VOL.8, NO.
1, 1982
Social Dysfunction and
Treatment Failure in
Schizophrenia
by Carmi Schooler Abstract
and Herbert E. Spohn
Recent evaluation of a 20-year-old
experimental ward resocialization
program for chronic schizophren-
ics indicates that the general level
of activity, much of it social, was
disruptive to the psychological
functioning of patients, particu-
larly sicker ones. Antipsychotic
drugs positively affected psycho-
logical functioning and also de-
creased social behavior. A review
of other studies indicates that we
are not unique in finding that in-
tensive socioenvironmental thera-
pies have adverse effects on schiz-
ophrenics. Furthermore, a wide
range of studies indicates that
schizophrenics are prone to avoid
social interaction and show a dec-
rement in functioning as the in-
tensity of such interactions in-
creases. Unfortunately, although
various hypotheses seem feasible,
little is known about the reasons
for schizophrenics' social dys-
function and little research is
presently being done. Given the
recent findings that neuroleptic
drug treatment by itself is insuffi-
cient to keep many patients out of
the hospital and that those that
stay in the community show an in-
crease in withdrawal, the devel-
opment of successful treatment
programs for schizophrenia may
.hinge upon our learning more
about the nature of and reasons
for the schizophrenic's social dys-
function.
This article reports an experimen-
tal treatment failure that took
place 20 years ago. Our general
finding is that the chronic schizo-
phrenic patients on a resorializa-
tion-oriented experimental ward
ended our program in worse psy-
85
chological condition than patients
on the custodially oriented control
ward.
Although we believe the evalua-
tion, design, and measurement of
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this program are reasonable by
contemporary standards and the
approach and its rationale careful-
ly documented, the report of such
an "ancient" failure would be of
no more than historical interest
and cathartic value if it did not add
something to our present knowl-
edge. One value such findings
have is that they serve as a van-
tage point for reviewing subse-
quent research by showing how, if
we had known then what we
know now, we would not have
been so bitterly surprised and dis-
appointed. These data, however,
can do more than serve as a focus
for a literature review. Both their
quality and the emergence of new
statistical techniques make it pos-
sible to use these data to add
meaningfully to what we now
know.
The Pretreatment Ward
Setting
In 1956 when planning for the ex-
perimental milieu treatment
started, medication was just be-
ginning to come into use, but the
liberalizing spirit that subsequent-
ly pervaded the mental hospital
world was in no way manifest at
the large Veterans Administration
hospital at which our work was
done. Well over 60 percent of the
patient population of this hospital
Reprint requests should be sent to
Dr. C. Schooler at the Laboratory of
Socio-environmental Studies, NIMH,
Bldg. 31, Rm. 4C-21, 9000 Rockville
Pike, Bethesda, MD 20205.
86
were chronic schizophrenics. Men-
tal patients who were susceptible
to social rehabilitation by means
then available had been dis-
charged years before. Besides the
occasional use of the new
antipsychotic drugs, treatment of
chronic schizophrenics under this
regimen consisted largely of the
busy-work adjunctive therapies.
Discharge rates were low, read-
mission rates high. A heavy aura
of pessimism pervaded, and per-
sonnel at all levels regarded as fu-
tile any concerted treatment ef-
forts. Preoccupation with
administrative detail and very
tight control over patient move-
ment and initiative served to limit
any contact with patients that
might lead to what was widely re-
garded as inevitably painful and
disappointing therapeutic involve-
ment.
In this context, we came to re-
gard the chronic schizophrenic pa-
tient as a socially disengaged,
anomic individual, who purpose-
fully avoided interpersonal
engagement and preferred the
impoverished and undemanding
role that the institution assigned to
him. The institution, in turn,
imposed no sanction upon the ex-
pression of pathological or abnor-
mal behavior which did not inter-
fere with the smooth functioning
of ward routine. Thus, the
interpersonal environment of the
ward provided no opportunity for
reality testing and the discovery of
the social inutility of inappropriate
behavior.
The hospital's view of the chron-
ic schizophrenic as incompetent
and unable to take any rational ini-
tiative on his own behalf was
made manifest in the form of an
extreme control of every aspect of
the patient's life, which cast him in
the role of a total dependent. This
implied not only that a variety of
choices, normally made by indi-
viduals for themselves, were made
for chronic schizophrenic patients
by hospital personnel but also,
and more significantly, that the
community of patients on the
ward was thus no community at
all. There were no common pur-
poses achievable through
cooperative or competitive enter-
prise, there was no pattern of role
differentiation and, of course, no
extended social interaction. The
ward in this hospital setting was
primarily an aggregate of isolates
(Schooler and Spohn 1960a).
We came to believe that the pat-
tern of asocial and inappropriate
behavior of hospitalized chronic
schizophrenics resulted from an
interaction between institutional
processes on the one hand and
disease processes on the other. It
seemed to us that the schizo-
phrenic's need for social with-
drawal, self-isolation, self-
effacement, and restriction of his
life space was sometimes subtly,
sometimes overtly fostered and
abetted by the institution. Con-
sciously or unconsciously, these
patient orientations were used by
the hospital staff to make the pa-
tient into a tractable hospital citi-
zen who fitted smoothly and effi-
ciently into a network of adminis-
trative and management routines
predicated on the assumption of
his incurability.
Such insights and feelings
guided the development and im-
plementation of an experimental
"socioenvironmental" treatment
program at the ward level.
