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Introduction

G“? ‘31 concepts
Cfieratiannlization .‘3
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ImplicatiOns
Pil?1ography

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FAMILY ACCEPTSYCT flXU IT? AFFECT‘

ON TYNE CCF'FTI'NITY AUTITSTVENT CF

TH” SCUIZ“?URENIC PATIEVT

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by

1‘ \p. a Q-‘V-\
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Fllen waulsman
Paul 3kfl“1urc
Glenn Reynolds

AFSTRACT

Suhmitfod in partial fulfillmcnf
of the requirement for
fbe degree of

VASTFR CF SOCIAL TFRK

Nichi{yu1 Sfate ‘fovcrsity
vchool cf gocial Work
East liuising, Bfixflzigan

19m

It was the intent of the authors to inv<stigate the
necessity of family or familymli;e suppcrt in tro
sucrersful community adjustment of the schizophrenic
yourg adult. Tte three areas around wtich this was none fl't
incluflefl the family's attitude toward the agent) ccntacts
with hnth amily and patient, the family's attitufie towar3
the patient's re~sorialization, and the family's attitude
toward the patient's hospitalization. The significance
of the family's attitude toward agency contacts and the
greater significance of the family's attitude toward
re-sorialization indicate the necessity for more ettensive
involvement of the family by the treatment agency in the
agency's efforts to assist the patient in making a successful
(TCfiWmlhll)’£UljUStflHH1t.

THo third area of study, the family's attitude surrounding
tlIe patient's hospitalization, was not found to be significant

arvl inflicates ‘he need for a mere extensive study.

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Is h vs teen ELL up to Let“ ‘Hese d

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cs, e r homes, w 10 r as
staff of the Lansing Consultation Ceatvr,

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PlJCC, can

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are their utients

neightornc; ention (tecau

unkempt personal as s, neglect

or other maladaptive behavior) does
.'5 refiosritali7ation. This study w

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facilitates

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37:17.1in 5 3‘ ‘1 t PM: Th 5‘01“}! ,

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lelatin to its family memters.

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*35k& 13 that Cu "mvticral su}“nr
sctfilchfirsn1;c E133 'tkpt sewn) t’;sk.

ufly con end ta

not

famil; relations of the schizophrenic have a major impact

on how successful the patient will be in sustained community
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living and adjus ment. Those familics whose cmctiona inp;

s of their goals for th‘ patient

*4.

is adequate, on the has

and accrptacne of his limitations and symptoms, will

- V

profluce a patient who will remain out of the hospital and
in the community longer and will function at a higher

adjustment level.

The major hypothesis to he tested in this study

states that family support and acceptance will significantly
agfect the patient's ability to satisfactorily adjust to

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t ; ~. /,»
commurity living. This can be further broken down into
thrce suh-hypotheses as follows: i) The family's attitude
toward patient and family contact w th the helping agency
will affect the patient's ability to adjust in the home and
(inmmunit); 2) The family's attitude toward the re-sccilazation

M

of‘ the patient upon hospital release will significantly
aflfect the ratient's home and community adjustment; 3) The

faunily's attitude surrounding the patient's hospitalization

w1_ll affect his adjustment after release.

It is felt that the first set of attitudes is the nnjor

fkactor in patient adjustnent to community living. Jhe

 

ssec:ond and third sets are Considered to be-.

inqnortart, although not to the degree of the first.

I“)

VETUCT

In order to test the previously stated hypotheses,
a sample was selected from the Lansing Consultation Center's
schizophrenic patient population (criteria for selection
will he discussed at a later point). Three broad areas
were defined as playing significant roles in the patient's
community-family adjustment. The first area covered the
family's attitude toward all patientmfamily contacts with

the agency. This included their attitude toward the

contacts the patient had with the agency as well as their

own contacts or in some cases, lack of contacts. It also

included the family's attitude toward the patient' overt

symptoms. It was felt that this particular area is related

to the kinds of attitudes the family has toward the agency
in general. Those families who accept the agency and see

it as a helping place are more likely to seek the agency's

tielp when symptoms arise, or seem to be worsening. The

second area included the family's attitude toward social-

ization. How did they View the patient and participation

1x1 activities that included others? It also included
exrmmtations the family held for the patient after his
rueturn from the hospital to the community. The third

brwaad area covered the family's attitude surrounding the-

rn~evious hospitalization of the patient. How did they feel

at: the time of hospitalization? Vhat was their attitude

tcnvard the patient's release? How often did they visit?

