Fam Proc 22:537-547, 1983

Perceptions of Family Environment Among Psychiatric Patients andTheir Wives

DAVID SPIEGEL, M.D.a

TERRY WISSLER, M.S.b

aAssociate Professor of Psychiatry and Behavioral Sciences (Clinical), Stanford University School of Medicine, Stanford, California94305.bPalo Alto Veterans Administration Medical Center, Palo Alto, California.We wish to thank Rudolf Moos, Ph.D., Professor, and Helena Kraemer, Ph.D., Associate Professor of Biostatistics of the StanfordUniversity Department of Psychiatry and Behavioral Sciences, consultants to the project. Data analyses were conducted with the help ofSteven Cutcomb, Ph.D., Kent Emett, B.A., and David Worthington, B.A.

This study compared the perceived family environments of former psychiatric inpatients with thought, affective, andsubstance abuse disorders to those of normative comparison couples using the Family Environment Scale. Familyenvironment was assessed among patients and wives separately at hospital discharge and at three- and twelve-monthfollow-ups. Patients and their wives were consistently more incongruent in their perceptions of their shared environmentthan normative couples. In addition, low-functioning patient couples reported less family cohesion, expressiveness, andrecreational emphasis than their higher functioning counterparts; the high-functioning patient couples more closelyresembled the norm. The paper discusses possible relationships between positive family contact and better patientfunctioning.

Since families are a major support system for patients (3), differences between normal families and those with apsychiatric patient are of clinical as well as theoretical interest. Few attempts have been made systematically to evaluatefamily environment (21), and many involve ratings by outside observers (2, 4, 29, 33). Assessing how family membersperceive their own family environments is important in understanding and predicting their behavior (15, 19, 27). In thisstudy, family environment is described using the perceptions of family members rather than those of an outside observer.

In the few studies comparing the perceived family environments of psychiatric patients and normals, the FamilyEnvironment Scale (FES, 22, 24) has been most frequently used. Results are summarized in Table I.

Table 1Studies Using the Family Environment Scale to Compare Specified Clinical Populations to Normal Comparison Families

Moos, InselHumphrey (24)

Scorseby andChristensen (30)

Penk et al. (28) Moos & Moos (23)

Psychiat clinic orprobation/parole

Outpatientcounseling center

Heroin abusers Relapsedalcoholics

Recoveredalcoholics

versus versus versus versus versus

Matched controlfamilies

Nonhelp-seekingfamilies

Normalcomparisonfamilies

Recoveredalcoholics andcontrol families

Control families

Cohesion - - -

Expressiveness - -

Conflict +

Independence

Achievement +

Intellectual-Cultural - -

Recreation - - - -

Moral-Religious +

Organization - +

Control

Incongruence in Perceptions No difference Not reported N/A. Data for + No difference

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heroin abuser only

+ = Clinical family or family member score significantly higher on this subscale than normative comparison group.- = Clinical family or family member score significantly lower on this subscale than normative comparison group.

In comparing the family environments of psychiatric patients and normals, the possible relationships between thepatient's current level of functioning and perceived family environment are important. For example, in the one FEScomparison study in which patient level of functioning was considered (26), recovered alcoholics' perceptions of theirfamily environments were similar to matched controls, whereas the perceptions of relapsed alcoholics differed from boththose of the recovered alcoholics and controls. In another study using the KDS-15 questionnaire (16), patients with adiagnosis of bipolar illness in remission and their well spouses reported marital adjustments closely resembling those ofnonpatient couples (12). As in the previous study, the fact that the patients were recovered may have accounted for theabsence of differences.

An important characteristic of family environment is the extent to which family members agree in their perceptions (21,22). There is abundant clinical and theoretical literature describing, from the perspective of a third-party observer (1, 5, 13,17, 20, 34), disordered communication patterns of families with a psychiatric patient. If families with a psychiatric patientare characterized by unclear and distorted communication, it is reasonable to hypothesize that members of these familieswill hold more discrepant perceptions of their environment than normal comparison families do. Data relevant to thishypothesis are contradictory (see Table I). To our knowledge, the only study of family members' incongruence ofperceptions involving a general psychiatric population found no significant difference in incongruence between a group ofclinical and normal comparison families (24). Neither psychiatric diagnosis nor patient level of functioning was specified.Moos and Moos (23), however, did find more incongruence in families of relapsed alcoholics than in those of recoveredalcoholics or normals.