SCHIZOPHRENIA BULLETIN
Changes on the Experimental
Ward
Major changes in the social,
administrative, and physical struc-
ture were implemented on the
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48-patient experimental ward. The
total ward group was subdivided
into five six-man and two nine-
man groups. A "group leader,"
usually a psychiatric aide, but in
some cases an adjunctive thera-
pist, was permanently assigned to
each group. These leaders met
with their groups twice a day, 5
days a week, in permanently as-
signed group meeting rooms or al-
coves. Group leaders were trained
to encourage discussion among
patients about attitudes and feel-
ings they shared concerning
events in and outside the hospital.
They were also trained to promote
feelings of group participation and
belonging and to foster the view
that the group was a small social
unit which both satisfied individu-
al needs and made demands for
individual contributions to group
welfare.
In order to achieve these aims
through the group meetings proc-
ess, group leaders employed a
number of procedures. They
sought to stimulate group
discussion of current events. Indi-
vidual patients were asked to read
news stories out loud and others
were encouraged to comment on
them. Similarly, individual group
members described projects
undertaken in occupational thera-
py and were urged to comment on
those of other patients in the
group. Games entailing coopera-
tive and competitive behavior
were widely used by group leaders
to stimulate and sustain social in-
VOL 8, NO. 1, 1982
teraction. Patients who anticipated
family visits were encouraged to
share their feelings in this regard
with the group both before and af-
ter such visits. Groups went on
trips together to athletic games, to
theaters and for shopping and
were escorted on such trips by
their group leader. Afterwards the
group was encouraged to discuss
the trip experience.
Finally the group leaders were
trained to function as models and
guides in reality testing,
emphasizing, especially in the
context of the group situation, the
importance of controlling sympto-
matology in the interest of clear
communication and group partici-
pation. Levels of group discussion
and activity were carefully ad-
justed to the capacities of each
group. In order to associate as
closely as possible with the group
experience those gratifications
which remain important to chronic
schizophrenics, group leaders dis-
tributed patient luxuries (mostly
cigarettes) before one of the group
experience periods, while before
the second, they supervised a
snack period with beverages and
food. Typically, individual pa-
tients were encouraged to partici-
pate in the process of dispensing
luxuries and comestibles to the
members of their group. In order
to extend the activity of the group
beyond these sessions and to pro-
vide as many group-shared experi-
ences as possible, the major ward
activities—cleanup, shaving,
showering, and eating—were re-
organized as group functions.
Parallel with the small group
structure, a program of intensified
individually oriented activity was
instituted. After a careful review
of individual needs and capacities,.
off-ward therapeutic activity as-
signments were made for many
patients, while the most with-
drawn and confused patients re-
ceived daily periods of occupa-
tional therapy and recreational
activity. All patients were encour-
aged to avail themselves of in-
creased opportunities to exercise
individual choice in matters of
food, personal care, clothing, lux-
uries, and participation in recrea-
tional activities. The formerly
white and beige color scheme of
the walls and the dormitory beds
was broken by a variety of drapes,
colored bedspreads, and pictures,
in part selected by the patients
themselves.
The group leaders were super-
vised by the ward nurse and ward
psychologist at regularly sched-
uled semiweekly conferences.
During both the training period
and the supervisory conferences,
emphasis was placed on the belief
that the chronic withdrawal and
alienation of the schizophrenic pa-
tient could be reversed through
the intensification of interpersonal
relationships. It was stressed that
attention to individual needs and
capacities would restore feelings of
identity, self-confidence, and initi-
ative, and that the example and
guidance of group leaders would
lead to the development of ward
standards of behavior similar to
those of a normal human commu-
nity. As the implementation of the
group process progressed, super-
visory conferences began to take
on increasing importance for
group leaders. In such conferences
they were helped to share and
come to terms with feelings of
frustration, resentment, and guilt
in response to the difficulties they
encountered in efforts to promote
social interaction among the pa-
tients in their gToups.
87
Methods of Measurement and
Evaluation
Measurement. The 100 male veter-
an patients selected for this study
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were randomly assigned to two
closed wards, one experimental,
one control. The selection criteria
were primary diagnosis of schizo-
phrenia, 3 or more years of hospi-
talization, a stable adjustment on a
closed ward, and poor prognosis
for recovery. The patient groups
thus selected had been continu-
ously hospitalized for an average
number of 8 years, with an aver-
age age of 42.7 years. Every major
subdiagnostic category was repre-
sented in balanced numbers on
both wards.
Baseline measures were collect-
ed for a period of more than a
year, while the two wards contin-
ued to function under psychiatric,
nursing, and administrative proce-
dures in every way similar to those
of the rest of the hospital.
Evaluations were focused on
two concepts—social behavior and
psychological functioning.
The measures of social behavior
included:
• Percentage of observations of
individual patients when engaged
in social interaction. The Location
Activity Inventory (LAI) (Hunter,
Schooler, and Spohn 1962;
Schooler and Parkel 1966) is a
structured observational technique
that gathers minimally inferential
profiles of patients' location and
activity patterns on a time-
sampling bases.
• Rate of interaction with oth-
ers. The Interaction Protocol (IP)
(Solomon and Spohn 1958;
Wilensky and Solomon 1960) is a
prestructured observation instru-
ment designed to assess the char-
acteristics of patients' social inter-
88
actions on the ward. During each
evaluation period, 55 one-hour pe-
riods of observation were made at
random times during the day. The
interaction rate is the ratio of the
number of a patient's social con-
tacts to the number of observation
periods in which he was on the
ward.
