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UnderstandingCross-CulturalPrognosticVariabilityforSchizophrenia.

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ARTICLE

Understanding Cross-CulturalPrognostic Variabilityfor Schizophrenia

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AMY G. WEISMANUniversity of California, Los Angeles

Research suggests that critical and negatively charged family environments cor-relate with poor prognosisfor schizophrenia across cultures. International re-search also suggests that the increasing industrial status of a country is associ-ated with a less favorable outcome for the disorder This article reviews theliterature on culture and schizophrenia. An argument is made for using an at-tribution-affect model to help identify factors that may lead to unfavorable emo-tional reactions toward individuals with schizophrenia. In addition, specific so-ciocultural values and beliefs are proposed that are hypothesized to contribute toa favorable clinical course for schizophrenia in less industrialized countries.© 1997John Wiley & Sons, Inc.- schizophrenia culture expressed emotion · attributions values ·

industrialization

Cross-cultural variability for the course ofschizophrenia has been noted for some time.Strong evidence suggests that outcome forindividuals with schizophrenia living in de-veloping societies is markedly superior tothat of individuals with schizophrenia fromindustrialized countries (Jablensky et al.,1992; K. Lin & Kleinman, 1988). Perhaps themost striking evidence for better prognosisfor schizophrenia in developing countriescomes from the World Health Organiza-tion's (1979) International Pilot Study ofSchizophrenia (IPSS). This large-scale,

multinational study found that ill individualsfrom the developing nations of Nigeria, In-dia, and Colombia have fewer symptoms andbetter functioning between episodes than illindividuals from more industrialized coun-tries such as Denmark, the United Kingdom,and the United States. Two- and 5-year fol-low-up studies reaffirmed the IPSS's originalfindings (Leff, Sartorius, Jablensky, Korten,& Ernberg, 1992).

Evidence of a better course and history ofschizophrenia in developing societies has ledresearchers to hypothesize that "cultural fac-

* Editor's Note: Renato Alarc6n, MD, served as action editor for this article.Reprint requests should be directed to Amy Weisman, Ph.D., Department of Psychology,

University of Massachusetts at Boston, 100 Morrissey Boulevard, Boston, MA 02125-3393.

Cultural Diversity and Mental Health, Vol. 3, No. 1, 23-35 (1997)© 1997 by John Wiley & Sons, Inc. CCC 1077-341X/97/010023-13

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tors" may impact the manifestation and out-come of psychotic disorders. Few investiga-tors, however, have set out to examine thespecific sociocultural characteristics that maycause differences in form, intensity, and du-ration of major psychiatric illnesses amongcountries of different developing statuses (K.Lin & Kleinman, 1988).

In this article it is proposed that a society'sbeliefs about schizophrenia influence its reac-tions toward mentally ill individuals; society'sresponse, in turn, is believed to be a criticalfactor in accounting for differences in illnessprognosis. Specifically, attributions regard-ing the cause, and controllability of psychoticillness are hypothesized to be of central im-portance in determining how members willrespond to those who are mentally ill. In addi-tion, a society's value systems and customs, in-cluding religion and kinship structure are be-lieved to guide and shape conceptualizationsof mental illness, and in some developingcountries may lead to practices that minimizestress, social stigma, and self-devaluation.

This article begins with a general reviewof a theoretical model linking attributions ofcontrol to emotional responses. Evidence isthen presented for applying an attribution-al-affect model to the study of expressedemotion (EE), a construct found to be a reli-able and valid predictor of schizophrenicprognosis. A discussion of sociocultural fac-tors proposed to account for cross-culturalprognostic variability for schizophrenia fol-lows. The article concludes with a summa-rization of the strengths and weaknesses ofthe existing research, followed by a discus-sion of clinical and research implications.

An Attributional (Controllability) Modelof Emotions

Research suggests that perceptions of one'sability to control the cause or outcome of anevent are related to the emotional reactionsthat follow (Fiske & Taylor, 1984). Weiner(1986) offered a model that calls specific at-tention to linkages between controllability

attributions and affective consequences. Spe-cifically, Weiner proposed that when pre-sented with an unpleasant event or behaviorof another person, individuals will evaluatethat person's ability to have controlled orprevented the occurrence. According to thetheory, when controllable factors are impli-cated, people are likely to respond to the per-son with negative emotions such as angerand dislike, and in turn, antisocial responses.Correspondingly, when the same event or be-havior is perceived as outside the perpetra-tor's personal control, people are expectedto respond with positive emotions such assympathy, pity, and prosocial behavior.

