SCHIZOPHRENIA RESEARCH ELSEVIER
Schizophrenia Research 29 (1998) 275-286
Social skill as a determinant of social networks and perceived social support in schizophrenia E.M. Macdonald a,,, H.J. Jackson b, R.L. Hayes c, A.J. Baglioni, Jr c, C. Madden a,1 a La Trobe University, Bundoora, Victoria 3083, Australia b University o f Melbourne, Parkville, Victoria 3052, Australia
° University of Queensland, Queensland4072, Australia
Received 10 September 1996; accepted 4 July 1997
Abstract
Factors influencing supportive social networks of people with schizophrenia are little understood. Data from 46 outpatients with schizophrenia were analysed using structural equation modelling to test plausible sets of interrelationships between social skill, social networks, and social support. The data supported a tentative model about the causal relationships between variables. Paths showed that people with greater social skill had larger social networks, but did not necessarily perceive greater support from these networks. Negative symptoms accounted for some of the effect of social skill on social networks. Whereas groups of single-admission and multiple-admission participants did not differ in terms of social skill, social networks, or support, the age of the participants influenced their social skill and the size of their social networks. Younger participants had greater social skill and larger social networks. The results appear to suggest the importance of early intervention for young people with first-episode psychosis. © 1998 Elsevier Science B.V. Keywords: Social skill; Social network; Social support; Schizophrenia; First-episode psychosis; Early intervention
I. Introduction
Supportive social networks are thought to help people with schizophrenia function independently and maintain community tenure (Liberman and Mueser, 1989). Although people with schizophrenia often experience deterioration and difficulty in social relations, social withdrawal, and * Corresponding author, at: School of Occupational Therapy, Faculty of Health Sciences, La Trobe University, Bundoora, Vic 3083, Australia. Tel: +61 3 94791111; e-mail:
[email protected] 1Deceased. 0920-9964/98/$19.00 © 1998 Elsevier Science B.V. All rights reserved. PH S0920-9964 (97) 00096-0
social isolation (American Psychiatric Association, 1987), there is little understanding about the interrelationships between symptoms of schizophrenia, social skill deficits, and a person's social networks and social support. Several cross-sectional studies have found positive relationships between social competence, social networks, and social support for people with schizophrenia (Denoff and Pilkonis, 1987; Faccincani et al., 1990; Brugha et al., 1993). However, none of these studies has considered the impact that an individual's social skill may have on their social networks and social supports. N o r have they considered the impact that a range of
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illness-related variables, such as severity of psychotic symptoms or phase of illness (Carpenter and Kirkpatrick, 1988), may have on the social networks or social support of people with schizophrenia. Severe negative symptoms have been found to be associated with small social networks and few, close supportive relationships (Hamilton et al., 1989; Brugha et al., 1993; Cresswell et al., 1992; Romney, 1995). Similarly, negative symptoms are associated with social skill deficits (Jackson et al., 1989a,b; Mueser et al., 1990b, 1991; Bellack et al., 1994). Two studies have examined the relationship between social skill and community social functioning in the context of psychotic symptoms of schizophrenia (Mueser et al., 1990b; Halford and Hayes, 1995). However, these studies did not determine the relative contribution of participants' psychotic symptomatology; nor did they specifically measure the characteristics of participants' social support networks or the quality of the social support obtained from these relationships. It is thought that the protective quality of people's social support arises primarily from their subjective experience of the relationships in their social networks (Heitzmann and Kaplan, 1988), and that people with schizophrenia can find intense or conflictual relationships stressful (Henderson, 1980). It is therefore particularly important to measure the subjective experience, or perception, of social support in studies of people with schizophrenia. Given the heterogeneity of schizophrenia, it is important to differentiate between people at different stages of their illness (Lieberman et al., 1992). It is unclear whether the social skill or social networks of people with schizophrenia change with increasing age and prolonged illness (Walker et al., 1993). Intervention with people with schizophrenia may be most effective at particular ages and stages of illness in increasing social networks and social support. Few social network or social support studies have differentiated between people with prolonged schizophrenia and people with recent-onset schizophrenia (Jackson and Edwards, 1992). The research reported in this paper explores the
relationship between the level of social skill and the psychotic symptomatology of people with schizophrenia and their perceptions of the number of people in their social networks and the support received from these relationships. Variables are examined in the context of people's phase of illness: specifically severity of symptoms of schizophrenia, chronicity or stage of illness, and age. The purpose of this study was to test theories relating to the relative impact of people's social skill, psychotic symptoms, and phase of illness on the size of the social support networks and the perceived social support of people with schizophrenia.