• Rate of interaction specifically
with other patients (IP).
• Number of interactions initi-
ated toward other patients (IP).
• Number of interactions initi-
ated toward staff (IP).
• Number of interactions re-
ceived from other patients (IP).
• Number of interactions re-
ceived from staff (IP).
The measures of psychological
functioning included:
• An abbreviated Wechsler
Adult Intelligence Scale (WAIS).
The subtests used include infor-
mation, Digit Span, Picture Com-
pletion, Block Completion, Block
Design, and Digit Symbol
(Wilensky and Solomon I960). 1
• Rorschach Developmental
Level Score (Becker 1956). This
score is based on a one-response-
per-card Rorschach in which a
high score is interpreted as indi-
cating a high level of perceptual
organization and by inference a
mature level of personality inte-
gration.
• Goodrich Psychiatric Rating
Score (Goodrich 1953). Evaluation
is based on a written report of a
standard mental status exam con-
ducted by psychiatric residents
under staff supervision.
1 mental effect which resulted in an
Some IQ data were missing for 26
subjects. Estimates of these scores
were made by using the other varia-
bles in the model to predict IQ and
using the resultant constants and beta
weights to construct estimated scores.
• Mental Health Rating Scale. A
six-level global rating (made by the
ward psychologist) is focused on
the patient's presumed ability to
assume independent responsibility
in caring for himself.
• Nonfunctional behavior on the
LAI (Hunter, Schooler, and Spohn
1962). Included are nonfunctional
movement and object manipula-
tion, nonsocial verbal, gestural
and laughing behavior.
The measures used during the
baseline period to examine patient
adjustment were readministered
on both wards after the experi-
mental program had been in oper-
ation for 2 years. During this peri-
od the control ward remained
under the standard regimen used
by the hospital to treat chronic
schizophrenics. At this time, 41
members of the experimental
group and 34 of the control group
were still on their respective
wards.
Among the patients who re-
mained in the study through the
posttreatment measurement peri-
od, there were two significant dif-
ferences in baseline measures,
both of them on social variables,
between the two wards. Among
these patients there were signifi-
cant differences in rate of interac-
tion (p = .021) and rate of patient-
patient interaction (p = .037). In
both cases the patients who re-
mained on the control ward
showed a higher level of interac-
tion than those who stayed on the
experimental ward. As will be
seen, the direction of this differ-
ence runs counter to the experi-
increase in social behavior on the
experimental ward.
Examination of the baseline ob-
servational data mirrored our
bleak impressionistic picture of
SCHIZOPHRENIA BULLETIN
life on the wards. Patients spent
less than 3 percent of their time in
any kind of social interaction, and
about 19 percent in nonfunctional
pathological behavior. (For a more
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extensive description, see Hunter,
Schooler, and Spohn 1962).
Given both the nature of the
population and of several of the
individual measures of social be-
havior and psychological func-
tioning, the question of the relia-
bility of the measurement of these
two concepts arises. Test-retest
studies such as this are particular-
ly susceptible to the eventuality of
measurement error because the
magnitude of the effect of the
pretreatment (independent) varia-
bles on the posttreatment (de-
pendent) variables will be
underestimated in direct propor-
tion to the amount of error in the
measurement of the pretreatment
variables (Blalock 1972; Heise
1975).
Fortunately, Linear Structural
Equations System Analysis
(LISREL) makes it possible to ob-
tain a measurement-error-free
measure of a concept through the
use of confirmatory factor analysis
(Joreskog 1973; Maruyama and
McGarvey 1980; Schooler, in press).
Given multiple indicators of a con-
cept, models can be constructed
which divide the variance of each
of the indicators into two
parts—one part reflecting the con-
cept being measured, the second
part reflecting anything else,
which for measurement purposes
is considered error. Such models
can take into account the possibili-
ty that errors of measurement are
correlated over time—that what-
ever errors there may have been in
the measurement of any of the in-
dices of a concept in the
pretreatment period are correlated
VOL. 8, NO. 1, 1982 S9

with errors in the measurement of
that index in the posttreatment pe-
riod. The program reduces these
models to a series of simultaneous
equations, which it solves using it-
than the pretreatment period. In
the pretreatment period the LAI
measure of social activity, which
does not specify the initiator or the
other participants, had the highest
other hand, rate of patient-patient
interactions, which had the lowest
loading on the pretreatment meas-
ure, had the second highest load-
ing on the posttreatment measure

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erative function minimization pro-
cedures. It also tests the signifi-
cance of the loadings of the indices
on the concepts and the degree of
fit of the model to the original
data.