Some evidence for applying an attribu-tion-affect model to the study of psycho-pathology comes from research on a con-struct known as expressed emotion. EE is ameasure of attitudes of a close relative towarda mentally ill family member. Specifically, theconstruct assesses critical and hostile com-ments and evidence of emotional overin-volvement (e.g., exaggerated affect, overlyself-sacrificing behavior; Jenkins & Karno,1992). Studies conducted over the past fewdecades consistently indicate that individualswith schizophrenia who return from the hos-pital to live with relatives who talk aboutthem in a critical, hostile, or emotionallyoverinvolved way (high-EE) during a semi-structured interview suffer elevated relapserates in comparison with individuals whoserelatives do not express these negative atti-tudes (low-EE; for a review, see Kavanagh,1992). Some data suggest that the associationbetween high relapse rates for mentally illindividuals from families with emotionallyoverinvolved relatives, characterized as ex-pressing overprotective attitudes and exces-sive concern, may be a function of these in-dividuals having poorer premorbid historiesand more severe symptomatology (Miklowitz,Goldstein, & Falloon, 1983). The same doesnot hold true for ill individuals from theother two subtypes of high-EE. Researchersconsistently fail to find differences in severi-ty of residual symptoms and/or level of pre-morbid functioning between ill individuals

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CULTURE AND SCHIZOPHRENIA

from low-EE families and those from high-EEfamilies, defined by highly critical or hostileattitudes (Kavanagh, 1992).

A few investigators have alluded to therole of families' attributions or explanationsof their relative's disorder in order to helpunderstand the psychological processes thatunderlie certain relatives' high-EE criticaland hostile attitudes. Hooley (1987) specu-lated that high levels of EE in relatives maybe interpreted within an illness framework.High-EE attitudes (based on critical com-ments) are hypothesized to develop whenrelatives perceive that the symptoms are notthe result of a legitimate illness and are, atleast to some degree, controllable by the illindividual. High-EE relatives will thus be in-clined to nag and criticize the ill family mem-ber in an attempt to modify undesirable be-havior. Hooley speculated that ill familymembers who are criticized often may besubjected to higher levels of stress, hence in-creasing the probability of relapse.

Hooley (1987) hypothesized that low-EErelatives also make attributions about the dis-order in a way consistent with a medical mod-el. Low-EE relatives are hypothesized not tohold mentally ill individuals responsible fortheir bizarre behavior because it is perceivedas the inevitable side effect of a genuine ill-ness. These relatives are thus thought to re-spond to the schizophrenic symptomatologywith patience and understanding. More pos-itive reactions by relatives would reasonablybe associated with a more stable and "men-tally healthy" environment, correspondingwith less stress.

Some qualitative data offer indirect sup-port for Hooley's (1987) theory. Leff andVaughn (1985), for example, noted differingattitudes toward the legitimacy of the illness,and differing expectations for the ill individ-ual's functioning between low-EE and high-EE relatives. The authors observed that low-EE relatives tended to attribute the cause ofabnormal behavior to a genuine illness, cou-pled by respect for the afflicted family mem-ber's feelings and perceptions when ill. Incontrast, the authors observed that high-EE

relatives frequently questioned or deniedthat the family member was genuinely ill.These relatives were generally intolerant ofcomplaints of illness and repeatedly engagedin confrontations with the ill family member.Jenkins, Karno, de la Selva, and Santana(1986) reported observing similar differ-ences in attributions toward illness betweenhigh-EE and low-EE relatives in a sample ofMexican Americans.

A few recent studies offer more direct sup-port for the view that attributions of controlare related to EE. Three sets of researchers(Barrowclough, Johnston, & Tarrier, 1994;Brewin, MacCarthy, Duda, & Vaughn, 1991;Weisman, L6pez, Karno, & Jenkins, 1993)found that low-EE relatives made less con-trollable and less personal (rather than uni-versal) attributions for their ill family mem-ber's behavior than did high-EE relatives(designated by high levels of criticism). In ad-dition, Weisman et al. found that attributionsheld by relatives were related to their affectivereactions. Specifically, relatives who per-ceived the ill family member as having controlover the symptoms of schizophrenia tendedto express greater negative emotions such asanger and annoyance toward the individualthan did relatives who viewed the symptomsas beyond the individual's personal control.

