Social Support and Schizophrenia - Semantic Scholar · PDF file58 Social Support and Schizophrenia ... Clinical Significance The Community Mental Health ... Outline In this essay on

58 Social Support andSchizophrenia

SCHIZOPHRENIA BULLETIN

by C. Christian Beels Abstract

This essay is an introduction to areview of the literature on meas-urement of social support inschizophrenia. It proposes a natu-ral history for the development ofthe career of the schizophrenic inhis social network. The dimen-sions of social support in this ill-ness are shown to be specific to it,and different from what has beendescribed for other illnesses suchas depression. Certain qualitativeand quantitative characteristics ofthe clusters which make up the so-cial network are suggested forstudy.

This essay provides a conceptualintroduction to the problem ofmeasuring social support inschizophrenia. It is background fora critical review of the literatureand instruments of measurementin this area, which is being pre-pared by a group of colleagues atColumbia University under the di-rection of the NIMH Center forSchizophrenia Studies (to be pub-lished separately).

The principal purpose of thepresent article is to make a connec-tion between several areas:

• Clinical and phenomenologicalexperience with the schizophreniasyndrome.

• Studies of the social context ofthe illness.

• Sociological and anthropologi-cal studies of normal social net-work formation.

• A small but growing body ofspecific epidemiological investiga-tions of social supports in schizo-phrenia.

If these areas can be connectedto make a coherent structure, we

will have the beginnings of atheoretical basis for the design ofnew studies.

Clinical Significance

The Community Mental HealthCenter movement of the early1960s and the policy of dein-stitutionalization of chronicmental patients which began in the1950s had a common goal: to makepossible a better life for chronicschizophrenics in some place orsurrounding natural and conven-ient for them. The legal reformswhich have appeared more re-cently, especially those concernedwith the "least restrictive alterna-tive" to hospitalization, have hadthe same end in view. But all thesereforms in psychiatric administra-tion have come about with very lit-tle development of systematicknowledge about the social lives ofchronic schizophrenics and otherswith serious mental disorders.Gerald Caplan, an early theorist ofthe community psychiatry move-ment, wrote originally, and hope-fully, of the possibility of preven-tion through early identification ofcases and early treatment of thosewhich are known. More recently,after the movement has experi-enced some disillusionment with"treatment" of patients in thecommunity, his writings have em-phasized the "natural social sup-ports" of mental patients (Caplan1974, 1976). We have begun torealize there is something aboutthe environment of actual helping

Reprint requests should be ad-dressed to Dr. Beels at WashingtonHeights Community Service, NewYork State Psychiatric Institute, 722West 168th St., New York, NY 10032.

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and supporting people surround-ing patients which requires our at-tention and understanding—andour strategic support.

Most recently the President'sCommission on Mental Health(1978) has declared in its leadingsection:

Personal and community sup-ports, when they emphasize thestrengths of individuals andfamilies and not their weak-nesses, and when they focus onhealth rather than sickness,may be able to help reduce thestigma often associated withseeking mental health care.These largely untapped com-munity resources contain agreat potential in innovationand creative commitment inmaintaining health and pro-viding needed human serv-ices, [p. 15]

The Report recommends that:A major effort be developed in thearea of personal and communitysupports which will

• Recognize and strengthen thenatural networks to which peoplebelong and on which they depend.

• Identify the potential socialsupport that formal institutionswithin communities can provide.

• Improve the linkages betweencommunity support networks andformal mental health services.

• Initiate research to increaseour knowledge of informal andformal community support sys-tems and networks.

The first three points emphasizeour conviction about the clinicalwisdom of involving natural net-works in treatment, and the fourthacknowledges our scientific ignor-ance about what is involved. It isnot clear, beyond the invocation ofclinical experience, how a therapistwould recognize a social support if

he saw one among the collection offacts that make up a clinical rec-ord. We do not really know, forexample:

• Which patients have supportsthat are helping them as much aspossible and should be left alone.Some of the "successes" of socialtreatment may be with attractivepeople who will do well enoughwithout us.

• Which patients have no accessto support and need to have it con-structed for them by professionalsponsors.

• Which patients have potentialsocial supports to which for somereason they have not become con-nected. These may need to haveonly a few connections supplied byprofessionals—support for thesupports, so to speak.

• Which patients will return forlong stays in a hospital or someother total institution no matterhow well-connected they are orwhat professional effort is ex-pended on them.

The practical importance of thesequestions, especially with limitedtreatment resources, is obvious.But they can only be approached ifwe have a way of defining and de-scribing the structures that alreadyexist in the lives of patients andrelating them to the success andfailure of treatment. They arenecessary questions to ask if weare to avoid wholesale expenditureof yet more money on a treatmentthat should not be the same foreveryone. Social therapies, likedrug treatment or hospitalization,should be applied with judgment,and for this, we need a parsimoni-ous and scientific set of indica-tions.

Background

This essay is built upon the ideasin a previous issue of Schizo-phrenia Bulletin, which I edited(Beels 1978). The first article in thatissue (Hammer, Makiesky-Barrow,and Gutwirth 1978) reviewed re-cent research in this field. Ham-mer, Makiesky-Barrow, and Gut-wirth (1978) noted that the "socialnetwork"—an empirically definedgroup of family, neighbors, andfriends—is the subject of much re-cent social science research. It ap-pears to be one conceptual toolthat will help us to arrive at aworkable definition of social sup-port to be used by scientists andclinicians. The network concept isrelated to several others in psy-chiatric epidemiology (e.g., migra-tion, social marginality, isolation,social class, marital status, em-ployment, sex, age, and ethnicgroup) and is also related to recentideas about treatment for thispopulation (e.g., crisis interven-tion, resocialization, work rehabili-tation, and partial hospitalization).

