Journal of Consulting and Clinical Psychology 1978, Vol. 46, No. 5, 839-843
Personality Traits and Environmental Variables as Independent Predictors of Posthospitalization Outcome George A. Clum Virginia Polytechnic Institute and State University A set of predictor variables, identified as intrapsychic, and a second set, identified as environmental, were examined in a multiple regression analysis as to their independent contribution in predicting posthospitalization adjustment. The analyses indicated that level of adjustment at baseline hospitalization was the most salient prognostic variable. Significant others' expectations for the patients' self-help performance contributed independently to a follow-up criterion of total symptomatology as rated by the significant other. The results provide moderate support for the hypothesis that environmental as well as intrapsychic variables are important prognostic indicators.
A recent review of prognostic factors of hospitalized psychiatric patients (Clum, 1975b) has shown that two types of variables, intrapsychic and environmental, can be hypothesized to be independent predictors of posthospital outcome. This conclusion was largely inferential, however, and no substantive data exist that demonstrate the independent contribution of each set of variables. To accomplish this, three conditions must be met: (a) A set of predictor variables, identified as intrapsychic, must be found to predict posthospital outcome; (b) a set of predictor variables, identified as environmental, must be found to predict posthospital outcome; and (c) both sets must contribute independent variance to the criterion in a multiple regression format. In line with the previous definition of these variables, intrapsychic variables include any "measurable cognitive or personality characteristics the patient exhibits. Environmental variables are defined as socioThis study was supported by Grant UVAC-12-70 from the Commonwealth of Virginia Department of Mental Hygiene and Hospitals; by funds from the Fluid Research Fund, University of Virginia School of Medicine; and by a University Computing Grant, University of Virginia. Requests for reprints should be sent to George A. Clum, Department of Psychology, Virginia Polytechnic Institute and State University, Blacksburg, Virginia 24060.
psychological phenomena within the patient's life space, but external to the patient himself" (Clum, 1975b, p. 416). One example that may clarify the problem involves the relationship between marital status and prognosis. The personality trait view suggests that individuals who are single and socially withdrawn will not be selected as marriage partners and will tend to have a bad prognosis. Being single has been found to be related to an individual's continued stay in a mental institution and also to poor social adjustment on release from the hospital (Clum, 1975b). In contrast, the environmental view suggests that being married acts as a buffer that leads to a greater likelihood of the patient having a good prognosis. People who are married have a definite role in the family, whereas people who are single are neither the homemaker nor the breadwinner and hence have roles secondary to the functioning of the family. The press to perform will accordingly be less for the single individual and might be anticipated to lead to poorer performance for such people according to an expectation hypothesis. To determine whether the relationship between single status and poor prognosis is due to a selection process or to a buffer hypothesis, the initial level of patient dysfunction must be controlled. If it can be shown that single individuals do not exhibit more disturbance
Copyright 1978 by the American Psychological Association, Inc. 0022-006X/78/4605-0839$00.75
839
840
GEORGE A. CLUM
than married individuals on admission to a hospital but that they do exhibit a poorer prognosis, the buffer hypothesis would be supported. Another example that can be addressed to the question of independent contribution to prognosis would be that of expectations and outcome. The personality trait view would predict that the more disturbance exhibited by the individual, the lower would be the expectations, resulting in a poor prognosis; that is, level of disturbance would determine level of expectations. The environmentalist would predict outcome from expectations independent of level of disturbance. The relative importance of these two sets of variables has been studied previously in relation to in-hospital criteria of length of hospitalization and rated improvement at discharge (Clum, 197Sa). Although Clum's (197Sa) study supported the hypothesis that environmental variables are predictive of length of hospitalization, it must be considered an inconclusive test. Length of hospitalization is a relatively weak criterion because of its fluctuation on the basis of administrative considerations and because of the fact that in a shortstay hospital such as the one in his study, the criterion variance is severely truncated. Accordingly, the present study expands this analysis using a criterion of rated adjustment 1 year after initial hospitalization. Method Subjects Subjects in the present study (N = 79) included all patients admitted to the University of Virginia psychiatric service who were also available for follow-up evaluation 1 year after admission. This sample represented a severely truncated subsample (50%) of the subjects who had completed all baseline data, a reduction of subjects which, however, is comparable to other studies using mailings and phone calls to obtain follow-up data. A comparison of the two groups, however, revealed no differences on variables of marital status, age, race, social class, and initial level of symptomatology on five symptom factors. The subjects were between the ages of 16 and 65 and included only those who did not have a diagnosis of organic brain damage.