What was their general attitude toward the illness before

and during hospitalization?

These were the general concepts involved in he
hypothesis. The actual operationalizing was done as follows:

Area one was broken down into three categories (each of
which was then scaled). Category one was the family's
attitude toward the patient's contacts with the consultation
center. An accepting family was defined as one that
encouraged patient-agency contacts, coioperated with the
agency's suggestions and encouraged the patient's co—operation.
A non~accepting family was one that hindered the patient's
coming to the agency and tried to destroy or sabotage the help
offered there. Category two dealt with the family's attitude
toward their own contacts with the center. An accepting
family saw their contacts as necessary, while a rejecting
family refused all contacts. Category three involved the
family's toleration of the patient's overt symptoms. Such
symptoms aroused hostility in the rejecting family (who did
nothing hut react with hostility), while the accepting
:family tried to act on agency recommendations on how to
handle them. These categories were weighted more heavily
tharwthe others because it was felt that they were more

indicative of family support of change in the patient.

Area two was broken down into four categories.

The first required scaling of the family's attitude toward

the patient as a participant in the family. The accepting
family encouraged the active participation of the patient

in family affairs while the rejecting family worked to

keep him an inactive, possibly withdrawn member. The

accepting family might encourage the patient to help with
family chores, participate in family recreational activities
and interact with other memhers. Non~accepting families
encouraged isolation and minimal contact with other

memters. Category two scaled the family's attitude toward

the patient's participation in outside social/community
activities. The accepting family encouraged such participation
while the non-accepting did not allow such participation on

the part of the patient. Category three was concerned with
the family's attitude toward employment for the patient.

Th accepting family was in favor of employment if it was

in the interest of the patient and encouraged his efforts

in that direction. They also might have aided him in his
search for a joh that was within his ability to tandle.

1Y1e final category indicated the family's expectations for
tflie patient upon release from the hospital. The accepting
fkunily expected -he patient to get better, but also
exqoected him to move at his own pace. The expectations at

the: other end of the scale were for the patient to get well

innnediately upon release (or to have been cured before

all—ll. .-

 

release) or for him to remain at his release level of

functioning and never progress.

The third area was also broken down into three categories

surrounding hospitalization. The first included the family's

attitude toward the patient's hospitalization at the time

of the hospitalization. The accepting family saw a need for

it and had encouraged it. Hospitalization may have been at

their own request. At the other end of LHC stale, the family

v-5

tendedto hinder Hwe hospitalization process, submitting to

it only in the face of some outside pressure. (The authors

began with the premise that encouragement of hospitalization

is a positive support for the patient as it provides help for

liim despite evidence of a generally non-accepting attitude.

(Sase histories tended to support this premise.) Category

twvo dealt with the family's attitude toward the patient's

refllease from the hospital. The accepting family worked toward

tiis release and encouraged him to do likewise, At the other

erui of the scale, they were against his release and might

{give set up hlocks in planning for the release. Category

tlrrce was concerned with the frequency of family visits

:iuxéing hospitalization. The accepting family was defined as

c)n(? which visited the hospitalized patient often, or at

fileaaSt with some regularity (assuming that the distance

etwveen home and hos ital was not Jrohihitive) while the
9

1~e‘jecting family never visited during the course of hospitalization.

The final category scaled the family's attitude toward the
patient's illness before and/or during the patient's
hospitalization. The accepting family felt it would be

of some benefit to the patient and viewed the patient as
ill. They did not expect a miracle cure however. The
non-accepting family usually did not view the patient as
ill, and tended to see little reason for or value in

hospitalization.*

As to the dependent variable, a patient's family and

community adjustment was defined as successful if certain
criterion were met in terms of roles and the performance
of the tasks apprOpriate to those roles. Within the family,
the patient needed to be participating as an active member.
Tle needed to be more than an isolated individual who spent
the entire day in his room or watching television. The
housewife needed to be able to assume responsibility for
some of the jobs around the house and be able to cooperate
with those who were also assuming responsibilities.
'There also had to be an indication that she was performing
\vell generally and notjust fulfilling specific roles while
seeming to come apart overall. For example, these patients
“duo were either employed or conscientiously seeking

*See ”Tyfigfllfi 1 for details of scaling as shown in the

instHHCht itself.

