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    Indian J Psychiat. 1992, 3 4 3), 231-235

    FAMILY ENVIRONMENT OF PSYCHIATRICPATIENTS :STUDY OF A NORTH INDIAN SAMPLE

    PREET KAMAL AND SHIV GAUTAM2The study aimed at finding out the relationship of family environm ent to schizophr enia, affectivedisorders and neurosis in comparison to controlgroupmatched on socio-economic status in a NorthIndian Sample. 600 subjects-150 schizophrenic patients, 150patients with affective disorders, 150neurotics, diagnosed according toICD-9,werestudied Results one way ANO VA) revealed that thereexists a significant difference in family environm ent of three categories of patients with psychiatricdisorders as well as in com parison to control group. Significantly low scores of cohesiveness, independence, expressiveness,active recreational orientationand organization, control and moral religiousemphasis werefound in schizophr enics. Similarly inthefamilies of patients with affective disordersthere were less cohesion and control and more expressiveness, conflict, independence and moral-relegious empha sis, while the family of neurotics had low levels of cohesion, intellectual-culturalorientation,active recreationalorientation,organisation and control.

    T h e term 'en vironm ent ' is used freque ntly in every day discourse. However, the reare neither universal definitions nor consen-sually defined operational indices of environment. The researchers working in the field ofenviron men t and health agree that there exist ahealth-illness continuum and human functionsrise and fall accordingly. It is clear that a widevariety of environmental factors influence howa persons feels and functions, and thus contribu te to illness. There fore the seemingly isolated societal element of poverty, inflation,unemployment, housing, ethnic conflict, familypro ble m s are, in reality, aspects of environmental heal th. These contribute directly to a varietyof difficult ies, including numerous mentalhealth problems and physical disorders associated with worries, fears and anxiety ofphysical stress (Willgoose, 1979).Recent researchers haveestablished apositive relationship between the environmentthe individual lives in and his mental state.Schizophrenia and neurotic depression havebeen reported to be related to environment ofthe individual's family (Paskiewiez, 1977; Wetzel, 1978, 1980). Moos and Moos (1976, 1981)

    by using Family Environm ent Scale ( FE S) havereported a significant difference between perceived family environments of normal familiesand of distressed families (families with one ormore 'd isfunct ional ' members) . Some havestudied family environment of a lcohol ics(Filstea d, 1979; An gela , 1985) an d B ulimics(Cra ig Flach , 1985), while oth er s havereported significant influence of changes inhome environment on social adjustment inadolescent (Nihira et al., 1985). Moreover,several investigators have assesse d the differential effects of family interactions on psychiatricdisorders (Rastogi and Mahal,1971;Shetty an dM ahal, 1977; Chan nabasa vanna and B hatt i ,1982;Gautam and K amal, 1986; Ga utam et al.,1986). However, little attempt have been m adein India n setting to study family env ironm ent asa whole in relation t o various psychiatric disorders.

    There fore, a prospective studywastakenup to find o ut the relatio nship of family environ ment to Schizophrenia, Affective disor ders andNeuros i s i n compar i son to con t ro l g roupmatched on socio economic status.

    1. Research Psychologist, 2. Associate Professor, Psychiatric Centre, S.M.S. Medical College, Janta Colony, Jaipur 302 004.

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    3 P R E E T K A M A L etal.

    MATERIAL AND METHODS A M P L E included 600 subjects, out ofwhich 450 were psychiatric patients attendingO.P.D. a t S .M.S. Hospi ta l and Psychiat r icCe ntre, Jaipur on randomly selected three daysof a week (Monday, Tuesday and Saturday)over a perio d of one year Patients were selectedf r o m t h e O . P . D . w h e n a d i a g n o s i s o fschiz ophre nia , Affect ive Disord er (manic-depressive psychosis, endogeneous depression,hypomania) and Neurosis (all types) was madeaccording to ICD -9 byaconsultant psychiatrist.150 patien ts were included in each gro up. Res tof the 150 we re norm al subjects, from the com m u n i t y . T h . e s e l 5 0 n o r m a l s u b j e c t s w e r eselected from the Raja Park and Tilak Nagararea of Jaipur city. The houses were randomlyselected and the investigators personally administered GHQ to these subjects matched onage, sex and socioeconomic status and if theGHQ score was less than seven the individualwas included as a normal subject in the study.Each group had 150 subjects matched on age,sex and socioeconomic status (Kuppuswamy'sscale). One-to-one matching was done at the

