Coping With Negative Symptoms of Schizophrenia:
Patient and Family Perspectives
by Kim T. Mueser, David P. Valentiner,
and Julie Agresta
1986; Barrowclough and Tarrier 1992; Mueser et al.
1994a).
Assessments of the strategies that patients and relatives naturally use to cope with symptoms have been an
important source of information for clinicians attempting
to improve coping. Many studies have examined the specific strategies patients use to cope with positive symptoms, such as hallucinations and delusions, and the perceived efficacy of these strategies (e.g., Falloon and
Talbot 1981; Heilbrun et aJ. 1986). Less research has evaluated how patients or relatives cope with the negative
symptoms of schizophrenia, such as anhedonia or problems with attention. However, some work has addressed
coping responses of patients to the "basic symptoms" of
schizophrenia (Baker et al. 1984; Takai et al. 1990; Wiedl
1992), a concept that includes some negative symptoms.
A better understanding of how people cope with negative symptoms could be useful for several reasons.
Negative symptoms tend to be more stable over time than
positive symptoms (Pogue-Geile and Zubin 1988; Mueser
et al. 1991), with positive symptoms present between
episodes in only about 40 percent of patients (Silverstein
and Harrow 1978; Curson et al. 1988). Thus, patients and
their relatives are more often confronted with the problem
of negative symptoms than with positive symptoms. For
example, Raj et al. (1991) found that families reported
similar levels of burden associated with positive and negative symptoms immediately after a symptom exacerbation, but at the followup period after stabilization, greater
burden was associated with negative than with positive
symptoms. In addition, patients report a high level of subjective awareness of impairments related to negative
symptoms (Wiedl 1992).
There is also some evidence that negative symptoms
may result in more burden on relatives than positive
Abstract
An exploratory study was conducted of the strategies
that schizophrenia patients and their relatives employ
to cope with negative symptoms. Coping strategies and
their perceived efficacy were elicited in semistructured
interviews conducted separately with patients and relatives. Coping responses were coded according to the
following dimensions:
behavioral-cognitive,
social-nonsocial, and problem focused-emotion
focused. Overall, the number of coping strategies was
related to perceived coping efficacy for both patients
and relatives, regardless of the type of strategy.
Perceived coping efficacy tended to be highest for apathy; intermediate for alogia, anhedonia, and inattention; and lowest for blunting. Relatives with more
knowledge about schizophrenia used more coping
strategies and reported higher levels of coping efficacy.
Patient rejection by relatives and distress (either
patient or relative) tended to not be related to coping
strategies. The findings suggest that patients and relatives use a wide variety of strategies to cope with negative symptoms of schizophrenia. Future clinical work
and research need to evaluate whether families may
benefit from psychoeducational approaches to teaching them how to better manage negative symptoms.
Schizophrenia Bulletin, 23(2):329-339,1997.
Psychosocial treatment for schizophrenia has evolved in
recent years with the awareness that patients and relatives
do not passively suffer the symptoms of the disorder, but
are often actively involved in coping with it (Hatfield and
Lefley 1987; Mueser and Gingerich 1994). A variety of
individual treatment programs have been developed to
teach patients strategies for coping with their symptoms
(Tarrier et al. 1993). Similarly, several programs have been
developed to help families better cope with a relative who
has schizophrenia (Falloon et al. 1984; Anderson et al.
Reprint requests should be sent to Dr. K.T. Mueser, New
Hampshire-Dartmouth Psychiatric Research Center, Main Bldg., 105
Pleasant St., Concord, NH 03301.
329
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
K.T. Mueseretal.
The patients included 13 males (65%) and 7 females
(35%), with an age range of 23-46. Most patients had
never married (n = 17; 85%) and were living with their
family of origin (n = 16; 80%). Of the remaining patients,
three were currently married and two were living with
their spouse; the remaining two patients were living in
community rehabilitation residences. The relative sample
included 8 males (40%) and 12 females (60%), with ages
ranging from 40 to 74. Among the relatives, 11 (55%)
were mothers, 6 (30%) were fathers, and 3 (15%) were
spouses.
symptoms (Fadden et al. 1987; Oldridge and Hughes
1992), possibly because relatives tend to believe these
symptoms are under the patient's voluntary control
(Hooley et al. 1987). Several surveys have found that negative symptoms, such as the patient's inability to make
productive use of time, are among the most common
problem behaviors faced by relatives (Runions and Prudo
1983; Spaniol 1987). Helping family members develop
better strategies for managing these symptoms might
reduce the overall burden experienced by relatives in close
contact with a schizophrenia patient. Indeed, many relatives express a strong interest in improving their ability to
deal with common problem behaviors (Francell et al.
1988; Mueseretal. 1992).
An important step toward assisting relatives and
patients in developing more effective strategies for coping
with negative symptoms is to assess which strategies they
currently use. The present study had four major aims.
First, we evaluated the relationship among interviewer ratings of negative symptoms, patient self-reports, and ratings by relatives. Second, we explored the strategies
employed by patients and relatives for coping with specific negative symptoms. Third, we examined the relationship between different attributes of the coping strategies
and their perceived efficacy. And fourth, we determined
the relationship between coping strategies and relatives'
and patients' distress, relatives' rejection of the patient,
and relatives' knowledge of schizophrenia.
Measures. Three types of measures were obtained: selfreport, interviews, and specific dimensions of coping.