Utilizing an interpersonal perception method of having husbands and wives rate their families with scales that bear somesimilarity to the cohesiveness, conflict, and control subscales of the FES, Laing et al. (18) found significantly lessagreement in disturbed, as compared with nondisturbed, marriages. There were also significantly more misunderstandingsabout one another's point of view in the disturbed marriages. However, no information about specific psychopathology inone or the other of the members of these families was provided.

In the present study, a sample of previously hospitalized psychiatric patients was divided into high- and low-functioninggroups based on several indices of psychological and role functioning. We hypothesized that patient couples would be moreincongruent in their perceptions of family environment than normative couples would be. We also predicted that patientcouples would report more conflict and control and less cohesion, expressiveness, independence, recreation, achievementand intellectual-cultural orientations, and organization than normative couples and would differ in moral-religiousorientation, but in which direction could not be predicted on theoretical grounds. We further hypothesized that thesemeasures would differentiate similarly between high- and low-functioning patient couples, with high-functioning patientcouples more similar to the norm.

Method

Sample SelectionAs part of a larger study, all veterans who had been hospitalized on a psychiatric ward at the Palo Alto Veterans

Administration Medical Center and who lived with their families were contacted soon after discharge to complete a batteryof questionnaires. The subsample used in this study (N = 60) were male veterans who returned to live with families ofprocreation. Follow-up data were collected three months (N = 53) and one year (N = 47) after hospital discharge. Thepatients tended to be middle-aged (47 years on the average), moderately educated (42 per cent had completed high school;27 per cent had had some college), Caucasian (77 per cent), and either Catholic (47 per cent) or Protestant (33 per cent).They were stably married (63 per cent had been married 10 years or more) and most had one or more children (18 per centhad none; 43 per cent had 1-2, 23 per cent had 3-4).

Psychiatric diagnoses of the index patients, determined by chart review using the Research Diagnostic Criteria (11, 31,32), were: 33 per cent depressive disorders, 22 per cent manic or bipolar disorders, 18 per cent schizophrenic, 12 per centalcohol or drug abuse, and 15 per cent miscellaneous. A subsample of 41 patients were diagnosed blindly by all three raters(the authors and an additional research psychologist). Paired interrater kappas ranged from .74 (N = 15, p < .001) through.70 (N = 12, p < .001) to .66 (N = 20, p < .001), an acceptable level of reliability.

Data for our normative comparison sample (N = 50) were obtained from the Social Ecology Laboratory, VeteransAdministration, and Stanford University Medical Centers at Palo Alto. Our comparison group was a subsample of 294normal community families drawn randomly from specified census tracts in the San Francisco Bay Area and was part ofnew FES normative data (22).

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Assessment of Family EnvironmentThe Family Environment Scale (FES) assesses family members' perceptions of their family environment along ten

psycho-social dimensions: the relationship domain comprises family cohesion, expressiveness, and conflict; the personalgrowth domain comprises independence, achievement, intellectual/cultural and recreational orientations, andmoral-religious emphasis; the system maintenance domain consists of organization and control. The FES was administeredindependently to both husband and wife. A Family Incongruence Score was obtained by calculating the differences betweenthe scores of each pair of spouses for each subscale and summing the absolute value of these differences. Psychometric testconstruction criteria, validity data, and further descriptive information are presented elsewhere (21, 22, 24).

The FES provides a general perspective of overall family characteristics based on the perception of family membersabout their families. It is not a measure of communication or interaction patterns. There is evidence (22) of a moderate butsignificant correlation between reports of activities engaged in by the family and the active recreational orientationsubscale, between reports of arguments and the conflict sub-scale, and between the reports of attendance at religiousservices and the moral-religious orientation subscale. Nonetheless, the scale is a measure of perception rather thaninteraction. Furthermore, it is clear that the FES, like any other testing instrument, is in part a means by which a personcommunicates with an institution administering it. The measures may reflect efforts by the patient or family member toconvey distress and the need for help or a desire to be left alone.