    time of selection of subjects because authorswanted to take family environment as an independent variable. Family Environment Scalewas administered to all patients. Before administering the scale a fair clinical assessmentof patients ability to understand the questionsasked and reply was made. Only those patientswho could do so were included in the study.Seriously disturbed Manics, Schizophrenicsand depressed patients, where it was not possible to elicit adeq ua te respo nses were excludedfrom the study.

    T O O L S O F I N Q U I R Y - F o l l o w i n gscale was used.Revised Hindi version of Moos FamilyEnvironment Scale (Joshi, 1984)- Originally,the Family Environment Scale (FES) wasdeveloped by Rudolph H. Mo os (1974). I tisone

    of the n ine social c l imate scales and wasprese nted in the form of sep ara te scalebyMoosand Moos (1981). It was modified and translated in Hindi by Joshi (1984). The scale hasbeen reported to be reliable and valid by theauthor in No rth Indian Popula tion. It com prisesof ten sub-scales that measures the social en-v i ronmental character is t ics of a l l types offamilies. These ten sub-scales assess three underlying domains or sets of dim ens ions : (i) Th ere l a t ionsh ip d imens ions ( i i ) The per soan lgrowth dimension and (iii) The system maintenance dimesion.( i ) T h e r e l a t i o n s h i p d i m e n s i o n s a r emeasured by the cohesion, expressiveness andconflict sub-scales.(i i) The personal growth dimensions aremeasured by the independence, achievementorientat ion, intel lectual-Cultural orientat ion,ac t ive- recrea t iona l o r i en ta t ion and mora l -relegious emphasis.(iii) The system maintenance dimensionsare measured by the organization and controlsub-scales.

    The scale consistsof 90-items and thereare 9 items in each sub-scales. Each item isscored on a five point scale, where the sc ore of4, represent the category of 'always' and thescore of 0, the category of 'never' . There is noaggregate sc ore for the scale. All the sub -scalesare scored separately. The sum of all the itemsin each sub-scales represent them.O P E R A T I O N A L P R O C E D U R E -After th e selection of samp le, each subject w asadministered the family environment scale toassess the social environment of their family inone to one setting. The investigator (PK) personally asked the questions to all the subjectswhether or not literate enough to rea d or und erstand the question in order to elicit- properrespon se. Scoringwasdon e accordingly and th e

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    F A M I L Y E N V I R O N M E N T O F P SY C H I A T R I C P A T I E N T S 33

    R E S U L T ST a b l e - 1 :Mean valueofvarious subscalesofFESand their significance invarious

    diagnostic categories

    S.No.

    1.2.3.4.5.6.7.8.9.10.

    Sub-scale of FFS

    Cohesion*Expressiveness*Conflict*Independence*Achievement OrientationIntellectual Cultural Orientation*Active-recreational Orientation*Moral-religious emphasis*Organization*Control*

    schizophrenia(N=150)

    13.0418.7021.3417.2724.3012.7414.0024.1426.5223.32

    Diagnostic categoriesAffectivedisorder(N= 150)

    21.1425.1218.5722.2825.3916.9315.3319.5522.6518.58

    Neuroses(N = 150)

    16.8619.9213.0218.9524.7814.2614.3818.5617.1419.32

    NormalN = 150)23.4218.2614.7818.2524.4416.4615.3017.8122.5123.48

    Significanceofdifference inscores among diagnostics categories ap pea red as.aresultofoneway AN O V A . F-ratios w ere significantat.01 levelof significance.raw data thus o btained was statistically analysedby using one way analysisofvariance.DISCUSSION

