The family's contribution to the etiology of schizophrenia: current status.

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SCHIZOPHRENIA BULLETIN

the family's contribution to the etiology of schizophrenia: current status

The concept that disordered family relationships may be a significant factor in the development of schizophrenia is not new. Reports of clinicians in the early part of the 20th century were replete with observations of disturbances in the familial environment and of psychopathology in the relatives of their patients (Pollack, Malzberg, and Fuller 1939, Sullivan 1925, and Terry and Rennie 1938). The psychoanalytic treatment of schizophrenic patients revealed specific patterns of feelings and associations about family relationships that, as in theories of neurosis, were believed to be etiologically related to the development of schizophrenia. In particular, the mother-child relationship was hypothesized to be disordered (Arieti 1955), and early clinical studies of mothers of schizophrenics (Gerard and Siegal 1950, Lidz and Lidz 1949, Prout and White 1950, Riechard and Tillman 1950, and Tietze 1959) seemed to confirm this hypothesis of the schizophrenogenic mother, as it was subsequently termed. Further research in the early 1950's broadened the concept of parental influence to include the father as well. But with the appearance of a more sophisticated "systems" view of family relationships in the late 1950's and early 1960's, notions of single parent-child relationships were considered oversimplified conceptualizations, and emphasis was placed instead on disturbances in the total family system.

extensive clinical studies of families containing schizophrenic offspring. Results of their independently conducted research suggested that these families have deviant patterns of communication—unusual sharings of feelings and ideas (Bateson et al. 1956; Lidz et al. 1958, and Wynne and Singer 1963a and 1963b). Each set of researchers concluded that these communication patterns are unique to the families of schizophrenics and not found in other psychopathological groups. An analysis of the communicational deviances in these families, it was felt, might explain the basic pathology of thought disorder in schizophrenia. The results of this analysis suggested that these communicational deviances were precursors to, and therefore etiologically linked to, the basic pathology of schizophrenic patients. Communicational deviance was not, however, the only family-system variable related to schizophrenic development. The Lidz group, in particular, emphasized disturbances in the total system of relationships summarized by the system characteristics of marital schism and skew (Lidz et al. 1957). These structural disorders were believed chronic and therefore a distorting influence upon the personality development of the identified patient and, to a lesser but still noticeable degree, upon his nonpsychotic siblings (Lidz et al. 1963).

Each of three major research groups that evolved independently during this period (at the Mental Research Institute in PaJo Alto, at Yale University, and at the National Institute of Mental Health) relied upon

These clinical findings generated extensive research activity during the subsequent 10-year period—perhaps reflecting an awareness of their potential value in generating a family treatment strategy that would attempt to modify the family environment which was thought to maintain psychosis in the schizophrenic offspring. The models tested during this period can be represented as a series of assumptions as follows:

'Reprint requests should be addressed to the senior author at Department of Psychology, University of California at Los Angeles, Los Angeles, Calif. 90024.

• Assumption 1: Families of schizophrenics are discriminably different from those containing other off-

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Michael J. Goldstein and Eliot H. Rodnick*

ISSUE NO. 14, FALL 1975

spring with other types of disturbances, particularly in role relationships, affect, and communication style. • Assumption 2: These differences occur early enough in the life experiences of the potential schizophrenic to have a significant impact on his development • Assumption 3: These disordered family relationships are a necessary but not sufficient condition for the development of schizophrenia.1

Differences in Families of Schizophrenics and Other Family Groups Research was performed on assumption 1 by the Palo Alto group and the Yale group. Their Work did not directly compare the differences between families of schizophrenics and families of other psychopathological groups, since their investigations were largely confined to families of schizophrenics and did not use control groups, per se. They did, however, base their contrasts upon extensive clinical experience with other family groups. The core hypothesis of the Palo Alto group—the double bind—has been followed up by other investigators, but the evidence derived in these attempts has been disappointing on a number of levels (Schuham 1967). First, to operationalize the concept so that its full meaning is captured has proved difficult and, second, where operationalized, the concept cannot discriminate between families of schizophrenics and families of other pathological groups. The Yale group's hypothesis of disorders in role and affective relationships that, by their nature, cover extended developmental periods has proved even more difficult to test objectively. Some supportive evidence was provided by the "follow-back" study of Waring and

1 Because of current evidence that suggests the Importance of genetic factors in the development of schizophrenia, the more conservative assumption of the necessary but not sufficient role of familial factors seems more tenable. The assumption, as formulated, does not preclude the possibility that subsequent evidence could reveal that disordered family relationships are necessary and sufficient conditions for the development of schizophrenia.

Ricks (1965) in which the marital relationships specified by Lidz et al. (1957) were found more commonly in the child guidance records of youngsters who subsequently became schizophrenic than in the records of clinic patients who did not. A type of marital relationship, termed emotional divorce, was found to be most discriminating, particularly for chronic schizophrenics. The Waring and Ricks study also pointed to the importance of considering quantitative variations in measures of family structure. They found that an index of marital skew failed to discriminate between parents of future schizophrenics and other groups unless a distinction was made between moderate and severe skew. Severe marital skew was found most commonly in families of future schizophrenics, but moderate skew did not discriminate among different psychopathological groups. Since the examples of marital skew provided by Lidz et ai. (1957) do seem extreme, testing their hypothesis may require sensitivity to the implicit suggestions of the severity of the distortion of role or affective relationships. Probably because the NIMH group developed objective measures of their concepts that could be handled quantitatively and could be used by other investigators, the greatest body of empirical evidence has been directed at Wynne and Singer's hypothesis of communication deviance in families of schizophrenics. The series of studies carried out by Wynne and Singer (1963a and 1963b) and Singer and Wynne (1965a and 1965b) strongly supported the assumption that a specific type of attentional-communicational style is found in parents of schizophrenics and not in parents of depressives, personality disorders, neurotics, and normals. Further, they suggested that there are two general variants of the disturbed style, one termed amorphous and the other fragmented, that are related, respectively, to the process and reactive forms of schizophrenia. The Wynne and Singer hypothesis has become more elaborate in recent years as the relative amount of thought disturbance in the two parents has been considered. Parents who reinforce each other's deviant style increase the probability of schizophrenia in the offspring; on the other hand, if one parent acts as a "corrective agent" to the deviant communication style of the other, the likelihood of schizophrenia is reduced (Singer 1968). Further investigation of this process will require the articulation of an efficient model of transactionaJ mechanisms within the family system capable of


