152 Stress, Social Supports, and Schizophrenic Disorders: Toward an Interactional Model by Anthony J. Marsella and Karen K. Snyder Abstract The present article proposes an in- teractional model of schizophrenic disorders in which three parame- ters of stressors (e.g. stressor cate- gory, stressor content, stressor de- scriptors) interact with four parameters of social networks! supports (e.g. structure, interac- tional properties, qualitative prop- erties, functional indices) to pro- duce a stress state characterized by positions along three orthogonal dimensions: overload-underload, positive-negative affect, high arousal-low arousal. The stress state, it is speculated, is recipro- cally related to various clinical di- mensions, functional system im- pairments, quantitative response parameters, and qualitative re- sponse parameters which consti- tute the "schizophrenic" disorder. The basic point of the model is that the formative, precipitative, ex- pressive, and maintaining forces of schizophrenic-type disorders are influenced by the simultaneous in- teraction of stressors, supports, and stress states. The medical and behavioral sci- ences are entering an era which of- fers the promise of exciting de- velopments that will affect our un- derstanding and possible control of severe mental disorders. Re- search paradigms increasingly involve models of behavior that emphasize the simultaneous inter- action between organismic and environmental variables. This viewpoint is in contrast to older perspectives that focused on either organismic variables (e.g., person- ality theories, biochemical theories, constitutional theories) or environmental variables (e.g., radical behaviorism) to the exclu- sion of their interactional prop- erties. The new'paradigm has been variously termed an ecological model, an interactional model, and a biosocial model of behavior (see Marsella and Higginbotham 1973; Ekehammar, 1974; Marsella and Higginbotham, in press). Kurt Lewin (1936), one of the pioneers in this area, has stated: In psychology one can begin to describe the whole situation by roughly distinguishing the per- son (P) and the environment (E). Every psychological event de- pends upon the state of the per- son and at the same time on the environment, although their rel- ative importance is different in different cases. . . . Every scien- tific psychology must take into account whole situations, i.e., the state of both person and en- vironment, [p. 12] Others who espoused similar philosophies included Henry Mur- ray (1938), Andreas Angyal (1941), and Egon Brunswik (1957), with their concepts of "need press," the "biosphere," and "probabilistic functionalism," re- spectively. More modern expo- nents of interactional positions in- clude John Dawson (1972), Roger Barker (1968), John Berry (1977), and Endler and Magnusson (1976). Beginning in 1967, a series of studies on interactional theories of psychopathology were carried out in the Philippines (e.g., Mar- sella, Escudero, and Santiago 1969; Marsella, Escudero, and Gordon 1972; Marsella, Escudero, and Brennan 1975), Korea (e.g., Mar- sella and Kim 1974), and Taiwan Reprint requests should be sent to Dr. Marsella at The Queen's Medical Cen- ter, 1301 Punchbowl St., P.O. Box 861, Honolulu, HI 96808.
Transcript
152 Stress, Social Supports,and SchizophrenicDisorders: Toward anInteractional Model
by Anthony J. Marsellaand Karen K. Snyder
Abstract
The present article proposes an in-teractional model of schizophrenicdisorders in which three parame-ters of stressors (e.g. stressor cate-gory, stressor content, stressor de-scriptors) interact with fourparameters of social networks!supports (e.g. structure, interac-tional properties, qualitative prop-erties, functional indices) to pro-duce a stress state characterized bypositions along three orthogonaldimensions: overload-underload,positive-negative affect, higharousal-low arousal. The stressstate, it is speculated, is recipro-cally related to various clinical di-mensions, functional system im-pairments, quantitative responseparameters, and qualitative re-sponse parameters which consti-tute the "schizophrenic" disorder.The basic point of the model is thatthe formative, precipitative, ex-pressive, and maintaining forces ofschizophrenic-type disorders areinfluenced by the simultaneous in-teraction of stressors, supports,and stress states.
The medical and behavioral sci-ences are entering an era which of-fers the promise of exciting de-velopments that will affect our un-derstanding and possible controlof severe mental disorders. Re-search paradigms increasinglyinvolve models of behavior thatemphasize the simultaneous inter-action between organismic andenvironmental variables. Thisviewpoint is in contrast to olderperspectives that focused on eitherorganismic variables (e.g., person-ality theories, biochemicaltheories, constitutional theories) orenvironmental variables (e.g.,radical behaviorism) to the exclu-
sion of their interactional prop-erties.