    In the presen t s tudy the family env i r o n m e n t wasfound to vary infamiliesofpa t ien ts wi th sch izoph renia , af fective d isord e r sandneu rosi s as wel lasnorm al subjects .Schizophrenics perceived thei r fami l ies asb e i n g l e s s s u p p o r t i v e and help fu l lowcohesiveness) ; repor ted that thei r fami l iesd id noten co ur ag e, assert iv e, self sufficcientb e h a v i o u r low i n d e p e n d e n c e ) and beingless involved in social and recrea t iona lact i v i t i es low a c t i v e - r e c r e a t i o n a l o r i e n t a t i o n ) as c o m p a r e d to n o r m a l s u b j e c t s .In t e res t ing ly these sub jec t s v i ewed the i r

    families as experiencinga great deal of conflict and ang er (high conflict) and yet theyreported thatopen, direct expression was discouraged lowexpress iveness) .Fur thermo re,they reported that their families have clearorganization and structure (h igh organizat ion ) and m o r e e m p h a s i s on e t h i c a l andr e l ig ious i s sues and values (h igh m ora l -rel igious em pha sis) , but rules and pro ce du resto run family life (con trol) w ere found tohavee q u a l i m p o r t a n c e in the f a m i l i e s ofschizophrenics as well as norm al subjec ts.Moreover, although theachievement expectations (achievement orientation) were not significantly different in all thegroups, the rewasless emphasis infamilies of schizophrenicsonintellectual and social activities low intellectual-cultural orientation ).

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    234 PREE T KAMALetat

    Similarly in the families of patients withaffective disorders there was less cohesion andcontro l and more expressiveness, conflict, independence and moral religious emphasis, whilethe families of neurotics had low level ofcohesion, intellectual-cultural orientation, active recreational orientation, organization andcontrol.These findings are supportedby some ofthe previous studies e.g. Moos and Moos(1976,1971) by using family environment scalehave reported a significant difference betweenfamily environment of normal families and ofdistressed families. They found the distressedfamilies to be less cohesive, expressive, organized, independent, achievement oriented,religious andwithmore conflict. These familieswere also less concerned with intellectual cultural and recreational activities. Such differences have been identified in other studies also.The most cosistent finding is that distressedfamilies are seen as having less cohesion andexpressiveness and m ore conflict (Youngetal.,1976;Lange, 1978; White, 1978; Scoresby andChristensen, 1976). Such families also tend to

    be less well organized (Scoresby and C hristensen, 1976); less oriented towards indep endence ,achievement and religious activities (Youngetal.,1976; W hite, 1978) and less concerned withintellectual and recreational pursuits (Janesand Hese lbrack, 1976; Lange, 1978).Further it may be added that in thepresent study various dimensions of family environmenthavebeen studiedas perceivedbythepatients. Though full carewastakentosee thatfamily environment scale is administered tosuch patients who could understand the questions asked and hadthecognitive ability to replythem, even than the importance of disease incolouringtheperception of family environmentcannot be ruled out. Family environment scalewasalso administeredto anadult healthy familymember of the patient (results not included inthe present study) did not reveal any difference

    in family environment. Some of the patternsobservedin thefamilies arelikely tobe culturally determined e.g. concept of independence isnot encouragedasmuchas inthewest. tis quitelikely taat a person with affective disorder be causeofthepsychopathology itself maybemoreexpressive and may report high independence,while it isnotsorepo rted by the schizophrenics,neurotics as well as normal individuals. Thehigh score of independence perceived in thefamilies of patients with affective disorders^needto befurther verifiedinsubsequent studiesby studyingthefamily environmentasperceivedby normal adult individuals of the same family.The questioniswhether charac terisitcs of familyenvironmenthave acause and effect relation-sh ip to the menta l d isorders o r thecharacteristics of environment are brought bydeviance in one ofitsmem bers. This study onlyesatablishes the fact that these are characteristics of family environment related tovarious group of psychiatric disorders.

