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Background. Causal, responsibility and blame attributions for positive and negative symptom behaviours were examined in 70 caregivers of persons with schizophrenia.
Methods. The majority of subjects belonged to self-help group organizations. The three types of attributions for positive and negative symptom behaviours were assessed by self-report questionnaires.
Results. The extent of patient responsibility did not differ between the two types behaviours. Intentionality and knowledge were equally important in predicting responsibility for positive symptom behaviours, while intent was the most important predictor of responsibility for negative symptom behaviours with the patient capacity playing a significant but minor role. The entailment model was not supported for the two types of behaviours.
Conclusions. Increased attention should be given to responsibility dimensions in assigning moral accountability to the patient. The entailment model should be further explored in problematical caregiving situations.
Attribution of blame: theory^
An orderly sequence, or entailment process has been proposed to account for the relations among the three types of attributions (Bradbury & Fincham, 1990; Shaver, 1985) such that a blame attribution presupposes a judgement of responsibility which, in turn, rests upon the determination of causality. The first step of this entailment process for the caregiver is to determine the extent to which the patient is seen as the main cause for the occurrence of a behaviour. Following this step, the caregiver determines the patient responsibility, which relies on the sequential evaluation of four dimensions. These are the knowledge of the possible consequences of the behaviour, the intentionality of the behaviour, the presence of coercive factors forcing the patient to behave in such a manner (e.g. command hallucinations, peer pressure), and the patient's capacity to understand the moral wrongfulness of the behaviour, which may be altered by cognitive deficits associated with schizophrenia. The presence of coercive forces and limitations in the patient's capacity are likely to decrease judgements of responsibility for the behaviour.
Once held responsible, the process of assigning blame occurs. Central to the assignment of blame is the evaluation of excuses to account for the behaviour. Resulting from a negotiation between the caregiver and the patient, blame is moderated or not assigned at all when the caregiver partially or totally accepts the patient's excuses. Blame judgements are unaffected where the caregiver refuses the patient's excuses.
Attribution of blame: evidence^
Social psychological research shows that people make causal, responsibility and blame attributions according to the entailment model outlined above when they judge the acts of hypothetical others (Fincham & Shultz, 1981; Shultz & Schleifer, 1983; Fincham & Roberts 1985). But caregivers are not making attributions about a hypothetical person and so it behoves us to examine a body of research on attributions in relationships (see Bradbury & Fincham, 1990; Fincham, 1998), a domain more relevant to the relationship between caregiver and patient.
Lussier and his colleagues (1993) found strong evidence to support the entailment model among 206 cohabiting couples when they made judgements about relationship conflict. In contrast, when Fincham & Bradbury (1987) tested a slightly modified entailment model in which casuality, responsibility criteria (i.e. volition, motivation and intentionality) and capacities (knowledge, foreseeability and skill) determine responsibility, which, in turn, determine partner blame for conflict, they found mixed evidence for their model. In addition, Fincham & Bradbury (1992) argued that the distinction between responsibility and blame was tenuous. Further work therefore appears warranted to clarify the status of the entailment model in the context of attributions made in relationships such as those represented in the caregiving context, particularly when it comes to positive and negative symptom behaviours.
Attributions for positive and negative symptom behaviours^
Most attribution research for symptom behaviours has been done in relation to the concept of expressed emotions or negative family attitudes, such as emotional over-involvement, hostile and critical comments. Attributions for patient behaviour are thought to give rise to expressed emotion (Greenley, 1986; Weisman et al. 1993; Barrowclough et al. 1994). There is some evidence to suggest that relatives who consider the causes of problem behaviours to be personal to the patient and controllable by him or her tend to be more critical and/or hostile toward the patient (Brewin et al. 1991; Weisman et al. 1993; Barrowclough et al. 1994).