1.1. Hypothesized models Ideally, theory testing involves comparing the goodness of fit of models representing competing theories (Tabachnich and Fidell, 1996). In the present example, there is competing evidence about causal relationships between phase of illness and symptomatology, and about the comparative impact of social skill and negative symptoms on social networks and social support. Because models may be misspecified, it is important to test models that account for varied ordering of variables (Morris et al., 1991). Two models of the relationships between symptoms, social skill, size of social support networks, and perceived social support were therefore considered: (a) the first model (Model A illustrated in Fig. 1), which specified that phase of illness impacted on social skill and positive and negative symptoms, all of which influenced the size of the social support network and perceived social support; and (b) an alternative and more theoretically sound model (Model B illustrated in Fig. 2), which specified that phase of illness and positive and negative symptoms impacted on social skill, which in turn influenced the size of the social support network and perceived social support.
2. Method
2.1. Participants Participants (n=46) were recruited from three inner-suburban community mental health clinics
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Socialskill -.36"
-.17
-.06
Age
.25 .20
Positive ~ symptoms
network ]
~
.1~
!
17
.3t* Negative symptoms
""
-- I
Averagesocial I support I
Fig. 1. Model A: Path diagram relating age, social skill and symptoms to social networks, and social support of people with schizoprenia.
t/•
-..17
,•
Sizeofsupport I network
~,,
Age
.34*
P
-.06 Positive
I
symptoms
A
.30" Negative symptoms
-.08
I
/
.15
I Socialskill
-.31" ,
f
,8
"~
Averagesocial support
I
Fig. 2. Model B: Alternative path diagram with social skill mediating the effect of symptoms.
affiliated with a large psychiatric hospital in Melbourne, Australia. Eligible outpatients had a DSM III-R (American Psychiatric Association, 1987) chart diagnosis of schizophrenia, which had been confirmed by their treating psychiatrist and by one of two PhD level clinical psychologists during interviews assessing participants' symptomatology. Initially, eligible outpatients had a history of either a single or multiple hospital admissions; however, as the study progressed, only outpatients with a single hospital admission were considered eligible as a means of increasing the numbers of single-admission participants in the sample. In order to reduce the impact of acute symptomatology on the assessment (Jackson and Edwards, 1992), all eligible outpatients had been discharged from hospital for at least 2 months since their most recent acute psychotic episode. Approximately 25% of eligible outpatients participated in the study. Another 25% of the eligible outpatients declined to participate in the study; case managers judged another 25% as unable to
participate because of their mental status at the time of assessment, and approximately 25% could not be included in the research study because of their inability to keep appointments (non-participants). For ethical reasons, only data on age and sex could be obtained for the non-participants. Analyses comparing a group of randomly selected non-participants (n = 37) with a group of randomly selected participants ( n = 3 7 ) revealed no differences in the age or sex of participants and nonparticipants. Thirty-four men and 12 women participated in the study. Their mean age was 34.04 years (s.d. = 9.30); 30% had either undertaken some, or completed, post-secondary education; 87% were single; 83% were not currently engaged in paid employment; 43% were living alone or in rooming house accommodation, and 57% were living with kin or non-kin in shared or supported accommodation. The sample's illness history included means of 28.41 years (s.d. = 8.09) for age of onset of illness (dated since first psychiatric contact), 5.63 years
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(s.d.=5.82) for duration of illness (dated since first psychiatric contact), 4.07 (s.d.=4.18) for number of prior hospitalizations, 0.56 year (s.d. -0.67) for the time spent hospitalized, and 414.93mg (s.d.=415.95) for the average prescribed dose of antipsychotic medication in chlorpromazine equivalent units. The sample comprised two specific sub-groups that differed in terms of number of hospitalizations or 'chronicity of receiving treatment' as defined by Strauss and Glazer (1982) (p. 208). Participants were allocated to one of two sub-groups: 18 participants with only one admission (FA group), and 28 participants with multiple (i.e. three or more) hospital admissions (MA group). A classification based on hospital admissions was more reliable than one based on episodes because it could be more reliably determined from participants' charts and was less dependent on subjective recollection. A first- and multiple-admission distinction has been used in longitudinal cohort studies (Shepherd et al., 1989) and in social support studies (Lipton et al., 1981) in order to minimize sample heterogeneity and compare participants in different stages of their illness. Descriptive data for the two groups are shown in Table 1. Chi-square analyses found no association between FA and MA groups on the variables of sex, education level, employment status, marital status, or living situation (i.e. living with others or living alone). 2.2. Measures 2.2.1. Symptomatology Clinical symptoms were assessed using the Schedule for the Scale for the Assessment of Positive Symptoms (SAPS; Andreasen, 1984), and the Scale for the Assessment of Negative Symptoms (SANS; Andreasen, 1983). Inter-rater reliability was calculated by two project clinicians for a randomly selected subset of 15% of ratings. The correlations were I C C = 0 . 9 6 ( p = 0 . 0 0 0 ) for positive symptoms (SAPS) and I C C = 0 . 7 6 ( p = 0.01) for negative symptoms (SANS). Medication side-effects were measured using the side-effects sub-scale of the Manchester Scale (MS; Krawiecka et al., 1977). The I C C = 0 . 9 2 ( p < 0 . 0 0 1 ) for medication side effects (MS).