Each of these assumptions, based on the current state of the field, and some specific issues involved in testing their validity are considered below.

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A recent search of the literature for family studies of schizophrenics has revealed interesting patterns of activity. Most of this research was concentrated in a 10-year period between 1958 and 1968, with the bulk of the effort in the 1960-68 period. Since 1968, reports of family interaction studies carried out with families of schizophrenics have declined very sharply, and such efforts now rarely appear in the literature. For greater details on the studies carried on during this 1960-68 period, the reader is referred to two excellent reviews, one by Riskin and Faunce (1972), which deals with methods of research, and the other by Jacob (1975), which summarizes the substantive findings across these studies. The decline in research on schizophrenic families may not indicate a loss of interest in the problem area so much as a shift in emphasis to the high risk model, which will be discussed later.

Direct Observational Studies of Families of Schizophrenics After the pioneering hypotheses on the differences between families of schizophrenics and families of other psychopathological children were articulated, researchers attempted to test their validity in systematic studies of family interaction. This involved a shift from predominantly clinical observational studies to observations of family groups under relatively controlled conditions

using objective measures of the observed interactions. In contrast to the earlier clinical studies, these direct observational studies generally involved single observational sessions with patients currently in, or recently released from, mental hospitals and were not related to the clinical treatment of the patient. The variables selected for measurement drew heavily from the hypotheses offered by Bateson et al. (1956), Lidz et al1. (1957), Wynne and Singer (1963a and 1963b), and Singer and Wynne (1965), as well as from hypotheses derived from social-psychological research on group process. But often, the variables bear only a vague resemblance to the original theory and so, for instance, role relationships are reduced to measures of dominance such as who talks most or who ends up as the group decisionmaker. Such operational simplifications are, of course, necessary in scientific research. But ultimately research measures must be consonant with the complexity of the original theory they seek to test; they must not be distortions of concepts critical to that theory or hypothesis. Many differences separate the various studies that compare families containing schizophrenic offspring with other family groups. In most studies, the contrast is between families of schizophrenics and normals, and no other groups are used to control for the presence of psychopathology in the family. In a few instances, variables found useful for reducing the heterogeneity among schizophrenic patients, such as the formation of subgroups of patients, have been used in family studies (Baxter and Arthur 1964, Farina and Dunham 1963, Farina and Holzberg 1968, and Mishler and Waxier 1968). Since these studies have yielded significant results (although not always consistent with one another) as a function of such attributes as premorbid adjustment, those studies contrasting schizophrenics as a class with another group may fail because of cancellation effects across the good and poor premorbid samples of schizophrenia. As pointed out by Jacob (1975), the sex of the target child has been largely ignored. But given the provocative findings of Lidz et al. (1963) and Mishler and Waxier (1968) that the family interaction is affected by the sex of the identified patient offspring, the neglect of this issue probably is another important source of variance that should be controlled in direct observational studies. Another factor considered by the Mishler and Waxier study, and not by most others, was the need to


encompassing the pattern of influence and counterinfluence involved in the development of psychopathology. Most of the evidence confirming the NIMH group's (Wynne et al. 1975) hypothesis of the uniqueness of families containing schizophrenic offspring has come from their own data. An independent attempt by other investigators (Hirsch and Leff 1971) to replicate the NIMH group's data found a statistically significant difference between parents of schizophrenics and parents of nonschizophrenics in communication deviance score but also found considerable overlap among the groups. Recently, J. Jones (1975), using Thematic Apperception Test (TAT) data, was able to formulate decision rules that effectively discriminated between parents of hospitalized schizophrenics and those of other psychopathological patients. As suggested by the hypothesis of the corrective parent, Jones found a clearer association with schizophrenia in the offspring when both parents manifested transactional style deviance.

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Summary of Direct Observational Studies of Families of Schizophrenics As pointed out by Jacob (1975), direct observational studies have tended to measure four classes of variables: dominance between parents and child and between the two parents, conflict, affect, and clarity of communication. Despite the great differences across studies in research methods and subject samples, searching for any consistent trends that have emerged to date may be valuable.