We obtained additional preliminary construct validity data in this study. Based on results from previous studies (24, 26,28, 30), we selected the five FES subscales of cohesion, expressiveness, conflict, active recreational orientation, andmoral-religious emphasis to be included in our validity study. A research staff member (all were psychologists) visited eachpatient couple in their home soon after the patient was discharged from the hospital to administer the baselinequestionnaires. Using observational data obtained in this 1½-hour home visit, a subsample (N = 42) of the patient coupleswas rated blindly to FES scores on a scale of 1 to 5 on these five FES dimensions by the staff person who had made thehome visit. Correlations between these independent staff ratings and patients' and spouses' mean scores were moderate yetsignificant for four of the five subscales (Spearman rho's between .22 and .53); only the correlation between ratings on theactive recreational orientation sub-scale failed to attain significance (r = .13, p < .12). Separate correlations between staffratings and patients' and spouses' ratings were virtually identical to correlations between staff ratings and partners' meanratings. In other words, raters' perceptions of these five dimensions were equally similar to the perceptions of the patientsand their spouses. These validity data suggest that similar dimensions are being rated by both family members andindependent raters. We did not obtain independent ratings of our normative couples.

Assessment of Patient FunctioningThe Vets Adjustment Scale is a self-rating measure of community adjustment (7, 9, 10). The Vets Global Adjustment

score is the mean of standardized scores on the moderately intercorrelated anxiety/ depression, vigor, alienation, andconfidence in skills subscales. The Personal Adjustment and Role Skills Scale (PARS) measures the patient's communityadjustment as perceived by the spouse (6, 8). The PARS Global Adjustment Score is the mean of standardized scores onthe moderately intercorrelated interpersonal relations, agitation-depression, confusion, and outside social involvementsubscales.

These two Global Adjustment scores measure related facets of community adjustment and symptomatology as seen fromtwo perspectives. Both measures have been found to be significantly correlated with trained staff ratings of patientfunctioning and with one another (10). We averaged each patient's standardized Vets and PARS Global Adjustment Scoresto obtain a single global measure of his functioning, a technique commonly used in psychiatric patient outcome studies. Themedian of the distribution of patients' global scores at each test administration was then used to divide the patient sampleinto high- and low-functioning groups. This dichotomy reflects differences in psychiatric symptoms and relatedinterpersonal and social involvement. Patient adjustment was relatively stable over time (e.g., r = .74 between the globalmeasure at hospital discharge and at one-year follow-up), consistent with Ellsworth's original data (10). The high- andlow-functioning patient samples did not differ significantly in diagnostic composition using chi-square analysis.

Data AnalysisWe compared data from our psychiatric sample at hospital discharge and at three-and twelve-month follow-ups with data

from normative couples. We performed a single stepwise multiple regression analysis for each FES subscale andincongruence score at each time point. In order to ensure that potential differences were not attributable to groupdifferences in demographic characteristics, we included as independent variables: number of children, length of marriage,ethnicity, husband's education, and religion, as well as dummy variables representing assignment either to the normal orpatient groups and to high- and low-patient functioning within the patient sample. Using this analysis, we were able todetermine whether clinical status (i.e., patient vs. normative, high vs. low functioning) accounted for a significant

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proportion of the variance in FES subscale scores after taking demographic variables into account in a single stepwisemultiple regression.

For only those subscales on which high-and low-functioning samples differed significantly, we used post hoc t-tests toexamine each group alone in comparison with the normative sample. Means were adjusted using regression coefficients tocontrol for the effects of relevant demographic differences.

Results

Incongruence in PerceptionsAs predicted, patient couples were significantly more incongruent in their perceptions than normative couples at all three

test administrations (Fig. 1). In addition, low-functioning patient couples were significantly more incongruent in theirperceptions than high-functioning patient couples one year after hospital discharge. Since incongruence in perceptions ischaracteristic of our patient couples, FES data for patients and wives will be presented separately instead of averagingsubscale scores, as has been done in some past studies (24, 30).