Because of the prevalence of secondary depression in schizophrenia (Siris, 1991) and the possible interaction between depressive symptoms and inter-personal relationships (Becket et al., 1987; Lin et al., 1981 ), a measure of depressive symptoms was obtained using the 21-item Beck Depression Inventory (BDI; Beck and Steer, 1987). Group mean substitution was used to allocate BDI scores for three participants who were unable to complete the self-report measure. The distributions of data on the measures of positive symptoms, side-effects, and depressive symptoms were positively skewed. Transformations were conducted to achieve more normal distributions (Tabachnich and Fidell, 1996); however, because there was no difference between the results for analyses with and without transformations, untransformed scores were used in the following analyses. Consequently, results associated with positive symptoms, side-effects, and depressive symptoms should be interpreted with some caution. 2.2.2. Social skill Because there is no single or best method of measuring social skill (Curran, 1982), two methods of social skill assessment were used in this study: Jackson et al's. (1989a) 5-Minute Conversation and the Simulated Social Interaction Test (SSIT; Curran, 1982). Global measures of social skill like these provide an accurate estimate of social competence in everyday situations (Jackson et al., 1989a). Video-taped responses from the 5-Minute Conversation and the SSIT were rated by trained independent raters using l 1-point unidirectional scales to give impressionistic or global measures of the participants' social skill. The nine separate ratings of social skill (one from the 5-Minute Conversation and eight from the SSIT) included in the composite measure of social skill were analysed for inter-item correlation and showed a strong positive correlation (Standardized Item Alpha=0.84), with little variation of the alpha if any one of the nine items was deleted. Scores obtained from the eight scenarios of the SSIT role-play test were averaged to obtain an overall score for the SSIT. A significant correlation @=0.80) between measures of global social skill
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Table I Descriptives for first-admission and multiple-admission groups Variables
First admission (n = 18) n/M
Multiple admission (n=28) s.d.
n/M
s.d.
8.54
18 10 36.05
9.36
Sex
Male Female Age Socio-demographic variables Education (n-45) secondary and below post-secondary Marital status single/separated/divorced current partner Employment status employed unemployed Living situation alone with others Illness history variables Age of onset of illness Duration of illness (years) Number of hospitalizations Time hospitalized (years)
16 2 30.92 13 5
18 9
16 2
24 4
3 15
5 23
6 12
14 14
27.78 3.13 1 0.20
for the 5-Minute Conversation and the SSIT has been reported (Jackson, 1987). The overall SSIT score and the 5-Minute Conversation score were standardized using Z-scores, and standardized scores were c o m b i n e d to give a composite measure o f social skill. D u e to a video-tape malfunction, the mean o f the SSIT scores calculated for eight participants was based on ratings f r o m seven scenarios, and for one participant, the mean was based on six scenarios. For a n o t h e r participant, the overall SSIT score was obtained by g r o u p mean substitution, as the participant was unable to complete the role-play assessment. To check for rater drift, inter-rater reliabilities were calculated for 50% o f ratings m a d e on three separate occasions. Significant inter-rater correlations were obtained for the SSIT with the I C C = 0.96 (p <0.001 ), and for the 5 - M C with the I C C = 0.93 (p < 0 . 0 0 1 ) . 2.2.3.
