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J A Doane, M J Goldstein, D J Miklowitz and I R Falloonclimate of families of schizophrenics.The impact of individual and family treatment on the affective

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British Journal of Psychiatry (1986), 148, 279—287

The Impact of Individual and Family Treatment on the AffectiveClimate of Families of Schizophrenics

JERI A. DOANE,MICHAELJ. GOLDSTEIN, DAVIDJ. MIKLOWITZand IAN R. H. FALLOON

Measures of parental affective style were compared for families of schizophrenics participating in a controlled treatment study which contrasted individual and family-basedtherapeutic programmes.The total number of critical statements and non-critical, intrusiveremarkswas significantly lower after three months for parents of schizophrenics participating in family therapy, compared to those whose offspring received only individual therapy.An increased risk for relapse was associated with an increase in the number of criticaland/or intrusive remarks for patients in individual treatment. A significant increase innon-emotional, problem-solving statements was observed in parents who received familytherapy, compared with those who did not. The results suggest that a behaviourallyoriented, problem-solving family approach may have reduced the risk of relapsd in thefirst nine months after discharge from hospital by teaching families concrete ways ofsolving problems and concomitantly reducing the amount of negative emotional relatingbetween family members.

In the past decade findings that the familial affectiveclimate has an important influence on the course ofillness for a schizophrenic family member haveemerged (Brown et al, 1972; Vaughn & Leff, 1976a;Leff & Vaughn, 1981; Vaughn et a!, 1982). Thesestudies demonstrated that certain attitudes expressedby relatives towards a schizophrenic patient recentlydischarged from hospital, viz—highly critical and/or emotionally over-involved attitudes (expressedemotion or EE), lower the patient's threshold forsubsequent relapse. These interactional behaviours,identified as psychotoxic, were fairly specific andinvolved styles of negative affective communicationwithin the family. The Camberwell Family Interview (Vaughn & Leff, 1976b) was developed tomeasure EE; however, EE is not a measure of actualbehaviour, but attitudes. Since attitudes and overtbehaviour are not always isomorphic with oneanother, our team of investigators has carried out aseries of studies that have attempted to assess therole of family affective climate in terms of behaviour, as it relates to the course of schizophrenia.

A measure of the family emotional climate reflecting actual verbal behaviour was developed byDoane et a!. (1981). This coding system, AffectiveStyle (AS), assesses several different kinds of affectively toned remarks made by the parent to thepatient during actual face-to-face discussion. Thus,this measure is best viewed as an index of the relatives' affective behaviour toward the patient.

In a previous study of families of vulnerablenon-psychotic adolescents (Doane et a!, 1981), aprofile method of grouping families on the ASmeasure was valuable in identifying cases among thesample whose initial disturbance subsequentlydeteriorated into major psychiatric disorder. Thismethod involved grouping parents into negative orbenign AS categories, according to whether or notthey demonstrated certain low-frequency markercodes in direct interaction. Adolescent offspring ofparents who used a negative AS marker code weremore likely to develop a schizophrenia spectrum disorder five years later, while those from famileswithout this attribute had relatively good psychiatric outcomes.

In a recent study, this profile approach to grouping families was applied to a sample of schizophrenics in an effort to identify those at risk forearly relapse (Doane et a!., 1985). The sample wascomprised of 36 recently discharged patients, mostof whom were from high-EE familes. The hypothesis was that among these high-EE homes, the moststressful, relapse-prone environments for the returning schizophrenic would be those in which thefamily interaction was characterised by a negativeaffective style. After an initial family assessment,patients were randomly assigned to either anindividual or family therapy treatment programme.The family assessment was then repeated, threemonths after treatment had begun.