Dominance A number of hypotheses suggest that there may be either insufficient parental authority or reversals in authority relationships between father and mother in the families of schizophrenics; thus a number of investigations have examined the relative dominance between parental pairs in intact families. Dominance is typically assessed in one of two ways: • Verbal activity counts (talking time, successful interruptions, statement length). • Judgments of factors such as yielding or accepting the view of the other family member. Results with measures of verbal activity rates have often been inconsistent with, and at times the opposite of, judgments of dominance-submissiveness. The studies using the former measure (Cheek 1964a, 1964b, and 1965, Farina 1960, Farina and Holzberg 1968, Ferreira, Winter, and Poindexter 1966, Lennard, Beaulieu, and Embry 1965, and Mishler and Waxier 1968) yielded results that either indicate no differences between schizophrenics as a group or greater dominance in

normals. In his early study, Farina (1960) did report paternal dominance for good premorbid schizophrenics in contrast to controls and a trend for maternal dominance in the poor premorbid group; but, an attempt to replicate these trends under somewhat different conditions failed (Farina and Holzberg 1968). The results of the Cheek (1964a, 1964b, and 1965) studies were more complex in suggesting an interaction with sex of the target child, but these findings are confusing as they appear to contradict those of Mishler and Waxier (1968), who also analyzed their data by sex of the target child. Rated measures of dominance-submissiveness did not reveal many stable intergroup trends. Generally, indices of dominance have not demonstrated consistent differences between schizophrenic and normal families. Research has further indicated that verbal activity measures of dominance may reflect other family processes, such as the liveliness and spontaneity of discussion. Future research should consider the relevance of verbal activity and its frequency to distinguish between adaptive and maladaptive rates of verbal acitivity. Conflict As with measures of dominance, conflict has been indexed by verbal activity rates (interruptions and simultaneous speech) and by judgments (agreement, disagreement, and conflict). In five studies (Farina and Holzberg 1968, Ferreira, Winter, and Poindexter 1966, Lennard, Beaulieu, and Embry 1965, Mishler and Waxier 1968, and Stabenau et al. 1965) either no differences were found or greater "conflict" was found in the normal than in the schizophrenic families. Rated measures of conflict do not reveal similar trends in the four studies in which they were used (Cheek 1964a, 1964b, and 1965, Farina and Holzberg 1968, Friedman and Friedman 1970, and Lennard, Beaulieu, and Embry 1965). Either no group differences were found or results were contradictory in regard to which schizophrenic families were judged to express more (Friedman and Friedman 1970) and less (Cheek 1964a, 1964b, and 1965) conflict than normal control families. The one early finding by Farina (1960) was confirmed by Farina and Holzberg (1968) who observed that when the premorbid status of the schizophrenic patient was considered, parents of poor premorbid patients expressed more conflict than parents of nonschizophrenic patients.


control, preferably with a nondisturbed sibling, the impact of the psychotic offspring on the family system. Other investigators have been aware of the need for such controls, but have been hampered by the costly and cumbersome nature of direct observational studies. The addition of another variable, such as matching for the sex of the identified patient or studying the nondisturbed sibling in interaction with his parents, often adds geometrically to both the complexity of the research design and the difficulty in obtaining the required family for research.

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Affect

Clarity of Communication Based on the earlier work of the Palo Alto and NIMH groups, numerous studies attempted to evaluate the clarity and adequacy of communication in schizophrenic families. Generally, ratings of this concept are required, and investigators have typically used multiple measures of the same concept. Although measures and conditions vary markedly across studies, the trend is quite consistent in suggesting a poorer clarity of communication in schizophrenic than in normal families (Behrens, Rosenthal, and Chodoff 1968, Ferreira and Winter 1968, Friedman and Friedman 1970, Haley 1968, Mishler and Waxier 1968, and Morris and Wynne 1965). The one set of nonconfirmatory evidence is provided by the studies of Cheek (1964a, 1964b, and 1965), where no group differences were found. In the Mishler and Waxier study the sharpest group differences were found in the variable of responsiveness, which reflects the degree to which family members acknowledge the intent and content of each other's messages. As with other data from this project, however, these findings were dependent upon the child who was present (schizophrenic or control sibling) and the schizophrenic offspring's premorbid adjustment. Some studies attempt to specify differences in com-

• Families of delinquents by their greater sensitivity to messages arising from within the family, and • Families of normals in their lack of sensitivity to messages arising from outside the family system. Reiss suggests that sharp differences in communication style may exist depending upon whether the family is dealing with its own members or responding to some agent outside of the family system. Since most of the studies that have demonstrated communication deviance in families of schizophrenics (Wynne et al. 1975) involve a parent and an examiner, Reiss cautions against generalizing these findings to patterns of communication that might exist within the family system. This is an important empirical issue for future research. A recent study by Hassan (1974) that used quite different observational data points to similar conclusions. She found that parents of delinquents, who were similar to parents of schizophrenics on a number of measures, did differ in their style of communicational difficulties, with the parents of delinquents showing "disconnection" in their stories and parents of schizophrenics, "contextual blurring."

Conclusions from Recent Direct Observational Studies of Families of Schizophrenic Offspring Conclusions drawn from diverse studies in which the families' tasks, sample characteristics, and measures vary so widely are not feasible. But certain robust trends do emerge from the large amount of "noise" contained in the studies reviewed. First, the theoretical positions that emphasize communicational deviance in the families of schizophrenics (Bateson et al. 1956, Singer and Wynne 1965a and 1965b, Wynne and Singer 1963a and 1963b, and Wynne et al. 1975) have received a degree of support from various independent studies. The specific hypothesis of the double bind, put forward by Bateson et al., and the details of the communication deviance, suggested by


Generally, affect is defined entirely by judgments made of recordings or transcripts. The three parameters of affect rated are typically total affect intensity, positive affect, and negative affect. But the studies show few consistent trends regardless of the measure used. The study by Mishler and Waxier (1968) had the most complex research design of all the observational studies and attempted to build in a wide variety of controls. Their findings point to the difficulties in drawing simple generalizations about the affect in schizophrenic families. For example, their findings of less total affect intensity in schizophrenic families hold only when the " w e l l " sibling is present and the premorbid status of the patient is considered. Perhaps their most provocative findings concern expressions of positive affect. Normal families were found to express more tension release, laughter, and indirect positive affect than families of good premorbid schizophrenics. Evidence is still lacking, however, that families of schizophrenics have less or more negative affect than families containing offspring with other psychopathological conditions.