Caregivers of persons with schizophrenia are confronted by a variety of behaviours (Provencher et al. 2000a) and considerable attention has been given to the cognitive appraisals and the care-giving consequences of positive and negative symptom behaviours. Positive symptom behaviours correspond to an exaggeration in function (e.g. delusions or hallucinations) whereas negative symptom behaviours refer to deficits in function (e.g. lack of conversation or energy) (Andreasen & Olsen, 1982). Some authors (Hooley et al. 1987; Lopez & Wolkenstein, 1990) have proposed that caregivers may perceive negative symptom behaviours as more volitional and less illness related than positive symptom behaviours. Based on the responses of undergraduate students to hypothetical situations, Weisman & Lopez (1997) found that negative symptom behaviours were perceived as more controllable than positive ones. For causal dimensions other than controllability, Barrowclough et al. (1994) reported that the causes of positive symptoms were seen as more idiosyncratic to the patient (personal) than those given for apathy and avolition (e.g. negative symptom behaviours). Brewin et al. (1991) did not find any significant difference in the perception of the cause as internal to the patient for positive and negative symptoms. Finally, Provencher & Mueser (1997) reported that, as responsibility decreased for negative symptom behaviours, the adverse effects on the caregivers (e.g. restriction on social life, physical and emotional problems) increased as well, possibly reflecting the caregiver's over-emphasis on the sick role (Parsons, 1951).
Research on attributions for positive and negative symptom behaviours is, however, quite limited. First, there has been no attempt to examine different types of attributions. This is important because attributions differ in how proximal they are to behaviour with blame attributions being most closely related to behavioural responses (Fincham & O'Leary, 1983). Secondly, no attention has been given to whether the dimensions underlying attributions, such as the patient's perceived knowledge, appreciation of the wrongfulness of the behaviour, intentionality and the presence of coercive forces, predict attributions equally well for positive and negative symptom behaviours. This is important as different dimensions may determine a caregiver's responsibility judgements and knowing the dimensions that affect attributions is important for developing effective interventions. Finally, the relations among attributions have not been examined for positive and negative symptom behaviours.
The present study therefore attempts to expand the investigation of attributions in caregiving relationships by eliciting attributions of responsibility and blame in addition to attribution of causality for positive and negative symptom behaviours. It also explores the relationships among the three types of attributions. This additional information has the potential to provide a better understanding of behavioural and affective responses to patients and possibly also of decisions involved in the management of the illness (Kanter, 1984; Lefley, 1987; Dixon & Lehman, 1995). The present study thus examines attributions of causality, responsibility and blame for positive and negative symptom behaviours among primary caregivers of persons with schizophrenia and tests three hypotheses.
Hypotheses^
The first and second hypotheses addressed the roles of responsibility dimensions in attributing responsibility to the patient. The third hypothesis concerned the applicability of the entailment model in the management of symptom behaviours.
1 Responsibility attributed to the patient for both positive and negative symptom behaviours will be positively related to the perceived intentionality in producing the behaviour, knowledge of its consequences, and the capacity to appreciate its wrongfulness. In contrast, the presence of coercive factors producing the behaviour will be negatively related to responsibility. This is based on the proposed linkages between responsibility dimensions and responsibility attribution (Shaver, 1985).
2 The process of attributing responsibility to the patient will differ for positive and negative symptom behaviours. This is based on the theoretical assumption that negative symptom behaviours are perceived as more volitional than positive ones (Hooley et al. 1987; Lopez & Wolkeinstein, 1990). Specifically: (a) more responsibility will be attributed for negative than positive symptom behaviours; and (b) intentionality will be the most important predictor of responsibility for negative symptom behaviours, but not positive ones.
3 Responsibility attributions will mediate causal and blame attributions for positive and negative symptom behaviours. This is based on the proposition that blame presupposes responsibility, which in turn relies on causality (Shaver, 1985).
METHOD^
Sample^
Seventy primary caregivers participated in the study (Provencher & Mueser, 1997). Fifty-seven caregivers were recruited from self-help groups, and 13 were referred by the patients' private therapists. The vast majority of caregivers were parents (90%) and female (81%). Their ages ranged from 34 to 76 with a mean age of 59. Thirty-four per cent had an annual family income of $50 000 or more. The amount of time spent with the ill relative on a weekly basis was mostly distributed among two groups. Forty-one per cent of primary caregivers spent <= 10 hours and 38% spent >= 26 hours. Almost all (93%) the caregivers were members of self-help groups. Almost three-quarters (74%) of caregivers had participated in psychoeducational programmes. Out of 45 caregivers, more than half (56%) had participated in more than 10 educational sessions.