Predictors At the time of hospitalization, each patient was administered a biographical inventory, the Life Change Inventory (described previously by Clum, 1976), and a measure of expectations for improvement. Information culled from the biographical inventory included total lime previously spent in mental hospitals, education, income, marital status, age, and number of friends. The patients' expectations were derived from the Katz Adjustment Scales (Katz & Lycrley, 1963). A significant other also rated his/her expectations for the patient's performance once the patient returned home from the hospital. Two measures of expectations were obtained—one regarding the patient's performance on self-help tasks, the other regarding the patient's social adjustment.
Criterion Measures Two criteria were used—total number of symptoms as noted by the patient and total number of symptoms as noted by the significant other. The Katz Adjustment Scales were used to evaluate symptomatology.
Procedure At the time of hospitalization, patients were asked to complete all research forms. A significant other (spouse, parent, relative, or friend) who was familar with the patient's adjustment in the month prior to hospitalization was also asked to complete the research instruments. One year Liter the patient and the same significant other were again contacted, and the same forms were readminislercd. The sample was then divided randomly into validation and hold-out samples to determine the stability of the results.
Results Patient-Related Symptomatology Both environmental and personality trait measures were entered into a stepwise multiple regression equation in order to assess the independent contribution of each variable to a criterion of total S3'inptomatology as rated 1 year after hospitalization. As Table 1 indicates, only total symptomatology at baseline, time in mental hospital, and education contributed independently to patient-rated total symptomatology at the 1-year follow-up. Further, only total symptomatology at baseline was found to contribute independently to the criterion in the hold-out cross-validation group.
841
PREDICTING OUTCOME Table 1 Regress-ion Analysis of Predictor Variables at Hospitalization to Patient-Rated Total Symptomatology at 1- Year Follow- Up Sample Val idation
Predictor variable Baseline patient-rated total symptoms" Time in mental hospital (complex) Education (complex) Income (complex) Significant others' expectations— self-help" Marital status'1 Age (complex) Patients' expectation — baseline* Level of performance as rated by significant other—social adjustment" No. friends (complex) Total stress" Significant others' expectations — social adjustment" Martial status Single = 2 All others = 1 (complex)
Simple K S0b**
.2ffi
-.39b* -.30 .36* -.04 -.21
-.15 .03 -.16
Hold out
Beta weight .46 .15
-.02
Simple R b
.47 * .41*
Beta weight .28
-.04 -.03 .32 .04 -.12 -.03 .12
-.18 .26 .15
.02 .69
.14 .47
" Intrapsychic. b Significant independent contribution in multiple regression. " Environmental. d Married = 1; all others = 2 (complex). * p = .05. = .01.