Five quantitative studies haveconnected the course of schizo-phrenia with network measure-ment. Pattison (1975) found thenetworks of psychotic patients tobe smaller and denser than thoseof normals and neurotics.Tolsdorf (1976) found that changesin network size and function beganat or before the time of first hos-pitalization. Cohen andSokolovsky (1978), working withchronic patients, demonstrated arelationship between network size,and the direction of exchange ofhelping network relations, on theone hand, with community tenure,on the other. Hammer (1963-64)investigated important links in thesocial network before and after

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hospitalization, and found that pa-tients whose close relations werewith individuals not connectedwith each other were more likelyto have their connections severedfollowing hospitalization. And fi-nally Garrison (1978) studied thenatural groups of nonkin supportson which migrant Puerto Ricanwomen in New York depend. Shedemonstrated that these groupsdiffered systemically across a spec-trum of illness from no psychiatricillness to least functional schizo-phrenia. Garrison's findings em-phasize the importance of the pa-tient's sex, ethnicity, and stage ofthe life cycle as keys to under-standing the natural history oftypes of groups available to the pa-tient and' norms of behavior gov-erning connections with people inthose groups.

These studies demonstrate thatthe investigation of the social sup-ports of schizophrenic patients,and the connection between theiravailable networks and the courseof their illness, is a promising areafor research, but that the investiga-tion of this area is just beginning.It is important at this point to con-sider the development of methodsfor the definition of importantvariables in the measurement ofsocial support.

Definitions

I take "social support" to be what-ever factors there are in the envi-ronment that promote a favorablecourse of the illness: I assume thatwe do not know exactly what thosefactors are, but, depending on cer-tain definitions of a favorablecourse—fewer or shorter hos-pitalizations, more independentsocial function, less symptomatic

distress—we can discover whatsocial support is through naturalhistory studies, analysis of correla-tions, and, eventually, clinical ex-periments. Although we do notknow with any great clarity whatsocial support is, we have seenevidence for it in some cases.There are patients who appear tosurvive crises with the help offriends, relatives, and therapists;and there are patients who de-teriorate when certain social con-nections disappear. On the otherhand, Bleuler has observed thatsome patients who have been inthe hospital for years will pullthemselves together and start tolive independent lives when a keyrelative dies. Clearly the respon-siveness of schizophrenics to theirenvironmental supports is notsimply a matter of "the more thebetter." Some patients are over-whelmed instead of supported bytheir social connections, in waysthat are not easy to define.

The "social network" as usedhere is simply one of several waysto define social life in relativelyobjective terms. Many of theseterms have been discussed in de-tail by Hammer, Makiesky-Barrow,and Gutwirth (1978) and Hammer(1981). What I want to recall here isthat the social network is not apriori good or bad for a given pur-pose. It is, rather, large or small,dense or sparse, old or new, andmay be based to varying extents onfamily, friends, neighbors, work-mates, fellow patients, members ofa church, etc. Everyone has a so-cial network, and different aspectsof that network may be importantat different times or for differentpurposes. A recent widow mayfind herself most supported by oldand close friends in the early daysof her bereavement, but may find

that new friends—perhaps otherwidows and single women—aremost important to her in buildingher new life a year later.

Outline

In this essay on social networksand schizophrenia, I will focus onthe following questions.

• What variety of social supportmeasures have been used in thestudy of health and mental health,and are they likely to be of use inresearch on schizophrenia?

• Considering what we know ofthe subjective experience, symp-tomatology, and life history ofschizophrenia, can we deducesome theoretical expectations con-cerning the relevance of socialsupports? An excursion into thenatural history of network-building in our culture will behelpful here, as well as some com-parisons with the course of schizo-phrenia in other cultures.

• How are social supports inschizophrenia likely to be differenteven from those in serious mentalillnesses such as psychotic depres-sion, which are similar to it in se-verity?

• What are the effects of ethnic-ity and social class on networkstructure, and do these effectshave consequences for the courseof schizophrenia?

• Finally, what are the measuresof networks and of other aspects ofsocial support which have themost relevance for schizophreniaresearch?

Social Support and Health

A review of the literature of socialsupport and health reveals a vari-

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ety of measures of support: inti-macy with spouse, availability offamily help in crisis, majority rep-resentation of one's ethnic groupin the community, favorable at-mosphere in the home or theworkplace, presence of a confi-dant, general good feeling aboutextended family relations—thesemeasures and many more havebeen applied to problems surveyedin the general population and inclinic populations such as heart pa-tients and pregnant women. Themental health variables measuredby survey have included cases ofdepression defined by psychiatricdiagnosis or by screening test,neuroticism defined by self-reportof symptoms, and general level ofdisturbance or anxiety defined bysymptom checklists. The assump-tion behind many of these studiesis that social support is a positivepresence rather than an absence(an absence of burdensome de-pendents, for example) and, in anintuitively obvious way, the moresupport the better.

On the other hand, a look at thevery important work of GeorgeBrown (Brown and Harris 1978)and his colleagues on depressionand on schizophrenia reveals thatwhen you start with such specificdiagnostic categories, you find thatdifferent aspects of social supportare important in different diag-noses. In their study of depressionamong the women of Camberwell,for example, Brown and Harrisfound that presence of a confidantin the form of spouse, boyfriend,or close friend protected women inthe community from developingdepression as measured by theirfield interview criteria, but did notdo so for women who developeddepression treated by a psychia-trist. That is, in spite of many

similarities of symptoms, some-thing about the severity of depres-sion that led to psychiatric treat-ment in a London suburb made itdifferent from depression encoun-tered by survey. One differencewas that treated depression wasless sensitive to social support.

Using the same instruments,Brown and Harris (1978) surveyedwomen on a Scottish island, andfound that a local type of stronglyintegrated social support system offamily and church membershipappeared to protect against de-pression, but such a support sys-tem was also strongly associatedwith symptoms of anxiety, whichthe depressed, less supported,women tended not to have. Thatis, a support that protects againstdepression may be a contributor toanxiety, and vice versa.

When one turns to Brown, Bir-ley, and Wing's (1972) work on thesocial supports of schizophrenicmen discharged home to theirfamilies, it is useful to compare theimportant variables in that studywith those in the depressionstudies. Important variables indepression—presence of a spouseconfidant, absence of young chil-dren at home, and employment—are not significant variables forschizophrenics because they tend tobe unmarried, childless, and unem-ployed as a group.