Self-report. Assessments were conducted of distress, relatives' knowledge of schizophrenia, and relatives'
rejection of the patient. Both patient and relative distress
were measured with the Beck Depression Inventory (BDI;
Beck et al. 1988) and the Spielberger State-Trait Anxiety
Inventory (STAI; Spielberger et al. 1970). The BDI
includes 21 items, each rated on 4-point Likert scales
(range = 0-63), with higher scores indicating more
depression. The STAI includes 20 items, each rated on 4point Likert scales (range = 20-80), with higher scores
indicating more anxiety. These two measures were standardized (Z scores were computed) and summed for each
subject to form a composite measure of distress.
Relatives' knowledge about schizophrenia was
assessed with the Information Questionnaire—Relative
Version (McGill et al. 1983). This questionnaire contains
14 multiple choice items (range = 0-44), with high scores
indicating more accurate knowledge. Relatives' attitudes
toward the patient were assessed with the Patient
Rejection Scale (PRS; Kreisman et al. 1988). The PRS
consists of 24 items, each rated on a 7-point Likert scale
(range = 24-168), with high numbers corresponding to
more rejection of the patient.
Interviews. Interviewer assessments of negative
symptoms were conducted using the SANS. These assessments were available on only 13 of the 20 patients.
To evaluate patients' and relatives' coping responses
to negative symptoms, a semistructured interview based
on the SANS was developed. This interview followed the
structure of the SANS, reviewing each of the global
symptom categories: blunting or affective flattening, alogia, apathy, physical anhedonia, social anhedonia, and
inattention. Physical and social anhedonia were separated
for this interview (and for the SANS ratings provided by
the clinical interviewer) because of the interpersonal
nature of the former.
The interview began with a brief introduction, fol-
Methods
Subjects. The subjects were 20 stabilized patients
receiving outpatient treatment at the Medical College of
Pennsylvania at Eastern Pennsylvania Psychiatric Institute
and 20 relatives (1 "primary" relative for each patient).
All subjects provided informed consent. No patient had
experienced a symptom relapse or hospitalization for at
least 1 year before participation in the study. Two patients
(10%) met DSM-II1-R criteria (American Psychiatric Association 1987) for schizoaffective disorder and 18 patients (90%) had schizophrenia. Diagnoses were established using the Structured Clinical Interview for
DSM-III-R (Spitzer et al. 1990) performed by interviewers who had received training and achieved satisfactory
levels of interrater reliability before the assessment of
study subjects. All patients were assessed as having experienced negative symptoms, either currently or at some
point in their illness, using the Scale for the Assessment
of Negative Symptoms (SANS; Andreasen 1982) administered by trained clinical interviewers (Mueser et al.
19946).
330
Coping With Negative Symptoms
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
lowed by an explanation of the first negative symptom,
which was also described on a card that the subject read.
After discussing the nature of the symptom, the subject
was asked whether he or she had ever experienced
(patients) or observed (relatives) the symptom and then
rated the severity of the symptom over the past week. The
interviewer then asked what, if any, strategies the subject
had used to cope with this symptom. Subjects were
encouraged to identify all coping strategies they had used,
regardless of effectiveness, but in practice ineffective coping strategies were rarely mentioned. The interviewer
wrote down the subject's description of each coping strategy. When the subject could not identify any other coping
strategies for a particular symptom, the interviewer then
asked the subject to rate his or her overall ability to cope
with the symptom on a 5-point Likert scale, with high
numbers corresponding to better coping efficacy. After
recording this rating, the interviewer repeated the procedure with the next symptom, following the same process
until coping strategies had been explored for all six global
negative symptoms. The entire coping interview took
between 15 minutes and 1 hour to complete.
Indices of coping. The three authors independently
rated coping responses from the patient and relative interviews using three frameworks derived from the coping literature (Compas et al. 1988; Dittmann and Schiittler
1990; Takai et al. 1990; van den Bosch et al. 1992). First,
coping responses were categorized as either cognitive or
behavioral. Second, coping responses were rated as either
social or nonsocial. Third, coping responses were rated as
either problem-focused or emotion-focused. Ratings of all
three coping dimensions were reliable (kappa range =
0.62-0.85). For each dimension of coping, the consensus
of the three raters was used to categorize the response.
Several coping indices were constructed for both
patients and relatives. An efficacy index was computed by
averaging the coping efficacy across the six symptoms.
We examined the total number of coping responses generated for the six symptoms. The number of cognitive coping responses, behavioral coping responses, social coping
responses, nonsocial coping responses, problem-focused
coping responses, and emotion-focused coping responses
was also examined. To evaluate whether the type of coping strategy was related to coping efficacy, distress, and so
on, independent of the number of coping behaviors
employed, we computed a cognitive-behavioral index, a
social-nonsocial index, and a problem-emotion index,
based on the rationale of Vitaliano et al. (1987). These
indices were defined as the percent of total coping
responses categorized as cognitive, social, or problem-oriented, respectively, with nonresponders coded as missing.
Results
We first examined the correspondence between the interviewer, patient, and relative ratings of the severity of negative symptoms. Second, we explored the relationship
between the different indices of patient and relative coping. Third, we evaluated the association between specific
symptoms and coping efforts for both patients and relatives. Last, we determined whether patient and relative
coping efforts were related to distress, relatives' knowledge about schizophrenia, and relatives' rejection of the
patient.