279

280 JERI A. DOANE, MICHAEL J. GOLDSTEIN, DAVID J. MIKLOWITZ, IAN R. H. FALLOON

Families were assigned to one of three AS profilegroups, based on the presence or absence of lowfrequency, particularly harsh negative affective stylebehaviours expressed by parents. Results showedthat after three months of the treatment, patientsfrom families that had negative AS profiles werelikely to relapse within the first nine months of treatment. This relationship was quite striking, but wastrue only for cases in the individual managementtreatment programme. Several cases in the familymanagement programme also had negative familyprofiles at three months, but none of them relapsed.In fact, only one of the 11 relapses in the sample wasin the family management programme. Clearly, thefamily treatment had a powerful effect on preventing relapse. Equally clear was that negative AS profiles were strongly associated with relapse in individually treated cases. What was unclear was whyno relapse occurred in those family treatment caseswhere the therapy failed to change the negative ASprofile.

We reasoned that perhaps something more subtlewas changing in these families—some dimension ofaffective communication not captured in the familyprofiles. The AS profiles rely exclusively on the presence or absence of certain low-frequency markercodes. Perhaps a more global, broadly-definedmeasure of affective communication would be moresensitive in picking up subtle, yet perhaps meaningful changes occurring in the quality of affectiveverbal exchange in these families. In other words,perhaps family therapy helped reduce the global,‘¿�atmospheric'dimension of intra-familial affectiveexpression, thereby helping to diminish the probability of relapse.

To test this hypothesis, we needed a measure ofAS which was different from the profile approachused in previous prediction studies. Our strategy inthe present investigation was to get a summarymeasure of all of the negatively toned affectiveremarks occurring during the interaction, irrespective of whether they were the low-frequency harshcodes or relatively benign ones (e.g., benign criticism, occasional neutral intrusiveness). Using AS inthis way, one can think of a total of all of the fivenegative codes as a combined score, reflecting thegeneral family emotional atmosphere or climate.

Our central hypothesis was that after threemonths of treatment, family management wouldreduce the family's combined AS score, relative tothose in individual treatment, and furthermore thatthis reduction would help to account for thesuperiority of family management in reducingrelapse in that condition. The primary goal of thelarger study, however, was to help families learn to

solve their real-life problems more constructivelyand to acquire a set of coping skills that would allowthem to handle the stresses entailed in living with aschizophrenic family member in a better manner.Thus, a related question was whether familiesreceiving behaviourally orientated family therapychanged over the course of treatment with respect totheir use of constructive, non-emotional types ofrelating. The behavioural family therapy is targetedspecifically to improve these coping skills; attemptsto modify emotional relating styles are not the primary focus. In this particular study, we asked whetherfamily therapy increased problem-solving skills, andif so, how this increment might increase understanding of why family affective style changes.

Subjects

Method

A total of 33 patients participated;all had a classificationof schizophrenia on the Present State Examination/CATEGO criteria (Wing et a!, 1974) and met DSM-III(American Psychiatric Association, 1980) criteria forschizophrenia.From the original sampleof 36 who completed the treatment study, post-test family assessmentswereunavailablefor two cases (one of them a relapsecase),and in one case, the father did not participate in the posttest assessment. This reduced the total n for the presentstudy to 33. All patients were between 18 and 45 years ofage, residedor werein dailycontact with one or both biological parents, and used English as the principal languagewithin the home. After informed consent was obtainedfromfamilymembers,the patientswererandomlyassignedto receiveeither family or individual therapy.

A more detailed description of the socio-demographiccharacteristics of the sample is available elsewhere (Falloon et a!, 1982). Briefly, the sample contained twice asmany men as women, and a substantial number of blacks(n= 13), Hispanics (n=6), and Asians (n=2). For bothgroups, the mean age of onset of disease was 22 years, andmean number of psychiatric admission was three. Theaverage age of the patients at time of entry into the studywas 25.6 years. Socio-economic status was middle tolower-middleelass. Approximately half of the familieswere single-parent households; the others weredual-parent.

Treatment protocols

Family management was compared with individual-basedmanagement, as currently practised in many outpatientafter-care programmes for schizophrenics. Patients werenot entered into the study until they had attained a stablebaseline of symptoms and social functioning, and were notshowing any further benefit from neuroleptic medication.Random assignmentwas carriedout once each patient hadbecome clinically stabilised after an acute episode ofschizophrenia, as defined by the PSE (four to six weeks

281TREATMENT OF FAMILIES OF SCHIZOPHRENICS

after discharge). In both conditions, patients were seenweekly during the first three months, then every other weekfor the next six months. All patients were carefully maintained on optimal dosages of neuroleptic medicationthroughout the duration of the study. The family therapyapproach used in this study has been described in detailelsewhere (Falloon et al, 1984). For the purpose of thepresent study, the two treatment conditions will be described briefly.