What was important for theirprognosis was a particular kind oftolerant, even-tempered family at-titude, called "low expressed emo-tion" (to which we will return).The small minority of schizo-phrenics who achieve either stablemarriage or competitive employ-ment are mostly in a separatefavorable group with a later onsetof illness (Huffine and Clausen1979). We can see here an example

of a recurring problem: in schizo-phrenia research, measures of theavailability of social supports areconfounded with measures of so-cial competence, and of generalprognosis. We can also see fromthis brief look at the social supportfield as a whole that there is notmuch point in talking about socialsupport in general as being relatedto mental health in general.

To see how difficult it may be toapply otherwise useful concepts ofsocial support to schizophrenia,consider the idea of the "confi-dant." A confiding relationship,especially with a spouse, has beenshown to be a protective socialsupport in a variety of conditions,from depression (Brown and Har-ris 1978) to heart disease (Medalieand Goldbourt 1976). But a confi-dant may be a very problematicperson for a schizophrenic.Vaughn and Leff (1981) have shownthat an important correlate of anintrusive, negative family attitude,which is specifically unfavorablefor schizophrenics, is disappoint-ment in the patient's refusal toconfide. What is important here isnot that the patient acquire a con-fidant but that the parent stoptrying to be one: It may be betterfor some patients to keep theirconfidences to themselves.

Social Support and thePhenomenology and NaturalHistory of Schizophrenia

We need a descriptive account ofthe social context of schizophreniawhich will connect clinical obser-vations of social events on the onehand to the phenomenology andnatural history of the illness on theother. In this way, we will have anordered set of theoretical expecta-

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tions to test in the field. Brownand his associates have done thisfor depression (Brown and Harris1978), relating the illness to theexperience of loss and adverseconditions before the onset ofsymptoms. Brown (1979) has alsopointed to the need for a theoreticalconnection between schizophreniaand the properties of social net-works.

Brown's colleague John Wing(1977) has already led the way inthis area, by relating the manage-ment of the illness to a sensitivityto stimulation, and to the tendencyto social withdrawal:

There are two major problems:(1) the reduction of an excessivelevel of social withdrawal andother associated behaviors byenriching the social environ-ment without provoking anacute relapse, and (2) the reduc-tion of an excessive level of so-cial stimulation without en-couraging undue dependence.

To summarize the processesinvolved: many patients whoexperience an attack of acuteschizophrenia remain vulnera-ble to social stresses of tworather different kinds. On theone hand, too much socialstimulation, experienced by thepatient as social intrusiveness,may lead to an acute relapse.On the other hand, too littlestimulation will exacerbate anytendency already present to-ward social withdrawal, slow-ness, underactivity, and an ap-parent lack of motivation. Thus,the patient has to walk a tight-rope between two differenttypes of danger, and it is easy tobecome decompensated eitherway. The difficulty in thinkingand tne inability to communi-cate verbally and non-verballywill be most evident in interac-tions with close kin, for exam-ple, and will be exacerbated inconditions of anxiety and higharousal, [p. 1335]

A social supports consequence of

these ideas is that schizophrenicsshould optimally have several dif-ferent social spaces in their livesthrough which they can move eas-ily and freely, so that they are nottrapped in one environment at onelevel of stimulation. This is, ofcourse, related to the observationthat patients do best if they havehome and parents available tothem, but are not confined byhabits or expectations to eitherhome with family or the isolationof a single room.

The next theoretical point re-quires that we make a few observa-tions about the dynamics of socialrelations in our society—in par-ticular concerning the way inwhich we normally develop socialconnections. I am relying here onideas suggested in Boissevain andMitchell (1973).

The roles we all play in the for-mal social structures of classicalsociology (e.g., family, work, andchurch) are only one part of sociallife. Our networks are built upfrom the exchange of goods andservices through informal connec-tions as well. These informal con-nections, which may be unsup-ported by role membership, aremade on the basis of mutual attrac-tion and interest. The creativeworking margin of network forma-tion is in the development of in-formal connections. That is, oneimportant way in which people incomplex societies like towns andcities overcome the limitations oftheir formal memberships is bydeveloping informal ones. In prac-tice, of course, the two are not byany means mutually exclusive, butthe analytic distinction, as I willshow presently, has particular im-portance in the lives of schizo-phrenics.

A second preliminary idea, for

which I am indebted to ConradArensberg, is that in these socialexchanges, the perception of ini-tiative is very important. Whomakes the move, or the offer; whomakes the response, or receives;how turns are taken; and what isthe balance of initiative over time,are all important to how the de-veloping relationship is viewed bythe participants.

To put these ideas together,then, the natural history of net-work formation in our societycould be thought of as operatingthrough a range of institutionsfrom more formal (family, work-place, school, church) groups tomore informal groups (eating anddrinking parties, weekend leisureactivities, hobbies and interestgroups). Oversimplifying to makea point, one could say that mem-bership in formal groups has aroutinized or regulated quality toit. Home and work are examples."Home is where they have to takeyou in." Work is supposed to be runby rules of competence and produc-tivity—at least there is some line ofwork one can get without depend-ing on social grace or influence. Thetwo types of organizations overlap.Of course, having gotten even themost menial kind of work (formalorganization), one is then faced withinformal groups and factions insidethe workplace: who has coffee orlunch together, who gossips withwhom.

Informal organizations, morethan formal organizations, dependon the graceful making and re-ceiving of social initiatives. It is ininformal groups that the mannersand tastes involved in the offeringof social goods, such as interest orentertainment or influence, aremost obvious, because they areunsupported by formal reasons for

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the exchange. Another way of put-ting this is that the dues whichhave to be paid as the price ofmembership in the two kinds ofgroups are different. You can makea low, routine, and in terms of ini-tiative, reactive contribution tochurch, family, or workplace, andstill be considered a member, al-beit perhaps a devalued one. Youcannot go on being a member of agossip clique for long without con-tributing something interestingand inviting the group, occasion-ally, to meet at your house.

If we say then that membershipin informal groups depends onfluctuations of taste, advantage,and initiative (one could also saygraceful manipulation or social re-sourcefulness), then the connec-tion of network formation andschizophrenia becomes clear.Grace and resourcefulness in socialinitiatives are precisely the qualitiesschizophrenics do not have.