Multi-informant Assessment of Negative Symptom
Severity. Correlations among patient and relative ratings of negative symptom severity and interviewer ratings
from the SANS are presented in table 1. The average correlation between the patient and interviewer ratings of the
six symptoms was 0.45. The average correlation between
the patient and relative ratings was 0.17. The average correlation between the relative and interviewer ratings was
0.59. Thus, there was a moderate level of agreement
between the interviewer's ratings of symptom severity and
the ratings of both patients and relatives. However, the
association between patient and relative ratings was fairly
low.
Relationships Among Patient and Relative Coping
Responses. Means, standard deviations, and correlations for patients' coping indices are presented in table 2.
Patients reported an average of 4.6 coping behaviors in
response to negative symptoms. There were substantially
more behavioral responses than cognitive ones, somewhat
Table 1. Correlations among patient, relative,
and interviewer ratings of negative symptoms
Informant pairs
Negative symptom
Blunting
Alogia
Apathy
Physical anhedonia
Social anhedonia
Inattention
'p<0.05.
2
p<0.01.
3
p<0.10.
331
Patient- Relative- RelativeInterviewer patient Interviewer
(n = 20)
(n=13)
(n=13)
0.31
0.39
0.46
0.36
0.792
0.37
0.01
0.15
0.24
0.16
0.383
0.10
0.661
0.702
0.503
0.682
0.722
0.30
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
Table 2.
Means, standard deviations (SDs), and correlations among patients' coping indices
Coping index
1. Total number of coping
responses
2. Cognitive-behavioral index
3. Number of cognitive coping
responses
4. Number of behavioral coping
responses
5. Social-nonsocial index
6. Number of social coping
responses
7. Number of nonsocial coping
responses
8. Problem-emotion index
9. Number of problem-focused
coping responses
10. Number of emotion-focused
coping responses
11. Efficacy index
V<o.oi.
2
3
K.T. Mueser et al.
Mean (SD)
4.6(4.31)
18.0(27.1)
0.8(1.12)
8
1
-0.09
0.751
0.522
0.981 -0.05
0.09
0.49
0.601
0.13
0.502
2.8 (3.08)
0.921
0.671
0.91 1
1.8(1.91)
48.3 (36.2)
0.781
-0.07
2.1 (2.31)
0.791
0.07
2.5 (2.87)
1.7(1.14)
0.871
0.791
0.08
0.12
3.8 (3.55)
59.5 (25.7)
10
0.11
0.03 0.621
0.15 -0.07
0.44
0.751 -0.50 3 0.472
0.30 -0.32 -0.11
0.01
0.701
0.731 -0.01
0.681
0.671
0.561
0.621
0.881
0.761
0.831
0.691
0.621 -0.50 3 0.37
0.661 0.05 0.791 0.532
0.14
0.11
0.52210-
p<0.05.
p<0.1.
emotion indices were not calculated for these individuals.
For the remaining patients, none of these three indices
were significantly correlated with the efficacy index.
Means, standard deviations, and correlations for relatives' coping indices are presented in table 3. Relatives
reported an average of 8.8 coping behaviors in response to
the patient's negative symptoms. There were substantially
more behavioral responses than cognitive ones, more
more social than nonsocial coping responses, and about
the same number of problem-focused as emotion-focused
responses. In general, reports of one type of coping
response were positively correlated with the reports of
other types of coping responses, and the number of each
type of coping response was positively correlated with the
efficacy index. Five subjects reported no coping strategies,
so cognitive-behavioral, social-nonsocial, and problemTable 3.
Means, standard deviations (SDs), and correlations among relatives' coping Indices
Coping Index
1. Total number of coping
responses
2. Cognitive-behavioral index
3. Number of cognitive coping
responses
4. Number of behavioral coping
responses
5. Social-nonsocial index
6. Number of social coping
responses
7. Number of nonsocial coping
responses
8. Problem-emotion index
9. Number of problem-focused
coping responses
10. Number of emotion-focused
coping responses
11. Efficacy index
V<o.oi.
Mean (SD)
8
8.8(4.31)
14.2 (13.5)
0.45
1.5 (1.82)
0.651
7.3 (3.42)
59.1 (18.5)
5.4 (3.50)
3.4 (1.82)
39.3 (16.9)
9
10
0.901
0.921
0.08 0.29
0.51 1 -0.10 -0.28
0.81 1
0.91 1
1.001
0.09
0.29
0.621
0.901 0.991
-0.15 -0.32 - 0 . 6 1 1
3.3 (2.08)
0.651 -0.15
5.5 (3.35)
2.2(1.18)
0.881
0.71 1
0.00
0.671 0.841
0.502 0.552
2
p < 0.05.
332
0.25
0.18
0.821
-0.33 0.24
0.621 0.18 -0.61
0.821
1
0.861 0.82 -0.03
0.671
0.61 1
0.11
0.36
0.661
0.641
0.761
0.81 1 -0.60 1 0.22
0.452 -0.09 0.502 0.61 1
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
Coping With Negative Symptoms
were performed to evaluate differences in coping indices
and symptom type. Except for the number of social coping responses, the other coping indices were related to
symptom type. The total number of coping responses as
well as the behavioral responses was greater for apathy
and inattention than for all other symptoms, and more
were reported for alogia than for blunting. The number of
cognitive coping responses was greater for apathy than for
the other symptoms. The number of nonsocial coping
responses was higher for apathy than for inattention and
higher for both of these symptoms than for the other
symptoms. The number of problem-focused coping
responses was greater for apathy and inattention than for
alogia, and was greater for apathy than for blunting. The
number of emotion-focused coping responses was highest
for apathy, followed by inattention, then alogia, followed
by the others, which did not differ. Last, the efficacy index
was highest for coping with apathy and alogia and lowest
for blunting.
social than nonsocial responses, and more emotionfocused than problem-focused coping responses. The
results of the correlations were similar to those found with
the patients. In general, reports of one type of coping
response were again positively correlated with use of
other types of coping responses. The number of each type
of coping response was again positively correlated with
the efficacy index. Two relatives reported no coping
behaviors, so cognitive-behavioral, social-nonsocial, and
problem-emotion indices were not calculated for these
individuals. The cognitive-behavioral index significantly
correlated with the efficacy index, but not the other
indices. We also explored the relationships between
patient coping indices and relative coping indices. No systematic patterns emerged in those analyses (correlations
not reported here).
