ), axis V in DSM-IV, they scored an average of 42.6 points (s.d. 5.7), i.e. they were all seriously impaired in their social or occupational functioning. All participants were taking medication and were in a psychopathologically stable state when entering the program. 2.3. Instruments The self-report measures of locus of control (LOC ) were assessed by the IPC-Scales of Krampen (1981), the German version of the internal ( I ), powerful others (P), and chance (C ) scales of Levenson (1972, 1974), which are a reconceptualization of Rotter’s ROT-IE (Rotter, 1966). The major differences to the ROT-IE are the three-dimensionality of the IPC-Scales, and that each statistically independent scale consists of eight items in a six-point Likert scale format, ranging from ‘completely wrong’ to ‘absolutely correct’. The items measure the degree to which a person perceives events in his life as being a consequence of his own acts, under the control of powerful others, or determined by chance. The self-concepts were assessed by the Frankfurt Self-Concept Scales (FSKN ) constructed by Deusinger (1986). The FSKN disting-

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uishes 10 different self-concepts, representing four dimensions of the self: competence and achievement, self-esteem, affects and sensibility, and a psychosocial dimension. The FSKN is a self-report instrument containing 78 items with a six-point Likert scale format ranging from ‘fits very well’ to ‘does not fit at all’. In accordance with the studies of Deusinger, in our sample, all 10 scales were highly intercorrelated (Pearson’s r ranged from 0.44 to 0.81), and the internal consistency was excellent (Cronbach’s alpha=0.95). These results legitimized our using the sum-score of the 10 scales as an overall measure of self-concepts. The patients’ expectancies of rehabilitation outcome were assessed by a specially constructed fivepoint Likert-format self-report scale devised by Ciompi et al. (1979). Expectation of vocational status at the end of the rehabilitation program ranged from ‘unemployed’ to ‘competitive fulltime job’. The patients’ psychopathology was assessed by the Positive and Negative Syndrome Scale (PANSS; Kay et al., 1992). The PANSS is a 30-item rating scale that constitutes three rationally derived categories: positive symptoms, negative symptoms and general symptoms. The five depressive symptoms were chosen from the general symptoms category in conformance with the fivefactor model of Kay and Sevy (1990), which has been confirmed by factor analysis by Lindenmayer et al. (1995). All ratings were done by the first author, who was trained beforehand by rating videotapes of Kay et al. Coping was assessed by a self-report questionnaire on stress-coping strategies developed by Janke et al. (1985). This contains 19 subscales of different coping strategies, each comprising six items in a five-point Likert scale format. The internal consistency (Cronbach’s alpha ranged between 0.66 and 0.92) and retest reliability (r ranged between 0.68 and 0.86) proved to be satisfactory (Janke et al., 1985). To reduce the complexity of the data, we conducted a factor analysis. Although the sample was small, Kaiser’s measure of sampling adequacy was 0.71 and the final communality estimates were >0.58 in all variables but one. Owing to the eigenvalues, the factor analysis with varimax rotation was restricted to two factors that explained 60% of the total vari-

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ance. Factor I explaining 31% can be termed ‘active-change oriented coping factor’ as it contains nine subscales such as ‘positive self-instruction’ and ‘search towards self-confirmation’. Factor II represents eight subscales such as ‘self-pity’, ‘resignation’ and ‘brooding’ and can therefore be termed a ‘depressive-resigned coping factor’. The two subscales with the lowest loadings, ‘playing down by comparison with others’ and ‘defense of guilt’ did not load on either factor. The consistency of both factors proved to be good with Cronbach’s alpha= 0.92 each. In a further analysis, only the two coping factors were used. Although the instruments used in this study depend on self-reporting and therefore suffer from common method variance, they all have been subjected to psychometric analysis and have already been administered to schizophrenics with reasonable results. 2.4. Procedure All instruments used to predict the outcome of rehabilitation were administered during the two weeks of the assessment phase. The assessment of individual outcome was carried out 6 months after the termination of the program that had a mean duration of 38.3 weeks (s.d. 28.8). As in a previous study (Hoffmann and Kupper, 1997), the patient’s

rehabilitation outcome was determined by the highest level that he had reached in the five-phase program: 1=dropped out of the program after the assessment phase (n=12); 2=dropped out of the program in phase 2 (n=14); 3=dropped out from the training job in phase 3 or 4 (n=5); 4=obtained competitive full-time employment, but lost the job in phase 5 within the following 6 months (n=5); 5=obtained and maintained competitive employment for over 6 months (n=10). Spearman correlations and backward logistic regressions were computed by using SAS (1989) statistical software.