Approximately three-quarters of the ill relatives (74%) were male, between 20 and 39 years of age (79%). Most were single (86%) and unemployed (83%). Almost one-quarter (24%) completed high school and over 60% had at least some college education. Over three-fifths of them (66%) lived with the primary caregiver. About three-quarters (74%) had a diagnosis of schizophrenia, the remainder had a diagnosis of schizo-affective disorders. The majority had been ill for more than 5 years (71%). The average number of previous psychiatric hospitalizations was five. Over three-quarters of the ill relatives (76%) were totally compliant with their medication. Most of the ill relatives (69%) did not participate in social or vocational programmes.
Instrument^
The Attribution Scale for Symptom Behaviors (ASSB) was a self-report measure evaluating the level of causal, responsibility, and blame attributions for eight positive and eight negative symptom behaviours. The ASSB was adapted from a previous instrument measuring the process of attributing blame among battered women (Drown, 1986), which was also based on Shaver's theory. The positive symptom behaviours were: obsessive behaviour, odd ideas, overactivity, rudeness, violence, harming self, odd behaviour and offensive behaviour. The negative symptom behaviours were: withdrawal, slowness, forgetfulness, underactivity, self-neglect, overdependence, indecisiveness and complaints about bodily aches and pains (Provencher & Mueser, 1997).
When a symptom behaviour was perceived as present by the caregiver, nine questions were asked. The first question assessed the level of causality assigned to the patient for the occurrence of the behaviour: 'how much do you think your relative caused_(the behaviour)'. Then, the responsibility dimensions were measured. Knowledge was assessed by 'how much do you think your relative knew that_(the behaviour) would happen?'. Intentionality was measured by 'how much do you think your relative intended (meant to bring about)_(the behaviour)?'. The presence of coercive forces was evaluated by 'how much do you think your relative was moved by overwhelming forces inside or outside of himself or herself to_(the behaviour)?'. The patient's capacities in knowing right from wrong in actions were measured by 'how much do you think your relative thought that it was wrong to_(the behaviour)?'. Then, a question was asked to determine responsibility (e.g. 'how much do you think your relative was morally responsible for_(the behaviour) to occur?'). Finally, attribution of blame was evaluated by the following question: 'how much do you think your relative is to blame for _(the behaviour)?'. Each question was rated on a 7-point Likert scale (1 = not at all, 7 = 'totally'). As the number of perceived behaviours varied from one caregiver to another, an individual mean score was computed for the attributions of causality, responsibility, and blame attributions for positive and negative symptom behaviours and their related dimensions. Test-retest reliability was obtained over a 7 to 10 day period. Across 15 caregivers, the percentage of agreement for positive and negative (in parentheses) symptom behaviours was 73% (67%) for causality, 67% (67%) for responsibility, and 67% (60%) for blame.
The ASSB was completed by most of caregivers at their residences, and in the presence of a research assistant. Eleven caregivers chose to complete the ASSB in a more convenient setting for them, such a friend's home or a library.
RESULTS^
Prior to testing any hypotheses, we examined whether the perceived severity of symptom behaviours, as measured by the Behavioral Disturbance Scale (Provencher & Mueser, 1997), was related to attributions. No significant correlation was found between the severity of positive and negative symptom behaviours and causality, responsibility and blame attributions (r (48) = -0.29, -0.17 and -0.03, respectively for positive symptom behaviours; r = -0.07, -0.13 and -0.15, respectively for negative symptom behaviours). Finally, it should be noted that the studied caregivers reported mild positive and negative symptom behaviours and moderate levels of burden (Provencher & Mueser, 1997).
Hypothesis 1^
Table 1 shows the means, standard deviations, and zero order correlations for the variables measured in this study. As predicted, it can be seen that patient knowledge and intentionality were strongly and positively related to attributed responsibility. Also, as predicted, perceived capacity to appreciate the wrongfulness of the behaviour was related to responsibility, but only for negative symptom behaviours. Finally, the presence of coercive forces was negatively related to responsibility but only attained significance for positive symptom behaviours. With the noted exceptions, strong support was obtained for the first hypothesis.
Hypothesis 2^
The first part of hypothesis two specified that patients will be held more accountable for negative symptom behaviours. This element of the hypothesis was examined using t tests. No differences were found in the level of responsibility assigned for the two types of behaviours. In fact, none of the measures used in the study yielded differences in response levels for the two types of behaviour. In addition, following Fisher's r to z transformations, comparison of correlations showed that the relation between intent and responsibility did not differ between positive and negative symptom behaviours, although the association knowledge-responsibility was significantly greater for the former category of behaviours, z = 2.52, P < 0.01.