The family management intervention was a home-based,behaviourally-orientated, problem-solving approach, inwhich family members first received two sessions of education about the nature, course, and treatment ofschizophrenia. Subsequent sessions focused on teachingthe family a structured problem-solving method for solving family issues or problems. The therapy tended to bedirected towards specific issues of problem-solving andcommunication that were functional deficits in eachfamily, and it did not primarily focus on changing negativeAS types of behaviour on the part of family members.

In contrast to the family interventions, the comparisontreatment was clinic-based, individual supportivepsychotherapy: patients in this group were assisted withproblems of everyday living and management of their illness. Like the family treatment group, these patientsreceivedoptimalmaintenancepharmacotherapy,comprehensive crisis intervention, case management services, andeducation about the nature, course and treatment ofschizophrenia.

Direct interaction procedure

During the initial pre-treatment phase (baseline), familiesin each group participated in two audiotaped direct interaction tasks involving the parent(s) and the patient. Thisprocedure was then repeated after three months of treatment. These direct interactional data were used to measureaffective style.

The structure of the interaction was a modification ofthe revealed differences technique developed by Strodtbeck(1954). Family members were asked to discuss a problemthey held in common and to attempt to resolve theirdifferences; this procedure is described in more detail byDoane et al. (1981). For both interactions, the family wasinstructed to discuss the topic, express their respective feelings and ideas about the problem, and make some attemptto resolve the issue; they were left alone for ten minutes.Verbatim transcripts of these discussions were used for theanalysis of AS.

Affective style measure

A critical incident model of coding was used to measurethe parental AS behaviour directed toward the patient during the interaction. A unit for analysis was defined as up tosix consecutive lines of uninterrupted speech by a singlespeaker. The unit was ended when a second speaker eithersignificantly interrupted the first or began a distinct reply.The following is a description of the negative codes in theAS scoring system;

1. Criticism (a) Benign criticism. The criticism is circumscribed, matter-of-fact, and/or directed toward specificincidents or sets of behaviours. Example: “¿�Youdon't helpwith the housework.―(b) Personal criticism. The criticismhas one or more of the following qualities: unnecessary oroverly harsh modifiers; reference to broad classes of behaviour; or reference to the person's nature or character.Example: “¿�Youhave an ugly, arrogant attitude.―

2. Guilt induction. Statements with guilt-inducing impacthave two components: they convey that the patient is toblame or at fault for some negative event and that theparenthasbeendistressedorupsetby theevent.Example:“¿�Youcause our family an awful lot of trouble.―

3. Intrusiveness. Intrusive statements imply knowledge oftheperson'sthoughts,feelingstates,or motiveswhen infact there is no apparent basis for such knowledge. (a)Critical intrusiveness. The intrusiveness contains a harshcritical component. Example: “¿�Youenjoy being mean toothers.―(b)Neutralintrusiveness.The intrusivenesshas aneutral quality and refers to the patient's emotional states,ideas, or preferences. Example: “¿�Yousay you're angry atus, but I think you're really mad at yourself.―

Reliability

Inter-rater reliability of the AS codes was previouslyestablished on another sample (Doane et al, 1981). Agreements on non-occurrence were not included in the calculations. Inter-rater reliability was computed using Cohen's(1960) Kappa, applied only to those instances in which oneor both raters believed one of the codes was applicable,and was 0.78, P-<0.OOl. Inzrarater reliability was above0.95 for all codes (Pearson r; 2-month interval). The transcripts in the present study were coded by two raters whowere blind to any family characteristics and to which treatment condition the patient was in.

Affective style scores

Three AS indices were used for the analyses reported in theresults section. For dual-parent families, these indices arebased on the sum of both parents' codes across the twointeractions. For single-parent families, the indices reflectthe sum of the one parent's codes across interactions.