3. Results 3.1. Correlational analyses The results presented in Table 1 demonstrate that the internal LOC significantly correlates with positive self-concept and that the two external LOC scales are strongly inter-related and highly correlate with negative self-concepts. Outcome expectations, however, do not significantly correlate with either LOC, self-concepts, or any symptomatology. Both negative and positive symptoms highly correlate with depressive symptoms. The presence

Table 1 Spearman correlations among all variables (n=46) Internal LOC by LOC by LOC powerful chance others LOC by powerful others LOC by chance Self-concept Outcome expectations Positive symptoms Negative symptoms Depressive symptoms Active-change coping Depressive-resigned coping Outcome

−0.02

Outcome Positive Negative Depressive Active- Depressiveexpectations symptoms symptoms symptoms change resigned coping coping

–

−0.21 0.58*** – 0.40** −0.52*** −0.57*** 0.24 −0.13 −0.29 −0.33* 0.16 0.25 −0.16 0.28 0.35* −0.21 0.06 0.34* 0.32* 0.14 0.20 − 0.11 0.51*** 0.64*** 0.08

Selfconcept

−0.51*** −0.54***

* p<0.05; ** p<0.01; *** p<0.001.

– 0.28 −0.46** −0.42** −0.49*** 0.03 −0.80*** 0.33*

– −0.26 0.01 −0.05 −0.16 −0.36* 0.42**

– 0.12 0.61*** 0.28 0.36* −0.01

– 0.48*** 0.04 0.35*

– 0.17 0.41**

−0.40** −0.10

– 0.34*

–

−0.08 −0.32*

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of all three kinds of symptoms correlates highly with negative self-concepts. Only positive symptoms significantly correlate with negative internal LOC. However, both negative and depressive symptoms significantly correlate with LOC by chance. Depressive-resigned coping strategies significantly correlate with all variables except the internal LOC. The latter, however, is the only variable that significantly correlates with active coping strategies — a result that not only makes sense but also sustains the distinction made among the coping variables by factor analysis. Poor rehabilitation outcome correlates highest with the two external LOC scales, followed by reduced outcome expectations and negative symptoms and, to a lesser degree, with negative selfconcepts and depressive-resigned coping strategies. Positive and depressive symptoms do not correlate with outcome at a significant level, nor do sociodemographic and work-historic variables. These findings confirm our hypothesis of the complex inter-relation of the different aspects of hopelessness.

3.2. Logistic regressions In order to determine which of the variables are predictive for outcome, backward logistic regression onto outcome was performed with all six variables that significantly correlated with outcome. The resulting model — presented in Table 2 — consisted of all variables but selfconcept. The effect of all independent variables on outcome was 24.7 with 5 df ( p=0.0002). The association of predicted probabilities and observed responses was concordant in 83.1% and discordant in 16.9%. Thus, it can be stated that in addition to negative symptoms, cognitive variables indicating hopelessness and depressive-resigned coping behavior predict a negative rehabilitation outcome in schizophrenia. To test the third study question of whether outcome can be predicted independently from the influence of negative symptoms, negative symptoms were first regressed onto all other variables except outcome. Thus, the variance that might stem from negative symptoms was eliminated. In a second step, backward multiple regressions of

Table 2 Backward logistic regression onto outcome of all variables significantly correlating with outcome (n=46) Variable

df

Parameter estimate

Standard error

Wald chi-square

Pr>chi-square

Standardized estimate

Intercept 1 Intercept 2 Intercept 3 Intercept 4 LOC by powerful other LOC by chance Outcome expectations Negative symptoms Depressive-resigned coping