These above null findings make the support found for the second part of the hypothesis intriguing. It was hypothesized that intentionality would be the most important predictor of responsibility for negative symptom behaviours. This was tested by conducting a regression analysis in which responsibility attributions were predicted from the responsibility dimensions of knowledge, intentionality, coercion and capacity. These predictors accounted for 43% of the variance in responsibility attribution, F (4,57) = 10.93, P < 0.001, with intent, [beta] = 0.50, t = 3.92, P < 0.001 and capacity, [beta] = 0.26, t = 2.42, P < 0.05, emerging as significant predictors. To examine whether perceived intentionality was a more important predictor of responsibility than capacity, LISREL 8.3 was used to constrain the beta weights for the two predictors to be equal. This resulted in a model that did not provide a good fit to the data, [chi]2 (1) = 3.71, P < 0.06, confirming that intentionality is the most important dimension in determining responsibility attributions for negative symptom behaviours.
A similar regression analysis was conducted for positive symptom behaviours. The four responsibility dimensions accounted for 67% of the variance in responsibility attributions, F (4, 44) = 21.98, P < 0.001. Knowledge, [beta] = 0.55, t = 4.22, P < 0.001, and intent, [beta] = 0.31, t = 2.62, P = 0.01, significantly predicted responsibility attributions. Using LISREL to constrain the beta weights to be equal showed that they did not differ from each other as this model provided a fit to the data, [chi]2 (1) = 1.26, P > 0.10.
These findings show that responsibility attribution processes differ for positive and negative symptom behaviours. Consequently, we examined whether causal attributions mediated the relation between responsibility dimensions and responsibility judgements. To do this, we tested a model in which responsibility dimensions predicted causal attribution which, in turn, predicted responsibility attribution. For both positive and negative symptom behaviours, this model did not fit the data. For negative symptom behaviours, it was necessary to include direct paths from intentionality and capacity to responsibility to obtain a satisfactory model fit, [chi]2 (2) = 0.55, P > 0.10. In contrast, including a direct path between knowledge and responsibility attributions provided a satisfactory model fit, [chi]2(3) = 5.07, P > 0.05, for positive symptom behaviours. These results again emphasize that different dimensions underly responsibility attributions for positive and negative symptom behaviours.
Hypothesis 3^
In light of differing findings for positive and negative symptom behaviours we examined whether the relations among causal, responsibility and blame attributions were comparable across positive and negative symptom behaviours before examining the third hypothesis. Based on two-tailed tests, the associations causality-responsibility (z = 2.43, P < 0.05) and responsibility-blame (z = 2.59, P < 0.05) were significantly larger for positive than negative symptom behaviours. These significant differences provide some evidence to support the importance of responsibility in differentiating the process of blame attribution for positive and negative symptom behaviours.
Positive symptom behaviours^
To demonstrate that responsibility mediates the relation between causal attributions and blame, three tests have to be met (Baron & Kenny, 1986). First, there needs to be a significant relation between cause and blame. Secondly, the relation between responsibility and blame needs to be significant. Thirdly, the relation between cause and blame needs to be significantly reduced or become non-significant when responsibility is partialled out of the relationship between causality and blame. From Table 1 it is clear that the first two tests were met. However, causal attributions remained a significant predictor, [beta] = 0.45, t = 4.36, P < 0.001, when responsibility attributions, [beta] = 0.50, t = 4.86, P < 0.001, were entered with them into a regression equation to predict blame. Together, causal and responsibility attributions accounted for 78% of the variance in blame, F (2,46) = 82.46, P < 0.001, with both accounting for unique, and not significantly differing, amounts of variance. Thus, the entailment model was not supported.
Negative symptom behaviours^
Similar results were obtained when testing the entailment model for attributions regarding negative symptom behaviors. Table 1 shows that the correlations between causal and blame attributions and between responsibility and blame attributions are significant. Although the first two criteria for mediation were fulfilled, the third was not. When responsibility and causality attributions was entered into a regression equation predicting blame, they accounted for 60% of the variance in blame judgements, F (2,59) = 44.04, P < 0.001. Again, with both cause, [beta] = 0.56, t = 6.07, P < 0.001, and responsibility attributions, [beta] = 0.34, t = 3.72, P < 0.001, accounted for unique, and not significantly different, amounts of variance.