munication style between families of schizophrenics and other psychopathological groups. Reiss (1967a, 1967b, 1968, and 1969) attempted to discriminate family communication patterns using an intricate problem-solving task in which simple messages are passed among family members. His research, although it measures communication style, is primarily designed to elucidate styles of familial organization. Reiss found that families of schizophrenics can be discriminated from:

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have not received much attention in direct observational studies of families. The representativeness of the research samples of the larger population of families with schizophrenics can be questioned and may place limits on the generalizations to be drawn from such studies. For example, a recent study by Wild, Shapiro, and Abelin (1974) found that when typical criteria, such as family intactness and reachability, were used to screen families for study from a larger epidemiological sample, only 29 percent were considered eligible. Of those considered eligible, approximately 30 percent, or 9 percent of the original sample, agreed to participate in a family study. While Wild, Shapiro, and Abelin do provide favorable data concerning similarities between the eligible cooperators and noncooperators, a residual 9-percent sample suggests caution in generalizing to a broader population of families of schizophrenics. The high rate of homes broken by death or divorce (28 percent) by the patient's 15th year raises issues concerning whether research on familial factors should be restricted to intact families. Any adequate theory concerning the family's role in the development of schizophrenia must account for relationship patterns within disrupted as well as intact family systems. Another important but rarely considered issue is that behavior observed in semistructural situations may not be representative of everyday behavior. Also, not all varieties of behavior are likely to occur in the laboratory or within the context of formal tasks. Obviously, we are not likely to see clear-cut examples of the sexual seductiveness, violent rage, or hurtful accusations reported by clinicians who have extensive contact with such families. It is not surprising, therefore, that direct observational studies have achieved their greatest—albeit modest—success in revealing stylistic differences in communication between families of schizophrenics and those of controls since it is these subtle aspects of family relationships that are most readily revealed under public scrutiny. The more personal and embarrassing "scenes," on the other hand, usually occur at home or emerge only in the context of long-term family therapy.

Significance of Differences in Schizophrenic Families Perhaps the decline in direct observational studies of families of schizophrenics previously alluded to has


Wynne and Singer, were never tested specifically by those studies. Therefore the confirmation bears out the general position rather than the specific hypothesis. Although communicational difficulties in schizophrenics appear to differentiate them from normals, results of direct observational studies do not permit one to discriminate between families of schizophrenics and those of other psychopathological groups. Thus, the studies of Wynne and Singer, which have relied upon projective test data from parents, remain the best evidence that a high frequency of communicational deviance is specific to families containing schizophrenic offspring. Second, clearer findings emerge when factors that reduce the heterogeneity of the schizophrenic sample, particularly those that consider the premorbid status of the patient, are used. The evidence is largely a demonstration of the value of such marker variables, but there is a need to articulate and identify the ways in which such variables relate to family dynamics. For example, there are suggestions in the findings of Farina (1960), Farina and Holzberg (1968), Lerner (1965), Mishlerand Waxier (1968), and Waring and Ricks (1965) that families of good and poor premorbid schizophrenics may be differentiated on several parameters of family structure. Good premorbids appear to reside in families with rigid role structure, more negative affect, and more control, particularly by fathers in families containing male schizophrenics. Poor premorbid schizophrenics, on the other hand, appear to reside in families in which conflict and fragmentation in communication are readily observable with parents who are chronically in conflict. The lack of conflict resolution may ultimately lead to the state of emotional divorce found in the data by Waring and Ricks (1965)' for their chronic (poor premorbid) patients. Third, many issues dealing with the representativeness of data still remain unresolved in the direct observational studies. These issues relate to such things as the representativeness of the parental behavior toward all children in the family, the representativeness of families selected for study, and the variety and breadth of family behavior that can be observed in a laboratory or clinical setting. For example, except for the Mishlerand Waxier (1968) research, there has been little concern as to why only particular children within the family manifest schizophrenia. The interesting psychological hypotheses offered during the 1950's to account for the special position or role of the identified patient within the family (e.g., the "scapegoat" or the "sacrificial lamb")

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Risk Defined by Child A ttributes The family project conducted by Rodnick and Goldstein (1974) at the University of California at Los Angeles was designed specifically to study intrafamilial relationships in groups believed to vary in their degree of risk for subsequent schizophrenia and schizophrenia-like conditions. The subjects selected for study are disturbed adolescents seen at a clinic for emotional difficulties. Although disturbances in the offspring cause disturbances in the total family system, it is hoped that the level of disturbance, being moderate in nature, does not have as severe an impact on the family system as that caused by a psychotic offspring. The basis for assuming that at least some of these adolescents are at risk for schizophrenia is derived from the general hypothesis that adolescence is a critical period in personality adaptation and that failures at this point increase the probability of subsequent difficulties. Our expectation that such a sample would contain a sufficient number of preschizo-

phrenics is supported by the findings of Nameche, Waring, and Ricks (1964) and Robins (1966) who followed up comparable clinic populations. More specifically, the design contrasted disturbed adolescents who were believed to be at greater than normal risk for schizophrenia-type disorders with disturbed teenagers who were probably at risk for other adult problems but not schizophrenia. The critical issue at this point was whether families of preschizophrenics were distinctively different from families of other disturbed adolescent groups and not whether they were different from normal family groups. Although normal families are important in such research, their introduction often involves issues of establishing comparability of motivation for participation in intensive studies of family relationships. By working solely within the psychopathological spectrum, one can assume equal motivation across groups in terms of anxiety over the adolescent, desire for help, and willingness to reveal intimate details of family life.