Especially, in the acutelypsychotic state, and to some extentafter it has subsided, the schizo-phrenic's experience of initiative,distance, and exchange is radicallyaltered. Schizophrenics often feelgreat anxiety at the simplest initia-tives. Their difficulty in carryingout greetings and negotiations withstrangers is famous, and is the rea-son why evidences of thought dis-order are especially present in thepsychiatric interview. There is dif-ficulty with control over social dis-tance. Feelings of pursuit, fusion,and rejection may overwhelm thepatient in situations where, formost of us, there is simply theproblem of encouraging someone orputting someone off.

The schizophrenic in mid-crisiscannot evaluate a social exchange.He either feels he has nothing tooffer or, by compensation, that he

has so much to offer, is so impor-tant, that others are stupefied byhis social potential (delusions ofgrandeur).

Because of defects in their abilityto perceive how social exchange isorganized, then, schizophrenicsare at a loss in the process of ordi-nary network formation, whichproceeds for most of us by low-riskexperimental offerings and invita-tions, mostly within informalgroups.

Most of the time, for mostpeople, the process of making newconnections and breaking old onescan be almost imperceptible. Onthe other hand, there are certainperiods of life which are markedby more definite passage from oneconfiguration of formal organiza-tion to another: adolescence, en-tering and leaving college, mar-riage, divorce, getting a job, mov-ing, retirement. And although themore obvious upheaval in thesetransitions is in the shift of formalmemberships, the accompanyingreorganization of informal mem-berships is also crucial. The abilityto develop new informal connec-tions is put to a severe test duringthese periods. Granovetter (1973)has noted, for example, that get-ting a job usually requires themobilization of weak, informalties.

Adolescence is the passage inwhich schizophrenia usuallymakes its first appearance. Duringadolescence, the transition fromdependence on family to a more orless formally recognized peergroup of friends (school or collegegroup, gang, workmates), a greatstrain is placed on the adolescent'sability to make new informal con-nections in order to explore whichpeer group he/she will join. Theadolescent is out on a social limb,

having broken somewhat with hisfamily, having not quite made it intoone group, thinking about joininganother. In this stage the ability toobtain tokens of acceptance of one'ssocial initiative is very important.Sullivan (1962) was especially in-terested in this phase of adolescenceand schizophrenia. He pointed outthat the experience before or duringadolescence of having a "chum"—acompanion whose presence assuredone of the possibility of being ac-cepted by at least one peer—was es-sential to passing through this de-velopmental crisis. He also notedthat the prodrome of a first schizo-phrenic episode often contained arebuff of the young person's socialinitiative—which could be anythingfrom an invitation to go bowling to aproposal of marriage. Such a rebuffmay come to signify the whole fail-ure to negotiate the passage, thecollapse of confidence in the effect ofone's initiatives with new people.

It is congruent with our theory,then, that first and recurringepisodes of schizophrenia seem tocoincide with the early passages oflife. What is such a passage like forthe patient who finds himselfgraduating, not into college, let ussay, but instead into a day hospi-tal? I described this in a recentarticle:

It is the regular experience ofpatients after an acute schizo-phrenic episode that they leavethe network they were in,where they were regarded asordinary citizens—and so re-garded themselves—and entera network of people the struc-ture and ideology of which isdetermined to a large extent bya new label. They lose many oldfriends, and the support ofsome relatives, and acquiresome new friends almost all ofwhom are fellow patients, theirrelatives, and friends. For

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some, this means a drop in so-cial class, a distressing changeof taste and interest, a crisis insocial confidence and compe-tence. Now since disability issuch a dominant definingcharacteristic of the schizo-phrenic and his network, it fol-lows that the ideology and mo-rale which he, or they, composein the face of his, or their, dis-ability, is crucial. [Beels 1979.]

There are several different pos-sible responses to this networkcrisis, all familiar to clinicians. Oneis to deny that the whole thing hashappened and substitute aparanoid or other fantastical ex-planation for why this particularperson finds himself in this situa-tion. Another is to retreat into astate of withdrawal where nothingsocial is happening at all. Anotheris to accept the same definition ofthe situation as family and othershave, and begin to compose anapproach to it. This last responseis accompanied by the best prog-nosis. It has been called "insight-ful" by students who like to locatesuch things inside the patient'shead. Scott and Montanez (1972)and others have demonstrated thatthis insightful attitude with itsfavorable prognosis is strongly re-lated to a particular kind of con-gruence of view between patientand family, and to certain attitudeswhich the family members havetoward their own participation inthe situation. Goldstein et al.(1978), Leff (1979), and Anderson,Hogarty, and Reiss (1980) have allemphasized the importance ofcommon understanding betweenstaff, patient, and family on the na-ture of the illness and treatment."Insight," then, is a socialphenomenon, requiring the consen-sus of the group that is participatingin the treatment. Such insight, or

ideology, is the essential ingredientof morale.

If you consider what goes onbetween members of organiza-tions such as Soteria House, asdescribed by Mosher et al., ofsome of the most effectivehalf-way houses, of the FountainHouse rehabilitation program inNew York, and Fairweatherlodges, you can see that they arenetworks which have had a cer-tain intense common experiencetogether, and which take prideas a group in their competencein dealing with this affliction.Members find each other jobs,room with each other, come tohelp one another in crises, andcollectively apply skills which theylearned together, as a result oftheir special experience. [Beels1979, p. 214]

From this point of view, it makessense that the various self-helpgroups which have arisen in themental health field (AlcoholicsAnonymous, Mental Patients Lib-eration, Recovery, Inc., AmericanSchizophrenia Association, andothers) are so intensely ideologicalin their approach to the problem.We who have accomplished ourtransitions into a high-moralegroup, such as a psychotherapyguild, tend to forget how confus-ing the transition was, and howmuch it helped to have a common(perhaps oversimplified) idea ofwhat it was all about which weshared with the other initiates.