1. Combined AS score—the raw sum of all of the negative AS codes; this score reflects an estimate of the overallamount of negative emotionality being directed at thepatient during the interaction.

2. Total criticism score—thesum of all of the benigncriticism, personal criticism, critical intrusiveness, andguilt-induction codes; this score reflects that part of thecombined AS score which is primarily critical in nature.3.Totalintrusivenessscore-thesum of thestatements

coded as neutral intrusiveness. As such, it reflects that partof the combined AS score which is made up of intrusive orinvasive (but not critical) remarks.

282 JERI A. DOANE, MICHAEL J. GOLDSTEIN, DAVID J. MIKLOWITZ, IAN R. H. FALLOON

Problem solving style

A system for assessingthe problem-solvingresponsesoffamily members during the direct interaction task wasdeveloped by the senior author (JAD). In this system,called Problem Solving Style (P55), 11 different categoriesof problem-solving statements are coded from typed transcripts of the interaction. Portions of this system wereadapted from an instrument employed in research byRobin et al. (1977). The total score reflects the degree towhich family members implemented techniques of solvingproblems taught to them in the family therapy sessions.The system was designed so that statements coded for ASwere mutually exclusive from those coded for PSS. Thecodes included statements such as: specifying the problem,transition statements, proposing a solution, and planningimplementation of a proposed solution. A summary scoreof the total number of parental PSS statements wascalculated at both baseline and at the three-month posttherapy reassessment. Inter-rater reliability for thesummary score was 0.91 (Pearson product-momentcoefficient).

Relapse

The major criterion of patient outcome used was whether aclinical relapse occurred during the first nine months oftreatment. Defining relapse is a difficult issue that oftenposes real problems in establishing meaningful criteria(Falloon et al, 1983). We were interested in whetherchanges in the general family emotional atmosphere wereassociated with the likelihood of clinical relapse; themeasures that follow were used to form an operationaldefinition of relapse.

Clinical exacerbation. This measure was used to estimatethe severity of illness throughout the nine-month followup period. It was judged to have occurred if the team ofthree clinicians unanimously agreed that there had been areturn of florid symptoms of schizophrenia that lasted forat least one week or required a major change in management (e.g. hospital admission or a substantial increase inthe medication dosage). Since it was made by the team ofclinicians doing the therapy, this dichotomous judgementwas not blind.

Target symptom ratings (TSR) These ratings were carried out at baseline and at monthly intervals throughoutthe nine-month period by clinicians who were blind to thetreatment condition of the patient. Two or three floridsymptoms of schizophrenia in each patient (i.e. targetsymptoms), characteristic of that patient's acute episodes,were selected prior to entry into the study, were then ratedon a seven-point scale of severity each month, and an average TSR score, calculated at monthly intervals.

Definition of relapse Information to determine whether apatient had suffered a relapse or significant exacerbationwas available from several sources; the two measuresoutlined above were the main criteria used to definerelapse. One criterion was whether the treating team ofclinicans unanimously agreed that the patient had relapsed(clinical exacerbation). Eight patients in the individualgroup and one in the family group were judged as relapsers, using this criterion. A second criterion was whether

the patient received a markedly serious elevation on hismean TSR. A cutting score of five on this scale was used toclassify patients as relapsers, on the basis of these blind ratings. There was considerable overlap between thenon-blind clinical judgement designation and the blindTSR method of grouping patients. Of the ten patientsjudged as clinical relapsers, seven also had elevations onthe TSR. The total number of patients who met one orboth of these criteria was ten.

In addition to the cases who met one or both of theabove two criteria for relapse, four others were admittedduring the nine-month period—twofrom the family groupand two from the individual group. Hospital records indicated that only one of these patients was admitted forexacerbation of schizophrenia; two were admitted for drugoverdose without psychotic symptoms, and one for transient lodging. Since we were concerned in this analysis withthe relation of AS to the exacerbation of schizophrenicsymptomatology, and not hospitalisation per se. weincluded in the relapse group only the case who wasadmitted (twice) for schizophrenic exacerbation but whowas not judged a relapse or rated as elevated on the TSR.(This occurred because it was not possible to carry outTSR ratings or clinical evaluation by project staff.) Thisleft a total of nine relapsers in the individual group and onein the family group.