Patient Coping as a Function of Symptom Type. The
mean number of each type of patient coping response for
each of the six negative symptoms is presented in table 4.
The cognitive-behavioral index, social-nonsocial index,
and problem-emotion index were not included for the
individual symptoms because some patients had zero coping responses for some symptoms, precluding calculation
of the indices.
Repeated measures analyses of variance (ANOVAs)
were used to examine whether the number of coping
responses differed as a function of symptom type. When
global tests indicated significant differences, paired (-tests
were used to test for differences between each pair of
symptoms. Except for the number of cognitive, behavioral,
social, and emotion-focused coping responses, coping
indices were significantly related to symptom type. The
total number of coping responses was higher for apathy
than for blunting, alogia, and social anhedonia. The number of nonsocial coping responses was also higher for apathy than for all the other symptoms, and higher for alogia
and inattention than for blunting. The number of problemfocused coping responses was higher for inattention than
for blunting, alogia, and social anhedonia, and higher for
apathy than for blunting. Last, patients' efficacy index was
higher for coping with apathy than for other symptoms.
Coping, Patient Rejection, Knowledge of Schizophrenia, and Distress. Correlations were computed to
evaluate the relationships between patient and relative
coping indices and patient rejection, relative's knowledge
of schizophrenia, and patient and relative distress. The
correlations for patient coping indices are included in
table 6 and for relative coping indices in table 7.
In general, patient coping strategies were related to
few other patient or family measures (table 6). There was
a weak tendency for patients who employed more coping
strategies to have relatives who were less rejecting.
Among the relatives' coping indices (table 7), greater
knowledge of schizophrenia was associated with using
more coping strategies of all types. There was no association, however, between relatives' coping and patient rejection or relative distress, and only one correlation was significant between relative coping and patient distress. To
determine whether the educational level of the relatives
mediated the relationship between knowledge about
schizophrenia and coping strategies, we computed correlations between education and these variables. Relatives'
education was not significantly correlated with either
knowledge (r = 0.08) or total number of coping strategies
(r - 0.06). Thus, relatives' educational level does not
appear to account for the association between knowledge
of illness and number of coping behaviors.
Relative Coping as a Function of Symptom Type. The
mean number of each type of relative coping response for
each of the six negative symptoms is presented in table 5.
As with the patients, the cognitive-behavioral index, the
social-nonsocial index, and the problem-emotion index
were not computed for the individual symptoms because
of zero coping responses by some relatives for some
symptoms.
As with patient coping, repeated measures ANOVAs
Discussion
There was a moderate relationship between clinical interviewer ratings of negative symptoms and both patient and
relative ratings, providing some concurrent validity for the
333
Table 4.
Mean number of patient coping responses and coping efficacy as a function of symptom type
!
Number of Symptoms, Mean (SD)
Coping responses
Total
Cognitive
Behavioral
Social
Nonsocial
Problem-focused
Emotion-focused
Efficacy index
1.
Blunting
0.6 (0.9)
0.1 (0.2)
0.6 (0.9)
0.6 (0.8)
0.1 (0.2)
0.2 (0.4)
0.5 (0.8)
1.2(1.6)
2.
Alogla
0.7 (0.9)
0.2 (0.5)
0.9 (0.7)
0.4 (0.6)
0.3 (0.6)
0.3 (0.5)
0.4 (0.8)
1.7(1.9)
4.
Physical
anhedonla
3.
Apathy
1.2(0.9)
0.3 (0.6)
0.9 (0.7)
0.4 (0.6)
0.8 (0.9)
0.5 (0.7)
0.7 (0.7)
2.7(1.7)
0.9(1.3)
0.0 (0.0)
0.9(1.3)
0.8(1.3)
0.2 (0.5)
0.3 (0.6)
0.6(1.1)
1.4(1.8)
5.
Social
anhedonia
0.4 (0.7)
0.1 (0.3)
0.3 (0.6)
0.2 (0.4)
0.2 (0.5)
0.2 (0.4)
0.3 (0.6)
1.3(1.5)
6.
Inattention
0.8
0.1
0.7
0.5
0.3
0.7
0.1
2.1
(0.9)
(0.3)
(0.9)
(0.8)
(0.6)
(0.9)
(0.3)
(1.6)
to
F (df)
Comments
1
2.60 (5,95)
1.86(5,95)
1.93(5,95)
1.59 (5,95)
4.90 (5,95)2
4.02 (5,95)2
2.04 (5,95)
3.27 (5,85)2
3 > 1,2,5
3 > 1,2,4,5,6; 2,6 > 1
6>1,2,5;3>1
o
8
3 > 1,2,4,5,6
Note.—SD - standard deviation.
