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them, may be important in disclosing their causal beliefs, since the situational cues salient in the event will determine the kinds of attribution that the relative makes. Given these limitations, the data suggested that the categories were relevant to the kinds of events that the relatives explained: over 50% of relatives made at least one statement for each category and only 8% of statements could not be classified.

9.2 SOME GENERAL OBSERVATIONS ABOUT THE ATTRIBUTIONS OF RELATIVES

T he expression of attributions: The type of causes that relatives expressed were reliably classified as given, explored or inferred. It was found that the majority (just over half) of causes fell into the inferred class, while just under a third were 'j i V & n and least attributions were expressed as explorations or suggestions. This ranking held irrespective of the content of the kind of event for which a belief was expressed with the exception of beliefs about illness onset and relapse. For these beliefs, given causes - that is causes where there was a clear causal connective or link word between the cause and event - just exceded inferred. The finding that relatives express most certainty about beliefs concerning the cause of the illness itself is of particular interest since other research on

relatives' understanding about schizophrenia has found that such attributions are very resistant to change. For example, Berkowitz,

Erbelaine-Fries, Kuipers and Left (1984) in assessing the impact of an educational intervention given to relatives, found that relatives

tended to retain their own versions of the causes of the illness; and this finding was supported in a study by Barrowclough et al (1987). An inspection of the sort of reasons relatives presented for the illness onset in this study indicates that the causes were diverse and idiosyncratic. They included blaming other people for causing the patient stress or worry: friends of the patient, teachers, divorced parents, and doctors who 'mistreated' them; other reasons were

* problems at work, physical traumas, illnesses or accidents. In no instance did any relative spontaneously give a biological explanation of the illness, and the majority of stressors mentioned predated the illness onset by several years, often having occurred in childhood, the directions of causal belief: For relatives as a whole,

attributions for patient causality were fairly evenly distributed between internal and external causes, and were predominantly personal, uncontrollable and unstable. With the exception of the internality dimension, these results were in accord with the findings of Brewin et al (1988). Brewin and colleagues' study found that causes were predominantly internal, but this difference may be explained by factors such as the absence of low EE relatives in their sample, and the coding of illness causes as internal to the patient. As would be expected, the dimensional scores were related with correlations ranging from .33 (stable and personal) to .57 (internal and controllable), but these associations suggest considerable

independence of the measures and this was born out by their different associations with other variables in the study,

the type of causal beliefs: A qualitative analysis of all the

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considerable interest, was not the prime focus of this study which sought to examine the direction of attributions within a theoretical framework. Some observations have been made about the sorts of beliefs relatives held about the illness onset, and three general classes of causal beliefs were examined in the study. The first of these was illness causes, that is where the relative gave illness or some synonym as the explanation for a described event. Given >. the nature of the study, it is unsurprising that almost two-thirds of the

relatives used this cause at least once. In fact it is perhaps

surprising that they were not more frequent and they represented only 13% of all the beliefs mentioned. Since many of the subjects were relatives of patients with longstanding illness and repeated hospital admissions, we can perhaps assume from these data that either they had been given little information about the causes of the patient's problems, or that this information had minimal inpact on their causal belief systems. Tarrier and Barrowclough (1986) and Barrowclough et al (1987) have suggested that many relatives have well developed and systematised knowledge of their own about the illness, and that

health professionals fail to acknowledge this when they present relatives with the medical model of diagnosis, symptoms, cause and so on. Such a mismatch of causal models is indicated in the sort of attributions that relatives made for the illness onset. A second class of beliefs studied was termed 'patient responsible for outcome' causes, where the cause was internal, personal and controllable by the patient (and external and uncontrollable by the relative). Most relatives made at least one such 'blaming' attribution' and this pattern of attributions was useful in discriminating between groups of relatives and as such may have clinical utility. The third class of causes w a s " relative responsible for outcome" and the most

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important finding here was very few such attributions were made. This finding, and the general infrequency of attributions which were either internal to or uncontrollable by the relative, is consistent with the basic attributional bias found in the literature: people tend to give external attributions for things that happen to them, and internal ones for things that happen to others (Jones and Nisbett, 1972). Although self blame attributions were rare, as with patient responsibility

attributions they are of considerable clinical interest. The results suggest strongly that relatives who report them are

experiencing affective disorders. Moreover, any suggestion by health professionals or others that the relative is to blame will in most

instances be at odds with the relatives' causal belief system and may result in alienating the relative, or at worst, possibly cause them distress.

There were few significant differences between attributions for patient causality in the different categories of outcome described, and these results should be viewed with caution since analyses were performed for reduced subject numbers (not all relatives made

attributions for all outcomes) and did not control for the number of attributions each relative made within a category of event. Thus any differences in causes given for different event categories could be due to the attributional style of relatives who made multiple

attributions for those events, rather than the events attracting different types of causes. Given these severe data limitations, a couple of points are worthy of note and suggest further investigation. Negative symptoms were divided into two categories, interpersonal problems and avolition or apathy, and the former category was found to be associated with more internal, personal and stable attributions than the latter. It would not seem unreasonable that relatives have

particular difficulty in attributing such behaviours as walking out of the room when visitors arrive, or failure to make or respond to

conversation, to illness or other universal and external causes. As one relative commented, "it's a funny kind of illness that stops you

speaking to your family". Family surveys (eg. McElroy, 1987) have shown that patients' social deficits are particularly problematic for families. These behaviours may be explained in a different way, than for example, not washing or dressing properly or lying around on the settee or in bed all day. It is possible that lethargy or tiredness are

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associated more easily with illness than are interpersonal problems. This remains speculative, but it should at least be noted that

'negative symptoms' as a unitary concept may have more meaning to the medical professions than to the lay relative. Another interesting finding from the event comparisons was the trend for positive

symptoms to be more often attributed to personal causes than such

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events as anxiety and depression, or apathy and avolition. This

suggests that the relatives who explained behaviours associated with delusions or hallucinations were offering a different causal model to the diagnostic medical model where such symptoms are universal schizophrenic phenomena, although it has elsewhere been suggested that positive symptoms would be easier to construe in illness terms than other patient problems because of their unusualness and deviance from 'normal' behaviours (Hooley et al, 1987). The results found that positive symptoms were most salient for relatives who made more personal attributions and it is later suggested that patients of such relatives may indeed be more ill in terms of having overt florid symptoms.