The preceding observations support theview that attributions play an important rolein the development of high-EE attitudes. Inaddition, the Weisman et al. (1993) findingsconducted with a Mexican American sample,together with the findings of Brewin et al.(1991) and Barrowclough et al. (1994) con-ducted with British samples, suggest that theattributional model may have cross-culturalrelevance in understanding the EE construct.

EE, however, is inherently socioculturaland qualitative in nature. The construct in-dexes a wide array of behaviors, emotions,and attitudes that are part of an individual'scultural repertoire, developed throughprocesses of socialization (Jenkins & Karno,1992; Jenkins et al., 1986). Not surprisingly,some variability has been found in the pro-files of EE families across cultural groups.

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Culture and EE Culture and Mental Illness

Jenkins et al. (1986) have observed markeddifferences in percentages of high-EE fami-lies between Mexican American and Anglo-American key relatives for a matched sample.For Mexican American key relatives, the ma-jority (69%) were rated as low-EE. For Anglo-Americans, on the other hand, the majoritywere rated as high-EE, with only 33.8%falling in the low-EE category. The differ-ences in percentages of high-EE families be-tween Mexican Americans and Anglo-Amer-icans seems to parallel qualitative dataregarding the attributions that the two groupsmake for their ill family member's disorder(Jenkins et al., 1986). On the whole, Mexi-can Americans were noted as much morelikely to view the problem as one of illnessthan were Anglo-Americans, irrespective ofEE status. Jenkins et al. also reported quali-tative differences in the emotional reactionsto the disorder between these two groups.For Mexican Americans, the most common-ly conveyed emotional reactions toward theillness were feelings of sadness, sorrow, andpity. Although Anglo-Americans also report-ed feelings of sadness (especially those low inEE), they occurred less frequently than othermore negative emotions such as anger andannoyance.

The observations byJenkins et al. (1986)and other cross-cultural researchers (e.g.,Waxler, 1979) suggest that there are differ-ences in perceptions of an individual's con-trol over schizophrenia across cultures. How-ever, previous investigations have generallyneglected to examine why different culturalgroups come to different conclusions re-garding the causes of mental illness and in-dividuals' abilities to exert control over theassociated symptoms. Identifying specificsociocultural values and beliefs that shapecultural views of psychopathology may helpelucidate important factors underlying themore favorable emotions expressed towardmentally ill individuals in developing soci-eties.

It is generally assumed that most beliefs andattitudes are acquired through our cultureand reflect experiences with our proximalenvironment. Not surprisingly, an individ-ual's beliefs about the world also affect whatinferences are made about the behaviors ofothers (Read & Miller, 1989). In this sectionit is proposed that sociocultural variations inreligion, spiritual beliefs, and kinship struc-tures shape a society's view of psychopathol-ogy and its members' emotional reactionstoward their mentally ill members.

Religion and the Supernatural

For many ethnic groups religion and spiritu-alism offer a culturally sanctioned explana-tory model for understanding illness, and forinfluencing attitudes and feelings towardindividuals suffering from mental disorders(Bach-y-Rita, 1982; Rogler, 1989). Among thepredominately Catholic Latino societies, forexample, the will of God is frequently in-voked as the cause of events, including men-tal illness and suffering (Bach-y-Rita, 1982;Lefley & Pederson, 1986). Many Latinos alsointegrate elements of native religions withChristianity. This process is termed syncretism(Gualtieri, 1984, p. 93). Thus, rather than re-ferring to psychiatrists or psychologists whenfirst presented with mental illness, some Lati-nos may consult indigenous healers insteadof, or in addition to, Catholic clergy (Creson,cited in Ruiz, 1982; Wintrob, 1977) althoughEdgerton, Karno, and Fernandez (1970) andPadilla, Carlos, and Keefe (1976) cautionedthat the numbers of Latinos who utilize tra-ditional healers may be overestimated.