'p<0.05.
p<0.01.
2
334
Table 5.
Mean number of relative coping responses and coping efficacy as a function of symptom type
Number of Symptoms, Mean (SD)
i
Coping responses
Total
Cognitive
Behavioral
Social
Nonsocial
Problem-focused
Emotion-focused
Efficacy index
1.
Blunting
0.7 (0.9)
0.1 (0.2)
0.6 (0.9)
0.6 (0.9)
0.1 (0.2)
0.3 (0.7)
0.4 (0.6)
1.1(1.4)
2.
Alogia
1.2(1.3)
0.3 (0.6)
0.9(1.1)
0.9(1.1)
0.3 (0.6)
0.3 (0.6)
0.9(1.3)
2.6 (2.0)
3.
Apathy
2.9(1.3)
0.7 (0.7)
2.3(1.3)
1.3(1.2)
1.6(0.8)
0.9 (0.9)
2.1 (0.9)
2.9(1.7)
4.
Physical
anhedonla
0.9(1.0)
0.2 (0.4)
0.7 (0.7)
0.7 (0.7)
0.2 (0.4)
0.6 (0.6)
0.4 (0.7)
1.6(1.7)
5.
Social
anhedonia
6.
Inattention
0.9 (0.8)
0.2 (0.4)
0.7 (0.7)
0.8 (0.7)
0.1 (0.3)
0.6 (0.6)
0.3 (0.6)
1.8(1.7)
2.3(1.4)
0.2 (0.4)
2.2(1.3)
1.2(1.3)
1.2(0.4)
0.8 (0.7)
1.6(0.9)
2.2(1.7)
F (df)
Comments
1
17.84 (5,95)
5.52 (5,95)1
13.04 (5,95)1
1.82 (5,95)
53.04 (5,95)1
2.49 (5,95)2
21.67(5,95) 1
3.89 (5,90)1
3,6>1,2,4,5;2>1
3 > 1,2,4,5,6
3,6 > 1,2,4,5; 2 > 1
3 > 6 > 1,2,4,5
3,6>2;3> 1
3 > 6 > 2 > 1,4,5
2,3>1,4;6>1
Note.—SD - standard deviation.
'p<0.01.
p < 0.05.
2
c
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
Coping With Negative Symptoms
Table 6. Correlations between patients' coping indices and relatives' rejection of the patient and
knowledge of schizophrenia
Coping Indices
Relative
patient
rejection
Total number coping responses
Cognitive-behavioral index
Number of cognitive coping responses
Number of behavioral coping responses
Social-nonsocial index
Number of social coping responses
Number of nonsocial coping responses
Problem-emotion index
Number of problem-focused coping responses
Number of emotion-focused coping responses
Efficacy index
'p<0.05.
2
p<0.10.
0.36
0.04
0.18
0.38
0.35
0.26
0.452
0.36
0.14
0.41 2
0.17
Relative
knowledge of
schizophrenia
Relative
distress
Patient
distress
0.20
0.08
0.11
0.22
0.15
0.25
0.05
-0.20
0.16
0.18
0.531
0.19
0.26
0.06
0.21
0.541
0.33
-0.10
-0.15
0.17
-0.15
0.01
0.05
0.19
0.17
0.01
0.19
0.10
-0.07
0.06
0.08
0.01
0.06
Table 7. Correlations between relatives' coping indices and relatives' rejection of the patient and
knowledge of schizophrenia
Coping Indices
Relative
patient
rejection
Relative
knowledge of
schizophrenia
Relative
distress
Patient
distress
-0.37
-0.24
-0.20
-0.36
0.01
-0.35
-0.20
0.07
-0.30
-0.29
-0.19
0.731
0.27
0.482
0.651
0.35
0.641
0.462
-0.10
0.423
0.651
0.522
0.20
0.06
0.04
0.23
0.33
0.24
0.01
0.15
0.23
0.12
0.31
-0.12
-0.26
-0.32
-0.02
0.09
-0.04
-0.29
0.562
0.34
-0.39
-0.05
Total number coping responses
Cognitive-behavioral index
Number of cognitive coping responses
Number of behavioral coping responses
Social-nonsocial index
Number of social coping responses
Number of nonsocial coping responses
Problem-emotion index
Number of problem-focused coping responses
Number of emotion-focused coping responses
Efficacy index
1
p<0.01.
^ < 0.05.
3
p<0.10.
family ratings. The relatively weak correlations between
patient and relative ratings of negative symptoms suggest
that the perspective of the person coping (i.e., insider vs.
outsider) is critical in determining coping responses. In
this respect, the association between coping strategies and
perceived coping efficacy within patients and within relatives is more important than any comparison of coping
between the different groups of respondents.
A number of other interesting patterns emerged from
the analyses. Examination of the perceived efficacy of
coping with negative symptoms indicated that patients
who employed a greater number of coping strategies,
regardless of the type of strategy used, reported that they
were more able to cope successfully with negative symptoms (table 2). These findings are in line with other studies of coping in schizophrenia, which have found that
number of coping strategies is related to either coping
efficacy or symptom severity for positive symptoms
(Falloon and Talbot 1981) or the subjective "basic disorders" of schizophrenia (B5ker et al. 1984; Takai et al.
1990). A similar pattern of results was found for the relatives: the number of coping strategies used to deal with
the patient's negative symptoms was strongly related to
their perceived coping efficacy (table 3).