    REFERENCESAngela, Peterson-Kelley (198 5). 'Family environment andAlateens : A note on alcohol abuse potential'. Journal ofCommunity Psychology, 13,1, 75-76.Channabasavanna, S.M. and Bhatli, R. (1991). 'A studyof interactional patterns and family typologies in familiesof mental patients'.In:A rikievand A. Venkoba Rao (Eds.),Readings in transcultural Psychiatry, Madras : Higgin-botham.Craig,J andFlach,A. (198 5). 'Family characteristics of 105patients with Bulimia'. American Journal of Psychiatry,142,1321-1324.FUstcad, W. (1979). 'Comparing the family environment ofAlcoholic and normal families'. Department of Psychiatryand Behavioural Sciences, North Western, University,Chicago.Gautam, S. and Kama), P. (1986). 'Family typology andfamily interaction in psychiatric disorders. InternationalJournal of Social Psychiatry, 32, 4,2 7-3 1.Gautam, S.; Nyhawan, M .; Kam al, P. and Ja in, S. (1986).'Family typology, family interaction and p erceiv ed stress inneurotic patients'. Paper presented in World PsychiatricAssoc iation Regional sympo sium on Psychosocial stres sand menta l health , Jaipur.

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    FAMILY ENVIRONMENT OF PSYCHIATRIC PATIENTS 35

    Jan es, C. and Hessel, V. (1976). Perceived family environment and social adjustment of children schizophrenics'.Paper presented at the American Psychological Association convention, Washington DC.Josh i, M.C. (1984 ). 'RevisedHindi version of M ooos' Family Environment Scale. Department of Psychology, JodhpurUniversity, Jodhpur.Lange, M. (1978). 'Some characteristics of the validity ofthe Dutch translation of the FES and WES'. Departmentof Clinical Psychology, Catholic University, Nijmegen,Netherlands.Moos, R.H. (1974), The Social Climate Scales : An overview. Palo Alto, California : Consulting PsychologistsPress.Moos, R.H. and Moos, B. (1976). 'A typology of familysocial environment. Family process, 15,357-372.Nlhira, K.; Mink, I.T. and Edward. M.C. (1985). 'Homeenvironment an d developm ent o f slow learning adolescents: Reciprocal relations'. Deve lopm ent Psychology, 21,78 4-Paskiewiez, P. (1977). 'Conceptualizing of the Psychological melieu of the aftercare client: An explanatory study.Masters thesis. Department of Psychology, OaklandUniversity Rochester, MN.

    Rastogl, D.S. and Mahal, A.S. (1971). 'Patterns of familyre lat ionsh ip in s ch izophren ia ' . Ind ian Journal ofPsychiatry, 13, 209-217.Scoresby,- A. and C hrlsten sen, B. (197 6). 'Differences ininteraction and environmental cond itions of clinic andnonclinic families: Implications for Coun seleis'. Journal o fMarriage Family Counseling, 2,63 -71 .Shetty, G. and Mah al, A.S. (1977). 'A too l to study familyinteraction Indian Journal of Psychiatry, 19,67 -70 .Wetzel, J. (1978). 'Depression and dependence upon un-sustaining environm ents'. Clinical Social Work Journ al, 6,75-89.White, D. (1978). 'Schizophrenics perceptions of familyrelationships'. Dissertation Abstract International, 39,1451-A.

    Willgoosc, C.E. (1979). 'Environmental health : Commitment for survival'. Philadelphia/London/T oronto : W .D .Saunders Company.Young, R.; Gaynor, J.; Gould, E. and Stewart, M. (1979).T h e family environm ent scale in a psychiatric in-patientsample. Department of Psychiatry, University of California, San Franscisco.