Results

Since systematic sex differences were not found for any ofthe analyses, male and female patients were groupedtogether for data analysis purposes.

20-

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FIG. I Pre-post change in summary AS (Affective Style)

Treatment groupChange in coIncreasembined

AS scoreDecreaseIndividualII5Family512

283TREATMENT OF FAMILIES OF SCHIZOPHRENICS

tially affecting two key dimensions of family affectivecommunication: criticism and intrusiveness. British worktreats criticism and over-involvement as independentdimensions in defining EE status. The codes in the affectivestyle system can be broken down into two somewhat parallel components—criticism and non-critical intrusiveness.Perhaps treatment influences one of these dimensions morethan the other. To examine this issue, two 2 x 2 repeatedmeasures analyses of variance were carried out, with preto post- Total Criticism and Total Intrusiveness scores asrepeated dependent factors, respectively, and treatmentgroup and time as the independent factors in bothanalyses. The changes in these two variables in the twotreatment groups between baseline and the three-month,post-therapy assessmentare indicated in Figure2. The AS xtreatment interactions for criticism and intrusiveness were

12

Impact of Treatment on Combined AS Score

The first question asked was whether there was a decreasein the combined AS score for families in the family management condition, compared to families of individuallytreated patients. To test this, a 2 x 2 repeated measuresanalysis of variance was carried out, with treatment condition and time as the independent variables and combinedAS score as the repeated dependent factor. After threemonths of therapy, the combined AS score had markedlyincreased in the individual condition and decreased in thefamily management condition (n = 33; d.f. =1, F = 8.25,P<0.0l, for the interaction) (Figure 1). Within-groupt-tests were significant for the individual condition (n = 16,d.f. = 15, t=2.25, P<0.05, two-tailed test), indicating anincrease in combined negative AS over time. For thefamily group, a nearly significant trend was observed(n= 17, d.f.= 16, t= 1.78, P<0.lO, two-tailed test) in thedirection of a decrease in combined AS. Between-groupsimple main effects for treatment group at the pre-test werenot significant (X combined AS score for the individualgroup was 12.6 statements; and 10.9 for the family group.)The post-test group differences were significant, however,(18.2 statements for the individual group, and 7.0 for thefamily group) n = 33, d.f. = I, F = 13.67,P<0.00l).

The family management treatment was clearly superiorto individual management in reducing the total number ofnegative emotional communications made by the parents(Figure 1). It is important that not only did the individualtreatment fail to reduce AS, but over time, it increasedsignificantly. However, the pattern of group means doesnot say anything about how many actual families reducedtheir combined AS from the pre- to post-therapy assessment. We therefore grouped the families into two categories: increase-those whose post-pre difference waspositive; and decrease—those whose difference score wasnegativeor zero. Twelveof the 17 (71%) familiesin thefamily treatment decreased their combined AS scorewhereas in contrast, the predominant change in theindividual condition was an increase in negative AS (11 of16 cases or 69%). Of the nine relapse cases in individual

TABLEIChange in combined AS in individualandfamily therapy treatment

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FIG. 2 Pre-post change in criticism and intrusiveness

both significant in the expected direction (criticism: n = 33,d.f.=l, F=5.41, P<0.03; intrusiveness: n=33, d.f.=l,F=5.24, P<0.03).

Within-group t tests were significant for the increase incriticism observed in the individual group (n = 16,d.f. = 15,t=2.84, P=0.Ol), but not for the decrease observed in thefamilycondition.Thus,withregardtocriticism,themostdramatic change occurred in the individual managementgroup. These parents, who did not receive family treatment, dramatically increased their level of criticismtowards the patient, despite the fact that their son ordaughter was in weekly individual therapy throughout thisthree-month period. Family management apparently functioned to ‘¿�hold'or ‘¿�contain'the criticism in the parents andprevented it from escalating, rather than dramaticallyreducing it.