Based on these results, we speculate that attempts to
cope with negative symptoms may contribute to feelings
335
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
K.T. Mueser et al.
which strategies to try. Clinicians may help family members learn any of a wide range of strategies for coping
with negative symptoms, such as some of those listed in
table 8.
Different negative symptoms tended to elicit different
coping responses, consistent with other studies of coping
in schizophrenia (BSker et al. 1984; Takai et al. 1990;
of self-efficacy, regardless of whether the types of coping
strategies employed are behavioral or cognitive, social or
not, or problem-focused or emotion-focused. Coping
effort appears to be more critical than the specific type of
strategy used. Patients and relatives often express an interest in improving their ability to cope with symptoms
(Francell et al. 1988; Mueser et al. 1992) but are unsure of
Table 8.
Examples of coping strategies for specific symptoms and coping efficiency
Patient
Symptom
Coping Strategy
Relative
Efficacy
Blunting
Alogia
Apathy
Physical
anhedonia
Social
anhedonia
Inattention
1. Spending more time with others
in order to participate in
conversations
2. Forcing myself to think more clearly
1. Pushing myself to do things, like
attend day program or exercise
2. Setting alarm so I can get up and
do things
1. Making myself get out of the house— 4
taking a walk or going to the mall
2. Making myself read books
5
3. Trying to participate in new activities 5
Coping Strategy
Efficacy
1. Discussing symptom with patient and
other relatives
5
1. Taking a break when a problem is interfering with communication
2. Recognizing it is a symptom of illness
and not the patient's fault
3. Asking patient to repeat what is being
said to check on understanding
4. Being patient—waiting for patient to
answer and, if necessary, coming back to
conversation later
5
1. Accepting it as part of patient's illness
2. Giving positive feedback when patient
does well
3. Getting patient involved in activities
around house, like chores or errands
4. Involving patient in family activities—
not leaving patient alone
5
5
1. Realizing it is part of illness and patient
is doing the best he or she can
2. Trying to engage patient in activities
the patient previously enjoyed
3. Asking patient for help in chores and
inviting the patient to participate in
recreational activities
4. Not putting pressure on patient to do
things he or she does not want to do
1. Making myself get involved with
others
2. Participating in family activities that
require little talking, such as bowling
3. Distracting myself with TV to get
my mind off it
1. Encouraging patient to socialize
2. Pointing out to patient when the patient is
having a good time socializing—the patient
is not always aware, so I let the patient know
when he or she is laughing and talking
3. Trying to get the patient interested in doing
things
4. Letting it be—ignoring symptom
1. Taking extra time to listen carefully
so I can concentrate better
2. Asking people to repeat what they
have just said
3. Watching educational TV programs
and sitting through the entire program
1. Recognizing that it is part of illness
2. Redirecting patient when he or she does
not seem to be paying attention—such as
asking "did you understand?"
3. Using brief sentences and having short
interactions with the patient
336
5
5
5
5
5
5
5
5
4
5
5
5
5
Coping With Negative Symptoms
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
were not statistically significant, but all were in the same
direction. Although these findings are suggestive, more
work is needed on larger samples to determine the relationship between coping with negative symptoms and
patient rejection.
The distress of relatives or patients, as measured by
depression and anxiety questionnaires, was related to
almost no coping indices. Anxiety and depression can be
influenced by many factors, and any contribution of negative symptoms to such distress may be too small to detect
in this limited sample or the sample size may have been
insufficient. It is also possible that a more complex, interactive relationship exists between coping and distress
such that distress motivates coping, which in turn
decreases distress. If this is the case, one would not expect
to find zero-order correlations between distress and coping effort
One question this study did not address was patients'
perceptions of which coping strategies used by their relatives were most helpful. Optimal coping strategies might
enhance the coping efficacy of both the relative and the
patient, other strategies might affect the relative but not
the patient, and some strategies might be experienced as
negative by patients. Evaluating patients' perceptions of
the helpfulness of relatives' coping behaviors could
inform clinicians about which coping strategies are most
important to teach to family members.
Some researchers have proposed a distinction between
"primary" negative symptoms and "secondary" or transient negative symptoms due to factors such as mood,
psychotic symptoms, or medication side effects
(Carpenter et al. 1988). Although all of the patients in this
study were symptomatically stable, we did not attempt to
evaluate whether their negative symptoms were primary
or secondary. Other researchers might consider exploring
whether strategies for coping with negative symptoms differ as a function of their primary versus secondary nature.
For example, it is possible that patients with the deficit
syndrome (enduring, primary negative symptoms) might
experience less distress and attempt fewer coping strategies than patients with secondary negative symptoms. On
the other hand, relatives of patients with the deficit syndrome might experience higher levels of frustration, leading to more coping efforts than relatives of other patients.
This exploratory study provides encouraging findings
regarding how patients and relatives cope with negative
symptoms. The number of coping strategies, rather than
the type of strategy used, appeared to be the most important predictor of coping efficacy for both patients and relatives. Furthermore, patients and relatives reported the
most success and the greatest number of strategies in coping with apathy compared with other negative symptoms.
Wiedl 1992). For patients, apathy was associated with significantly more coping efforts than the other negative
symptoms, as well as better perceived coping efficacy
(table 4). Apathy was most strongly related to the number
of coping strategies patients used that were behavioral,
nonsocial, and problem-focused. These types of strategies
indicate active attempts on the part of patients to overcome this problem, usually by themselves rather than with
the help of others. Patients also reported using a greater
number of problem-focused coping strategies to deal with
inattention than for other symptoms, although their perceived efficacy at managing this symptom was not higher.