1 1 1 1 1 1 1 1 1

−6.21 −3.80 −2.91 −2.01 0.23 0.20 −1.15 0.11 −0.03

3.23 3.16 3.14 3.12 0.10 0.08 0.45 0.05 0.01

3.71 1.44 0.86 0.41 5.31 6.13 6.49 6.31 6.52

0.05 0.22 0.35 0.52 0.02 0.01 0.01 0.01 0.01

– – – – 0.57 0.66 −0.47 0.49 −0.63

Table 3 Backward logistic regression onto outcome of all variables significantly correlating with outcome after eliminating the influence of negative symptoms (n=46) Variable

df

Parameter estimate

Standard error

Wald chi-square

Pr>chi-square

Standardized estimate

Intercept 1 Intercept 2 Intercept 3 Intercept 4 LOC by powerful others

1 1 1 1 1

−1.26 0.37 0.90 1.52 0.20

0.36 0.32 0.34 0.39 0.07

11.94 1.39 7.01 15.09 7.94

0.0006 0.24 0.01 0.0001 0.005

– – – – 0.47

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the residuals from step 1 were computed onto outcome. This time, only LOC by powerful others was left in the model as shown in Table 3. Its effect was 8.01 with 1 df ( p=0.005). The association of predicted probabilities and observed responses was concordant in 64.0% and discordant in 34.4%. For comparison, logistic regression was performed again onto outcome, but with negative symptoms as the only independent variable. The effect of negative symptoms on outcome was 7.46 with 1 df ( p=0.006). The association of predicted probabilities and observed responses was concordant in 64.9% and discordant in 31.5%. Thus, external control beliefs, uninfluenced by negative symptoms, were not only the cognitive variables indicating hopelessness with the greatest impact on rehabilitation outcome but furthermore predicted outcome to the same extent as negative symptoms alone.

4. Discussion The findings of the present explorative study suggest a considerable impact of hopelessness on rehabilitation outcome. As illustrated in Fig. 1, the two external loci of control (i.e. the beliefs of being controlled by powerful others and by chance) and negative self-concepts are strongly inter-related, whereas low outcome expectancies seem to be quite independent of them. The incidence of high inter-relations among cognitive variables indicating hopelessness, and these in turn with depressiveresigned coping behavior, corroborates our hypothesis that these variables have one factor in common, namely: ‘giving up’. These findings are in line with Bandura’s model (Bandura, 1982) that if both self-efficacy and outcome expectancies are low, hopelessness and apathy will result. The presence of depressive symptoms and, to a lesser degree, both positive and negative symptoms also significantly correlates with a preference for depressive-resigned coping strategies. A negative rehabilitation outcome, however, can be predicted only in part by symptomatology (i.e. negative symptoms) and at least to the same extent by the cognitive variables indicating hopelessness. When interpreting the findings of this study, it

should be borne in mind that they are representative of schizophrenic patients about to enter a rehabilitation program. The findings do not reflect the evaluation of patients with acute schizophrenia, nor of a sample with chronic psychiatric disorders. In this study, self-concept was removed in the logistic regression analysis, although it was outlined in the review of Anthony and Jansen (1984) as one of the best outcome predictors in vocational rehabilitation. On the one hand, the LOC construct proved to be the more powerful, and on the other hand, depressive-resigned coping strategies are very strongly related to negative self-concepts and probably replaced them in the model. Another unanticipated result was that although depressive symptoms correlated highly with depressive-resigned coping behavior, as was expected, they do not predict a poor rehabilitation outcome. A reason for this might be that both depressive and positive symptoms were only of minor significance in the highly selected study sample of stabilized schizophrenic patients. In further studies, the use of more sensitive instruments than the depressive factor of the PANSS for assessing depression in schizophrenia, e.g. the new Calgary Depression Scale by Addington et al. (1993), might serve to clarify this question. Our factor-analytical division into two different coping styles does not exactly conform to that of Lazarus and Folkman (1984), who distinguished an emotional-focused and a problem-focused coping form. Closer examination, however, reveals that the first form also encompasses coping strategies to avoid and deny stressors, while the second comprises active coping efforts to change the environment. Both strategies influence one another and are often used in conjunction. However, it is noteworthy that in the present study, neither active, change-oriented coping nor internal control, both of which seem inter-related (cf. Kraemer and Schikor, 1991), had a significant impact on outcome. Different studies have revealed that an internal, as opposed to external, control has only minimal discriminating value (Seeman and Evans, 1962; Levenson, 1974). This would indicate the independence of internal and external LOC. Krampen (1979), however, found that in factor analysis, internal items load on two different