‘

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employment (in addition to performing adequately in the

home) were judged a success. Those holding jobs needed

to be stable in them (as opposed to those who were constantly
job-hopping) and getting along relatively well with fellow
employees and employers. Success in employment was not

rated solely on the ability to obtain a job and perform some
of the tasks appropriate to it. Return to school was also
considered a measure of success in adjustment. The patient
whc constituted the strongest success was the patient who
was able to do above average work and complete the course(s)

enrolled in. A final measure of Success was progress in

therapy as judged by the individual's therapist.

Success and failure were measured on a very pragmatic
basis. The patient who was having difficulty with his
family, could not hold a job, exhibited much bizarre
behavior, appeared very withdrawn and isolated, or finally
was returned to the hospital could not be termed a success.
If he seemed to be functioning without a great deal of
difficulty and seemed to be making an effort to perform,
[19 was termed a success regardless of the necessity of
.agency support. It was felt that it was appropriate for
the patient and/or his family to look to the agency for
uruierstanding and guidance, and would be a sign of strength
ratflier than failure. No actual score was recorded for

SLHZCGSS or failure. If the patient indicated more areas

(.0

of adjustment strength than failure and stabilization or
consistent progress (rather than regression) was indicated,

he was recorded as a success. If he showed little pregress
beyond hospital release level, regression or was having

a great deal of difficulty in most areas of functioning, he
was recored as a failure. Success was judged on an individual
basis rather than on a general group scale because of the
diversities of adjustment levels at the time of hospital

release and agency/therapist expectations for each patient.

The sample for this study was drawn from the schizophrenic
population seen at the Lansing Consultation Center and its
branch in Jackson, Michigan. This agency serves all discharged
and convalescent status patients from state hOSpitals and
training schools who live in the Lansinngackson area. Initial
contact begins after hospital release and terminates at the
decision of the patient or patient and therapist. In rare
instances it is required of such a patient that he be in
contact with the agency as a condition of his release from

To

tr: hospital, but all patienisin the sample were seen at the

agency on a voluntary basis.

Selection for the sample was made of the basis of age,
(tiagnosis and length of contact. The age range was twenty
years to thirty years of age AT THE TIME OF FIRST CCYTACT

witfli tte Consultation Center. This increased the likelihood

of there being a family involved with the patient. It
decreased the inclusion of patients with a long history of
previous hospitali7ations. The diagnostic label was
limited to that of schizophrenic reaction. Personality
disorders were not included. Severely retarded patients
were also not included, although borderline and very
moderately retarded patients were included as long as the
major diagnosis was schizophrenic reaction. The sample
was also limited to patients having had contact with the
agency for at least four months, regardless of how
extensive such contacts may have been. This allowed the
patient's worker sufficient time to get to know the patient

and evaluate an? record the patient's prOgress.

The data was collected in two parts, which were the
attitude ratings and the success-failure ratings. All

the information needed for both was available in the

-W __.__
M-Q... _ _

patient's case record. There was the possibility of each
rating being influenced by the other in that a rater might
be more likely to score a patient successful if he know
that there had been much positive family involvement and
vice—versa. It was felt that there was minimal biasing

of scores for both parts as the material for the two areas
(svccess-failure and acceptance) appeared in separate parts

of the file. The acceptance rating score was derived from

the first half of each record by two researchers independently.
In most instances there was very close agzeement between the
two independent scores for each item. In the case of
differences in scores, the two raters came to an agreement

on a score by discussion. Once the ratings were done, the
file was given to a third rater who determined success or
failure entirely on the basis of the other part of the record.
fill ratings and judgements were made on the basis of the

material recorded in each case record.

ll

DATA AXALYSIs 63 flit

The four hypotheses concerning The effect of the
family's acceptance of the scriZOphrenic patient on his

adjustment to community living were translated into null

hypotheses for purpoaes of testing. TheSL are:
1. Family support and acceptance will not significantly
\
affect the patient's ability to satisfactcrily \
t
55
adjuat to community living;
7. The family's attitude toward patient and family
contact with the helping agency will not affect
the patient's ability to adjust in the home and )

community;

3. The family's attitude toward the rewsocialiZation

of

the patient upon hospital release will not

J

significantly affect the patient': home and community
adjustment;

h. The family's attitude surrounding the patient's
hospitalization will not affect his adjustment I
after release.