The new'paradigm has beenvariously termed an ecologicalmodel, an interactional model, anda biosocial model of behavior (seeMarsella and Higginbotham 1973;Ekehammar, 1974; Marsella andHigginbotham, in press).
Kurt Lewin (1936), one of thepioneers in this area, has stated:
In psychology one can begin todescribe the whole situation byroughly distinguishing the per-son (P) and the environment (E).Every psychological event de-pends upon the state of the per-son and at the same time on theenvironment, although their rel-ative importance is different indifferent cases. . . . Every scien-tific psychology must take intoaccount whole situations, i.e.,the state of both person and en-vironment, [p. 12]
Others who espoused similarphilosophies included Henry Mur-ray (1938), Andreas Angyal(1941), and Egon Brunswik (1957),with their concepts of "needpress," the "biosphere," and"probabilistic functionalism," re-spectively. More modern expo-nents of interactional positions in-clude John Dawson (1972), RogerBarker (1968), John Berry (1977),and Endler and Magnusson (1976).
Beginning in 1967, a series ofstudies on interactional theoriesof psychopathology were carriedout in the Philippines (e.g., Mar-sella, Escudero, and Santiago 1969;Marsella, Escudero, and Gordon1972; Marsella, Escudero, andBrennan 1975), Korea (e.g., Mar-sella and Kim 1974), and Taiwan
Reprint requests should be sent to Dr.Marsella at The Queen's Medical Cen-ter, 1301 Punchbowl St., P.O. Box 861,Honolulu, HI 96808.
VOL. 7, NO. 1, 1981 153
Figure 1. Basic components of proposed interactional model of schizophrenic disorders
Stressors Supports
Stress states
Adaptational patterns(normal-abnormal)
(Hwang 1976). These studies werebased on a conceptual frameworkwhich considered patterns ofpsychopathology to be a functionof the interaction of variousstresses and coping strategies. Theforms of psychopathology werethought to be shaped by the in-teraction of stresses associatedwith various functional areas of life(e.g., housing, employment, mar-riage, interpersonal relations, andnutrition) and coping sources(e.g., philosophies of life, crisisbehavior patterns, and social re-sources). Through the use of mul-
tivariate data processing proce-dures such as factor analysis andregression analysis, it was possibleto relate certain patterns ofpsychopathology to the interfacebetween various stresses and cop-ing strategies. Adaptations ofthese ideas have been positedmore recently by Andrews et al.(1978), Cobb (1976), Dean and Lin(1977), Eaton (1978), Johnson andSarason (1979), and Zubin andSpring (1977).
The present article extends someof the previous studies to a moreelaborate model of psychopathol-
ogy with special emphasis onschizophrenic disorders. Figure 1displays the major components ofthe proposed model.
Stress and Stressors
The research literature on stresshas now reached such enormousproportions that any effort to por-tray it in some systematic or or-ganized form may be frustrated. Itsimply subsumes too many con-cepts and too many disciplinaryareas of inquiry. Cofer and Appley
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(1964) recognized this problemyears ago when they stated thatstress had
all but preempted a field pre-viously shared by a number ofconcepts. . . . It is as though,when the word stress came intovogue, each investigator who hadbeen working with a concept hefelt was closely related substitutedthe word stress for it and con-tinued in his same line of investi-gation, [p, 441, p. 449]
The term "stress" came intovogue in the early 1950s with thework of Wolff and his colleagues atthe University of Cornell (Wolff,Wolf, and Hare 1950). The nexttwo decades witnessed an explo-sion of publications on stress.
Our current knowledge aboutstress developed largely from thework of early pioneers in physi-ology and medicine includingCharles Darwin, Claude Bernard,Walter Cannon, Helen FlandersDunbar, Franz Alexander, andHans Selye. Selye's work was ofspecial importance because he pos-ited a universal human response tostressors. This response—termedthe "general adaptationsyndrome"—was considered to beinvariant, regardless of the stressorsthat evoked it. A problem with thisconcept was its inability to accountfor the specific disorders that indi-viduals developed. As a result, itwas necessary to posit two condi-tions for a given disorder: (1) ageneralized response pattern theoryand (2) a specific response patterntheory. Although researchers haveseldom disagreed with Selye's no-tions about the changes that occur inthe "general adaptation syndrome,"they have suggested a number ofdifferent theories to account for thespecific disorders that develop.These theories variously emphasize(1) genetic weaknesses, (2) acquired
vulnerabilities, (3) acquired organ-emotional response patterns, and (4)personality pattern determinants.