A similar pattern between coping and different types
of negative symptoms emerged for the relatives. Relatives
also identified more coping strategies to deal with apathy
than other symptoms and reported moderately high perceived efficacy in dealing with this symptom (table 5).
Like the patients, relatives used more nonsocial and problem-focused strategies to cope with apathy than other
symptoms. An interesting finding was that relatives also
used much more behavioral-focused and emotion-focused
and somewhat more cognitive coping strategies for apathy
than other symptoms, whereas patients did not. Patients
may be more task-oriented in trying to cope with their apathy, whereas relatives employ a wider variety of task- and
nontask-related strategies when coping with this symptom
in an ill family member. Aside from apathy, relatives
tended to use more coping strategies to deal with inattention and alogia than for blunting or physical or social
anhedonia and had higher efficacy indices for these symptoms compared with patients. The results indicate that relatives are often actively involved in trying to cope with
their family member's negative symptoms and perceive
that they are able to cope better with some symptoms than
others.
More knowledge about schizophrenia by relatives was
significantly associated with their using a greater number
of coping strategies. In addition, knowledge was related to
both relative and patient coping efficacy. Furthermore, relatives' educational level was not related to either knowledge or coping behaviors. Thus, relatives who knew more
about schizophrenia felt that they were more able to cope
with negative symptoms, as did their ill family member.
These results raise the possibility that educational programs may help relatives develop more effective strategies
for coping with negative symptoms (Barrowclough and
Tamer 1992; Mueseretal. 1994a).
Both patient and relative coping was weakly related
to relatives' rejection of the patient in a similar manner
(tables 6 and 7). High scores on patient rejection by the
relative were related to fewer coping strategies by the
patient and by the relatives. Most of these correlations
337
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
K.T. Mueser et al.
The results clearly indicate that some relatives and
patients are actively involved in trying to cope with the
negative symptoms of schizophrenia. Such coping efforts
may be especially important as they were related to the
relative's knowledge of the illness and rejection of the
patient. Teaching patients and relatives strategies for coping with negative symptoms may enhance their perceived
efficacy, and perhaps enable them to better achieve goals.
Future work needs to explore the clinical effects of teaching such coping strategies.
burdens: A study of the spouses of depressed patients.
British Journal of Psychiatry, 151:660-667, 1987.
Falloon, I.R.H.; Boyd, J.L.; and McGill, C.W. Family
Care of Schizophrenia. New York, NY: Guilford Press,
1984.
Falloon, I.R.H., and Talbot, R.E. Persistent auditory hallucinations: Coping mechanisms and implications for management. Psychological Medicine, 11:329-339, 1981.
Francell, C.G.; Conn, V.S.; and Gray, D.P. Families' perceptions of burden of care for chronic mentally ill relatives. Hospital and Community Psychiatry, 39:12961300, 1988.
References
Hatfield, A.B., and Lefley, H.P., eds. Families of the
Mentally III: Coping and Adaptation. New York, NY:
Guilford Press, 1987.
American Psychiatric Association. DSM-III-R: Diagnostic and Statistical Manual of Mental Disorders. 3rd
ed., revised. Washington, DC: The Association, 1987.
Heilbrun, A.B.; Diller, R.; Fleming, R.; and Slade, L.
Strategies of disattention and auditory hallucinations in
schizophrenics. Journal of Nervous and Mental Disease,
174:265-273, 1986.
Anderson, CM.; Reiss, D.J.; and Hogarty, G.E. Schizophrenia and the Family. New York, NY: Guilford Press,
1986.
Andreasen, N.C. Negative symptoms in schizophrenia:
Definition and reliability. Archives of General Psychiatry,
39:784-788, 1982.
Hooley, J.M.; Richters, J.E.; Weintraub, S.; and Neale, J.M.
Psychopathology and marital distress: The positive side of
positive symptoms. Journal of Abnormal Psychology,
96:27-33, 1987.
Barrowclough, C , and Tarrier, N. Families of Schizophrenic Patients: Cognitive Behavioural Intervention.
London, England: Chapman & Hall, 1992.
Kreisman, D.; Blumenthal, R.; Borenstein, M.; Woerner,
M.; Kane, J.; Rifkin, A.; and Reardon, G. Family attitudes
and patient social adjustment in a longitudinal study of
outpatient schizophrenics receiving low-dose neuroleptics: The family's view. Psychiatry, 51:3-13, 1988.
Beck, A.T.; Steer, R.A.; and Garbin, M.G. Psychometric
properties of the Beck Depression Inventory: Twenty-five
years of evaluation. Clinical Psychology Review, 8:77100,1988.
Bbker, W.; Brenner, H.D.; Gerstner, G.; Keller, F; Miiller,
J.; and Spichtig, L. Self-healing strategies among schizophrenics: Attempts at compensation for basic disorders.
Acta Psychiatrica Scandinavica, 69:373-378, 1984.
McGill, C.W.; Falloon, I.R.H.; Boyd, J.L.; and WoodSiverio, C. Family educational intervention in the treatment of schizophrenia. Hospital and Community
Psychiatry, 34:934-938, 1983.
Carpenter, W.T., Jr.; Heinrichs, D.W.; and Wagman, A.M.I.
Deficit and nondeficit forms of schizophrenia: The concept.
American Journal of Psychiatry, 145:578-583,1988.