To summarize the foregoing de-scription in terms which could beused in network research, I wouldsay that the schizophrenic crisis isaccompanied by a loss of the abil-ity to advance one's career by thedevelopment of new relationships.It produces, at least temporarily, amore or less complete reliance onrelatively dense formal clusterssuch as family and hospital or

clinic which require little initiativeor exchange ("social dues") tomaintain membership. This dis-ability of initiative persists to vari-ous degrees after the crisis, andthe further social career of the pa-tient (development of independ-ence from family and clinic) de-pends on the availability of otherclusters, generally based in othersocial spaces, where disability andlack of initiative are not a bar tomembership (church, self-helpgroup, sheltered work). Indeed, ina positive sense, the ideology—theattitude which such groups havetoward disability—may be moreimportant than their structure andorganization, formal or informal.Outside of such clusters, as Ham-mer (1963-64) has demonstrated,single unsupported friendshipswill tend to be lost as a result ofthe schizophrenic episode,whereas supported ones (in whicha third party is also a friend of thefriend) have a better chance ofbeing retained. The third partymay be able to moderate the failureof initiative by fostering the con-nection for the patient.

Cultural Relativity of This For-mulation. The description we havejust given is culture-bound in thesense that it implies the "healthy"ideal of a relatively independentpersonal career which has de-veloped to its greatest extent inurban industrial societies and israther less important in villageagrarian societies, where kinship,economic career, and the villagesociety are all closely and formallylinked. I want to mention brieflytwo consequences of this.

One is the confounding of themobilization of social support withother indicators of major mentalillness in our society. That is, in

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our urban society, the recruitmentand mobilization of social supportfrom a more or less open market ofpotential supporters is seen by allof us as a life task. Failure in thisrecruitment is very much boundup with the whole concept of psy-chiatric illness itself. The proposi-tion can be put this way:

Serious psychiatric illness (espe-cially schizophrenia) occurs to-gether with a relative failure to de-velop types of social supportswhich are expected in the life cyclein this culture—that is, movementfrom family dependency in child-hood and early adolescence to (1)steady and gainful employment inthe competitive market, (2) inti-mate and stable relationships in ahousehold independent of originalfamily (what used to be called mar-riage and children), and (3) a de-veloping circle of friends withwhom various social goods are ex-changed. The association betweendefective social supports andschizophrenic illness is thus aclinical commonplace in oursociety.

Now the causal direction of thisassociation—that is, whether de-fects of social support producemental illness or vice versa—is aquestion which has been raised. Iwant to emphasize that it shouldbe raised, not to be settled oneway or the other, in favor of a na-ture or nurture model of schizo?phrenia, but rather to emphasizethat the two factors interact witheach other to produce better orworse courses of development ofthe illness. Committed environ-mentalists can design studies toshow the impact of social sup-ports, and constitutionalists canshow that neurophysiological vul-nerability is important, but neitherof them will have provided much

help for patients or clinicians.What we really want to know is,given a certain disposition to theillness, what kind of social sup-ports produce better adaptation?Under what conditions do socialfactors make more or less differ-ence? As Henderson et al. (1980)have stated, the ultimate approachto this kind of problem will be theexperimental manipulation of so-cial supports. Eventually we willtry supplying particular kinds ofsupport to well-defined subgroupsof schizophrenics (first breaks,good and poor premorbids, etc.).But before doing that we need nat-ural history research, using multi-ple correlations to discover whatwe want to manipulate.

The second point is this: Someenlightenment about the interac-tion of the illness and its social fac-tors is being provided by the natu-ral experiments of cross-culturalcomparisons. We may learn moreabout the nature of social supportsin schizophrenia by examining cul-tures in which the definition of anormal career does not require therecruitment of new connections.Waxier (1979) has shown, forexample, that in Sri Lanka, al-though the lifetime incidence ofschizophrenia is the same as inother countries, both the rate ofrecurrence of episodes and thesubsequent course are, in general,much more benign than in urbansocieties. She suggests a labeling-theory explanation of this. I wouldrather emphasize that in such vil-lage societies there is no structureoutside the family into which de-viants can be extruded, so thattheir failure to label people as de-viant is not so surprising. It ismore a question of structure. Thereis evidence (Murphy 1976) thatsuch societies know perfectly well

that the person is psychotic andtherefore unmistakably deviant.But since the career consequencesof this and the consequences forgroup membership are different inthat society than in ours, thecourse of the illness is different. Ifour theory of the illness is correct,the course of schizophrenia will bedifferent in a society where a per-son has to take initiative to findnew connections in launching acareer, from a society where thereis already an acceptable or indeedunavoidable career with its con-nections provided by family andvillage structure. The developmentof informal connections in the lat-ter society may not be so importantto a viable career.

Schizophrenia as a SpecialSocial Experience

Most schizophrenic patients ex-perience a crisis of identity differ-ent from that experienced by other"mental patients" such as neurot-ics, character disorders, etc. Theirexperience is different even fromthat of depressives, who maysometimes have a similar decreaseof function. Depressives experi-ence considerable pain, loweringof mood, and devaluation of them-selves as persons, but especiallywith modern treatment, they re-tain the same place and identity intheir network, even though theymay regard their contribution tothe exchange of social goods asstrongly on the debit side. They donot experience themselves as radi-cally transformed. Depressives ormanic depressives, especially ifthey have good interval functionbetween episodes, may come tosee their periods of illness as ab-sences like the exacerbations of

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other kinds of recurrent illness,such as chronic lung or heart dis-ease. The expectation of their net-work is that when they have re-covered, they will be able to regaintheir old place. An episode of af-fective illness generally does not,like schizophrenia, leave its stampupon the whole life and personal-ity.

Some schizophrenic illnessesappear before the patient has beenable to have a try at late adolescentindependence, or acquire a certainlevel of school or work experience.These disorders of early onset leadto a more radical sense of incompe-tence, both in the patient's expec-tations of self and in the expecta-tions others have of him. Huffineand Clausen (1979) have docu-mented this for work and career,and Strauss and Carpenter (1974)have pointed out that previous ex-perience in the areas of work andsociability independently predictprognosis in each of these areas.

A schizophrenic episode is alsomore frightening for the others—the friends and family—than is thecase with affective illness. Affec-tive disorder, whatever it is like forthe sufferer, is for the others moreon a continuum with familiarlesser invalidism such as grief,demoralization, discouragement,fatigue, or physical illness.