Stress was not found to be related to the criterion. However, significant others' expectations for the patient's performance on selfhelp tasks correlated in the expected direction with outcome but did not contribute independently to its predictions. Significant-Other-Rated
Symptomatology
The regression analysis of significant-otherrated total symptomatology at the 1-year follow-up (see Table 2) demonstrated that baseline total symptomatology, significant others' expectations for self-help, number of friends, marital status, and patients' baseline expectations were the only variables of those examined that contributed independently to the criterion. Significant others' expectations of self-help were significant at the .01 level, supporting the importance of expectations as a prognostic variable, independent of personality traits. Marital status was also reliably re-
lated to significant others' ratings of total symptomatology, again, in a negative direction. This was contrary to predictions. Of these five predictors only total baseline symptomatology and significant others' expectations cross-validated as independent contributors to the criterion. The vast majority of previous research has found single people to have poorer prognoses. Since most of these studies were conducted on predominantly schizophrenic populations, it was decided to reanalyze the relationship between marital status and outcome separately for schizophrenic and schizoid personality patients and all other diagnostic groups. Pearson correlation coefficients were computed between marital status and total symptomatology at follow-up for patients diagnosed as schizophrenic or schizoid personality. The results indicated that marital status and total symptomatology at follow-up were related (r = .41 between marital status and significant others'
GEORGE A. CLUM
842
Table 2 Regression Analysis of Predictor Variables at llospilalization to Significant-Other-Rated Symptomatology at 1- Year Follow- Up
Total
Sample Validation Predictor variable ted total Baseline significant-other-rated symptoms" Significant others' expccta ons— self-help" Martial status (complex)'1 No. friends (complex) Patients' expectations—baseline 2line"1 Significant others' ratings of level of performance—social adjustment" Age (complex) Education (complex) Significant others' expectations— social adjustment" Time in mental hospital (complex) Total stress" Income (complex) Marital status (complex) Single = 2 All others = 1
Simple R
Beta weight
.55'-** .54h** -.41b* .2\h .03''
.21 .33 -.45 .27 -.15
Hold out Simple R ,40>>* .24" -.11
.08 .23
.17 .22 .14 .17
.27 .33 .13 .14
-.28
.36 .25
-.33
.47* -.08 -.31
-.23*
Beta weight
.13 .59
" Intrapsychic. 11 Significant independent contribution in multiple regression. l! Environmental. ll Married = 1; all others = 2. * p = .05. **/> = .01.
ratings; r = .43 between marital status and patients' ratings) in a generally positive direction, altho'Ugh not reaching significance due to the small sample size (8). Thus, for this subgroup of patients, a single status led to a poorer prognosis, as was previously predicted. Discussion The present study sought to determine whether environmental factors are of independent prognostic significance when considered conjointly with personality trait variables. A multiple regression format in which both types of predictors were considered was used to make this determination. The results provided partial support for the hypothesis that predictor variables representative of both classes of variables would contribute independent predictor variance. Specifically, initial level of symptomatology was consistently related to the criterion. In addi-
tion, significant others' expectations for selfhelp were related to total symptomatology as rated by the significant other but not as rated by the patient. This provides moderate support for the import of an environmental factor of others' expectations as an independent prognostic variable. Heretofore, it has been unclear whether the relationship of expectations to outcome was attributable to the fact that others' expectations were lower for those individuals whose adjustment was poor. It is arguable whether poor prognosis in this case was a function of the expectations or the already poor adjustment. The fact that expectations for self-help were not independently related to patients' ratings of symptomatology suggests that for this criterion the impact of expectations is determined largely by its relationship to initial level of symptoms. No other prognostic variable, either personality or environmental, cross-validated.
PREDICTING OUTCOME
843
This is especially confusing with regard to be increased. Decisions to continue hospitalmarital status, since this variable has been ization for a longer period of time or until such most consistently related to prognosis (Clum, time as those factors predictive of outcome 1975b). The vast majority of these studies, have been modified could be affected. however, included Veterans Administration or The second implication concerns those areas state hospital patients, most of whom were targeted for change. Since previous studies schizophrenic and chronic. In the present have focused on intrapsychic variables and study a marital status of married was posi- have related these to outcome, the focus of the tively correlated with significant-other-rated clinician has remained at effecting changes in symptomatology, as compared with a negative the patient's personality. With the addition, relationship