In the present article, schizo-phrenic-type disorders may beconsidered "adaptational"disorders—response patterns topsychological and physiologicalstates or conditions of stress.These conditions are elicited byexternal/internal stimulus patternsor stressors. "Stressor" represents"any event/object/process thatelicits a state of change in an or-ganismic system." The particularpattern of schizophrenic disorderthat develops is a function of thestressor/stress interactions. Thispattern is in a continual state ofchange, although the variationsmay be minor. If we are to under-stand the various clinical parame-ters associated with schizophrenic-type disorders (e.g., symptom dis-plays, disability profiles, courses,prognoses), it is necessary first todelineate those parameters of thestressors, stresses, and supportnetworks that may be critical in theproposed model.
Stressor Parameters
Although numerous dimensions ofstress could be explored in an ef-fort to link stress and schizo-phrenia, we will emphasize threeparameters: category, content, anddescriptors.
Stressor Category. Stressor cate-gory refers to the particular lifefunctioning area from which thestressors are emanating. Forexample, stressors might be as-sociated with such specific areas offunctioning as housing, employ-ment, health, marriage, childrearing, recreation, nutrition, andinterpersonal relations. Obviously,
these are not discrete categories,and although one category mayemerge as a major source of stres-sors, it can eventually carry overinto other categories of function-ing. Nevertheless, these categoriesdo provide a beginning point forreferencing the contextual sourceof various stressors. It is certainlypossible that specific categoriesmay be distinctly linked to par-ticular patterns of stressful experi-ence by posing patterns of stres-sors which are unique.
Stressor Content. Stressor contentrefers to the particular type ofstressor that develops in a givencategory—for example, "loss" ofjob, spouse, status, or wealth;other possibilities include "confu-sion" over roles, "conflict" in ex-pectations, "frustration" due toblocked goal seeking, and "dis-crepancies" between certainaspiration-achievement patterns inemployment, housing, and mar-riage. The stressor content essen-tially focuses on the quality of the"demand" characteristics of thestressor. Within this context, stres-sor content can be related to cer-tain response patterns.
At a more general level of analy-sis, stressor content can be clas-sified in the following categories:(1) acculturation stressors, (2) roleconflict stressors, (3) goal-strivingdiscrepancy stressors, (4) valueconflict stressors, (5) life changestressors, (6) role deprivationstressors, (7) noxious stressors(e.g., noise, temperature, toxins),(8) social change stressors, and (9)nutritional deprivation stressors.As these examples indicate, stres-sors can be related to a spectrum ofsituations that involve conflict,deprivation, frustration, and con-fusion.
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Stressor Descriptors. Stressor de-scriptors refer to various parame-ters of stressors which are capableof being measured. As noted pre-viously, the stressor descriptorscan be applied to biological, psy-chological, and sociological levelsof functioning. Some of the moreimportant parameters include
• Frequency— How often doesthe stressor occur?
• Intensity—How much demanddoes the stressor have?
• Duration—How long does thestressor last?
• Shape—Is the stressor spo-radic, continuous, ascending, de-scending, linear, or curvilinear?
• Complexity—Is the stressorcomplex (i.e., additive, multiplica-tive)?
• Discriminability—Is the stres-sor interpretable and/or identifi-able?
• Controllability—Is the stressorcapable of being controlled byeither personal or social re-sponses?
• Familiarity—Is the stressorfamiliar? Has the organism hadprevious experience with the stres-sor?
• Predictability—Is the stressorpredictable or consistent?
• Conflict—Does the stressorhave positive and negative va-lences?
Stress States
Stress states are the organismicexperiential conditions that emergefrom the interaction of stressorsand supports. Stress states are ex-perienced at biological, psycho-logical, and sociological levels offunctioning much as stressors and
supports exist at multiple levels.1 Anumber of stress state dimensionsare important in the proposedmodel.