Social support
Social support was assessed using the Social Relationship Scale (SRS; M c F a r l a n e et al., 1981).
8.84 5.15 0.13
28.81 7.24 6.04 (n =26) 0.80
7.71 5.73 4.33 0.77
Using the SRS, participants identify up to six people w h o m they talk to for six different areas o f life: work, m o n e y and finances, h o m e and family, personal and social, personal health, and issues relating to society in general, and financial. For each person identified, participants rate the helpfulness o f the discussion that they have concerning the relevant areas o f life on a seven-point bi-directional scale, from - 3 (makes things a lot worse) to + 3 (helps things a lot). Specific information obtained using the SRS includes (a) the size o f the social support network measured as the total n u m b e r o f unique individuals or relationships in the network, (b) the average a m o u n t o f perceived social support offered by unique individuals in the network, (c) the n u m b e r o f reciprocal relationships, and (d) the different types o f relationships (e.g. family, friends, workrelated people, professionals, neighbours, fiat mates, and others including casual acquaintances). (Only (a) and (b) are reported in this study.) D a t a were c o m b i n e d across the six areas o f life providing only one measure for each dimension.
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The SRS assesses 'verbal' social support and provides a measure of participants' appraisal of their social support network and the effectiveness of the support that they receive, rather than simply the availability or receipt of support. In addition, the bi-directional nature of the SRS enables participants to identify both positive and negative aspects of social relationships. Because relationships can have both a positive and negative impact (Shinn et al., 1984; Coyne and Downey, 1991), the SRS scores the impact on overall support by including both helpful relationships and less than helpful or conflictual relationships. This emphasis on the differential effects of social support is particularly important for people with schizophrenia who can find helping behaviors and intense relationships stressful (Henderson, 1980).
3. Results
3.1. Preliminary analyses: phase of illness Because community-based psychiatric care (e.g. community assessment and treatment teams) was operationalized in Victoria over the course of the research (Psychiatric Services Division, 1994), it became increasingly likely that our research participants received treatment without necessarily being hospitalized during their psychotic episodes. It was also possible that some first admission participants had either a prolonged illness or lateonset schizophrenia. Consequently, in order to determine differences between the first- and multiple-admission participants, FA and MA groups were compared on variables pertaining to illness history. Comparisons using t-tests showed no significant differences between the age or the age of onset of participants in the FA group or MA group. However, as expected, FA and MA groups were significantly different on measures of chronicity of illness such as duration of illness since first psychiatric contact, t ( 4 4 ) = - 2 . 4 6 , p = 0.018, and total time spent hospitalized, t ( 4 2 ) = - 3.96, p = 0.000. Group differences for the combined illness variables (positive symptoms, negative symptoms, depressive symptoms, side-effects) were evaluated
using Hotellings criteria for MANOVA and found to be non-significant, F(4,40)= 1.50, p=0.22, as were group differences for the combined social support variables (average amount of perceived social support and size of social network), using a second MANOVA with F ( 2 , 4 3 ) = 0.80, p = 0.46. A univariate test of group differences for social skill was non-significant, F(1,44)=0.02, p=0.90. Because first-admission and multiple-admission participants did not differ on variables of clinical symptoms, social network/support, and social skill, the two groups (FA and MA groups) were combined and treated as a single sample for all further analyses. With the onset of schizophrenia usually occurring in late adolescence or early adulthood (American Psychiatric Association, 1994), the age of the person may be closely related to their phase of illness. The age of the participants was significantly correlated with their age of onset of illness (r=0.78, p = 0 . 0 0 0 ) , and with their duration of illness (r=0.78, p=0.000). Younger participants had an earlier age of onset of illness and had a shorter duration of illness. Because of the significant positive correlation between participants' age and both their onset and duration of illness, age was used as a 'proxy' variable for phase of illness in the subsequent analyses of data in this research. Younger participants had both an earlier and a more recent onset of illness than older participants and were more of a homogeneous group. They had an 'early onset' of illness and were in an 'early phase' of their illness.