Between-group simple main effects for the treatmentgroup at the pre-test were not significant (X Total criticismscore for the individual group was 4.4 statements, and 4.0for the family group. The post-test group differences were

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treatment, seven came from families whose combined ASincreased. The one family treatment relapse was in thedecrease group (Table 1).

Impact of treatment on criticism and intrusiveness

Wenext investigatedwhethertreatmentmight be differen

284 JERI A. DOANE, MICHAEL J. GOLDSTEiN, DAVID J. MIKLOWITZ, IAN R. H. FALLOON

significant, however, (8.3 statements for the individualgroup, and 2.8 for the family group) n = 33, d.f. =1,F=7.62, P<0.Ol.

With the intrusiveness dimension, the picture is reversed.The within-group t tests for this variable were not significant for the increase in the individual group, but were forthe decrease in the family management condition (n= 17,d.f. = 16, t = 2.48, P<0.03). Thus, the family interventionused in this study was less effective in reducing total criticism than it was in decreasing non-critical intrusive orinvasive statements. This is not surprising, since parents inthe family management group were actually encouraged touse criticism of the benign sort, and no attempt was madeto reduce it.Between-groupsimplemain effectsforthetreatment

group at the pre-test were not significant (X Totalintrusiveness score for the individual group was 8.2 statements, and 6.9 for the family group). The post-test groupdifferences were significant, however, (9.9 statements forthe individual group, and 4.2 for the family group) n = 33,d.f.= 1, F=9.25, P<0005.

In sum, without family intervention, criticism rosedramatically, but did not accelerate if the family wasinvolved in the treatment. Intrusiveness, was reduced withfamily treatment, but remained basically stable inindividual treatment.

All but one of the relapses occurred in the individualmanagement condition. Given the pattern of relationships(Figure 2), we next investigated how changes in one orboth of these dimensions of affective climate might relateto relapse; e.g. whether families in which both criticism andintrusivenessrose had a higher relapseratethan familieswhere both dimensions declined.

In order to pursue this hypothesis, it was necessary todivide the families in each treatment condition into threegroups: (1) dual increase (DI), in which both criticism andintrusiveness increased from pre- to post-test; (2) dualdecrease (DD), where both declined (or stayed the same);and (3) a mixed (MX), group in which one attributeincreased while the other decreased or stayed the same.

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Figure 3 presents the frequency of each type of familychange pattern by treatment group. It also indicates thenumber of relapses that occurred in each of thesepattern-based category groups.

The modal family pattern of change for the two treatment groups differed dramatically. In the individual condition, the most common outcome after three months oftreatment was a dual increase pattern i.e. parents weremore critical and intrusive toward the patient (8 out of 16cases). This pattern was observed in only two of thefamily-treated cases. A mirror-image is observed when oneexamines the modal change pattern for cases in the familymanagement condition, where a reduction in both criticism and intrusiveness was predominant (9 out of 17cases).Conversely, only four of the 16 individually treatedfamilies had this pattern. The mixed pattern, in which onedimension increases while the other decreases, was equallycommon in both treatment conditions. Thus, there is aclear trend for a reduction in one or both forms of thenegative AS dimensions in the family treatment condition(15 out of 17 cases, 88%).

The relapse rate among these sub-groups differs widely(Figure 3). Examining the probability of relapse within thetwo modal change patterns for the individual andfamily-treated cases, the rate is 63% for those in theindividual management dual increase group, whereas insharp contrast, the relapse rate for the family managementdual decrease families is only 11%.

Three out of the four mixed cases in individual treatment relapsed. Thus, for patients in individual treatment,risk of relapse was relatively high unless both dimensionsof AS decreased: 67% of cases in the dual increase andmixed groups relapsed versus 25% of those in the dualdecrease group. There were eight cases in the familytherapy condition with the dual increase pattern (n = 2)or the mixed pattern (n = 6) who did not relapse. It isimportant to remember that this reassessment of thefamilies occurred after only three months of familytherapy, and it is possible that with sustained therapeuticcontacts over the subsequent six months, changes in theaffective climate of these families did occur.