The measurement models for
both social behavior and psycho-
logical functioning seem to reflect
their respective underlying con-
cepts and to fit the original data
quite well.2 Examination of the
measurement models for social be-
havior (see table 1) indicates that
there was a shift between the
pretreatment and the posttreat-
ment concepts in the relative im-
portance of the different indicators
of social behavior. Initiating inter-
actions and interacting with peers
were more reliable indices of social
behavior during the posttreatment
loading while in the posttreatment and initiating interactions with
period it had the lowest. Receiving other patients had the highest.
social interactions from the staff, This pattern of different loadings
which had the second lowest load- suggests that social behavior was
ing on the posttreatment measure, more reliably measured by indices
also had a higher loading on the reflecting passive social behavior
pretreatment measure. Receiving during the pretreatment and indi-
interactions from other patients ces reflecting active social behavior
had a similarly higher loading on during the posttreatment. Despite
the pretreatment than the these differences both
posttreatment measure. On the pretreatment and posttreatment
Table 1. Measurement model for social behavior
Standardized Standardized
loading on loading on
pretreatment posttreatment Standardized
social social over-time
Indicator behavior factor behavior factor correlated error
Percent social
behavior (LAI) .89 .38 ( - .005)

Rate of
2
The confirmatory factor analyses interaction (IP) .35 .61 (-.006)
of the measurement models were
carried out using the MILS program, Rate of inter-
an advanced version of LISREL action with
(Joreskog and van Thillo 1972) devel- patients (IP) .26 .94 (-.01)
oped by Ronald Schoenberg. The cor-
relations between the confirmatory Interactions
factor analysis based concepts and initiated toward
other concepts used in the causal patients (IP) .82 .95 (-.01)
analyses were obtained through the
use of factor scores based on Interactions
Bartlett's method (Lawley and Max- initiated toward
well 1971, pp. 109-112). MILS not staff (IP) .76 .77 .16
only provides factor weights for
deriving such scores but also makes Interactions
possible an estimate of their reliability received from
by producing their correlations with patients (IP) .70 .61 (•10)
the true scores. The correlations be-
tween these factor scores and the oth- Interactions
er variables were then computed and received
the resulting correlations corrected from staff (IP) .57 .39 . .49
for the known unreliability of the
Bartlett factor scores. Chi-squared/c/r - 4 8950; () indicates NS, p > .05.
90
measures unquestionably index
patient social behavior.
Examination of the measure-
ment model for psychological
functioning indicates that the
loadings of the different indices
are remarkably similar for both pe-
riods (see table 2). Level of intel-
lectual functioning as measured by
the abbreviated WAIS has the
highest loading at both times, and
the other loadings, including the
one based on ward observations
(LAI nonfunctional), are reasona-
bly high and significant.3
Evaluation. Two types of statistic-
al analysis were carried out to ex-
amine the effectiveness of the
ward program. The first is an anal-
ysis of covariance comparing the
posttreatment means of the exper-
imental and control wards ad-
justed for pretreatment level. This
analysis is performed on each of
the 12 variables used as indicators
of the psychological and social
measurement models (contained
in tables 1 and 2).
However, such an analysis can-
not readily be carried out when the
factor scores based on the meas-
urement models are adjusted for
'Although there were some signifi-
cant differences in the individual in-
dices, there was no significant differ-
ence between the two wards in the
social behavior factor among the pa-
tients who remained in the study
through the posttreatment measure-
ment phase. There was, however, a
significant difference (p = .05) on the
psychological functioning factor. The
subjects who stayed on the experi-
mental ward had a higher level of
pretreatment functioning than those
who remained on the control ward, a
difference which runs counter to the
experimental effect.
measurement error, since the re-
sultant output is a variance-
covariance matrix among the rel-
evant variables. Such a matrix can,
however, be used for reduced
form equation analysis, the second
type of analysis presented, which
simply consists of a set of multiple
regression analyses in which each
dependent variable is allowed to
be affected by the complete set of
independent variables. Besides
making it possible to adjust for the
effects of measurement error, such
an analysis has several additional
advantages.4 It is very similar to
analysis of variance when the lat-
ter is reduced to its basic regres-
sion components. The standard-
ized reduced form coefficients
(which are the paths cited in the
text) tell how much change can be
expected in the dependent variable
per unit change in the independ-
ent variable.
The dependent variables in the
reduced forms equation analysis
are (1) posttreatment psychological
functioning; (2) posttreatment so-
cial behavior. The independent
variables are (1) experimental con-
dition (experimental ward = 1,
control ward = 0); (2) pretreatment
'Since every independent variable
is allowed to affect every dependent
variable, such an analysis should not
be confused with a confirmatory caus-
al analysis, in which the paths from
some of the independent to some of
the dependent variables may be hy-
pothesized not to exist. Several more
complex forms of causal analysis were
tried in an attempt to confirm
hypotheses about reciprocal causal ef-
fects among the posttreatment meas-
ures, but relatively parsimonious re-
duced form equation analysis
provides the clearest and least ambig-
uous results.
SCHIZOPHRENIA BULLETIN
psychological functioning; (3)
pretreatment social behavior; (4)
age; (5) number of weeks on
antipsychotic drugs;5 (6) the
residualized orthogonal interaction
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of experimental condition and
pretreatment psychological func-
tioning;6 and (7) the residualized
3
The two drugs used were
reserpine and chlorpromazine. Unfor-
tunately, this is the only measure of
chemotherapy recoverable. Among
the patients who stayed through the
posttreatment measurement, there
were no significant differences be-
tween the two wards in average per-
cent weeks on medication (control
ward = 71 percent, experimental
ward = 78 percent, p = .47).
6
Residualized interaction terms or-
thogonal to the main effects whose in-
teraction they represent had to be
constructed because the inclusion of
nonorthogonalized interaction terms
in a regression equation would render
meaningless the main effect estimates
(Cohen 1978; Cohen and Cohen 1978).