DISCUSSION^
Underlying dimensions of responsibility^
As predicted, the direction and significance of the relations between responsibility dimensions and responsibility attributions were consistent with those outlined by Shaver (1985). For both positive and negative symptom behaviours, as caregivers perceived that the patient had more knowledge about the occurrence of the behaviour and more intention to produce the behaviour, attributed responsibility increased. The reason for the non-significant relationship between patient capacity and responsibility for positive symptom behaviours remains unclear. Coercion was not related to responsibility for negative symptom behaviours. Considering that this type of behaviour entails omission (e.g. deficits in function), the caregivers may have been reluctant to believe that the patients were forced to withdraw, to be underactive, to do things slowly and so on. These results are further discussed below.
Process of responsibility attribution^
Contrary to the first part of hypothesis 2, the degree of responsibility attributed to the patient did not differ for positive and negative symptom behaviours. These results contrast with previous theoretical assumptions (Hooley et al. 1987; Lopez & Wolkenstein, 1990).
In spite of no differences in intentionality and responsibility across positive and negative symptom behaviours, some interesting findings emerged regarding differences in the relations among the variables for the two types of behaviours. For positive symptom behaviours, knowledge and intent were significant predictors of responsibility, but neither one was more important in ascribing responsibility to the patient. In addition, intent was found to have only an indirect effect on responsibility. The secondary role of intent in positive symptom behaviours is not surprising when considering the salience of these behaviours in terms of abnormal illness experiences (e.g. odd ideas, odd behaviours) (Runions & Prudo, 1983). The role of the knowledge dimension may reflect the need to prevent the occurrence of such behaviours, given their potential for generating crisis situations (e.g. patient hospitalizations) (Mueser & Gingerich, 1994). For negative symptom behaviours, caregivers mainly based their responsibility judgement on the volitional nature of these behaviours, although they also considered the patient's capacity to know the wrongfulness of the behaviour. This finding is congruent with the central role of intent in the attribution of responsibility (Shaver, 1985). The fact that the caregivers also paid attention to the patient's capacity indicates that they made their responsibility judgement in a context-specific environment (Kanter, 1984, 1985).
In summary, specific patterns of responsibility dimensions emerged for positive and negative symptom behaviours. However, intent did not play the expected role in differentiating the two types of behaviour. To understand these findings further, we need to broaden our analysis to contextual factors that might have influenced the caregivers' attributions, such as their expectations about patient conduct and their views about the patient's role in the recovery (Lefley, 1997).
Schlenker et al. (1994) have proposed that 'people are held responsible to the extent that: (a) a clear, well-defined set of prescriptions is applicable to an event (prescription-event link); (b) the actor is perceived to be bound by the prescriptions by virtue of his or her identity (prescription-identity); and (c) the actor is connected to the event, especially by virtue of appearing to have personal control over it (identity-event)' (Schlenker et al. 1994, p. 640). As applied to the current study, 'identity-event' corresponds to the attributions for positive and negative symptoms; 'prescription-event' to the specific and clear goals related to the management of the two types of behaviours; and 'prescription-identity' to the obligation or duty of a person having schizophrenia. Based on these theoretical considerations, some explanations are now offered for the specific responsibility dimensions obtained for positive and negative symptom behaviours.
Positive symptom behaviours^
Related to the prescription-event link, caregivers may have clearly identified the use of neuroleptic medication as a valuable aid in preventing the occurrence of this type of behaviour. Concerning the identity prescription link, caregivers may have held strong convictions about the patient's duty to control positive symptom behaviours in taking the prescribed medications and recognizing signs of relapse. The category of positive symptom behaviours was here broadly defined, and included some anti-social behaviours (e.g. offensive behaviour, rudeness and violence). In spite of the heterogeneity of positive symptom behaviours, the strategies used to control typical positive symptom behaviours (e.g. odd ideas) may have been also applied for the prevention of antisocial behaviours, such as the use of neuroleptic medications in preventing agitation (prescription-event link), and the patient's duty to comply to medication and to monitor early signs of violence (prescription-identity link). Considering that the majority of the studied caregivers had participated in several educational sessions, they may have been sensitized to the importance of preventing as much as possible the occurrence of positive symptom behaviours (Birchwood & Tarrier, 1992; Mueser & Gingerich, 1994). This may partly explain the special attention that the caregivers gave to the dimension of knowledge when ascribing responsibility to the patient.