The above results support the notion that a reduction inthe overall level of negative affective communication canbe achieved with family therapy. This intervention alsosignificantly reduces the risk for relapse. Exactly why thisreduction in overall AS occurred is less clear: reducing oreliminating negative emotional interaction was not themajor focus of the treatment. Rather, the primary aim ofthe family therapy intervention was to teach families adefined, step-by-step method of solving problems. At thispoint, we hypothesised that treatment-induced incrementsin problem-solving behaviour might help to explain theobserveddecreasesin AS.

Changes in PSS

A measure of constructive problem-solving behaviours(PSS), derived from the interaction task, was available forthe parents for both the baseline and three-month, posttest interactions. The two treatment groups did not differ

Family Therapy Individual Therapy(n=17) (n=16)

DI-Dual Increase

MX-MixedDD-DualDecrease

Relapse (n= 10)

8

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CHANGE IN CRITICISM / INTRUSIVENESS

FIG.3 Family changepattern, treatmentand relapse

FamilyTherapy

285TREATMENT OF FAMILIES OF SCHIZOPHRENICS

families where both dimensions ofAS declined, changes inPSS cannot explain the changes in AS that were observed.

Discussion

The major finding in the present study is that a significant reduction in the overall negative affectiveclimate of the family occurred when schizophrenicswere treated with family as opposed to individualmanagement. Family therapy very dramaticallyreduced the likelihood of early relapse in thissample of adult schizophrenics. It also significantlyincreased the parents' ability to use non-emotional,constructive ways of talking to the patient during anemotionally charged discussion. Since an emotionally stressful home environment has been linked toincreased probability for relapse (e.g., Vaughn &Leff, 1976a), a logical conclusion to be drawn fromthe present study is that reducing the level ofnegative affect expressed by family members helpsto prevent relapse.

The findings here suggest that parents of recentlydischarged schizophremcs who do not receive familytreatment may become more frustrated with tryingto cope, as the post-hospitalisation period lengthens, and may express some of this stress bybecoming even more critical or intrusive towards thepatient. This finding is consistent with the widelyaccepted notion among clinicians that close relativesof persons in individual therapy often experiencedistress once treatment gets underway. When anacceleration of affect was observed in this particularsample, the probability of relapse was quite high.This finding is consistent with the earlier report onthis sample, which showed that families in which thelow-frequency harsh AS marker codes (such asblatant hostility and guilt-inducement) persisted,had a very high likelihood of relapse (Doane et a!,1985). The present findings suggest that apart fromthe harsh marker codes, more subtle, less blatantforms of negative relationship are also changing;when the ‘¿�emotionaltemperature' rises across time,the family environment continues to be a stressfulenvironment for the relapse-prone patient, whichmay in some cases exceed his capabilities for coping,and result in a return of psychotic symtomatology.

The results also demonstrate that family therapycan lower the ‘¿�emotional temperature' of the homeenvironment, and suggest that this may be due tothe fact that specific, constructive ways of handlingstress-producing problems were learned by thefamily. If so, it would follow that although negativeremarks do not necessarily disappear from heatedfamily discussions, they become less frequently the

with regard to PSS score at pre-test. A repeated measuresanalysis was used to examine the relationship betweenchanges in PSS from pre- to post-test in the two treatmentconditions. The analysis revealed an interaction betweentreatment group and PSS (n = 33, d.f. = I, F = 6.08,P<zO.02). Parents in individual treatment did not changein their problem-solving behaviour from pre- to post-test(from eight to ten statements). However, for those in thefamily condition, a dramatic increase was observed (from10 to 25 statements) (Figure 4). Between groups, simple

30 -

Pre Post

ASSESSMENTTIMEFIG. 4 Pre-post change in PSS (Problem Solving Style)

main effects for treatment group at the pre-test were notsignificant. The post-test effects, however, were significant(n=33, d.f. = 1, F=7.75, P<0.0l).

The data suggest that the families are perhaps reducingtheir negative affect because of a concomitant rise in theusage of non-affectivetypesof problem-solvingverbalbehaviour. Since AS and PSS are mutually exclusivecodes,yet both are measured from the same sample of verbalinteraction, any increased in one must be accompanied bya probable decrease in the other.