For all these reasons, whichhave to do with the phenomenol-ogy of the illness—the persistenceof the thought disorder, the diffi-culty of communication, the al-tered perceptual world, the needto reorganize experience alongparanoid or other uncanny lines of*explanation—a person sufferingfrom schizophrenia has a needgreater than that of other sufferersfrom mental illness to reorganizehis social life around the specific

requirements of his illness or situa-tion. That is why we need to inves-tigate the varieties of reorganiza-tions which have been undertakenby patients who manage to stayrelatively free and happy for moreof the time than their fellows.

Now consider that the argumentI have gone through may be in-verted in the following way: Weare beginning to discover thatsome people, whom we used toclassify as schizophrenic becausein the pie-DSM-HI days we singledout their thought disorder as themain sign of their illness, are, oncareful examination of their hered-ity and their responses to drugs,more likely cases of affective dis-order (Pope and Lipinski 1978).Like manics and depressives, theyhad good previous adjustment,later onset, better interval func-tion, and more of a tendency to-ward episodic illness. But duringperiods of illness, their behaviorand subjective experiences are in-distinguishable from those of"true" schizophrenics with a morepersistent and malignant course.Could it be that these patients withatypical affective disorders learnedfrom the way in which their family,friends, and therapists, perhapsespecially their hospitals, treatedtheir first episodes? Could it bethat they learned to emphasize andpay attention to some morepsychotic features of their experi-ence rather than others, so thatthey develop more schizophrenia-like symptomatology when they fallill again from time to time? This is aspeculation of mine based on someexperience. If it is so, the manner ofhandling first episodes is crucial,and we should begin to see a differ-ent phenomenology of psychosisappearing in patients whose firstepisodes were dealt with in experi-

mental programs such as SoteriaHouse (Mosher, Menn, and Mat-thews 1975). Further, there may befeatures of network organizationand attitude at the time of first ill-ness which are fateful for the aspectsof the experience which the patientand others learn to identify as theessential, and therefore expectableand recurrent, features of goingcrazy.

This hypothesis could be inves-tigated by a retrospective study ofthe circumstances of the firstepisode in different groups of pa-tients, and confirmed by prospec-tive studies of cohorts from verydifferent institutions.

Clusters and the SocialSupport of Schizophrenia

Hammer (1980) notes that a per-son's typical network of about40-50 people frequently seen ismade up of five or six clusters —groups of people richly connectedto each other. There are very fewmembers of the network who areconnected only to the informantand not to anyone else (unsup-ported connections), and there areseveral connections between clus-ters (spans).1 She also notes thatschizophrenic individuals, bycomparison with normals, appear

•So far, these entities can be de-fined by purely mathematical conven-tions, derived from inspecting anumber of examples of networks andsetting up indices of connectedness.That is, a cluster is defined as a groupof individuals having a greater den-sity of interconnection with eachother than any of them has withothers. Spans are defined as connec-tions between members of differentclusters.

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to have not only smaller networks,but are also characterized by:

• Few clusters.• More unsupported connec-

tions.• Few spans.

These facts and their relation toschizophrenia are important be-cause, as Hammer (1963-64) hasalso demonstrated, after an admis-sion to a psychiatric hospital, thechances of losing an unsupportedconnection are greater than thoseof losing a supported one. A clus-ter can thus be seen as a collectionof mutually supported connectionswhich are unlikely to be severed ina crisis.

Clusters can be further classifiedby whether or not they are sup-ported by a formal group, in whicha person does not have to exert hisinitiative or pay his dues. Drop-incenters, day hospitals, and keep-in-touch clubs are organizationsof relatively effortless sociabilitywhich professionals have set upfor schizophrenics. We want to beable to identify other such group-ings which arise naturally in thecommunity to see whether theycan substitute for professionallysponsored ones. Does a bar or alunch counter function this way,for example? What are the qualitiesof atmosphere or sponsorship thatpromote this kind of cluster forma-tion? One way to identify suchgroupings in the community is totake note of the kinds of socialspaces—the actual buildings orrooms—that they occupy. Weneed to examine the ways in whichchronic or recurrently schizo-phrenic persons find alternativeclusters to those offered by theirethnic group for the normal pur-suit of a career, the extent to which

those clusters are supported byformally located organizations, theideology and atmospheres of thoseorganizations and places, and theextent to which, in some ethni-cities (as Garrison, 1978, has pointedout for Puerto Rican women) theseclusters occur naturally, independ-ent of formal organizations.

Social Supports, Social Class,and Ethnicity

Different lives, as defined by socialclass or ethnicity, imply differentnetwork characteristics. This ismost dramatically illustrated byPoole and Kochen's (1978) data onpersonal networks of blue-collarworkers, white-collar workers, andprofessionals. Blue-collar workerssee almost half their network moreoften than twice a week, and lessthan a quarter more rarely thanonce a month. Professionals, onthe other hand, have networkswhich are more than twice as largein total as those of blue-collarworkers, and more than half ofthose contacts are rarer than once amonth. (White-collar networks areintermediate on most of thesemeasures.) Thus, blue-collarworkers inhabit small, compactworlds of considerable stability,but, as Hammer notes, they aremore vulnerable to change, such asjob change or migration. Profes-sionals, on the other hand, main-tain far-flung networks with asmall core of frequent contacts anda large perimeter of rare contacts,and those many rare contacts areused for making connectionsneeded for new information ormovement. It is a network adaptedto a changing career.

These observations may be re-lated to the fact that upper- and

middle-class schizophrenics oftenmove downward in the class struc-ture ("downward drift"). Theycannot maintain the largeperiphery that supports profes-sional and middle-class position.And whether they drifted down orwere born into the lowest class,people with a predisposition toschizophrenia will hardly be sup-ported there without professionalintervention. Studies of socialnetworks by Stack (1974) andLiebow (1967) in Black inner-cityClass V society show that constantattention to informal social connec-tions is a condition of survival inthat class. The high rate of treatedschizophrenia in Class V is proba-bly due in part to the demands ofdaily life. Hustling and swappingare not things schizophrenics aregood at, and their friends andfamily have too little left over fromtheir own scramble to be able tomaintain them without strong in-stitutional support.