in most other studies. Since most in the present study, of the importance of exof the patients in the present study were pectations and possible role models as indeneither schizophrenic nor chronic, it was de- pendent predictors of outcome, a new direccided to analyze the relationship between tion for targets for change should be forthcommarital status and outcome separately for ing. Specifically, attention should be paid to those patients diagnosed as schizophrenic or changing the patient's families' expectations schizoid and those with all other diagnoses. for performance, such that higher demands on The results confirmed the finding of previous the patients performance o'f self-help tasks studies: Married status was related to a bet- should be emphasized. The importance of aster outcome for the schizophrenic and schizoid suming a significant role in the family as a subgroup. It is possible, therefore, that diag- breadwinner or homemaker appears specific nosis is a moderator of the marital status-out- to schizophrenic patients. For this group, accome relationship, rendering marital status an cordingly, the importance of developing sigeven more powerful prognostic variable. nificant social roles would seem to be a target Whether it contributes independently to out- for therapeutic intervention. In contrast, being come for schizophrenic patients still remains married was found to be a negative prognostic an unanswered question. factor for nonschizophrenic patients. AccordThe environmental variable of life stress ingly, affecting a more positive relationship was not found to be of any reliable conse- within the marital context should receive quence. However, in another study (Clum, greater attention in this group. 1976), it was demonstrated that whereas life changes prior to hospitalization were unreReferences lated to symptomatology at follow-up, they were related to the level of symptoms at the Clum, G. A. Intrapsychic and environmental variables as predictors of length of hospitalization and rated time of hospitalization. Similarly, life changes improvement at discharge. Journal of Consulting subsequent to hospitalization were predictive and Clinical Psychology, 1975, 43, 276. (a) of level of symptomatology 1 year after hos- Clum, G. A. Intrapsychic variables and the patient's environment as factors in prognosis. Psychological pitalization. This supports Rahe's (1972) noBulletin, 197S, 82, 413-431. (b) tion that stress only in the preceding year is Clum, G. A. Role of stress in the prognoses of menpredictive of symptomatology. tal illness. Journal of Consulting and Clinical PsyImplications The implications of this study are twofold. First, the question of prognosis that confronts the clinician is related to decisions regarding disposition. For example, if a patient can be predicted to have a poor prognosis, the insistence on further follow-up treatment could
chology, 1976, 44,1, 54-60. Katz, M. M., & Lyerley, S. B. Methods for measuring adjustment and social behavior in the community. I. Rationale, description, discriminative validity and scale development. Psychological Reports, 1963, 13, 503-5,55. Rahe, R. H. Subjects' recent life changes and their near future illness reports. Annuals of Clinical Research, 1972,4, 250-265.
Received October 18, 1976 •
Personality Traits and Environmental Variables as Independent Predictors of Posthospitalization Outcome George A. Clum Virginia Polytechnic Institute and State University A set of predictor variables, identified as intrapsychic, and a second set, identified as environmental, were examined in a multiple regression analysis as to their independent contribution in predicting posthospitalization adjustment. The analyses indicated that level of adjustment at baseline hospitalization was the most salient prognostic variable. Significant others' expectations for the patients' self-help performance contributed independently to a follow-up criterion of total symptomatology as rated by the significant other. The results provide moderate support for the hypothesis that environmental as well as intrapsychic variables are important prognostic indicators.
A recent review of prognostic factors of hospitalized psychiatric patients (Clum, 1975b) has shown that two types of variables, intrapsychic and environmental, can be hypothesized to be independent predictors of posthospital outcome. This conclusion was largely inferential, however, and no substantive data exist that demonstrate the independent contribution of each set of variables. To accomplish this, three conditions must be met: (a) A set of predictor variables, identified as intrapsychic, must be found to predict posthospital outcome; (b) a set of predictor variables, identified as environmental, must be found to predict posthospital outcome; and (c) both sets must contribute independent variance to the criterion in a multiple regression format. In line with the previous definition of these variables, intrapsychic variables include any "measurable cognitive or personality characteristics the patient exhibits. Environmental variables are defined as socioThis study was supported by Grant UVAC-12-70 from the Commonwealth of Virginia Department of Mental Hygiene and Hospitals; by funds from the Fluid Research Fund, University of Virginia School of Medicine; and by a University Computing Grant, University of Virginia. Requests for reprints should be sent to George A. Clum, Department of Psychology, Virginia Polytechnic Institute and State University, Blacksburg, Virginia 24060.