Additional analyses revealed that among the individually treated group, change in affective style was a betterpredictor of relapse than was PSS. Since there were virtually no relapses in the family condition, the associationbetween AS and PSS to relapse cannot be examined.Although the biggest increments in PSS occurred in

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286 JERI A. DOANE, MICHAELJ. GOLDSTEIN, DAVID J. MIKLOWITZ, IAN R. H. FALLOON

primary or exclusive modality for expression of tension or dissatisfaction about some problem with thepatient. The net effect of such a change in interactivestyle could, theoretically at least, cause the family(including the patient) to experience the homeenvironment as a less unpredictable, affect-laden, oremotionally stressful arena to deal with theday-to-day stresses of life.

In this study, the patient living in a home whereboth criticism towards him and intrusions into hisinner life increases, appears to be at a clear disadvantage. However, a comparable disadvantageexists for the individually-treated patient whoseparent(s) increases only one kind of emotionalnegativity. This would suggest that the importanceof successful family treatment lies in the extent towhich it is able effectively to reduce the overallemotional temperature of the family environmentand, concomitantly to provide the family with alternative ways of coping with patient-related problems. Individually-treated patients whose familiesaccomplished a reduction in both AS dimensionswithout systematic family intervention were far lesslikely to relapse. These findings are consistent withthe notion that the overall family affective environment is an important intervening variable in thecourse of the illness.

The question of which discrete components offamily treatment cause or interact with other variables to result in a reduction in overall affect cannotbe answered in this study. The data are suggestive,however, that at least in this particular study,improved ability to cope with family stresses andproblems (i.e. increased PSS) operates as a substitute for emotional ventilation. It would appearthat when decreased AS was achieved, the familywas better able to focus on constructive problemsolving strategies and perhaps attitudes. Thus,the data suggest a marked reciprocity betweenuncontrolled, negative affective expression focused

upon the patient and a more controlled, cognitiveform of behaviour focused on common familyproblems.

The design of the study did not allow us tomanipulate AS and PSS independently, and therefore we cannot speak to the sequential linkagebetween these two dimensions of family behaviour.Unfortunately, studies of this sort are difficult to do,since in real life the affective and cognitive dimensions of interpersonal exchanges are inextricablytied together. However, efforts are needed to disentangle the discrete components of family interventions, in order to understand better how the familyemotional atmosphere affects the course of illness,and what contribution to prevention of relapse ismade by the modification of the affective climate bya family therapy approach.

The findings, if replicated, have important implications for the treatment of schizophrenia, but thisstudy had some limitations. The cases did not constitute a typical sample of schizophrenics: all ofthem were living at home with at least one biologicalparent. The sample was small, predominantlyhigh-EE, and all agreed to participate in a two-yeartreatment programme. These factors should be keptin mind, when attempting to generalise the findings.Also, this study compared a home-based, familymanagement program with clinic-based, individualtreatment, so that the setting in which treatmenttook place is confounded with the type of treatmentdelivered. Because of this aspect of the design, it isnot possible to assess whether home visits per seinfluenced the outcome of patients or the changesobserved in the affective climate of the family.

AcknowledgementsThis research was supported by National Institute of Mental Health Grants MH 30911, MH 08744, and MH 33138.Sibyl Zaden was the research assistant.

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*Jen A. Doane, PhDAssistant Proftssor of Psychiatry (Psychology), Yak University School of Medicine, andYale Psychiatric Institute, P.O. Box 12A, Yak Station, New Haven, Connecticut, 06520, USA.

Michael J. Goldstein PhD Professor of Psychology, University of California, Los Angeles, Cal@/'ornia, USA.

David J. Miklowitz, MA Research Associate, Department of Psychology, University of Cal@ftirnia, LosAngeks, Cal y―ornia,USA.

Ian R. H. Falloon, MD MRCPsychAssociate Professor of Psychiatry, University of Southern Cal@/'orniaSchoolof Medicine, Los Angeles, California. Consultant Physician (Mental Health), Buckingham Hospital,Buckingham, Bucks.

5Correspondence

(Accepted 22 May 1985)