Briefly, the residualized interaction
terms were developed by first con-
structing an "observed" interaction
term. Subjects who were in the exper-
imental group and above the sample
median in social behavior were as-
signed the score they had obtained for
social behavior while all other sub-
jects were assigned a value of 0. This
observed interaction term was then
used as a dependent variable in a
multiple regression equation in which
the independent variables were ex-
perimental group and social behavior
score. Estimated scores were then
constructed on the basis of the con-
stants and beta weights of the result-
ant regression equations and the esti-
mated scores subtracted from the
observed ones. When they are in this
residual form, the interaction terms
are uncorrelated with the main effects
and they measure only that variance
which is unexplained by the main ef-
fects.
VOL. 8, NO. 1, 1982 91

Table 2. Measurement model for psychological functioning in table 3 reveals something about
both the quantitative differences
Standardized Standardized and the qualitative differences be-
loading on loading on tween the two groups. Thus the
pretreatment posttreatment experimental ward group is seen

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psychological psychological Standardized not only as socially more active at
functioning functioning over-time posttreatment and as receiving a
Indicator factor factor correlated error much greater number of social
overtures from staff, but they also
IQ (abbreviated show a trend toward initiating a
WAIS) .80 .78 .27 larger number of interactions vis-
a-vis both staff and other patients
Developmental than the control group. This
level implies some reduction in the ex-
(Rorschach) .61 .49 .47 perimental ward group in social
passivity characteristic of chronic
Goodrich schizophrenic patients (such as the
Psychiatric control group) on custodially ori-
Rating .74 .73 (09) ented wards in public mental hos-
pitals in the era in which this
Montrose Mental study was performed.
Health Rating .77 .67 (•06) Examination of the reduced form
equation analysis, in which the ef-
Percent fects of measurement error have
nonfunctional been purged from the psychologi-
behavior (LAI) -.37 -.37 -.33 cal and social measures, reveals
that the level of stability from
pretreatment to posttreatment of
Chl-squared/d/ - 2.4651; () Indicates NS, p > .05 both psychological and social func-
tioning is very high (see table 4).
orthogonal interaction of experi- The only two exceptions are The standardized reduced form co-
mental condition and pretreatment nonfunctional behavior, where efficient from pretreatment to
level of social behavior. there is no difference between the postreatment psychological func-
wards, and the mental health rat- tioning is .92, and from pretreat-
Results ing scale, on which the experi- ment social behavior to post-
mental ward did relatively better treatment social behavior .92.
For the individual items that than the control ward. In Since we never expected any mira-
were the dependent variables in evaluating the latter finding, it cles, we were not surprised by the
the covariance analyses, the differ- should be borne in mind that the high stability of the patients' social
ences between the experimental global mental health ratings were and psychological functioning.
and control wards in the posttest not made blindly, but by the ward What we were not originally pre-
means adjusted for initial level psychologist. In such circum- pared for is the negative effect on
(but not measurement error) are stances raters' expectations may the patients' psychological func-
not generally significant. Howev- well produce results contrary to tioning of being on the experimen-
er, the direction of the differences those obtained by more controlled tal ward. The path from being in
is congruent with the hypothesis evaluation procedures. the experimental condition to
that the experimental condition in- Comparison of the patterning of posttreatment psychological func-
creased the level of social behavior the control and experimental tioning is —.20. Furthermore, this
and decreased the level of psycho- group posttreatment adjusted decrement in the experimental
logical functioning (see table 3). means for social behavior shown ward patients' psychological func-
92 SCHIZOPHRENIA BULLETIN

Table 3. Analysis of covariance of individual posttreatment measures covarying pretreatment level

Adjusted means
Variable Control Experimental F P

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Social behavior Indicators
Percent of social
interaction (LAI) .03 .07 8.683 .004
Rate of interaction
with others (IP) .37 .46 .055 .815
Rate of interaction
with patients (IP) .13 .19 .496 .484
Number of interactions
initiated toward
patients (IP) 6.04 7.21 .506 .479
Number of interactions
initiated toward
staff (IP) 4.12 7.87 1.791 .185
Number of interactions
received from patients (IP) 6.59 9.00 2.734 .103
Number of interactions
received from staff (IP) 6.53 14.63 39.235 .000
Psychological functioning Indicators
Abbreviated WAIS 81.08 76.31 .551 .460
Rorschach developmental
level score 26.38 22.26 1.991 .166
Goodrich Psychiatric
Rating score 2.48 2.20 .563 .128
Mental Health Rating
Scale 31.65 36.08 9.577 .003
Nonfunctional behavior
(LAI) .13 .13 1.358 .248

Honing took place in a context of
increased social interaction. The
path of .13 from experimental con-
dition to posttreatment social
functioning indicates that the ex-
perimental manipulations did suc-
ceed in increasing the level of the
patients' social behavior compared
to that on the control ward.
An anecdote may serve to dram-
atize our finding that as social in-
teraction on the experimental ward
increased, the level of psychologi-
cal functioning decreased. A pa-
tient on the experimental ward de-
scribed his preexperimental ward
program self-isolation and with-
drawal as akin to being inside a
glass shell from which he could
see out but could not hear what
was going on around him. With
the advent of the program, he ex-
perienced both staff and other pa-
tients as seeking to shatter his
shell and this frightened him
greatly. Such a reaction seems to
have been more prevalent among
the sicker than the healthier pa-
tients on the experimental ward.
While the significant main effect
for ward indicates that being on
the experimental ward resulted in
poorer psychological functioning,
the significant residualized inter-
action effect (path = .14) of ward
and initial psychological level indi-
cates that this effect is stronger for
patients whose initial level of psy-
chological functioning was lower.