Stress State Contents. Stress statecontents refers to particular pat-terns of organismic experiencecharacterized by positions on thefollowing three parameters: (1)system overload-system under-load (2) positive-negative, and(3) high arousal-low arousal.These three parameters representbasic functional dimensions ofhuman experience which are rela-tively independent of oneanother and which capture funda-mental poles of human experience.They have particular relevance forschizophrenic disorders becausetheir representational propertiesmay well shape schizophreniformadaptational patterns throughprocesses of conditioning organ-ismic and situational cues. Forexample, a stress state consistingof high overload, negative experi-ence, and high arousal might, de-pending on its parameters of oc-currence, condition a confused,delirious, agitated, and fearful pro-file of schizophrenic functioning.In contrast, patterns of underload,negative experience, and lowarousal might condition a with-drawn, flat, apathetic, hallucina-tory profile. Particular stress states
'Although the major determinants ofthe stress state are the interactionalpatterns between the stressors andsupports, an important role is playedby such moderator variables as age,gender, social class, education, occupa-tion, health status, and so forth. Itshould also be noted that stressors,supports, and stress states exist atbiological, psychological, and sociallevels of functioning.
can be differentiated along theseparameters and eventually linkedwith distinct patterns of schizo-phrenic experience. If particularpatterns are experienced over longperiods of time, they can shapedistinct epistemological orienta-tions (i.e., distinct orientations ofcausality, time, and space). Im-plicit within any affective and cog-nitive state is a sense of causality,time, and space. Thus, if we arehighly aroused, we experience theworld according to a differentcausal pattern. We may see caus-ality as a function of contiguity ofevents (e.g., superstitions) insteadof "logical" relations. Similarly,our concept of time is altered sothat events seem longer or shorterthan they do under differentarousal conditions.
The nervous system codes real-ity according to our experience. Ifwe experience reality at particularlevels of arousal, overload-underload, and positive-negativeaffect, with their distinct epis-temological implications, then par-ticular patterns of reality will be-come the normative experience. Ina previous article, these pointswere considered in the context ofindividuals taking LSD over longperiods of time. Under LSD, real-ity (i.e., causality, time, space) isaltered. But the drug experience isno less real to the nervous systemwhich codes the new reality ex-perience. Thus, even when thedrug is no longer being used, thedrug reality experience mayemerge as a competing reality tothat of the "normal state" (Mar-sella and Price-Williams 1974).
Stress State Parameters. Stressstate parameters refer to variousdescriptors that can be assigned tothe stress state at either a specific
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or general level of functioning.They enable investigators to profilethe stress state experience. Thespecific parameters suggested arethe same as those listed as stressorparameters (i.e., frequency, inten-sity, and shape).
Many investigators have impli-cated stress in schizophrenic dis-orders. What is lacking, however,are conceptual frameworks forlinking various stress parametersto specific aspects of schizophrenicfunctioning, and also empiricalstudies that demonstrate theselinkages in human populations.Although stressor and stress statedimensions that are felt to meritgreater attention in schizophreniaresearch are delineated in thepresent article, these dimensionsby themselves cannot account forvarious aspects of schizophrenicdisorders. A third component isneeded: support systems.
Networks and Social Supports
Definitions. Most people live in acomplex social environment com-posed of various combinations offamily, friends, neighbors, ac-quaintances, and community socialand service organizations. Thetheoretical, conceptual, andmethodological approaches of so-cial scientists to this environmentare numerous and diverse. Oneformulation of the social arena isthe social network. Adams (1967,p. 64) defines the social network as
those persons with whom onemaintains contact and has someform of social bonds.
More recently, Walker, MacBride,and Vachon (1977, p. 35) suggest
the network is the set of per-sonal contacts through whichthe individual maintains his so-cial identity and receives emo-tional support, material aid andservices, information and newsocial contacts. . .[it] may in-clude relatives, friends,neighbors. . . .
As the research on social networksdevelops, we can expect that thedefinitions will reflect the need forspecificity in our conceptualiza-tions, terminology, and opera-tional constructs.
The social network approach hasits roots in social anthropology andsociology. The concept of "socialnetworks" was introduced byBarnes (1954) in his study of aNorwegian community, and Bott(1957) later used social networks inher study of conjugal role per-formance. For a review of the bodyof research that has since been car-ried out in this area, see Mitchell(1974).