Secondly, the role of intentionality in predicting responsibility for positive symptom behaviours may seem counterintuitive as these behaviours are not assumed to be volitional. However, this finding may reflect the presence of antisocial behaviours in the category of positive symptom behaviours. These anti-social behaviours have a very disruptive impact on the family (Estroff et al. 1994; Lefley, 1996; Hyde, 1997) and sanctions are part of the management strategies applied to this type of behaviour (Mueser & Gingerich, 1994). The attention given to intentionality possibly means that the caregivers thought that the patient could change these behaviours in working more on his temperament, and then to conform to expected rules (prescription-identity link). Attributed responsibility may then be viewed as an attempt to regulate those patient behaviours (Kanter, 1985). The fact that intention was not the most important predictor of responsibility for this type of behaviour may indicate that the patient's character was not the single and sufficient cause of anti-social behaviours. Other causes may have been perceived to be relevant (e.g. biological vulnerability to stress).
Negative symptom behaviours^
Given that the vast majority of caregivers belonged to self-help groups and had received considerable training in the management of the illness, they were likely to be aware of the importance of delineating clear and specific goals for negative symptom behaviours (prescription-event link) and of making realistic and simple requests on the patient for controlling this type of behaviour (prescription-identity link). The perceived intentionality of these behaviors led the caregivers to attribute some responsibility to the patient, possibly as a means of discouraging him (her) to behave like this, and as a call for change in order to fulfil his (her) duties (prescription-identity link). The recognition of the patient capacity as a responsibility dimension may indicate that the caregivers viewed the negative symptom behaviours as partly illness-related, as stressed in psychoeducation. The delineation of the altered capacity due to the illness was then an important issue for the caregivers because of its potential impact on the extent of duties to be expected from the patient (prescription-event link) and its mitigating effect on the degree of moral responsibility to be attributed to the patient (identity-event link) (Kanter, 1984).
Finally, the lack of differences in the association intent-responsibility and in the levels of responsibility across the two types of behaviour may have been masked by the presence of anti-social behaviours in the category of positive symptom behaviours. Offensive behaviour and rudeness received the highest levels of responsibility among positive symptom behaviours thus likely to inflate the means of this category of behaviours.
Causality, responsibility and blame attributions: the entailment process^
No evidence was obtained to support the entailment process: responsibility did not solely explain the variance in blame, causality also did. In regard to positive symptom behaviours, the secondary role of intent in assigning moral responsibility may partly explain why responsibility attribution did not mediate the relation between causal and blame attributions. Given that these behaviours were not perceived as mainly intentional, restricted caregivers may have been reluctant to sanction their occurrence through the assignment of blame (event-identity link) because the patients apparently fulfilled their obligations in controlling these behaviours. The majority of them were compliant to medication (prescription-identity link). The unique contribution of causality in explaining blame may indicate that the caregivers strongly believed that these behaviours were mainly illness-related and unlikely to be blameworthy. From these findings, it can be inferred that when the illness is perceived as the main cause for positive symptom behaviours, the patient is relegated to a peripheral role for which the process of blame attribution is less suitable. In contrast to the present study, moral accountability and blame for this type of behaviour may be more at issue for the caregivers of patients non-compliant to treatment (Bebbington, 1995; Weiden et al. 1995; Smith et al. 1997) or with co-occurring substance use disorder (Mueser et al. 1998; Drake et al. 1999).
In the case of negative symptom behaviours, we mentioned above that the caregivers may have perceived these behaviours to be partly illness-related. As suggested for positive symptom behaviours, the entailment model may be less applicable in situations in which biological processes play a major role. For negative symptom behaviours, the caregivers may have perceived that it was illogical to assign blame to someone who was remotely involved in the occurrence of these behaviours and had altered capacity. In contrast to the studied caregivers, critical and/or hostile caregivers behaviours (Brewin et al. 1991; Barrowclough et al. 1994) may be more likely to assign blame to the patient for negative symptom behaviours. Additional work on the entailment model should also be examined in caregivers not benefiting from family interventions (Penn & Mueser, 1996) and through the stages of family responses to mental illness (Terkelson, 1987).