Thus the sicker patients on the ex-
perimental ward were relatively
more adversely affected than were
the healthier ones.
In this sample of chronic schizo-
phrenics, age, not surprisingly, is
VOL. 8, NO. 1, 1982
Table 4. Significant standardized reduced form coefficients1
1. Experimental ward
2. Pretrial psychological functioning
3. Pretrial social behavior
4. Interaction ward x pretrial psychological
functioning (residualized)
5. Age
6. Antipsychotic medication
1
Indicate the amount of change In standard units that can be expected in a dependent varia-
ble per unit change In an independent variable with the effects of the other mdspendent varia-
bles controlled.
related to low levels of both social
behavior and psychological func-
tioning in the posttreatment peri-
od. The path from age to
posttreatment social behavior is
-.18 and to posttreatment psycho-
logical functioning -.10.
Initially more surprising, but
more in line with the findings on
the negative effects of the experi-
mental ward on psychological
functioning, are the negative ef-
fects of antipsychotic medication
on social behavior. The path from
number of weeks on antipsychotic
drugs to posttreatment social be-
havior is -.08. At the same time,
the path from weeks on medica-
tion to posttreatment level of psy-
chological functioning is moder-
ately strong and positive (.13).
The pattern of results strongly
suggests that the general level of
activity on the experimental ward,
much of it social, is disruptive to
the psychological functioning of
the patients, particularly the sicker
ones. In this situation medication
decreases the amount of social be-
havior and possibly blunts its ef-
fects.
Finally, our evidence suggests
that our intensive socioenviron-
Po8ttreatment
Psychological Social
functioning behavior
-.20 .13
.92
.92
.14
-.10 -.18
.13 -.08
mental treatment effort did not re-
pay its cost to patients by
preparing them for life outside of
the hospital. There were no signif-
icant differences between the ex-
perimental and control groups in
discharge or length of stay in the
community during a period fol-
lowing termination of the project
from May 1960 to September 1965.
That the proportion of experimen-
tal ward patients (25 percent) dis-
charged in the first 3 years after
termination of the program was
slightly larger than that of control
ward patients (9 percent) is proba-
bly due to the fact that experimen-
tal ward patients were better
known to staff than control ward
patients.
Discussion
The results described above are
obviously most applicable to long-
term, chronic, male, veteran schiz-
ophrenics subjected to a particular
treatment regimen in the late
1950s. There may well be a
declining gradient of generaliza-
tion to the extent that the nature of
the social situation or of the schiz-
ophrenic population differs. How-
93
ever, an examination of the litera-
ture indicates that congruent
findings have generally emerged
among a wide range of schizo-
phrenic populations and social
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ by guest on September 16, 2016
contexts. Thus more recent studies
indicate that we were not unique
in finding that intensive
socioenvironmental therapies have
an adverse effect on the psycho-
logical functioning of hospitalized
schizophrenics. In a review article
Hemsley (1978) cites a series of re-
ports of deterioration in the be-
havior of at least a minority of
schizophrenics in intensive reha-
bilitation programs. He also finds
evidence of increased behavioral
abnormality among schizophrenics
who took part in token economy
programs.
Reviewing his own and related
work, Wing (1975) concludes:
negative impairments [e.g., so-
cial withdrawal, flatness of af-
fect, and lack of motivation] oc-
cur more frequently and more
intensely in conditions of social
poverty. . . . Florid relapse
[unpredictable associations, in-
coherence of speech, hallucina-
tions] occurs more frequently
and intensely in socially
overstimulating environments
. . . through too vigorous at-
tempts at rehabilitation or too
intensive group therapy,
[p. 257]
In another review article Van
Putten and May (1976) conclude
"that milieu therapy does not add
much to the treatment of schizo-
phrenics once adequate chemo-
therapy is used and gross neglect
corrected" (p. 230). They cite a
series of treatment studies sup-
porting "the concept that the ap-
plication of intensive milieu thera-
py is conceptually unsound for
some schizophrenic patients"
(p. 233). They also discuss three
studies (Hamilton et al. 1960;
94
Freedman et al. 1961; Paul et al.
1972) in which drug treatment
seems to increase social withdraw-
al and to decrease both social re-
sponsiveness and the effectiveness
of social interventions. These latter
results are intriguing from the
vantage point of our finding that
chemotherapy has a positive effect
on psychological functioning and a
negative effect on social interac-
tion.
Also relevant are the ward stud-
ies carried out by Kellam et al.
(1966, 1967) on the effects of ward
atmosphere on the psychological
functioning of schizophrenics on
admission wards. In these studies
which were conducted as
part of a larger study on the effects
of phenothiazines, ward atmos-
phere was characterized in terms
of a series of dimensions measured
by staff report or observation.