psychological phenomena within the patient's life space, but external to the patient himself" (Clum, 1975b, p. 416). One example that may clarify the problem involves the relationship between marital status and prognosis. The personality trait view suggests that individuals who are single and socially withdrawn will not be selected as marriage partners and will tend to have a bad prognosis. Being single has been found to be related to an individual's continued stay in a mental institution and also to poor social adjustment on release from the hospital (Clum, 1975b). In contrast, the environmental view suggests that being married acts as a buffer that leads to a greater likelihood of the patient having a good prognosis. People who are married have a definite role in the family, whereas people who are single are neither the homemaker nor the breadwinner and hence have roles secondary to the functioning of the family. The press to perform will accordingly be less for the single individual and might be anticipated to lead to poorer performance for such people according to an expectation hypothesis. To determine whether the relationship between single status and poor prognosis is due to a selection process or to a buffer hypothesis, the initial level of patient dysfunction must be controlled. If it can be shown that single individuals do not exhibit more disturbance
Copyright 1978 by the American Psychological Association, Inc. 0022-006X/78/4605-0839$00.75
839
840
GEORGE A. CLUM
than married individuals on admission to a hospital but that they do exhibit a poorer prognosis, the buffer hypothesis would be supported. Another example that can be addressed to the question of independent contribution to prognosis would be that of expectations and outcome. The personality trait view would predict that the more disturbance exhibited by the individual, the lower would be the expectations, resulting in a poor prognosis; that is, level of disturbance would determine level of expectations. The environmentalist would predict outcome from expectations independent of level of disturbance. The relative importance of these two sets of variables has been studied previously in relation to in-hospital criteria of length of hospitalization and rated improvement at discharge (Clum, 197Sa). Although Clum's (197Sa) study supported the hypothesis that environmental variables are predictive of length of hospitalization, it must be considered an inconclusive test. Length of hospitalization is a relatively weak criterion because of its fluctuation on the basis of administrative considerations and because of the fact that in a shortstay hospital such as the one in his study, the criterion variance is severely truncated. Accordingly, the present study expands this analysis using a criterion of rated adjustment 1 year after initial hospitalization. Method Subjects Subjects in the present study (N = 79) included all patients admitted to the University of Virginia psychiatric service who were also available for follow-up evaluation 1 year after admission. This sample represented a severely truncated subsample (50%) of the subjects who had completed all baseline data, a reduction of subjects which, however, is comparable to other studies using mailings and phone calls to obtain follow-up data. A comparison of the two groups, however, revealed no differences on variables of marital status, age, race, social class, and initial level of symptomatology on five symptom factors. The subjects were between the ages of 16 and 65 and included only those who did not have a diagnosis of organic brain damage.
Predictors At the time of hospitalization, each patient was administered a biographical inventory, the Life Change Inventory (described previously by Clum, 1976), and a measure of expectations for improvement. Information culled from the biographical inventory included total lime previously spent in mental hospitals, education, income, marital status, age, and number of friends. The patients' expectations were derived from the Katz Adjustment Scales (Katz & Lycrley, 1963). A significant other also rated his/her expectations for the patient's performance once the patient returned home from the hospital. Two measures of expectations were obtained—one regarding the patient's performance on self-help tasks, the other regarding the patient's social adjustment.
Criterion Measures Two criteria were used—total number of symptoms as noted by the patient and total number of symptoms as noted by the significant other. The Katz Adjustment Scales were used to evaluate symptomatology.
Procedure At the time of hospitalization, patients were asked to complete all research forms. A significant other (spouse, parent, relative, or friend) who was familar with the patient's adjustment in the month prior to hospitalization was also asked to complete the research instruments. One year Liter the patient and the same significant other were again contacted, and the same forms were readminislercd. The sample was then divided randomly into validation and hold-out samples to determine the stability of the results.
Results Patient-Related Symptomatology Both environmental and personality trait measures were entered into a stepwise multiple regression equation in order to assess the independent contribution of each variable to a criterion of total S3'inptomatology as rated 1 year after hospitalization. As Table 1 indicates, only total symptomatology at baseline, time in mental hospital, and education contributed independently to patient-rated total symptomatology at the 1-year follow-up. Further, only total symptomatology at baseline was found to contribute independently to the criterion in the hold-out cross-validation group.