To give just a few examples ofhow ethnicity dictates the organi-zation of networks in ways whichare important to the course ofschizophrenic illness:

1. White, middle-class, unmar-ried patients have difficultynegotiating the "independence"phase of their development inwhich they are supposed to liveapart from families of origin andchoose friends and a career. Thehalfway house movement has pro-vided a substitute transition periodwith social supports (Budson andJolley 1978; Beels 1978). More re-cent immigrant groups (Italiansand Hispanics, for example) do notexpect unmarried young people togo through such a phase of inde-pendence from family, but ratherto go directly to marriage. Thispresents other problems for

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schizophrenic offspring who needsome acceptable exit from the fam-ily other than marriage.

2. Flexibility of child-rearing ar-rangements in the extendedAmerican Black family providesface-saving relief for mothersgoing through periods of crisis andan acceptable definition of the re-lationship between women in thefamily during the mother's in-capacity (Stack 1974). Thus, unlikeher isolated surburban counter-part, a Black woman in an urbanlower-class extended family can fitinto the flexible child-rearing net-work by helping to care for chil-dren even while she is quite dis-abled in other respects, and if sheis herself a mother, she can gethelp taking care of her childrenfrom such a network, withouthaving any of these arrangementslabeled as deviant by the family,and sometimes without creatingexcessive strain for the others.

3. A small group of Albanians ina Bronx catchment area faced spe-cial problems of language, immi-gration barriers, and family at-titudes toward psychosis whichwere insoluble without the inter-vention of the priests of theirchurch. Psychiatrists at the localclinic worked with the priests asco-therapists in crisis interventionand achieved synergies of religiousand medical authority which pro-vided relief and avoided hospitali-zation in otherwise unmanageablesituations (Weiser 1974).

4. Garrison (1978) has shownthat Puerto Rican schizophrenicwomen, who would otherwisehave difficulty locating social sup-ports, acquire self-definition, pur-pose, and support from beingmembers of spiritist cult groups.

She described seven patterns ofnonkin network organization

among Puerto Rican women in theBronx, and showed how patientsof different symptomatology andhistories of hospitalization fittedinto each of these availableecological systems. From a net-work standpoint, Garrison's class-ification defines a variety of non-kin clusters with different mem-bership requirements and patternsof initiative.

What is needed is detailed atten-tion to the modal and variantforms of organization of socialnetworks in different ethnicgroups so that the strengths andweaknesses of these forms can berelated to the problems faced bypatients of particular age, sex, anddiagnosis. Garrison provides amodel of field work and ethnog-raphy by which this can be done.

Application of TheseConcepts to the Literature andto the Design of FurtherInvestigation

There are two directions in whichthis discussion should go. One istoward a review of the existing in-struments for the measurement ofsocial support in schizophrenia,and we are undertaking such a re-view for publication elsewhere.Some of the considerations we willtake up will be the evaluation of:

• Network structure, size, den-sity, balance of exchange with therespondent, multiplexity of ties,frequency, and range of sourcesfrom which connections aredeveloped—all measures familiarfrom other reviews.

• Definition of clusters andspans.

• Ease of access and "dues"—formal or informal—that need tobe paid for membership.

• Attitudes or atmospheres ofclusters with respect to disability.

For reasons I have developedhere, these are matters of concernin approaching schizophrenia ingeneral.

A second direction would be tosee whether these ideas are con-sistent with findings of studiesthat have distinguished betweensubgroups of schizophrenics withdifferent courses of illness. I willconclude by giving just threeexamples of how these ideas canbe applied to clinical studies whichI find particularly interesting.

The Expressed Emotion (EE)Studies. Probably the most quotedand best replicated measure of thequality of social supports inschizophrenia is Brown, Birley,and Wing's (1972) "expressed emo-tion" (EE) rating—a count of criti-cal or rejecting remarks recordedduring an interview with the rela-tives of patients shortly after thepatient is hospitalized. The interra-ter reliability of this raring (made onsound recordings of the interviewwith the relative—usually a parent)is generally around 0.8. It predictsrehospitalization if the patient re-turns home to that family. Thenumbers are impressive: In a sampleof 101 patients returning home, 58percent of the high EE group re-lapsed as compared with 16 percentof the low EE group. The develop-ment of the EE measure is well re-viewed by L. Kuipers (1979).

What is of interest for our pur-pose is Vaughn and Leff's (1981)work, described in this issue, onthe correlates of high EE in suchfamilies, and the use of these con-cepts in treatment described byLeff (1979). Brown et al. (1972)noted in their earlier work several

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features of high and low EEfamilies.

1. Patients in low EE familiesneeded less medication than thosein high EE families; that is, failure totake medication was related to earlyrelapse in high but not in low EEfamilies. Thus, medication buffersthe effect of EE.

2. The effect of high EE could bereduced by reducing the amount ofcontact between parents and patient:arranging a day program for the pa-tient, having a work schedule suchthat the parents were asleep whenthe patient was up and vice versa.Thus, space and distance buffer high

. EE.

3. Parents with low rates of con-tact with friends and relatives out-side the house, with no one else be-sides the patient at home, and singleparents with no one else but the pa-tient at home were all more likely toregister high EE. Thus, EE may bepartly a function of social space.

The connection of the last twopoints to network characteristics—household composition andnumber of social spaces or clustersavailable—is interesting. Beforerelating them to our discussion,however, some additional pointsshould be made:

1. The EE measure may not holdup across cultures. It has failed topredict relapse in a New Delhisample which registered a verylow rate of EE altogether (Day1979). In the samples where it is avery strong predictor of relapse, itmay be an indicator of attitudeswhich can be measured in anotherway.

2. Vaughn and Leff's (1981)work suggests what some of theseattitudes might be. They found ahigh correlation of EE with

• Intrusiveness.• Feeling the patient's illness

status was unjustified.• Disappointment.• Pressure on the patient to act

normally.

This somewhat contradictory setof attitudes is recognizable fromclinical experience with adversefamily atmosphere in schizo-phrenia, and it is easy to see howsuch a set could coincide with so-cial isolation and a sense of patientand parent being "trapped" witheach other. If in addition there isno other space for either to movein, the only "out" is to send thepatient back to the hospital.

3. Leff (1979) has had therapeu-tic success with an essentiallynetwork-oriented intervention forthe treatment of high-EE families.He puts them into parent groupswith low-EE families and notesthat they learn other ways ofdealing with their patient-offspring in the course of thetreatment. The meeting with theother families provides a new so-cial connection, not for thepatients, but for the parentsprimarily.