A mention of curanderos (Mexican folkdoctors) and espiritistas (spiritual healers)and their specific treatments is relevant tothis discussion, because it is thought to be areflection of core Latino values including be-liefs about mental illness and their causes.Religion is the central focus of folk healers(Kiev, 1968): Afflicted individuals are taught

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to view illness and suffering in a holistic fash-ion, including spiritual, physical, emotional,and social factors (G. Canino & I. Canino,1982; Comas-Diaz, 1992; Ho, 1987).

One philosophical orientation that is re-portedly common among Latino groups andencouraged by folk healers is fatalism (San-doval & de la Roza, 1986). The fatalisticstance presupposes the existence of super-natural and external forces that unpre-dictably interfere in human affairs. WhereasCatholicism, fatalism, and folk teachingsseem to encourage resignation and passivity,and may discourage efforts to change theworld, they also provide a sense of security,acceptance, and comfort for the patient andhis or her loved ones. It has been suggestedthat one function of folk healing is to preventthe labeling of the participant as crazy, be-cause the spiritualist session has created apermissive group setting wherein all abnor-mal behavior is given meaning and is madeacceptable (Gomez, 1982). When a halluci-nation or other unusual behavior can belinked to religious beliefs and the supernat-ural, it may minimize its impact on the fami-ly because it is viewed as a more normal andnoble expression of distress (Torrey, 1970).

Folk healers and Catholic clergy, in gen-eral, encourage Latinos to believe that an-other's suffering is symbolically their own. Inaddition, the acceptance of things one can-not control, espoused by fatalism, psycholog-ically and culturally prepares people for life'suncertainties (Kiev, 1968). This belief systemsupports the perception that there is no pro-tection against adversity and that anythingthat happens to others can also happen tooneself. It would seem that this externallocus of control perspective might impressLatinos with the need to be more compas-sionate, understanding, and tolerant of oth-er people's failures, such as mental illness.This orientation may be one of the factors ac-counting for the low levels of anger and hos-tility elicited by Mexican American familieswhen presented with schizophrenic relatives(Jenkins et al., 1986).

Observations of Samoan folk knowledgeof mental disorder as described by Clement(1982) parallel many of the Latino folk be-liefs discussed here. Using traditional ethno-graphic approaches, Clement found thatSamoan representations of mental disordersare heavily influenced by the belief that men-tal conditions are due to spirit possession.The traditional view is that a spirit may takepossession of a person's body and cause themto behave strangely. Clement suggests sever-al latent functions of the Samoan system forresponding to mental illness. The victim gen-erally is not held responsible for disturbedbehavior and thus can vent emotions andanger by acting out occasionally, with onlybenign punishment such as apologizing to adeceased ancestor. This may serve as a safetyvalve for the individual and his or her family.Once the individual "regains control" and isrestored to health, he or she can resume anormal position and social role. In line withthe ideas put forth here, Walters (1977) sug-gested that Samoan conceptualizations of,and reactions toward, mental illness likely ac-count for the discrepancy between the ex-pected rate of mental illness in the countrybased on population, and the comparativelylow rate of actual cases of mental illness di-agnosed in Samoa.

Research conducted in Bali (Connor,1982) suggests that Balinese views of mad-ness also center around supernatural forces.As in Samoa, belief that madness is due to anancestral or divine curse is commonplace inBali. When this occurs, the precipitating fac-tors are usually attributed to the neglect of animportant ritual by the family or mistakes ina ritual already completed. Hence the blameis typically diffused or diverted. Connor alsoreported that with Balinese folk healers, in-dividuals seemed to recover quickly, afteronly a short course of traditional treatment.Unlike established Western psychiatric andpsychological techniques, there the diagno-sis orients directly to a culturally construedcause of the disorder. The therapy is also rel-evant and sensitive to Balinese values and be-

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liefs. For example, the healing rituals in Baliare preformed under the guidance of a trust-ed folk healer and include the family (themost central and important unit in Balineseculture) in all stages of the preparation andperformance.

Like Latino, Indonesian, and South Pa-cific societies, in Vietnamese and Chinesethought there is also a strong belief that allextents have a place within a supernaturallogic, and any unexplained affliction like psy-chosis is attributed to uncontrollable, super-natural causes. In some traditional Asianfamilies, behaviors that would likely be con-sidered psychotic in some Western culturessuch as talking to deceased relatives and be-lieving that their spirits guide one's behavioris not only condoned, but may even be con-sidered respectful of past generations (Yee &Hennessy, 1982).