3.2. Symptoms, social skill, and social support The data analysis focused on testing a structural model of the inter-relationship between personal characteristics and perceived social support. Because of the limitations of Structural Equation Modelling with small samples, this research tests plausible sets of inter-relationships and proposes a tentative model that could not be constructed using zero-order correlations. With small numbers of participants, the model could not be tested separately for each sex. However, when the variance-covariance matrices
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were tested for equality, there were n o significant differences b e t w e e n m e n a n d w o m e n for the variables o f age, social skill, positive s y m p t o m s , negative s y m p t o m s , size o f s u p p o r t n e t w o r k , a n d average social s u p p o r t . T h a t is, we c o u l d n o t reject the null h y p o t h e s i s o f h o m o g e n e i t y o f v a r i a n c e for m e n a n d w o m e n . Because the p a t t e r n o f c o v a r i a n c e was the same for b o t h m e n a n d w o m e n , a c o m b i n e d m a t r i x was used ( s e p a r a t e c o r r e l a t i o n m a t r i ces for m e n a n d w o m e n are p r o v i d e d in A p p e n d i x A a n d B). O n l y s y m p t o m s o f s c h i z o p h r e n i a (positive a n d negative s y m p t o m s ) were i n c l u d e d in the model. Scores o f depressive s y m p t o m s o n the B D I ( M = 12.70, s . d . = 1 0 . 0 4 ) a n d side-effects o n the M S ( M = 1.54, s.d. = 2.09) were n o t significantly correlated with m e a s u r e s o f social skill o r social s u p p o r t . Significant positive c o r r e l a t i o n s were f o u n d between depressive s y m p t o m s a n d positive s y m p t o m s (r = 0.31, p = 0.04), a n d between depressive s y m p t o m s a n d negative s y m p t o m s ( r = 0 . 4 7 , p = 0.001 ); a n d between side-effects a n d positive s y m p t o m s (r = 0 . 3 5 , p = 0 . 0 2 ) . M e a n s a n d s t a n d a r d d e v i a t i o n s for variables i n c o r p o r a t e d in s u b s e q u e n t analyses a n d their i n t e r c o r r e l a t i o n s are p r e s e n t e d in Table 2. 3.2.1.
a s s u m p t i o n s a b o u t the p a t t e r n o f causal relationships a m o n g variables were p r o p o s e d a n d c o m p a r e d ( L o e h l i n , 1992; M a c C a l l u m et al., 1993). In b o t h m o d e l s (see Figs. 1 a n d 2) the p r e d i c t o r variables i n c l u d e d age, social skill, a n d the positive a n d negative s y m p t o m s o f schizophrenia. T h e outc o m e variables were the size o f the social n e t w o r k a n d the average a m o u n t o f perceived social support. In M o d e l A (see Fig. 1), age has a direct effect o n social skill, with negative s y m p t o m s directly influencing the size o f the s u p p o r t n e t w o r k . In the a l t e r n a t e m o d e l ( M o d e l B; see Fig. 2), age a n d negative s y m p t o m s are s h o w n as i m p a c t i n g directly on the i n d i v i d u a l ' s social skill, a n d h a v i n g an indirect effect o n social n e t w o r k s via social skill. C h i - s q u a r e tests were used to c o m p a r e the overall fit o f the two m o d e l s (see Table 3). T h e Z z o b t a i n e d for the d f a s s o c i a t e d with each m o d e l Table 3 Goodness of fit indices for models A and B Model A Chi-square df
p Normed Fit Index (NFI) Comparative Fit Index (CFI) Root Mean Square Residual (RMR) Root Mean Square Error of Approximation (RMSEA)
Path diagram
S t r u c t u r a l e q u a t i o n m o d e l l i n g was used to e x p l o r e the r e l a t i o n s h i p s between age, s y m p t o m s o f s c h i z o p h r e n i a , social skill, a n d social s u p p o r t . L I S R E L 8 was used to p r o v i d e p a t h coefficients a n d tests o f the overall g o o d n e s s o f fit o f the m o d e l ( J 6 r e s k o g a n d S 6 r b o m , 1993). T w o s t r u c t u r a l m o d e l s t h a t differed in their
Model B
2.12
9.12
3
9
0.55 0.94 1.00 0.04 0.00
0.43 0.75 0.99 0.09 0.02
Chi-square Difference Test 6.00
Z2
df
6
p
>0.05
Table 2 Means, standard deviations, and intercorrelations of study variables Variables
M
s.d.