Definition of Risk The definition of risk on this project has been an iterative process beginning with the manifest disturbed problem of the adolescent and including other variables as they have become available. The initial problem involved a definition of groups within the disturbed adolescent range (excluding psychotic adolescents). These groups were defined empirically from the presenting problems of the disturbed adolescents as follows: Group 1: Aggressive, antisocial. This group is characterized by poorly controlled, impulsive, and acting-out behavior. Some degree of inner tension or subjective distress may be present, but it is clearly subordinate to the aggressive patterns that appear in many areas of functioning, that is, in relation to family, school, peer relationships, and the law. Group 2: Active family conflict. Members of group 2 show a defiant, disrespectful stance toward parents, belligerence and antagonism in the family setting, and often exhibit signs of inner distress or turmoil—such as tension, anxiety, and somatic complaints. There are few manifestations of aggression or rebelliousness outside of the family. Group 3: Passive, negative. Negativism, sullenness, and indirect forms of hostility or defiance toward parents and other authorities are the main characteristics of this group. In contrast to group 2, overt defiance and


arisen because investigators have recognized that not only are such studies costly and cumbersome, but they are also equivocal in their implications. Even if it could be demonstrated more conclusively that families of schizophrenics are reliably different from families of other psychopathological groups, such findings may be trivial unless, as stated in Assumption 2, these differences occurred early enough in the patient's life to have had a significant impact on his development. As our sophistication concerning the impact of a psychotic offspring upon the family system has increased, the differences found for contrasting sets of families have become more difficult to interpret. Although rich and fruitful hypotheses concerning familial forces can be generated from studies of families containing psychotic offspring, clearly this is poor ground for testing these hypotheses. Thus, researchers concerned with familial factors related to the development of schizophrenia have shifted their emphasis to what has been termed the "high risk" model (see Garmezy 1974a and 1974b for a comprehensive review of this research approach). In this model, studies are carried out on populations with a higher than normal risk of developing schizophrenia. Two main methods have been used to define groups at risk: attributes of the child and attributes of the parent. Typically, the parental attribute is the occurrence, past or present, of schizophrenia in one or both parents.

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Hypotheses Concerning Risk Level After defining the four groups, working hypotheses concerning risk level were derived from the literature on adult schizophrenia (Rodnick and Garmezy 1957). This literature suggests that the poor premorbid patient demonstrates an adolescent history of extreme social withdrawal and low involvement with the opposite sex. The parallel between the description of the poor premorbid pattern and that of the withdrawn, socially isolated teenager was close enough for the project to define group 4 as having greater than normal risk for schizophrenia. The literature (Arieti 1955, Nameche, Waring, and Ricks 1964, and Robins 1966) also suggests another preschizophrenic pattern among adolescents, a pattern characterized by stormy, acting-out behavior confined largely to the family group. These descriptions resembled the active-family-conflict group in the UCLA sample, and therefore group 2 was designated as a second high risk group. Thus, groups 2 and 4 (active family conflict and withdrawn, socially isolated) were tentatively defined as being at greater than normal risk, while the other two groups, based on the literature, were not. Our preliminary analyses involved contrasting the four groups on numerous measures of family interaction using dimensions believed implicit in the groups, such as the predominant locus of the problem (inside home, groups 2 and 4, vs. outside home, groups 1 and 3) and the activity level of the problem (active, groups 1 and 2, vs. passive, groups 2 and 4). These contrasts have proved productive, and findings reported to date have focused upon the following: • Social influence and counterinfluence (Alkire et al. 1971); • Psychophysiological reactivity (Goldstein et al. 1970a);

• Projective indices of family relationships (Goldstein et al. 1970b); • Communication of intents between parent and child (McPherson 1970); • Responsiveness of communication between parent and child (McPherson, Goldstein, and Rodnick 1973); and • Parental descriptions of the child's problem (West, Rodnick, and Armstrong 1972). These findings strongly suggest that the locus variable is a particularly powerful one for identifying distinctive family interaction patterns and that variations on the general pattern could be identified within each locus group that might account for the differences in manifest behavior problems within each type. The activity variable, however, has proved less valuable in revealing distinctive intrafamilial patterns. Since the locus variable essentially divides the four behavior problem groups by hypothesized risk level (inside home = high risk; outside home = low risk), these findings suggest that the sharpest differentiation among family groups occurs by hypothesized risk level rather than by the manifest activity level of the adolescent's behavioral disturbance. The risk-level hypothesis was similarly supported by followup studies in which the teenagers were seen 5 years later as young adults. In these studies, the highest incidence of schizoid pathology was in the active-family-conflict and withdrawn groups (F. H. Jones 1974). Relationships among parameters of family interaction and outcome have not yet been explored but represent an important future aim.

Risk Defined by Family A ttributes The definition of risk on the basis of the adolescent's presenting problem fulfilled a need for a preliminary indicator of risk. To establish continuity with the literature on adult schizophrenia, however, a criterion of risk derived from family studies of schizophrenics seemed desirable. The transactional style deviance concept of Wynne and Singer, which has proven useful in discriminating parents of schizophrenics from other groups, appeared highly relevant for use with the UCLA project families. Application of the Wynne and Singer measures to data from the project permitted us to estimate risk for schizophrenia according to the degree to which parents manifested transactional style deviances of the


temper outbursts are infrequent and there is a superficial compliance to wishes of adults. School difficulties typically described as underachievement are frequent, but there is little evidence of disruptive behavior. Group 4: Withdrawn, socially isolated. Members of this group are characterized by marked isolation, general uncommunicativeness, few, if any, friends, and excessive dependence on one or both parents. They often have gross fears and show marked anxiety and tension. Much of their unstructured time is spent in solitary pursuits.