841
PREDICTING OUTCOME Table 1 Regress-ion Analysis of Predictor Variables at Hospitalization to Patient-Rated Total Symptomatology at 1- Year Follow- Up Sample Val idation
Predictor variable Baseline patient-rated total symptoms" Time in mental hospital (complex) Education (complex) Income (complex) Significant others' expectations— self-help" Marital status'1 Age (complex) Patients' expectation — baseline* Level of performance as rated by significant other—social adjustment" No. friends (complex) Total stress" Significant others' expectations — social adjustment" Martial status Single = 2 All others = 1 (complex)
Simple K S0b**
.2ffi
-.39b* -.30 .36* -.04 -.21
-.15 .03 -.16
Hold out
Beta weight .46 .15
-.02
Simple R b
.47 * .41*
Beta weight .28
-.04 -.03 .32 .04 -.12 -.03 .12
-.18 .26 .15
.02 .69
.14 .47
" Intrapsychic. b Significant independent contribution in multiple regression. " Environmental. d Married = 1; all others = 2 (complex). * p = .05. = .01.
Stress was not found to be related to the criterion. However, significant others' expectations for the patient's performance on selfhelp tasks correlated in the expected direction with outcome but did not contribute independently to its predictions. Significant-Other-Rated
Symptomatology
The regression analysis of significant-otherrated total symptomatology at the 1-year follow-up (see Table 2) demonstrated that baseline total symptomatology, significant others' expectations for self-help, number of friends, marital status, and patients' baseline expectations were the only variables of those examined that contributed independently to the criterion. Significant others' expectations of self-help were significant at the .01 level, supporting the importance of expectations as a prognostic variable, independent of personality traits. Marital status was also reliably re-
lated to significant others' ratings of total symptomatology, again, in a negative direction. This was contrary to predictions. Of these five predictors only total baseline symptomatology and significant others' expectations cross-validated as independent contributors to the criterion. The vast majority of previous research has found single people to have poorer prognoses. Since most of these studies were conducted on predominantly schizophrenic populations, it was decided to reanalyze the relationship between marital status and outcome separately for schizophrenic and schizoid personality patients and all other diagnostic groups. Pearson correlation coefficients were computed between marital status and total symptomatology at follow-up for patients diagnosed as schizophrenic or schizoid personality. The results indicated that marital status and total symptomatology at follow-up were related (r = .41 between marital status and significant others'
GEORGE A. CLUM
842
Table 2 Regression Analysis of Predictor Variables at llospilalization to Significant-Other-Rated Symptomatology at 1- Year Follow- Up
Total
Sample Validation Predictor variable ted total Baseline significant-other-rated symptoms" Significant others' expccta ons— self-help" Martial status (complex)'1 No. friends (complex) Patients' expectations—baseline 2line"1 Significant others' ratings of level of performance—social adjustment" Age (complex) Education (complex) Significant others' expectations— social adjustment" Time in mental hospital (complex) Total stress" Income (complex) Marital status (complex) Single = 2 All others = 1
Simple R
Beta weight
.55'-** .54h** -.41b* .2\h .03''
.21 .33 -.45 .27 -.15
Hold out Simple R ,40>>* .24" -.11
.08 .23
.17 .22 .14 .17
.27 .33 .13 .14
-.28
.36 .25
-.33
.47* -.08 -.31
-.23*
Beta weight
.13 .59
" Intrapsychic. 11 Significant independent contribution in multiple regression. l! Environmental. ll Married = 1; all others = 2. * p = .05. **/> = .01.