The number of cases in the sample was 65. 37 were scc Cd

‘1

succesqful, while 99 were scored failures. The mean scores

for the §nc<ess groups for all hypotheses were higher than

—.—-v v' ‘"

the mean scores for the failure groups. There was a

\

~. '__..

difference of 3.30 for the major hypothesis (1 above)

(t=1.72, p(,n”); 1,89 for subuhypotLesis one (t:1.75, p<.95)

_ ’10: .

o
9

(“Q

"a

‘—

1.99 for sub-hypothesis two (t:2.32, p(.05). While the
success group did score higher on sub-hypothesis three,

the difference between the groups was only 0.21. The
t-test showed three of the four to he significant at the /.J

\-_I-‘7- — ~--~ v... _ _. _ ..._ I
\d
‘

p<L05 level. The major hypothesis and the first two
sub—hypotheses were each found to be confirmed at this
level, while the third, concerning attitudes surrounding

the patient's hospitalization, was not confirmed.

Sub—hypothesis two, being so strongly significant (t:2.32,
p<.05), may have been the major factor in confirmation of
the total hypothesis. Sub-hypothesis One was weighted
more heavily in scoring (see Appendix 1), which may or may
not have had the effect of keeping One and Two as close as

they were.

The tests indicate a negation of three of the four
null hypotheses. The general hypothesis that family
support does significantly affect the patient's ability
to adjust satisfactorily to community living is thereby
confirmed, as are the particular hypotheses that the family's
positive attitudes toward contacts with the helping agency
and even more significantly that positive attitudes toward
the patient's re—socialization will facilitate the patient's

successful readjustment outside the hospital.

mroup Mean Secres

(3‘
Rf,

Attitude

Areas

 

 

 

Area Success Failure Differences
Group Group
n: 37 n;?8
Attitude tanri
agency coztwct 12.73 9.33 1.?3*

Attitude

’: r9" ”‘7: If“,

 

socialiratic: 9.03 ?.82 1.89*
Attitud t;"””

hospitxli a!“ u 9.81 9.60 0.21
Total CF ‘ ' 31.52 2c.33 3.30*

* These differenCes were significant at p(.

 

nav
1)

1h

The test results did not, however,permit us to reject

the fourth null hypothesis. There was no significant
‘f’ferrnce between the family's attitudes surrounding the
patient's hospitalization and the patient's adjustment after
release. This particular hypothesis was more difficult to
test tian the other three. There was more missing data
here. For those with no score for a particular category,
the mean score was assigned for that category. While the
information for categories A, C, and D was generally
available, it was more difficult to find and often had to

to isp‘ied. An accurate measurement was more difficult to

ohtain on this part than on any of the others.

IMPLICATIONS

S
The results of this study indicate that agency contact \Pr“qd’i
with both patient and family plays an important part in .Tfifi; .
aiding the schizophrenic patient to maintain a successful
community adjustment. It indicates further that the
family's attitude toward the patient's participation in

community and family affairs is also a very important

factor. The significance of this attitude holds an added

implication for the treatment agency. While individual
patient forms is important, an added emphasis on a broader,
family—centered focus may be beneficial. Such an emphasis
could be used hy the agency to aid the family in developing
the support and encouragement seen here to be important to

the patient's successful recovery and post-hospital adjustment.

Further research might delve into three areas suggested by

tlae test results. The difficulty in reaching any significant

ccniclusion about the family's attitude toward the patient's
liosrfiinlizaticn might be explored further. A more objective
FthJy might be done by gathering the data directly from the

liosgxital records where it is possible to review all dates

of thisits, correspondence with patient and hospital staff

arui reports of all other family contacts.