Mueser, K.T; Bellack, A.S.; Wade, J.H.; Sayers, S.L.; and
Rosenthal, C.K. Educational needs assessment of chronic
psychiatric patients and their relatives. British Journal of
Psychiatry, 160:674-680, 1992.
Compas, B.E.; Malcarne, V.L.; and Fondacaro, K.M. Coping with stressful events in older children and young adolescents. Journal of Consulting and Clinical Psychology,
56:405^11, 1988.
Mueser, K.T.; Douglas, M.S.; Bellack, A.S.; and Morrison, R.L. Assessment of enduring deficit and negative
symptom subtypes in schizophrenia. Schizophrenia
Bulletin, 17(4):565-582, 1991.
Curson, D.A.; Patel, M.; Liddle, P.F.; and Barnes, T.R.E.
Psychiatric morbidity of a long stay hospital population
with chronic schizophrenia and implications for future
community care. British Medical Journal, 297:819-822,
1988.
Mueser, K.T., and Gingerich, S.L. Coping With
Schizophrenia: A Guide for Families. Oakland, CA: New
Harbinger Publications, 1994.
Mueser, K.T; Gingerich, S.L.; and Rosenthal, C.K. Educational family therapy for schizophrenia: A new treatment model for clinical service and research. Schizophrenia Research, 13:99-108, 1994a.
Dittmann, J., and Schlittler, R. Disease consciousness and
coping strategies of patients with schizophrenic psychosis.
Acta Psychiatrica Scandinavica, 82:318-322, 1990.
Mueser, K.T; Sayers, S.L.; Schooler, N.R.; Mance, R.M.;
and Haas, G.L. A multi-site investigation of the reliability
Fadden, G.; Bebbington, P.; and Kuipers, L. Caring and its
338
Schizophrenia Bulletin, Vol. 23, No. 2, 1997
Coping With Negative Symptoms
Tamer, N.; Beckett, R.; Harwood, S.; Baker, A.; Yusupoff,
L.; and Ugarteburu, I. A trial of two cognitive behavioral
methods of treating drug-resistant residual psychotic
symptoms in schizophrenic patients: I. Outcome. British
Journal of Psychiatry; 162:524-532, 1993.
van den Bosch, R.J.; van Asma, M.J.O.; Rombouts, R.; and
Louwerens, J.W. Coping style and cognitive dysfunction in
schizophrenic patients. British Journal of Psychiatry,
161(Suppl. 18):123-128, 1992.
of the Scale for the Assessment of Negative Symptoms.
American Journal of Psychiatry, 151:1453-1462, 1994b.
Oldridge, M.L., and Hughes, I.C.T. Psychological wellbeing in families with a member suffering from schizophrenia: An investigation into long-standing problems.
British Journal of Psychiatry, 161:249-251, 1992.
Pogue-Geile, M.F., and Zubin, J. Negative symptomatology and schizophrenia: A conceptual and empirical review.
International Journal of Mental Health, 16:3-45, 1988.
Raj, L.; Kulhara, P.; and Avasti, A. Social burden of positive and negative schizophrenia. International Journal of
Social Psychiatry, 37:242-250, 1991.
Vitaliano, P.P.; Maiuro, R.D.; and Russo, J. Raw versus
relative scores in the assessment of coping strategies.
Journal of Behavioral Medicine, 10:1-18, 1987.
Runions, J., and Prudo, R. Problem behaviours encountered by families living with a schizophrenic member.
Canadian Journal of Psychiatry, 28:382-386, 1983.
Wiedl, K. Assessment of coping with schizophrenia:
Stressors, appraisals, and coping behavior. British Journal
of Psychiatry, 161(Suppl. 18): 114—122, 1992.
Silverstein, M.L., and Harrow, M. First rank symptoms in
the post acute schizophrenic: A follow-up study.
American Journal of Psychiatry, 135:1481-1486, 1978.
Acknowledgment
Spaniol, L. Coping strategies of family caregivers. In:
Hatfield, A.B., and Lefley, H.P., eds. Families of the
Mentally III: Coping and Adaptation. New York, NY:
Guilford Press, 1987. pp. 208-222.
The authors thank the following individuals for their
assistance in completing this study: Ellen Baize, B.A.,
Sylvia Gratz, D.O., and Linda Roth, R.N.
Spielberger, C D . ; Gorsuch, R.L.; and Lushene, R.E.
Manual for the State-Trait Anxiety Inventory (SelfEvaluation Questionnaire). Palo Alto, CA: Consulting
Psychologists Press, 1970.
Spitzer, R.L.; Williams, J.B.W.; Gibbon, M.; and First,
M.B. Structured Clinical Interview for
DSM-III-RPatient Edition. Washington, DC: American Psychiatric
Press, 1990.
The Authors
Kim T. Mueser, Ph.D., is Associate Professor, Departments of Psychiatry and Community and Family Medicine, Dartmouth Medical School, Hanover, NH. David P.
Valentiner, Ph.D., is Assistant Professor, Department of
Psychology, Northern Illinois University, DeKalb, IL.
Julie Agresta, M.S.S., is Research Associate, Department
of Psychiatry, Medical College of Pennsylvania at Eastern
Pennsylvania Psychiatric Institute, Philadelphia, PA.
Takai, A.; Uematsu, M.; Kaiya, H.; Inoue, M.; and Ueki,
H. Coping styles to basic disorders among schizophrenics.
Ada Psychiatrica Scandinavica, 82:289-294, 1990.
339