Social Networks and MentalHealth
The concept of social networks hasrecently begun to emerge in theliterature related to mental healthand mental disorder. It is a mul-tidisciplinary interest with contri-butions from psychology, an-thropology, sociology, and socialpsychiatry. The direction andinterest of the research can be as-signed to four general areas: Fin-layson (1976), Henerson et al.(1978, 1979), Litwak and Szelenyi(1969), Tolsdorf (1976), Walker,MacBride, and Vachon (1977), andothers have considered the socialnetwork as the location of re-sources and support. Horwitz
(1977, 1978), McKinlay (1973), andSalloway (1973) have investigatedthe relationship between socialnetworks, help-seeking behavior,and utilization of services.Attneave (1976), Rueveni andSpeck (1969), and Speck (1967)have used the social network in atherapeutic approach called "net-work therapy." Beels (1978),Hammer (1963), Hammer,Makiesky-Barrow, and Gutwirth(1978), and Henderson et al. (1978,1979) have contributed to thetheoretical and conceptual aspectsof social networks and psycho-pathology.
There is a large body of literaturethat attempts to establish thatstress and stressful life events areassociated with the onset and inci-dence of psychiatric symptoma-tology. The fact that the over-all strength of the relationship be-tween stress and illness has tendedto be small and unreliable suggeststhat other important variables maybe involved. A number of studieshave pointed to the role of socialfactors, including social supportsand support systems, as mediatorsof stressors, thereby reducing therisk of physical illness or psychiat-ric impairment (e.g., Caplan 1974;Cassel 1974; Cobb 1976; Tolsdorf1976; Dean and Lin 1977; Andrewset al. 1978). These proposedmediators are complex, mul-tidimensional variables that havebeen variously defined:
information leading the subjectto believe that he is cared forand loved, esteemed, and amember of a network of mutualobligations. [Cobb 1976, p. 300]
any action or behavior thatfunctions to assist the focal per-son in meeting his personalgoals or in dealing with the de-
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mands of any particular situa-tion. [Tolsdorf 1976, p. 407]
a complex that provides a bufferagainst adversity, a reservoir forvarieties of help in times ofstress, a source of feedback asto how others see us, and asense of belonging and accept-ance. [Caplan 1974, p. 4-6]
A more systematic formulation isneeded for the fruitful investiga-tion of the cogent dimensions ofthe social environment and theway in which they combine tocreate "social support." We definesupport as any object, event, orprocess that is capable of in-fluencing or mediating a stressoror stress state. A social networkapproach provides the foundationfor delineating and assessing thesupportive capacity of a definedsocial environment.
One of the most extensive effortsto quantify and to assess the socialnetwork has been produced byScott Henderson and his col-leagues at the Social PsychiatryUnit of the Australian NationalUniversity (e.g., Duncan-Jones1978; Henderson et al. 1978).
Social Network Dimensions
The social network model is a sys-tems approach for describing,quantifying, and analyzing thecomplexities of the social milieu. Awide range of dimensions, charac-teristics, and variables have beenproposed to characterize the socialnetwork, but four dimensions,each consisting of several vari-ables, appear most relevant for as-sessing the relationship betweenthe social network, stressors,stress states, and disordered be-havior like schizophrenia.
Structure. The structural dimen-sion would include morphologicalvariables such as size, density, fre-quency of interaction, and positionwithin the network. This dimen-sion provides a variety of measuresthat describe and quantify thestructure of the network.
Interaction. The interactional di-mension consists of variables thatdescribe the relationships betweenthe various network components.For example, reciprocity, sym-metry, directionality, and contentarea are interactional variables.Gluckman (1959) has used theterms uniplex and multiplex to dif-ferentiate between single- andmultistranded (content) linkages.
Qualitative. The qualitative di-mension includes variables de-scribing the affective componentsof the linkages. Some qualitativeaspects could be inferred from thestructural characteristics—intensity, for example, may be de-fined by "frequency of contact."Other qualitative variables need tobe directly assessed. An indi-vidual's perception of the qualityof a relationship (linkage) alongvarious dimensions (such asfriendly-hostile) is vital to the de-velopment of a holistic assessmentof the network.
Functional. The functional dimen-sion delineates those variables thatidentify and describe the linkagesin which an individual serves afunction for another individual.The social network can provide anarray of instrumental and expres-sive functions that are socially andpsychologically important. Thefunctions of interest need to bespecific and clearly defined. For
example, Tolsdorf (1976) suggestedthat one function of an interpersonalrelationship is "feedback," which hedefined as "the provision of evalua-tive statements regarding how theexpectations or requirements of aspecial goal were being met or sur-passed."