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Figure 1.Family Environment Scale (FES) Incongrunce Score

FES Relationship SubscalesOverall, patients' wives reported significantly less cohesion than low-functioning patients at two of the three test

administrations, a finding supported by the trend in their wives' scores (see Fig. 2).

Figure 2.Family Environment Scale (FES) Cohesion Subscale

Likewise, both high-functioning patients and their wives consistently reported significantly more expressiveness thanlow-functioning patient couples (see Fig. 3).

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Figure 3.Family Environment Scale (FES) Expressiveness Subscale

Contrary to our predictions, there were no consistent differences in reported conflict between th e normative sample andthe patient sample or between high- and low-functioning patients or their wives. Patients' wives reported more conflict thannormative wives at hospital discharge only (F(1, 105) = 7.38, p < .01), and high-functioning patients reported significantlyless conflict than low-functioning patients only at one-year follow-up (F(1, 94) = 6.18, p < .05).

FES Personal Growth SubscalesMost striking is the contrast between the high- and low-functioning samples in recreational orientation (see Fig. 4).

High-functioning patients and their wives consistently reported more emphasis on recreation than their more poorlyfunctioning counterparts.

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Figure 4.Family Environment Scale (FES) Recreational Orientation Subscale

Patients also reported more emphasis on a moral-religious orientation than normative husbands at three-month (F(1, 99)= 4.26, p < .05) and one-year (F(1, 94) = 4.76, p < .05) follow-ups, a finding supported by patients' wives at hospitaldischarge only (F(1, 103) = 5.54, p < .05). High-functioning patients reported more moral religious emphasis thanlow-functioning patients at three-month follow-up (F(1, 100) = 5.06, p < .05), and wives of high-functioning patientsreported more religious emphasis than wives of low-functioning patients at hospital discharge (F(1, 102) = 4.96, p < .05).High-functioning patients reported significantly more independence than their more poorly functioning counterparts athospital discharge (F(1, 105) = 8.96, p < .01) and three-month follow-up (F(1, 100) = 4.79, p < .05).

FES System Maintenance SubscalesThe only consistent difference was that wives of high-functioning patients perceived significantly less control (i.e., less

hierarchical organization and rule rigidity) than wives of low-functioning patients at hospital discharge (F(1, 103) = 4.10, p< .05) and one-year follow-up (F(1, 97) = 8.19, p < .01).

Relationships Among FES SubscalesA correlational and principal components and analysis was performed on the baseline family environment measures in

our total sample. Table II provides the Pearsonian correlations for the FES measures, which discriminated consistently

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among the normal and patient samples. The highest relationship was found between cohesion and expressiveness (r = .45).This means that, in our sample, the two scales have an overall shared variance of 20 per cent. The remainder of the scaleshave a common variance ranging between zero and 13 per cent. In the principal components analysis, cohesion andexpressiveness loaded high on the first factor, whereas recreation had a lower loading and incongruence an even lower,negative loading. Independence and intellectual-cultural orientation, which loaded high on this factor, did not discriminatebetween the normal and patient samples. There were moderate and similar loadings of the expressiveness and incongruencemeasures on one other factor (the third), which was essentially a conflict factor. The results of these analyses indicate thatthere was some overlap between the cohesion and expressiveness subscales. On the other hand, the recreational orientationand incongruence measures were absolutely unrelated. Although the cohesion and expressiveness findings, especially,cannot be viewed as entirely independent, the relationships among the measures are modest.

Table 2Intercorrelation Among Significant FES Measures at Baseline. (N = 110)

FES Cohesiveness Expressiveness RecreationalOrientation

Incongruence

Cohesion .45 .35 -.35

Expressiveness .36 -.12

Recreational Orientation 0

Differences From the Norm: High- and Low-Functioning Patient CouplesThe hypothesis that low-functioning patient couples differ more from the norm than their higher-functioning counterparts

was supported. For those subscales on which high- and low-functioning patient couples differed significantly, we comparedadjusted mean scores of both samples to the normative sample, using t-tests. Nineteen pairs of such t-tests were done.Low-functioning patients and their wives differed significantly from the normative sample in the predicted directions in 6 ofthe 19 comparisons; these significant differences were supported by a strong, but non-significant, trend in the predicteddirections in the additional 9 t-tests. In contrast, the high-functioning patient sample tended to vary more unpredictablyaround the norm. Only 5 of the 19 comparisons were in the predicted direction. In general, these data indicate that thelow-functioning patient sample deviated in the expected direction from the norm, whereas the high-functioning patientsample was not notably different from the normative comparison group.