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Table 1. Relationship between hypothesized risk for schizophrenia based upon parental TAT performance and behavior problems of the adolescent offspring. Symptom group Risk estimated from Aggressive, parental T A T antisocial

Low Females High Intermediate

Low

conflict

Passive,

Withdrawn,

negative

isolated

5 0 1

0 3 2

4 3 0

0 2 1

3 1 2

2 0 3

1

type and frequency found by these investigators in parents of schizophrenics. The project was designed to obtain projective test data using the TAT on each member of the family. A scoring system for the TAT that assessed transactional communication deviances along the lines specified by the Wynne and Singer hypothesis was developed by one of our collaborators, J. E. Jones (1974), with the help of Singer. Using factor score patterns that had been found on a blind basis to discriminate parents of schizophrenics from parents of offspring with other conditions, Jones was able to establish three categories of risk for schizophrenia—high, intermediate, and low—based on his findings regarding the probability of a schizophrenic diagnosis in the offspring. These patterns were then applied to the TAT data of the parents of the disturbed adolescents in the UCLA sample to identify levels of risk for schizophrenia. Jones found that there were a sufficient number of parents in the high risk group to indicate the sample's suitability for a prospective study of schizophrenic development. As shown in table 1, Jones' risk assignments were related to the form of the adolescent's behavioral problem. Overall, the high risk families are those containing active family conflict and withdrawn teenagers. As can be seen, when only male cases are examined, all of the high risk cases are in these two groups. These test cases bear out the working hypothesis that the levels of risk for

1

3

•

2 4 1

schizophrenia are increased for male teenagers whose parents have deviant transactional styles. When dealing with the family of a schizophrenic, it is natural to assume that the family's reaction to the disturbed child's cognitive and transactional problems might result in transactional style deviances in the entire family system. The hypothesis that a disturbed teenager could cause deviances in his family's transactional style is not supported, however, by the Jones et al. data (in press). The incidence of transactional style deviances of the type seen in the parents was strikingly rare in the teenagers and, where found, was unrelated to parental risk level. Surprisingly, where sibling data were available, transactional style deviance was most commonly noted in the "nondisturbed" siblings of the high risk teenagers. The absence of a relationship between parental and offspring transactional style does not rule out the possibility that the parental styles may be related to other aspects of offspring behavior such as the form of his behavior problem. The close relationship between risk level and the form of the male adolescent's behavior problem (table 1) can be interpreted, analogous to interpretations made of data on families of schizophrenics, as suggesting that high transactional style deviance in parents may represent a reaction to intense inside-home locus problems. We can rule out the hypothesis, however, that these style deviances are solely reactions to psychosis in the offspring.


Males High Intermediate

family

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The interrelationships among data obtained over a 6-week assessment period indicate that the transactional style index possesses considerable concurrent validity. The question asked, however, is: What is its predictive validity over more extended periods of time? This issue has been approached in a number of ways over varying time periods. After the completion of the assessment period, for example, each of the families has been offered psychotherapy. In addition to the very common use of family therapy, various members also have received individual, group, or conjoint therapy. The amount of therapy "absorbed" by the family system has been scaled by West and Jones (1975), whose data reveal a strong positive relationship between the risk index and therapy absorption. Despite the marked absorption of therapy by the high risk families, which could negate the significance of the foilowup data on these cases, the 5-year outcome ratings are still related to risk level. This finding suggests that high risk family systems may

Table 2.

absorb considerable therapeutic manpower but that the degree of change achieved may be modest. Evidence concerning the basis for the difficulty in modifying family relationships in high risk families is contained in a recent pilot study by Lewis (1974). She analyzed transcripts of very early family therapy sessions of high and intermediate risk families using the responsiveness code of Mishler and Waxier (1968) and found that parents of high risk families were significantly less responsive to the communications of other family members than were intermediate risk parents. A comparison of early sessions with those toward the end of family therapy revealed that both groups of families had increased their responsiveness score but that the high risk parents were still significantly less responsive than those with intermediate risk. Thus, although transactional communication problems in high risk families can be slowly modified by therapeutic intervention, a certain residual level appears difficult to eliminate entirely. The foilowup evaluations of the target offspring take place at 5-year intervals and are critical to the goals o f ' the study. To date, the first 5-year evaluations have been carried out on the initial series of 35 cases. Of these, 24 were male and have been reported on to some extent by F. H. Jones (1974). Unfortunately, since the transactional style deviance index from the TAT requres verbatim recordings, which were not initiated until after case 14, only 9 of these 24 cases have been assessed for risk and seen for foilowup. These have been solely from the intermediate and high risk groups. As can be seen in table 2, however, the relationship between risk index

Five-year foilowup global rating and hypothesized risk.

Foilowup outcome rating 1

Some positive signs of adjustment; occasionally rocky history Some strength; large areas of inadequate functioning Major psychological impairment; few strengths

Intermediate risk group 3

High risk group2

1/7 =-4)

(/7=5)

3

0

1

2

0

3

"From F. H. Jone$ (1974). 2 Risk estimated from parental T A T obtained S years before foilowup rating (J. E. Jones et al., in press). Significant Intergroup differences,/' = . 8 2 , p < .005, Fisher's exact test.


Another issue in this phase of the family project is whether these transactional style deviances are specific to projective tests or whether they are observable in the ongoing interactions of the families. Using a coding system developed by McPherson (1968), Jones was able to demonstrate that the pathologies in speech, coded in that system, are indeed correlated with the TAT rating of transactional style deviance. Similarly, the verbal behavior of family members as they discussed video tapes of their own interactions was found by Lieber (1974) to reveal more problems in focal attention in the high risk than in the other risk groups.