Henderson et al. (1977, 1978)suggested that a minimum leveland quality of social interaction isnecessary to maintain a reasonabledegree of affective comfort and tooperate effectively in the face ofadversity; below this level, the riskincreases for the emergence of anumber of psychiatric disorders.
The assessment of the relation-ship of these four dimensions ofthe social network provides the in-formation necessary to determinehow functional the network is inproviding social and psychologicalsupport in the presence of variousstressors. For example, linkagewith a particular array of struc-tural, interactional, and qualitativecharacteristics (high frequency ofinteraction, symmetry, and posi-tive affective quality) might pro-vide a particular kind of support(instrumental support—for exam-ple, the loan of a car) in the pres-ence of a particular stressor(malfunctioning car). This kind ofanalysis can begin to provide anormative context by which toevaluate a network. Research onnormal individuals has shownsome consistency in the size andstructure of their networks (Cubitt1973). Close examination of thedifferences in network dimensionsof various specifically definedpopulations will provide useful in-formation about the role of socialfactors within the behavior/symp-tomatology matrix (e.g., onset,course, and prognosis by fre-quency, intensity, and duration).
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The social network model is anapproach to the social environmentand its supportive capacities.Complicating this approach is thefact that the various dimensions ofthe network are not static. Becausethe network is a dynamic, ongoingsystem, its relationship to stres-sors, stress-states, and behaviorrequires an interactional model.The network influences the defini-tion of an event as a stressor; de-termines to some extent the typesof stressors that are experienced;mediates the stress-state that is in-voked; and is a factor in the be-haviors exhibited. Likewise thenetwork is influenced by the stres-sors, the stress-state, and the be-havior.
Social Networks and Schizo-phrenic Disorders
Research in schizophrenia has ad-dressed the social environmentfrom a number of differentperspectives. One focal area hasbeen the evaluation of outcome ef-fects of various treatments. In gen-eral, comparisons between drugand psychosocial treatments havenot systematically investigated thedimensions of the social treat-ments. A few recent studies (Paul,Tobias, and Holly 1972; Carpenter,McGlashan, and Strauss 1975)suggest that the psychosocialtreatment can have strong effects;but there is a need to be more spe-cific in our descriptions and defini-tions of social variables in order toidentify the necessary componentsof the treatments. The demon-strated effectiveness of phar-macological treatment in reducingsymptomatology, as well as thewidespread belief that the envi-ronment has little effect, has con-
tributed to the limited investiga-tion of social variables. Studiescomparing the differential effectsof various milieus need more dis-crete definitions of the milieu vari-ables. The intensive social treat-ments such as Soteria House havereported good outcomes, oftenwithout medication (e.g., Mosher,Menn, and Matthews 1975;Matthews et al. 1979). Again an as-sessment of the social variableswould identify the cogent aspectsof the treatment.
Network analysis may havesome explanatory power in otherareas of schizophrenia research.Socioeconomic status (Hol-lingshead and Redlich 1958;Dohrenwend and Dohrenwend1969), premorbid factors, espe-cially social isolation (Strauss andCarpenter 1972), and social disin-tegration (Leighton 1959) havebeen identified with an increasedincidence of schizophrenia. Eachone of these factors may involvesome idiosyncratic combination ofnetwork dimensions.
There is only a limited amount ofresearch directly assessing the so-cial networks of schizophrenic pa-tients. Hammer (1963) has re-ported a relationship between theschizophrenic patient's network,the speed of hospitalization, andthe kinds of assistance the patientreceived. Pattison et al. (1975)compared normal, neurotic, andpsychotic groups and found thatthe networks of the psychotic indi-viduals were smaller and more in-terconnected than those of the twoother groups (though the neuroticgroup showed the same tendencyto a less extreme degree). Tolsdorf(1976) observed that schizophrenicpatients had more kinship link-ages, but fewer intimate relation-ships, than nonpsychotic medical
patients. Sokolovsky et al. (1978),in a study of the schizophrenic andnonpsychotic populations of asingle room occupancy hotel,found that larger network size re-duced the likelihood of an ex-patient's being rehospitalized; ex-patients with residual symptomshad smaller, higher density net-works.
The kinds of network variablesassessed in these studies werenetwork size, interconnectedness,type of network members, sym-metry, and number of contentareas of a relationship. Althoughthere were some discrepancies,there was a general tendency forthe networks of schizophrenics tobe smaller, less interconnected,asymmetrical, and uniplex (con-taining only one content area).