DiscussionAs predicted, patient couples were significantly more incongruent in their perceptions of family environment than

normative couples. This difference was consistent across repeated measures, supporting the interpretation that greaterdiscrepancy in perceptions is characteristic of patient couples and not just an artifact produced by hospitalization and therecent absence of the patient from his family.

In general, there are more differences in perceived family environment between high- and low-functioning patientcouples than between patient couples and normative couples. On those dimensions in which high- and low-functioningpatient couples differed, low-functioning patient couples more frequently deviated from the norm. These data parallelfindings for recovered versus relapsed alcoholics (23, 25, 26).

Low-functioning patients and their wives consistently reported less cohesion than their higher-functioning counterparts.Items on the cohesion subscale measure the extent to which family members are concerned and committed to the family andthe degree to which they are helpful and supportive of each other. Similarly, lower-functioning patients and their wivesreported less expressiveness. Items on this subscale reflect the expression of both positive and negative feelings andmeasure the extent to which family members are encouraged to act openly and to express their feelings directly.

These findings are consistent with a pattern of poor communication in the lower-functioning patient couples. It may bethat family members who are less able to agree on the nature of their family environment are also less likely to agree onperceived problems and their solutions. Interestingly, the discrepancy in perceptions, lack of mutual support, and relativeisolation that characterized the reports of these couples were not accompanied by a report of relatively greater conflict.Items on the conflict subscale reflect the expression of anger through criticism, yelling, throwing things, fighting, andphysical contact. Although we measured perceptions rather than communications, it may be that poorly functioning patientcouples are characterized more by impoverished and inhibited communication than by overt conflict.

Among the personal growth dimensions, differences between high- and low-functioning patients on the recreationsubscale were most striking. Not surprisingly, families with poorly functioning patients reported less emphasis onrecreation. High-functioning patients also reported more independence (family encouragement to be assertive and

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self-sufficient) than their more poorly functioning counterparts.For schizophrenics and depressive neurotics, research has indicated that a high degree of expressed hostility and

criticism by key relatives is predictive of relapse rate (2, 33). In our somewhat different sample of patients with mixedpsychiatric diagnoses, perceptions of positive family contact are related to better patient adjustment. It is unclear, however,whether more family emphasis on cohesion, expressiveness, and recreational activity contribute to better patientfunctioning or whether the presence of relatively better functioning patients permits more positive family contact. We arecurrently investigating the longitudinal relationship between patient functioning and family environment in a larger sampleof psychiatric patients.

Our findings can be seen as congruent with the interesting exploratory work of Laing, Phillipson, and Lee (18). Lainggives an example of a couple taking an intelligence test, in which their joint performance may be worse than eitherindividual score. Less agreement and more misunderstandings may be related to our measure of in-congruence inperception of the shared family environment. We have no data on the certainty with which each member of the couple holdshis perception or the degree to which he believes it to be congruent with that of the other. We simply know that theperceptions of the members of patient couples are less congruent than those of normal couples. From this point of view,there is more room for misunderstanding, but we do not know to what degree the room is filled.

Data from this study provide empirical support for a number of long-held clinical observations regarding the families ofpsychiatric patients. Such family assessment techniques may prove useful in making the assessment of family distress moresystematic. As Jacobson and Margolin (14) have noted, the development of a "collaborative set" is a necessary prerequisiteto effective family intervention. Incongruence in perception of family environment is the converse, a measure of eachindividual's relative isolation. The quantification of this divergence of views within the family should help in the evaluationand treatment of families of psychiatric patients, analogous to the role of psychological testing in individual work. Insummary, families of more poorly functioning patients are separate while together, inhibited from independent expression,and experiencing relatively less enjoyment of the time spent with each other. These couples share littleneither thoughts,feelings, support, nor recreational activities.

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Manuscript received August 1982; Revisions submitted January 1983; Accepted April 1983.

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