Similarly, Anderson, Hogarty,and Reiss (1980) have designed aprogram of family treatment whichincludes an all-day seminar anddiscussion group with otherfamilies, the effect of which is tofocus common definitions of theproblem and acquaint them withother people who have had thesame experience, in order to en-hance their social network in theface of the challenge to under-standing and morale.

Evaluations of these treatmentprograms are now underway, andinclude measurement of change in

social structure surrounding thefamily. This whole line of thinkingrecognizes that the family as a con-text for the patient is most stronglyinfluenced by the family's owncontext, its structure, and at-titudes.

Scott and Montanez (1972). TheseEnglish investigators contributeanother way of looking at moraleand problem definition in the fam-ily. They divided a sample ofschizophrenics who had familiesinto (1) those who in the previous2 years had been mostly in thehospital, and (2) those who hadbeen mostly out with families. Onestriking finding at the outset is thatthis is a population with a stronglybimodal distribution: if "out" isdefined as 40 percent of the timehospitalized and "in" as 90 percentof the time hospitalized, only 15percent of the population falls be-tween those two groups.

When the patients and parentswere given an adjective checklistdescribing self and others, the twogroups differed strongly in thisway: The "out" patients and par-ents were congruent with eachother, defining the problem asbeing with the patient, and therewas fair agreement on attributionsof "sick" or "well" characteristicsto family members. The "in" pa-tients, on the other hand, regardedtheir parents as sick, and whereasthere was much greater incongru-ence of attributions in the "in"families, the parents tended to ratetheir own strengths lower than didthe "out" parents. This studyagain suggests the importance ofcongruence and coherence of defi-nition of the problem (shared "in-sight") and attitudes toward dis-ability within the important clusterof the family.

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The study also brings to mind apossible negative aspect of whatappears to be positive social sup-port. That is, only two alternativesocial spaces appear to be availableto the patient: family or hospital. Ifthe congruent attitudes of patientand family keep the patient fromreturning to hospital, they maykeep him from going anywhereelse either. (It is perhaps in thesame sense that, for the prostitutewhose alternative is jail, the con-gruent attitudes of the pimp andmadam may lead to a very stablelife.) What would happen to thepatients in Scott and Montanez'sstudy if patients in each of thesegroups, "in" and "out," wereskillfully introduced to other socialspaces? Would their responses bedifferent one from another, and inwhat way?

Lehmann's (1980) Studies ofHotels. Turning finally to thestudy of other clusters besidesfamily, we find an outstandingexample of the combination of at-titude survey and social structureanalysis in Lehmann's (1980) workon Manhattan single-room-occu-pancy (SRO) hotels. Lehmann andhis colleagues, in a series of pro-gressively refined surveys of hotelswhere psychiatric patients pre-dominate, found that measures oflife satisfaction and high socialfunction among patients werestrongly associated with casualrather than intimate or nurturingcontacts within the hotel. "Themore intense (intimate or affective)social relationships either makesmall negative contributions to thecriteria, or none at all." The other,nonpatient residents seem to valuethe hotel's social life for itself, butthe patients experience it as abackground condition for their rel-

atively quiet and isolated experi-ence of satisfaction and activity.Also, contacts with relatives andothers outside the hotel are nega-tively associated with patients'satisfaction and well-being. Myguess would be that these contactsare single visits not associated withsome other social space or clusterand experienced by the patient as ademand more than a support—butthat would be a question for fur-ther research. The important thinghere is that the hotel, as a socialspace with a certain perceived at-mosphere, is more associated withpositive outcome for ex-patientsthan are some of the expressive orinvolving types of contact whichnonpatients need, and in whichthey participate.

Lehmann notes that we do notknow the direction of cause inthese relationships, and argues, asI have done, that trying to resolveit is inappropriate: "Specific formsof social relationships are as-sociated with specific kinds of ef-fects." A study like this does,however, suggest the design ofexperimental programs in whichcertain kinds of social atmosphere,tolerance of deviance, optimal dis-tance, and background activity arepromoted. We can only promotethem if we learn more about howto describe them.

Summary

This essay connects the phenome-nology and natural history ofschizophrenia with studies of its so-cial contexts, especially studies of"social support" and the course ofthe illness. Precision about what ismeant by support and what is meantby schizophrenia yields importantdistinctions concerning the rele-

vance of social factors in differentdiagnoses. The normal developmentof social networks in stages of theadult career in our culture issuggested as a key to the analysis.The demands of this task vary withsex, social class and ethnicity. Thismay affect variations in the course ofschizophrenia. A particularly impor-tant dimension of the networks ofschizophrenics is the way in whichthey are divided into clusters. Somerelevant characteristics of clustersare proposed in the light of recentresearch.

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The Author

C. Christian Beels, M.D., is Direc-tor of Training, WashingtonHeights Community Service, NewYork State Psychiatric Institute,New York, NY.

World Congressof BiologicalPsychiatry

The World Federation of the Societiesof Biological Psychiatry and theSwedish Society of Biological Psy-chiatry announce the Third WorldCongress of Biological Psychiatry, tobe held in Stockholm, Sweden, June28-July 3, 1981. Each day a plenarysession will be followed by two orthree symposia suggested by thevarious societies. Participants are in-vited to structure reports either asoral presentations or as posters.Abstracts will be made available.

Preliminary deadline for papers:February 1, 1981.

English, French, and Spanish willbe official languages. Simultaneoustranslations from and into theselanguages will be arranged.

Exhibitions will display new equip-ment in experimental disciplines rele-

vant to biological psychiatry, as wellas drugs used in treatment and re-search.

An attractive social program, aswell as pre- and postcongress tourswill be offered by the Congress Com-mittee to participants and all accom-panying persons. Weather in Swedenis generally at its best in June, withan average temperature of 20-23 °C,light evenings, and short nights.

For further information, write to:

The Organizing CommitteeThird World Congress of Biological

PsychiatryStockholm Convention BureauAtt.: Catharina HamiltonJakobs Torg 3S-lll 62 Stockholm, Sweden

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