ratings; r = .43 between marital status and patients' ratings) in a generally positive direction, altho'Ugh not reaching significance due to the small sample size (8). Thus, for this subgroup of patients, a single status led to a poorer prognosis, as was previously predicted. Discussion The present study sought to determine whether environmental factors are of independent prognostic significance when considered conjointly with personality trait variables. A multiple regression format in which both types of predictors were considered was used to make this determination. The results provided partial support for the hypothesis that predictor variables representative of both classes of variables would contribute independent predictor variance. Specifically, initial level of symptomatology was consistently related to the criterion. In addi-
tion, significant others' expectations for selfhelp were related to total symptomatology as rated by the significant other but not as rated by the patient. This provides moderate support for the import of an environmental factor of others' expectations as an independent prognostic variable. Heretofore, it has been unclear whether the relationship of expectations to outcome was attributable to the fact that others' expectations were lower for those individuals whose adjustment was poor. It is arguable whether poor prognosis in this case was a function of the expectations or the already poor adjustment. The fact that expectations for self-help were not independently related to patients' ratings of symptomatology suggests that for this criterion the impact of expectations is determined largely by its relationship to initial level of symptoms. No other prognostic variable, either personality or environmental, cross-validated.
PREDICTING OUTCOME
843
This is especially confusing with regard to be increased. Decisions to continue hospitalmarital status, since this variable has been ization for a longer period of time or until such most consistently related to prognosis (Clum, time as those factors predictive of outcome 1975b). The vast majority of these studies, have been modified could be affected. however, included Veterans Administration or The second implication concerns those areas state hospital patients, most of whom were targeted for change. Since previous studies schizophrenic and chronic. In the present have focused on intrapsychic variables and study a marital status of married was posi- have related these to outcome, the focus of the tively correlated with significant-other-rated clinician has remained at effecting changes in symptomatology, as compared with a negative the patient's personality. With the addition, relationship in most other studies. Since most in the present study, of the importance of exof the patients in the present study were pectations and possible role models as indeneither schizophrenic nor chronic, it was de- pendent predictors of outcome, a new direccided to analyze the relationship between tion for targets for change should be forthcommarital status and outcome separately for ing. Specifically, attention should be paid to those patients diagnosed as schizophrenic or changing the patient's families' expectations schizoid and those with all other diagnoses. for performance, such that higher demands on The results confirmed the finding of previous the patients performance o'f self-help tasks studies: Married status was related to a bet- should be emphasized. The importance of aster outcome for the schizophrenic and schizoid suming a significant role in the family as a subgroup. It is possible, therefore, that diag- breadwinner or homemaker appears specific nosis is a moderator of the marital status-out- to schizophrenic patients. For this group, accome relationship, rendering marital status an cordingly, the importance of developing sigeven more powerful prognostic variable. nificant social roles would seem to be a target Whether it contributes independently to out- for therapeutic intervention. In contrast, being come for schizophrenic patients still remains married was found to be a negative prognostic an unanswered question. factor for nonschizophrenic patients. AccordThe environmental variable of life stress ingly, affecting a more positive relationship was not found to be of any reliable conse- within the marital context should receive quence. However, in another study (Clum, greater attention in this group. 1976), it was demonstrated that whereas life changes prior to hospitalization were unreReferences lated to symptomatology at follow-up, they were related to the level of symptoms at the Clum, G. A. Intrapsychic and environmental variables as predictors of length of hospitalization and rated time of hospitalization. Similarly, life changes improvement at discharge. Journal of Consulting subsequent to hospitalization were predictive and Clinical Psychology, 1975, 43, 276. (a) of level of symptomatology 1 year after hos- Clum, G. A. Intrapsychic variables and the patient's environment as factors in prognosis. Psychological pitalization. This supports Rahe's (1972) noBulletin, 197S, 82, 413-431. (b) tion that stress only in the preceding year is Clum, G. A. Role of stress in the prognoses of menpredictive of symptomatology. tal illness. Journal of Consulting and Clinical PsyImplications The implications of this study are twofold. First, the question of prognosis that confronts the clinician is related to decisions regarding disposition. For example, if a patient can be predicted to have a poor prognosis, the insistence on further follow-up treatment could
chology, 1976, 44,1, 54-60. Katz, M. M., & Lyerley, S. B. Methods for measuring adjustment and social behavior in the community. I. Rationale, description, discriminative validity and scale development. Psychological Reports, 1963, 13, 503-5,55. Rahe, R. H. Subjects' recent life changes and their near future illness reports. Annuals of Clinical Research, 1972,4, 250-265.
Received October 18, 1976 •