In brief, theory and research inschizophrenia have consistentlysuggested a prominent role for socialfactors in shaping and maintainingschizophrenic behavior andmediating the recurrence of symp-tomatology and rehospitalization.
Schizophrenia
Historical Considerations. Thereare few terms in our medical lexi-con that elicit more conceptualconfusion than "schizophrenia."As is well known, the term wasoriginated by Bleuler in 1911 to re-solve problems with the earlierterminology "dementia praecox"advanced by Morel and Kraepelin.But evidence is now mounting thatour rather unconditional accept-ance of the earlier notions aboutschizophrenia may have led usinto errant channels of inquiry andpractice. Clearly, the efforts ofKahlbaum, Kraepelin, and Bleuleroccurred at a time in history when
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medicine was enjoying tremen-dous progress in the identificationof new diseases, many named forthe individual who made the dis-covery.
The Zeitgeist of the time had con-ditioned the idea that various dis-eases had distinct causes, symp-tom profiles, courses, and out-comes. It was natural, within sucha context, for the early pioneers inpsychiatry to assume that concep-tions of psychological disorderwould parallel those of medicaldisorders: distinct causes, orderedpatterns of expression, identifiablecourses and prognoses, and, ofcourse, specific treatments. Suchan assumption was unwarranted!Today our increased sophisticationabout the determinants of humanbehavior, normal and abnormal,requires that we redefine our con-ceptions of schizophrenia to con-form with our growing awarenessof the multivariate natures of thecauses and patterns of mental dis-orders.
The early theorizing about thenature of schizophrenia may nowbe impeding modern conceptualadvances. When all is said anddone, we must acknowledge thatschizophrenia is a "construct"—a term created by scientists to helpexplain or summarize certain typesof behavior. It does not have a real-ity of its own. Rather, its meaningderives from our inclinations to useit in certain ways and not in others.Thus, when we encounter an indi-vidual who is behaving in strangeways (i.e., confused thinking, hal-lucinations, bizarre behavior), weare likely to state that the individualis "schizophrenic" or suffers from"schizophrenia.;'
This type of thinking forces us,mistakenly, to reify a construct.Our problems are amplified when
we forget that we are invoking ourconstruct very carelessly to de-scribe or summarize a multiplicityof behavior patterns that often re-semble one another very little andmost likely have numerous causalfactors operating in countlesscombinations. Multiple causesinteract to produce multiple pat-terns of disordered behavior. Tothis, we should also add that mul-tiple factors operate once the dis-ordered behavior patterns developto shape further the expression,course, and eventual outcome ofthe pattern. In addition, we facethe problem of "equifinality," inwhich different causes have thesame end effect and similar causesmay have different effects.
Dysfunctional Profiles: AnAlternative Strategy
As is well known, diagnostic labelslike paranoid schizophrenia, sim-ple schizophrenia, and hebe-phrenic schizophrenia are of ques-tionable utility clinically and scien-tifically. They are unreliable, andforce us into stereotypic thinking.Increasingly, researchers areturning to other approaches thatemphasize more quantifiablemethods (e.g., process versus reac-tive distinctions, use of Lorr's In-patient Multidimensional Psychiat-ric Scales, Eysenck's multidimen-sional classification schema, andfunctional analyses of behaviorproposed by various behaviortherapists). Clearly, if we are tomake further progress in schizo-phrenia research, it is critical to ar-rive at some method for increasingthe specificity of our observations.The use of broad labels with mini-mal attention to specific symptomparameters can only serve to hin-der our understanding.
What is needed is a system forclassifying behavior that permits amore systematic analysis of thosebehaviors we associate withpsychopathology. We would liketo suggest an alternative strategywhich might prove useful for re-lating adaptive behaviors to thethree components of the model:stressors, supports, and stressstates (see figure 1).
An Alternative ClassificationStrategy. Instead of focusing onsymptoms in general, it might beuseful for researchers and theoriststo profile behaviors that are as-sociated with schizophrenic func-tioning along two dimensions:(1) functional systems and (2) simpleand complex response parameters.2 Al-though human behavior can bedivided into many differentcategories, there are cogent reasonsfor grouping it according to variousfunctional systems of behavior.These include the following: soma-tic, sensory, perceptual, motor, cog-nition, affective, and interpersonaland self. Each of these systems has anumber of functions that it performsat varying degrees of involvementwith the other systems:
• Sensory: information, acquisi-tion, and processing.