58


In summary, the UCLA family project has engaged in a series of boot-strapping operations to define family systems at varying risk for schizophrenia. Results to date have suggested that transactional style deviances of the type originally described by Wynne and Singer (1963a and I963b) and Singer and Wynne (1965a and 1965b) are observable in sufficient amounts in parents of disturbed adolescents to be feasible criteria for defining high risk samples. Since in the UCLA study these deviances in the family system were found to exist before the onset of severe psychopathology in the child, it is unlikely that they are caused by a reaction to the child's disturbed behavior. The data analyzed so far suggest that defining risk for schizophrenics based on transactional style deviances in the family has moderate concurrent validity (in that it relates to other measures of the concept collected during the same time period) and short-term predictive validity. It also shows signs of possessing long-term predictive power as an index of disordered intrafamilial functioning. Current work on the UCLA project is being directed at defining analogous risk indices for other psychopathological conditions-for example, for sociopathy based on the findings of Robins (1966)—to determine the specificity of particular patterns of intrafamilial relationships for different types of adult pathology.

Risk Defined by Psychiatric Status of Parents The other approach to the study of family relationships has been to define groups by using the genetic

criterion of risk based on parental psychiatric status, such as children of schizophrenics and children of depressives. This research was originally directed by biological-genetic theories, and only recently has attention been paid to its potential value for elucidating the intrafamilial forces operating to increase the likelihood of subsequent schizophrenia. Although such studies are clearly superior to those that define risk on the basis of child attributes when directed toward the goal of identifying specific behavioral precursors of adult schizophrenia in high risk cohorts, they possess certain inherent difficulties in studying familial factors in schizophrenic development. First, only 10 percent of schizophrenics come from families in which one or more parents are schizophrenics, and therefore, the findings may only be generalizable to a limited population of adult schizophrenics. Second, these studies start with a highly disordered family system that has not only been disturbed by the parental psychosis but also by subsequent separations and divorces and by the economic penalties attendant to psychosis. Recently, workers in the high risk area have become aware of the need for closer evaluation of the parental psychiatric and psychosocial status both during and preceding the period of assessment of the family. There is now greater recognition that a parent who has had a prior schizophrenic episode may be chronically psychotic, in partial or full remission, intermittently psychotic, or totally recovered from a single discrete psychotic episode. The report (Strauss 1974) of a recent conference held by a collaborating group of high risk investigators, all of whom define risk by parental psychiatric status, reveals that in the future more attention is likely to be paid to the heterogeneity in parental psychiatric and social adjustment status as a source of significant variance in these family studies. One hazard is that the variance may be so great in factors likely to be correlated with family functioning that enormous sample sizes will be required to isolate their relative contributions. One high risk program, that of Anthony (1968), has been in the forefront in recognizing the need to account for the variations in parental psychosis and their impact on the offspring. Anthony's attempt to classify the degree of the children's involvement in the parental psychosis represents one very fruitful way of accounting for the intrafamilial environment created. Relationships between such indices and the subsequent adjustment of


established on data collected 5 years earlier and ratings of adjustment in early adulthood is quite good. The only cases rated as severely maladjusted that show signs of schizophrenia, schizoid, or borderline adjustment are from the high risk sample. Naturally, more data are needed to assess the validity of these early findings concerning the long-term validity of the transactional style index in predicting schizophrenia and schizophrenia spectrum disorders. While such data are being obtained, there is a further need to pinpoint more clearly the other attributes of the family system that relate to risk status—such as role organization, affect, and dominance—and those parameters that might clarify the construct validity of the concept of transactional style deviance.

59


The project of Wynne and his associates is a modified longitudinal design in which children of various psychiatric groups are studied initially at varying ages and retested 4 years later so that the total period from middle childhood to early adulthood is spanned. This project does have a more systematic analysis of family interaction, in which projective and direct observational

measures are included. It also possesses considerable overlap with measures used on the UCLA study so that meaningful comparisons can be made between studies in which risk was defined by a child attribute and the Rochester study in which risk was defined by a parental mental illness status. As yet, no results are available from this project, but the use of the modified longitudinal design will permit an analysis of a critical issue—the dependence of familial interaction upon the age of the offspring.

Importance of Family Relationshijjs in the Development of Schizophrenia Assumption 3, the critical assumption underlying all of the prior research on intrafamilial processes, is that disordered family relationships are a necessary but not sufficient condition for the development of schizophrenia. This assumption recognizes the potential significance of other factors in the development of schizophrenia, including those based on genetic and constitutional components. One variant of this recognition is a diathesis-stress model in which the primary stress is a long-term derivative of disordered family relationships. Clearly much of the enthusiasm for family-system theories of schizophrenia in the 1950's was based upon the hope that existential intervention at a family level could resolve the schizophrenic psychosis. Clinical case examples were offered in which such intervention was successful in producing remissions with schizophrenics. Despite these early enthusiasms for intensive family therapy, the advent of the phenothiazines has shifted the treatment emphasis to pharmacological agents. This shift in treatment philosophy does not necessarily violate earlier hypotheses regarding the etiological role of the family. To use an analogy, it may be just that it is far more economical to relieve a tension headache by aspirin than by psychotherapy, despite the obvious and pervasive role psychological stress may have played in precipitating the headache. In fact, it well may be that an understanding of the family's role in the etiology of schizophrenia is more relevant in preventing psychotic breakdowns through preventive or early intervention programs than it is in treating adult schizophrenics once a psychotic breakdown has occurred. It is very difficult to obtain hard and fast evidence that disordered family relationships are the primary