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Fig. 1. Contributing factors to hpelessness and poor rehabilitation outcome according to our findings=correlations=logistic regression.

factors, i.e. the internal LOC seems inconsistent. In addition, in this study, Cronbach’s alpha of the internal LOC was an unsatisfying 0.31. Our findings substantiate the results of recent studies that negative symptoms are the best outcome predictors of all schizophrenic symptoms (Solinski et al., 1992; Lysaker and Bell, 1995; Hoffmann and Kupper, 1997), but also substantiate Strauss’s statement (Strauss, 1989) that the long-term course and outcome of schizophrenia are determined by the interaction between the disorder and the person. In the present study, it was not possible to determine whether fatalism, negative self-concepts, or depressive-resigned coping strategies existed prior to the onset of the disorder and therefore contributed to the individual’s vulnerability, or whether they were a sequel or consequence of the disorder. Even if these factors are a consequence of the disorder, in time, they would become autonomous and develop their own dynamics. Frenkel et al. (1995) demonstrated that external LOC assessed in normal adolescents is a good predictor of a DSM-III-R diagnosis of schizophrenia 15 years later. These findings support the hypothesis that a perceived external control pre-exists as a vulnerability marker.

Conversely, there is evidence that some negative symptoms are secondary and may be seen as maladaptive coping strategies. Social withdrawal is a typical example of a negative symptom that represents depressive-resigned coping behavior but can also be considered a consequence of fatalism. The example of social withdrawal illustrates not only the overlap of different psychiatric constructs, but also the complex interaction of personality and disorder. A similar interaction exists between perceived external control, helplessness, and depression ( Hiroto, 1974; Seligman, 1975). Individuals who tend to believe that they exercise little or no control in a specific situation are inclined to generalize this belief and will, when experiencing a situation of real uncontrollability, be quicker to react helplessly and give up. The interaction between the individual’s behavior and the disorder is not linear but circular, and may lead to reciprocal escalation and stagnation in a vicious circle. This is particularly prevalent in the interaction between negative or depressive symptoms and hoplessness. The patient seems to develop negative behavioral motivation, loses selfconfidence, becomes demoralized, and finally gives up believing in a successful outcome. In time, such

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interaction patterns become increasingly stable. The consequence is the development of chronicity, which itself precludes frequent active changeoriented coping behavior. Once the role of being a chronic patient is adopted as a mode of coping, the individual allows others to take control, and gives up expectations for the future. However, belief in the future is crucial to adaptation. The preference for adopting depressive-resigned coping strategies in schizophrenia, which has also been substantiated by Kraemer and Schikor (1991), may be seen as a typical expression of chronicity, not of schizophrenia itself. Several studies have revealed that many schizophrenic patients also develop active coping strategies (Breier and Strauss, 1983; Bo¨ker, 1987; Thurm and Ha¨fner, 1987) that prove far more helpful than passive-resigned coping behavior in managing the disorder (Heim, 1988). Speculating on the implications for therapy of our findings is premature. However, if they should gain support in future research, rehabilitation programs for schizophrenics should place more emphasis on reducing fatalistic beliefs and helplessness and on inducing more positive self-concepts and more optimistic but realistic expectations. Objections may be raised that the aforementioned behavior patterns are not specific to schizophrenia, but this view does not take into account the fact that the non-specificity of many protectors, stressors, and potentiators is integral to the vulnerability-stress model of schizophrenia. Indeed, it is the nature of the interaction among non-specific stressors, potentiators and protective factors with specific psychobiological vulnerability that determines the onset, course and outcome of schizophrenia (Liberman, 1986). In-depth clarification of these interactions should be the aim of future research. A major finding of this study, however, is that non-specific cognitive variables, such as external control beliefs, that indicate hopelessness can have the same predictive value for rehabilitation outcome as do negative symptoms.

Acknowledgements This research was supported by the Swiss National Science Foundation, Grant 3200-028795.

The authors would like to thank Professor F.A. Henn for his kind assistance in selecting a substitute term for ‘resignation’, which was originally used in this work. We were advised that the primary operational definition of the term ‘resignation’ within the context relevant to our research is often confined to the act of resigning tenure of employment. In order to avoid semantic ambiguity, we have decided to replace it with ‘hopelessness’.

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