• Perceptual: information sort-ing, interpreting, judging.
• Motor: coordination, move-ment.
2 Some of the ideas in this concep-tualization were first called to thesenior author's attention in 1965 dur-ing a graduate course in psychopathol-ogy conducted by Donald Ford andHugh Urban at Penn State University.
Whether we are speaking of nor-mal behavior or abnormal be-havior, these are the systems in-volved. Abnormal behavior differsfrom normal behavior less in thekinds of responses of the differentsystems as in the attributes and thesituations in which the responsesoccur.
Some of the more important re-sponse attributes for studying ab-normal behaviors include the fol-lowing:
• Inconsistency: is the responseinappropriate to the preceding re-sponses?
• Interpenetration: does the re-sponse intrude in a sequence butbelong to another sequence?
• Perseveration: does the re-sponse occur repeatedly?
• Interruption: does a responsesuddenly stop?
• Fragmentation: are responsesrandom and inefficient?
• Incongruence: are responsessplit up?
• Conflict: are two or more re-sponse sequences incompatible?
• Antecedents: is a response in-appropriately related to a stimuluswhich sets it off?
Within this context, researchersand clinicians are able to specifythe "symptoms" in more detail,and a greater understanding oftheir properties results.
A Conceptual Model
The previous sections discussedthe four major components of themodel: stressors, social supports,stress states, and schizophrenia.Each of the first three componentswas discussed with regard to thevarious parameters assumed to berelevant to understanding, de-scribing, and predicting the etiol-ogy, expression, course, and prog-nosis of various dysfunctional pro-files associated with schizo-phreniform disorders.
The purpose of the previous sec-tions was to suggest that schizo-phreniform disorders can be concep-tualized as organismic adaptiveefforts which reflect the complexinteraction of various stressor, socialsupport, and stress state paramet-ers. This approach is closely relatedto newer theoretical and researchstrategies which emphasize interac-tional relationships between differ-ent variables and variable categories.
This article is a first step towardthe development of an interac-tional model of schizophreniformdisorders. It delineates some of thevariables and variable categorieswhich should be considered in
conceptualizing the problem. Table1 provides a listing of these vari-ables.
In the future, it will be necessaryto develop quantifiable indices ofthese variables and to specify or tohypothesize relationships amongthem. Empirical studies will thencomprise the final test of themodel's utility.
One of the major problems con-fronting the interactional theoriesand research strategies is that ofdata analysis. Clearly, multivariatemethods are required because ofthe many variables involved. Inaddition to factor analysis and re-gression analysis, researchers arecurrently exploring the pos-sibilities of applying topologicalmathematical concepts to be-havioral science topics under therubric of "catastrophe theory"(Zeeman 1975).
Each of these methods has itsown distinct advantages and dis-advantages as well as applications.All, however, offer researchersopportunities to examine manyvariables in interaction, and ob-viously, multivariate methodsmore accurately approximate"true" life conditions. One of themost unfortunate aspects of muchof our current research is that itoften fails to examine variableswithin a multivariate context.
There are numerous possibilitiesfor increasing our understandingof schizophreniform disorders byemphasizing interactional ap-proaches. By themselves, stres-sors, stress states, and social sup-ports cannot provide a sufficientanswer to the puzzles of schizo-phreniform disorders. But together,they offer us the chance to raisenew questions about an old prob-lem.
VOL. 7, NO. 1, 1981 161
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Acknowledgment
The preparation of this article wassupported by NIMH GrantNumber 5 R12 MH-31016-02awarded to Dr. Marsella and theQueen's Medical Center, Hon-olulu, Hawaii, for participation inthe WHO/NIMH CollaborativeStudy on the Determinants of theOutcome of Severe Mental Disor-ders.
The Authors
Anthony J. Marsella, Ph.D., is As-sociate Professor, Department ofPsychology, University of Hawaii,Honolulu, HI. Dr. Marsella is alsoDirector, WHO/NIMH Schizo-phrenia Research Project, TheQueen's Medical Center, Hon-olulu. Karen K. Snyder, M.A., isResearch Associate, Department ofPsychology, University of Hawaii,Honolulu, HI.