Implications for practice^
The studied caregivers apparently benefited from educational sessions about the illness and its management. They were reluctant to engage themselves in the process of assigning blame for symptom behaviours, as strongly advised in psychoeducational programmes (Barrowclough & Tarrier, 1992; Birchwood & Tarrier, 1992; Mueser & Gingerich, 1994). The knowledge acquired about the illness and the social exchanges with other self-help group members (Medvene & Krauss, 1989) may have helped them to reframe the two types of behaviours in terms of illness manifestations. However, the reframing of cognitions is a demanding task that goes beyond the acquisition of factual information (Barrowclough et al. 1987). Beliefs about normality, mind-body relationship, and sense of mastery in illness situations are likely to influence the attributions for symptom behaviours and deserve more clinical attention (Rolland, 1998). Cognitive-behavioral interventions for caregivers should be available on a long-term basis in order to sustain benefits (Bellack & Mueser, 1993). Finally, clinicians should pursue their efforts in encouraging caregivers to join self-help groups.
An important clinical task is to assist the caregivers to set appropriate limits on patient behaviours. The selection of management strategies is likely to be influenced by the moral accountability assigned to the patient. In the present study, patient responsibility was interpreted differently for positive and negative symptom behaviours. The role of the knowledge dimension for positive symptom behaviours underlies the clinical importance of supporting caregivers and patients in the monitoring of warning signs of relapse (Hertz & Lamberti, 1995; Falloon et al. 1998) and of updating them about new neuroleptic medications (Waddington et al. 1997). The role of the patient's mental capacity for negative symptom behaviours implies that clinicians should work closely with caregivers to determine the patient's deficits and strengths. While the under-estimation of patient capacity may restrict his (her) positive contribution to family life (Greenberg et al. 1994), its over-estimation may generate frustration in the caregivers and tension in the family environment. Finally, the finding that neither positive nor negative symptom behaviours were perceived as fully intentional suggests that, when addressed, moral responsibility should be examined in light of its underlying dimensions (e.g. knowledge, capacity, coercion).
Conclusion^
The present study is a promising first step in examining causality, responsibility and blame attributions in the management of symptom behaviours. However, three characteristics of the study limit its contribution. First, the assessment of causality was restricted to asking about the extent to which the patient was the main cause of symptom behaviour. Other components of the causal locus (Bradbury & Fincham, 1990) deserve more attention, such as the caregiver (Barrowclough et al. 1996), the outside circumstances (Brewin et al. 1991), the illness and the caregiver-patient relationship itself. Stability and globality are other causal dimensions of symptom behaviours that need to be further understood (Brewin et al. 1991; Barrowclough et al. 1994).
Secondly, our study did not attempt to measure affective and behavioural responses to attributions. The expected mediating role of attributions for symptom behaviours on emotional and behavioural responses remains to be demonstrated for caregivers of persons with schizophrenia. The patterns of attributions associated with the presence of forgiveness (Robinson, 1996), distress and anger in the caregivers all merit additional work as well as the coping styles of the caregivers. Contextual elements of the caregiving situation also need to be further understood in relation to attributions, including the quality of the relationship between the patient and the caregiver (Pickett et al. 1997) and the appraisal of the caregiving experience (e.g. burdensome, tolerance) (Schene et al. 1994; Szmukler et al. 1996).
Thirdly, the categories of positive and negative symptom behaviours were broadly defined. Future work on attributions for symptom behaviours could benefit from recent refinement in the assessment of patient behaviours from the perspectives of the caregivers (for a review, see Provencher et al. 2000a).
Despite these limitations, the present study is important because it is the first to examine the three types of attributions for symptom behaviours in caregivers of persons with schizophrenia. Our findings provide some support for the proposal that caregivers tend to engage in different attributional processes for positive and negative symptom behaviours. The use of a stress-coping framework (e.g. Lazarus & Folkman, 1984) is suitable to explore these attributions further as parts of the appraisal processes involved in the management of patient behaviours (Barrowclough et al. 1996; Provencher et al. 2000b).
This research study was supported by a grant from Sigma Theta Tau International Honor Society of Nursing (Xi Chapter, University of Pennsylvania, Philadelphia, PA).
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