1
1. Age 2. Social skill 3. Positive symptoms 4. Negative symptoms 5. Size of support network 6. Average social support
34.04 0.00 11.48 28.61 6.30 1.67
9.30 1.68 15.23 13.40 3.00 0.80
. -0.33 a -0.06 0.17 -0.33 a -0.05
Note: Z-score reported for social skill. ap<0.05.
2 .
. --0.16 -0.39 a 0.34" 0.17
3
4
5
--0.30~ 0.07 -0.12
----0.34 ~ -0.29
--0.24
.
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was non-significant, and the ~2: df ratio was less than 2, suggesting that there is concordance between the data and the hypothesized explanatory models (Tabachnich and Fidell, 1996). However, chi-square does not necessarily reflect accurate probability levels in structural equation modelling when sample sizes are small, and the model and the data may not be significantly different from each other, regardless of whether the ~2 is nonsignificant (Tabachnich and Fidell, 1996). Descriptive fit indices were obtained using the normed fit index ( N F I ) and the comparative fit index (CFI). The NFI indicated that Model B was a good fitting model. As the NFI may underestimate the goodness of fit of models using small samples, additional information was obtained on the fit of the model using a small sample by employing the CFI (Tabachnich and Fidell, 1996), which indicated that Model B was a good fit of the data. Further, values obtained for the root mean square residuals ( R M R ) showed that a small amount of the variance was unexplained by both models. Although small sample sizes can make it difficult to detect a difference between models, Model B described the data better than Model A as shown by the significance of the Z2 difference test. Model A was the more complex of the two models, whereas Model B was both the most theoretically sound and the more parsimonious model. Further, Model A accounted for 12% of the variance in the size of social networks and 3% of the variance in perceived social support, whereas Model B accounted for 15% of the variance in the size of social networks and 12% of the variance in perceived social support. In Model B, the effect of negative symptoms on social skill was - 0 . 3 1 , and the effect of social skill on size of the network was 0.34.
4. Discussion
The results of this study provide information about the role social skill, psychotic symptoms, and phase of illness as determinants of the size of the social networks of people with schizophrenia and the amount of support obtained from these
networks. We found that people with schizophrenia who were more socially skilled had larger social networks; conversely, people with more negative symptoms had smaller social support networks. However, the more socially skilled people did not perceive greater support from these networks than did the less socially skilled; nor did people with more negative symptoms perceive less support. Younger people in an earlier phase of their illness who were more socially skilled had larger social networks than older people, but they did not perceive their support networks as more or less supportive than those who were older. Even with the small sample size, data analysis revealed plausible paths within the identified models. It is important to note that the majority of first-episode and first-admission studies are small scale, with sample sizes of less than 50, and highlight the difficulties in obtaining these samples (Keshavan and Schooler, 1992). Although the results of this study should be interpreted with some caution, they provide evidence of a theoretical model of complex relationships between the symptoms and social functioning of people with schizophrenia. Future studies will enable more in-depth testing of these relationships. As stated in the Results, social skill only accounts for some of the variation in the size of the social networks when negative symptoms of schizophrenia directly influences social skill (Model B). This finding suggests that negative symptomatology may influence the use of skills in 'real-life' social situations. For example, avoidance of social stimulation (Gaebel, 1992) is likely to influence how or whether people use their social skills when interacting with people in their social networks. The independence of positive symptoms is consistent with previous research with medicated patients (Jackson et al., 1989a; Halford and Hayes, 1995). While negative symptoms and social skill influenced the size of the social network, these variables did not influence the amount of support obtained by the individual. It is possible that people with schizophrenia obtain support, regardless of their ability to establish or maintain social relationships, and/or even small networks are perceived as being supportive. Supportiveness may have more to do