the offspring will provide additional information concerning factors related to the expression of schizophrenia in high risk family systems. The other high risk research programs that seriously consider the role of familial factors are the Rochester studies of Sameroff and Zax and Wynne and his associates; see Garmezy (1974a and 1974b) for a description of both risk-related programs). In the Sameroff and Zax project, children of schizophrenics, neurotic depressives, personality disorders, and normal women are studied from their prenatal period through early childhood. While not a family study, per se, the project includes numerous attempts to measure mother-child interaction in the home and in the laboratory. Only preliminary data are available from this project (Sameroff 1974), but few differences in constitutional or temperamental variables have been observed during the immediate postnatal period that differentiate offspring of schizophrenics from those of neurotic depressives. Children in both groups do, however, show more anomalies than children of normal parents and, to a lesser extent, than children of parents with personality disorders. In early childhood, significant variations in developmental variables have been observed that relate to the mother's psychiatric status and the degree of residual psychopathology. In the most disordered schizophrenic and depressive mothers, deficiencies in interactions, particularly in touching and speaking to the child, have been noted that do relate to the degree of childhood behaviorial difficulties reported. If these data continue to be upheld, they suggest the critical importance of measuring variations in residual psychopathology among parents. They also promise to provide data concerning the earliest development of children born in disordered and normal family systems which relate to theories emphasizing disturbances in the earliest mother-child relationship. Another critical and still unresolved issue of high risk research is how early in the child's life the study must be initiated in order to measure highly relevant variables. The Sameroff and Zax study will contribute important evidence on this score.

60

The comments of one highly experienced clinician who has had intensive experience with large samples of schizophrenics and often with their families are important. Arieti (1974) suggests that in addition to the families of the type described by Lidz and by Wynne and Singer he has also seen families in which such psychopathology was difficult to detect. Intensive research on populations at risk for schizophrenia will serve two objectives: • First, it will indicate whether disordered family relationships are predictive of subsequent schizophrenia, and if predictive, the degree of specificity for this particular form of psychopathology. • Second, it opens the way for another critical type of evidence based on the effects of different types of early interventions on populations varying in risk for schizophrenia. Differential treatment regimens, particularly those targeted toward the modification of family relationships,

when assigned at random to high and low risk offspring, provide the opportunity to determine whether the subsequent incidence of adult schizophrenia can be modified by such interventions. Positive evidence would contribute significantly to the complex network of evidence concerning the role of familial factors in the development of schizophrenia. The recent reviews by Garmezy (1974a and 1974b) of high risk programs suggest that a number of these programs may be ready to begin studies of intervention. The research approach that contrasts offspring reared in adoptive homes with those reared in their biological homes promises to provide significant evidence on the relative role of familial factors in the development of schiozphrenia. To date, these studies (Wender, Rosenthal, and Kety 1968) have focused primarily upon the psychiatric status of adoptive and biological parents of schizophrenic offspring. Published data suggest that less diagnosable psychopathology is found in the parents whose adoptive children became schizophrenics than in the biological parents of schizophrenics. While manifest psychopathology and disordered family relationship systems may overlap at the extreme end of the psychopathology continuum, they can, however, be quite independent within the moderately disturbed to normal range. Wynne and Singer (1963a and 1963b) have repeatedly emphasized that the parents in their studies who manifested severe transactional style deviances rarely fit traditional diagnostic categories when assessed clinically. An analysis currently underway by the Wynne and Singer group of the parental Rorschach protocols from the Wender, Rosenthai, and Kety study will clarify this issue by indicating whether the independent assessment of transactional style deviance parallels the previous diagnostic impressions of the two groups of parents of schizophrenics. Currently, the evidence does not permit a clear-cut statement on the role of family factors in the development of schizophrenia. There are sufficient lines of positive, indirect evidence, however, to argue that research directed at this hypothesis, using multiple approaches, is promising andworthy of continued effort and support.

References Alkire, A. A.; Goldstein, M. J.; Rodnick, E. H.; and Judd, L. L. Social influence and counterinfluence within


cause of schizophrenia. The very nature of family life, which covers such extensive periods of time, makes the design of a critical experiment unlikely. Instead, evidence on the family's role will come about, as in research on the relationship between smoking and lung cancer, from accumulations of data derived from diverse sources, field studies, prospective studies, and ultimately laboratory-based studies. Currently there seems to be a statistical relationship between disordered family relationships and the presence of clinical schizophrenia. It is not clear, however, that these fanrly patterns are unique to schizophrenia when contrastpd with other psychopathological conditions. Again this is not unlike the early cancer relationship in which heavy smoking was found to be as strongly related to heart disease as lung cancer. Perhaps most lacking currently are large-scale epidemiological studies on the incidence of disordered family relations in broad representative samples of schizophrenic patients as contrasted to normally developing comparison groups. Most family studies have worked with small and probably nonrepresentative samples so that the generality of the statistical correlations found is still unknown. An adequate assessment of the necessary but not sufficient assumption is probably dependent upon the elucidation of the specific mechanisms through which the various interacting factors ranging from family dysfunctions to genetic loadings mediate the development of schizophrenia.



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Acknowledgment The preparation of this article was supported by NIMH grants MH-08744 and MH-13512. The authors would like to thank their colleagues Armand Alkire, Fredric Jones, James Jones, Sigrid McPherson, Lin Ng, and Kathryn West for their significant contributions to our research program.

The Authors Michael J. Goldstein, Ph.D., and Eliot H. Rodnick, Ph.D., are both Professors of Psychology, University of California, Los Angeles, Calif.


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