A larcakdown and analysis of the individual items and

suns—ajceae cf t“e rating scale might be helpful, to see

where the actual differences occur. This was not done

here only for reasons of limited time.

A third area for more extensive research lies in the
formation of research and control groups composed of
families where special work would be done in teaching
them how to give support and encouragement to their
schizophrenic members. If family support and acceptance
is indeed the key to the patient's successful adjustment, in
what ways can the family be helped to provide that support
most effectively? An assumption underlying this is that
the family can be so helped and that these attitudes are

not non-communicable. That,also_,wou1d need to be proven.

 

 

 

 

Trecnblatt, Nilto
Brooks, eds

A, Haida a, jolcmgn Anne Evans, George
, I
< htIT'IOPTTDT‘ IQ , C . C . Thoma

r :
“RUG “V“ SC" T”V“FF TV CWWCYIC

C\
\.'t
O

, S>riugfield, Illinois, 1

\3

Jacks; on, non r., ed., THE ETICLTSY or scurchuRENIA,
Basic Books, Ncw York,19€0.

Li dz, Theodore, Stephen Fleck, Alice R. Cornelison,
SCI IVC“"”FYIQ A\“ THE FAMILY, International Univelsities
Pless, New l’ork, 1955.

Lutz, Werner A., THE FAMIIY A3 A SYSTEM, Great Lakes
Regional Institute, Petroit, Micliga n, 1966.

 

 

C

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LIBRI

 

 

 

T

A '

APPENWIX l

ATTITUUE RATING SCALE

Attitude toward agency contacts

A.

Attitude toward pationt's contacts
a) attitude twca:d trhficcts n th QBCRCY per se
1. Winderci his ccni:.g
3. Allowed to come
5. Encouraged his coming
h) attitude toward help givcn at agency
I. Tried to destroy worker's help
3. Indifferent

5. Cooperated with worker's suggestion
Attitude toward own (fa nily ) contacts wit:h agency
1. Refused to come (refused all cc ta ct:s)

2. Reluctant

3. Came, but felt there was nothing there for them.

U. Saw some possible help

5. Sow as necessary

Tolora ticn cf patient's symptoms (as related to agency's
Views on handling)

1. Aroused hostilit

2. Ignored

3. ml cc-pted but did nothirg

k. Called agency frimazil» to complain)
S. Tried to act on agency recommendations

Attitude toward socialization

‘\
, a

Family's attitude toward patient's participation as
family member

1. Kept out of

?. Allowed participation

3. Encouraged participation

Family's attitude toward patient's participation in
outside social acti"ities

1. Not allowed to participat

2. Allowe

3. Encouraged to participate

Attitude toward employment

1. Against

?. Accepted

3. Encouraged

E?.mily's erpcctaH ons for patient upon hospital rcloaso
l. EXpocted Iationt to never get we 11 or to get well

immediately
2. Expected patient to get well
3. Expected patient to get well, but will allow patient
to go at own pace

II. Attitude surrounding hospitalization
A. Attitude toward patient's hosyitalization at time or
hospitalization

1. Hindered
2. AIIOE'CCl
3. Encouraged (may have rcqrestcd)
R. Attitude toward release
1. Against
2. Indifference or acceptance, tut did nothing in
anticipation
3. Worked for patient's release
C. Frequency of visits during hospitalization
1. Never
2, Seldom
3. Often
9. Attitude toward illness before or during hospitalization
1. Denied illness
2. Expected complete cure
3. Felt it would help somewhat

All statements about the agency are at the point nearest to,
but after four months after inital contact.

Point range: IQHUQ

 

STATE OF MICHIGAN

car-m

as

     
 

REGIONAL CONSULTATION CENTER-LANSING
I203 West Oakland Avenue
at» Lansing, Michigan 48915
GEORGE ROMNEY, Governor Area 517 373-1700

DEPARTMENT OF MENTAL HEALTH

WILLIAM H. ANDERSON, M.D., Dirodor

May 16, 1968

I hereby grant permission to Ellen Landsman, Paul McClure,
Glenn Reynolds, and Duanne Lafrenz to use agency records
for a group research project in partial fulfillment of

the requirements for a M.S;W. at Michigan State University,
School of Social Work.

 

Executi e Director

 

A!