Among these dimensions are dis-
turbed behavior (divided into ag-
gressive and bizarre) and adult
status (a measure of the degree to
which patients on wards are al-
lowed to maintain basic symbols of
adulthood). The first of these stud-
ies reports a correlation of .43 be-
tween the ward characteristics of
aggressive behavior and staff pa-
tient contact. Although some of
this correlation may be due to the
staff's response to the patients' ag-
gressive behavior, it is also possi-
ble that some of the patients' ag-
gressive behavior may be a
reaction to the staff's social intru-
siveness. The second article pre-
sents results which the authors find
paradoxical. Although, as they
predicted, ward atmospheres
characterized by disturbed behavior
seemed to lead to greater sympto-
matology, contrary to their expec-
tations, so did ward atmospheres
which allocated the patients more
adult status. What both of these
characteristics may have in com-
mon is greater social intrusive-
ness. Other patients' aggressive
and bizarre behavior can be as in-
trusive as the social demands
implied by treating the patient as
an adult. Interestingly, in terms of
the hypothesis that antipsychotic
drugs act to dampen the effects of
social intrusion, the effects of
these two ward characteristics are
greater for patients receiving pla-
cebo than for those receiving
drugs.7
The adverse effect of intensive
socioenvironmental therapy pro-
grams is not limited to hospital-
ized schizophrenics. Goldberg et
al. (1977) found that symptomatic
schizophrenic patients in the com-
munity relapsed more quickly
when they received Major Role
Therapy (a combination of social
casework and vocational rehabili-
tation) than when they did not.
The results of this study are also
similar to ours (and in keeping
with those of Fairweather et al.
1960) in that a significant interac-
tion was found, indicating that the
more symptomatic patients were
more likely to be adversely affect-
ed by the social intervention.
The negative effects of socio-
environmental treatment programs
7
Analyses were also performed for
three ward atmosphere measures of
social contact: aloneness, cluster-size,
and staff-patient contact. The most
frequent significant findings were for
cluster size. Unfortunately, the social
implications of this variable are
unclear. It is indexed by "the average
number of patients present per social
occasion." A high number may well
mean that the social interaction that
does take place is less individualized
and intense.
SCHIZOPHRENIA BULLETIN
become less surprising when we
consider the evidence that schizo-
phrenics are more likely than oth-
ers both to avoid social contacts
and to show a decrement of psy-
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ by guest on September 16, 2016
chological functioning as social sit-
uations become more intense.
Examination of both their actual
behavior and their expressed pref-
erences indicates that schizo-
phrenics are more prone to avoid
social interaction than are others
in similar situations. Thus the only
significant behavioral difference
between hospitalized schizophren-
ics and other chronic psychiatric
patients observed in an LAI study
of randomly selected patients in a
large mental hospital is that the
schizophrenics engage in less ver-
bal social behavior (Schooler and •
Parkel 1966). In the same study the
schizophrenic patients rated them-
selves as significantly more likely
to inhibit the expression of
interpersonal emotion than did the
other patients. In another study,
schizophrenics were found to ex-
press a distinct preference, com-
pared to normals, for reducing the
degree of interpersonal inteirelat-
edness in a two-person task situa-
tion or, if possible, for doing the
task alone (Schooler 1963).
That such a preference for social
withdrawal is not an ephemeral
problem is suggested by an analy-
sis limited to "behavior anteceding
the first manifestation of psychotic
onset" (Gittelman-Klein and Klein
1969, p. 39). The results show that
"withdrawn asocial behavior, and
a lack of interest in activities
involving one's peers are uniform-
ly associated with decreased fre-
quency of successful, lasting re-
covery" (Gittelman-Klein and
Klein 1969, p. 44).
Both experimental and
nonexperimental evidence also in-
VOL. 8, NO. 1, 1982
dicate that increasing the intensi-
ty of schizophrenics' social inter-
actions may result in a decrement
in their psychological functioning.
An experiment by Hunter (1960)
demonstrated that the level of task
performance of chronic schizo-
phrenics decreases as a function of
their interdependence with their
task partners. Johannsen (1961)
showed that schizophrenics per-
form at a significantly lower level
with social than with nonsodal re-
inforcement. Schooler and Spohn
(1960b) found that experimentally
increasing group pressure disrupts
the performance of chronic pa-
tients more than it does that of
normal controls.
Examining schizophrenics' ad-
justment in the community,
Vaughn and Leff (1976),
replicating an earlier study by
Brown, Birley, and Wing (1972),
found that contact with a relative
who expresses a high degree of emo-
tion is significantly associated with
a high relapse rate of schizophren-
ics. Furthermore, although main-
tenance therapy with pheno-
thiazines partially ameliorates the
negative effect of extensive contact
with an emotionally expressive rel-
ative, the negative effects of such
interpersonal contact are also seen
among patients receiving these
drugs.
The reasons for the deleterious
effects of social interaction on
schizophrenics remain in question.
Given the present state of our
knowledge, many plausible and
not necessarily contradictory
hypotheses can be put forth. The
problem may be primarily a cogni-
tive one. Social interactions are
generally cognitively complex.
Hemsley (1977), among others, has
argued that schizophrenics may be
in a state of information overload.
As a possible protection against
such an overload, acute schizo-
phrenics tend to adopt a perceptu-
al style which reduces the per-
ceived intensity of stimuli
(Schooler et al. 1976). Chronic
schizophrenics, who reduce the
perceived intensity of stimuli less
than do acutes, may protect them-
selves from cognitive overload by
reducing their social contacts fur-
ther.
There are also noncognitive rea-
sons why schizophrenics may be
negatively affected by social inter-
action. Besides being a cognitively
complex object, another person is
also likely to be a source or target
of emotion. Schizophrenics may
have particular difficulties in giv-
ing or receiving positive or nega-
tive emotion (Fromm-Reichmann
1950; Schooler 1963). Nor can psy-
chodynamic explanations not re-
lated to emotional difficulties be
ruled out. Thus it is possible, as
Fromm-Reichmann (1952) has sug-
gested, that interpersonal "close-
ness increases the schizophrenic's
ever-existing fear of . . . losing his
identity, of losing the sense of the
boundaries between himself and
the outside world" (p. 105).