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with the composition of their network (e.g. unconditional support provided by family, professionals, or religious groups), rather than factors intrinsic to the individual such as the ability to establish or maintain reciprocal, and mutually satisfying, relationships (Jackson and Edwards, 1992). The impact of the variable of age in the preferred model (Model B) showed that younger people with schizophrenia are more socially skilled and have larger social networks than older persons. This finding is consistent with the suggestion by Lipton et al. (1981) that the deterioration of social competence in people with schizophrenia over time results in a 'network collapse' and subsequent social isolation. Although Mueser et al. (1990b) found that the social skill of people with schizophrenia increased, rather than deteriorated, over time, their participants were hospitalized patients with a history of long-term illness, and may have shown an improvement late in the course of their illness as has been described by Carpenter and Strauss (1991). In comparison to inpatients, outpatients in the current study were likely to be at a higher level of psychosocial functioning. Also, a large proportion of participants in the current study had recentonset schizophrenia, and were less likely to have experienced a deterioration in social relationships that may be associated with a more prolonged illness. Regardless of the impact of age and symptomatology, social skill was not the overwhelming determinant of the number of social contacts. In addition to social skill, a complex interaction of other personal characteristics, and interpersonal and cultural environments is likely to impact on the individual's involvement in social relationships (Carpenter et al., 1988). Although not directly tested in this study, it is possible that women with schizophrenia who are more social skilled than men (Mueser et al., 1990a) have larger social networks; or that gender impacts on the relationship between social skill and perceived social support. These findings are limited to participants' subjective experience of their social support and social networks. It is possible that the social cue perception (e.g. Corrigan, 1994), neurocognitive deficits
283
(e.g. Green, 1996), and symptomatology of people with schizophrenia impacts on their self-report. The pattern of relationships could be quite different if an objective measure was used for the support actually received by participants. The question arises about how best to measure people's perception of their social support and social networks in a way that eliminates or minimizes the impact of a psychotic illness such as schizophrenia. Even in people without psychiatric illness, a person's mood can impact on his or her perceived social support (Cohen et al., 1988), and agreement between the self- and other-report is variable (Antonucci and Israel, 1986; Brewin et al., 1990; Stein, 1995). Future research needs to determine the differences between the impact of perceived versus actual receipt of support and social contact on the well-being of people with schizophrenia.
4.1. Implications for practice This study provides useful information about a population that frequently has a limited ability to develop new social contacts. Although negative symptoms influence the size of a person's social support networks, so does their social skill. As schizophrenia frequently develops during adolescence and early adult life, a focus on maintaining social skills during the early 'critical' period following a first episode of psychosis (Birchwood and Tarrier, 1992) could help to safeguard social relationships of young people who develop a schizophrenic illness before they experience a 'network crisis' or loss of social contacts (Lipton et al., 1981; McGorry, 1992). Although there has been only limited success with social skills training interventions (Mueser et al., 1995), it could be that enhancing the social skill of people with schizophrenia increases their ability to establish and maintain social relationships, and in turn increases the number of people in their social support networks. However, because social skill is not a major influence on the number of people in a person's support network, and does not contribute to their perceived social support, it is important to consider that people with schizophrenia may lose their support networks and/or perceive less social support regardless of their
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social skill. A focus on alternative cognitive strategies, including support-seeking, may impact on the availability and effectiveness of social support in people with schizophrenia.
cognitive strategies, including support-seeking, may influence the availability and effectiveness of social support.
Acknowledgment 5. Conclusion This research was supported by funding from the Faculty of Health Sciences, La Trobe University. We thank staff from community mental health clinics affiliated with Royal Park Hospital for their assistance with the research, and Angie Paton, Marion Kostanski, and Catherine Mihalopoulis for their assistance in rating videotapes and data coding.
In conclusion, intervention for young people in the early years following the onset of schizophrenia requires multiple personal and environmental interventions. Enhanced social skill may help people with schizophrenia access social relationships and reduce the risk of the network collapse described by Lipton et al. (1981). Alternative Appendix A
Means, standard deviations and intercorrelations of study variables for men (n = 34) Variables
M
s.d.
1
2
3
1. 2. 3. 4. 5. 6.
33.60 -0.08 12.74 31.06 6.06 1.68
8.63 1.69 16.01 13.04 2.99 0.78
--0.35 - 0.03 0.37 -0.42 -0.22
-- 0.15 - 0.39 0.36 0.14
---0.24 0.08 -0.04
--0.39 -0.32
4
Age Social skill Positive symptoms Negative symptoms Size of support network Average social support
4
5 ----
0.21
Appendix B Means, standard deviations and intercorrelations of study variables for women (n= 12) Variables
M
s.d.
1
2
3
1. 2. 3. 4. 5. 6.
35.28 0.24 7.92 21.67 7.00 1.63
11.34 1.70 12.68 12.40 3.05 0.89
--0.31 - 0.13 -0.19 - 0.17 0.30
-- 0.13 -0.37 0.27 0.25
---0.40 0.15 -0.42
Age Social skill Positive symptoms Negative symptoms Size of support network Average social support
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