In any case, the evidence is pre-
ponderantly in the direction of
higher autonomic arousal for
schizophrenics (Zahn, Carpenter,
and McGlashan 1981) and the
added arousal coming, for whatev-
er reason, from interpersonal in-
teraction may be dysfunctional.
The possibility that highly aroused
patients may therefore avoid social
contact is suggested by Venables
and Wing's (1962) finding that for
all but coherent deluded schizo-
phrenics, withdrawal is highly re-
lated to arousal. Moreover, in
chronic schizophrenics pheno-
thiazines somewhat reduce exces-
95
sive levels of arousal (Spohn et al.
1977). It may be, therefore, that
medicated patients can, as noted
above, tolerate social interaction
somewhat longer than nonmed-
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ by guest on September 16, 2016
icated patients.
Schizophrenics differ not only in
the level but also in the pattern of
their arousal. The schizophrenic's
arousal pattern shows less specific
responses to environmental de-
mands (Zahn, Carpenter, and
McGlashan 1981), and even among
schizophrenics specific responses
are linked to better performance.
Being in a social situation may af-
fect the schizophrenics' ability to
fit their responses to the
situational requirements. Experi-
mental evidence suggests that "the
social nature of the situation can
affect the direction of the relation-
ship between arousal and per-
formance" (Schooler and Zahn
1968, p. 400).
A cursory examination of the
reference list for the present article
quickly reveals that most of the
studies specifically directed at ex-
amining the schizophrenic's social
functioning are not particularly
new. Perhaps in part because of
the search for an underlying bio-
chemical cause and the apparent
efficacy of the psychotherapeutic
drugs, there have been few recent
studies concerned with either the
causes or the therapeutic implica-
tions of the schizophrenic's social
dysfunction.
Findings from -a recent study by
N.R. Schooler et al. (1979) should
serve to revive concern with these
problems. In their study of the
comparative effectiveness of
injectable depot fluphenazine
decanoate or oral fluphenazine hy-
drochloride, 28 percent of the pa-
tients relapsed within their first
year of community treatment.
96
Contrary to the original hypothe-
sis, there were no significant dif-
ferences between the two treat-
ments, thus ruling out the widely
held belief that phenothiazine
treatment failures are primarily
due to patient noncompliance in
taking their oral medication. In-
stead the evidence suggests that
phenothiazines by themselves do
not necessarily permit schizo-
phrenics to function at a level
which will permit them to stay in
the community.
Even more pertinent to the re-
sults of our socioenvironmental
treatment study is the finding that
the symptoms of emotional with-
drawal and blunted affect were ac-
tually more prevalent among
nonrelapsed patients at the end of
the 1-year community mainte-
nance phase than they were in the
beginning, although the preva-
lence of all other symptoms had
decreased. Thus it would appear
that some level of social withdraw-
al and noninvolvement is func-
tional for the schizophrenics' ad-
justment to their social
environment. It should be remem-
bered that in our study not only
did psychotherapeutic medication
increase level of psychological
functioning, it also decreased social
behavior. We are, however, left
with a difficult conundrum. On
the one hand, the N.R. Schooler et
al. study demonstrates that medi-
cation by itself is not sufficient to
keep many schizophrenics ad-
justed at a level acceptable to the
community. On the other hand,
socially based attempts at improv-
ing the schizophrenics' adjustment
seem to founder on the schizo-
phrenics' apparent need to avoid
social interaction and apparent
disturbance in psychological func-
tioning when they cannot do so.
The development of successful
treatment programs for schizo-
phrenia may hinge upon our
learning more about the nature of
this social dysfunction.
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Acknowledgment
Herbert E. Spohn, in collaboration
with Carmi Schooler, Richard
Blumental, Marvin Hunter,
Edward Klein, Leonard Soloman,
and Harold Wilensky concep-
tualized, developed, and imple-
mented the socioenvironmental
treatment program, and devised
its evaluation design and measure-
ment. We would also like to thank
Nina Schooler for directing our in-
terest back to these data and for
her substantial help in preparing
this report.
Grateful acknowledgment for
their roles in the implementation
of the socioenvironmental treat-
ment program is due to a large
number of individuals. Unfor-
tunately, not all of them can be
mentioned here. Without the sup-
port of Dr. Oscar Diethelm, Dr.
Leon Rackow, and Dr. Seymour
Klebanoff, this program could not
have been implemented. Also,
special recognition should be ac-
corded to Dr. Alvin Bernstein
who, as ward director of the pro-
gram, was able to sustain the ap-
SCHIZOPHRENIA BULLETIN
posite implementation of the pro-
gram over a period of several
years. We would like to extend a
very special thanks to Barbara
Miller for her instrumental role in
carrying out the statistical analy-
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ses. In addition, we are also grate-
ful to Ronald Schoenberg for his
important advice on the use of
MILS, an advanced version of
LISREL, and Jacob Cohen for his
statistical consultation both 20
years ago and now.
The Authors
Carmi Schooler, Ph.D., is Re-
search Psychologist, Laboratory of
Socioenvironmental Studies, Na-
tional Institute of Mental Health,
Bethesda, MD. Herbert E. Spohn,
Ph.D., is Director, Research De-
partment, The Menninger Founda-
tion, Topeka, KS.