Beliefs about supernatural forces haveimportant implications for the attribution ofresponsibility and punishment. In Samoa, forexample, delirious behavior that is seen asthe result of possession by an angry ancestralspirit is treated by spirit healers, and the ill in-dividual is exempt from blame. On the otherhand, if possession is doubted, the afflictedperson is regarded as responsible and mayeven be beaten as a result (Clement, 1982).Similarly, erratic behavior by a child fromBali may be tolerated if it is perceived as themanifestation of personality traits of an an-cestor reincarnated in the child (Connor,1982), otherwise the child would be severelycastigated.

Waxler (1984) purported that becausebeliefs about mental illness center on super-natural causation in many developing soci-eties, the person is not held responsible forhis or her illness. Hence, the "self' remainsunchanged and the person is able to shed thesick role quickly and easily. In contrast, wherepsychiatric illnesses are believed to involvepersonality change and personal responsibil-ity, individuals receive many messages thatsomething is seriously wrong; consequently,their perception and behavior may conform

to those messages and the corresponding ill-ness may have a long duration.

The Role of Family and Communityin Illness Prognosis

In an analog study using vignettes of an in-dividual described to meet the DSM-IVcrite-ria for schizophrenia, Weisman and L6pez(1996) recently found that family cohesionwas correlated with emotions toward schizo-phrenia. In that study, research participantswho perceived their own families as cohesiveand supportive expressed more intense posi-tive feelings and less intense negative feelingstoward a hypothetical family member withschizophrenia. One explanation for this find-ing may be that individuals with strongfamilistic identities perceive a family mem-ber with schizophrenia as less responsible forhis or her condition in order to preserve thesolidarity of the family. In line with an attri-bution-affect model, this view might lead tolow-key supportive environments in familis-tic societies, as well as other behaviors thatmight aid in the recovery process. Familieswho view the cause of their relative's illnessin a more benign and less blameworthy fash-ion may be more willing to help him or herin an instrumental sense. In addition to of-fering more affective support, these familymembers may also be more amenable to pro-viding the relative with financial assistance,advice, or help with activities of daily living.

There is general agreement in the litera-ture on Mexicans and Mexican Americans ofa strong basic value orientation toward inte-gration, intimacy, and enduring relation-ships within the family unit (Edgerton &Karno, 1971). Escobar and Randolph (1982)reported that in the Mexican American cul-ture there is often an unwillingness to aban-don a relative, even in the most disruptive orsevere cases. Jenkins (1981) has observedthat Mexican American families will go togreat lengths to interpret even schizophrenicbehavior in a positive or impartial light. Inone instance,Jenkins reported an incident in

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which a Mexican American mother was re-lieved that her son was happy again-afterseeing him laughing and talking alone. An-other example is the use of the term nervios(nerves) to explain illness behavior. Accord-ing toJenkins (1988a, 1988b), this euphemis-tic label protects the ill family member fromthe stigma of mental illness, and facilitatesmaintaining him or her at home.

Several investigators have also reportedthat, in the Latino community, there is astrong pressure to solve most problems with-in a family context (Jaco, 1959; Madsen,1964). Edgerton and Karno (1971) foundthat Mexican Americans believe that re-maining with the family would be most likelyto lead to recovery, whereas Anglo-Ameri-cans generally reported seeing no benefit tohaving a mentally ill person remain with thefamily. The fact that Mexican Americans areunderrepresented as psychiatric patientsproportional to their numbers in the UnitedStates (Padilla, Ruiz, & Alvarez, 1975; Pokor-ney & Overall, 1979) appears to add supportto this hypothesis. Given this distinctive pop-ulation's burdens of migration, prejudice,and poverty, speculations about the structur-al and functional aspects of Latino social net-works appear to be in order. The family's sup-portive atmosphere likely exerts a protectiveinfluence against psychopathology.

G. Canino and I. Canino (1982) noted thatamong some Latinos illness is perceived as afamily affair and thus requires a family inter-vention for its cure. Kiev (1968) observed thatMexican American family and friends activelyparticipate in the treatment of ill family mem-bers. Sickness is said to be taken very seriouslyand the sick are offered support and excusedfrom their usual social responsibilities andfrom their obligations to adhere strictly tonorms. The supportive treatment individualsreceive, the reduction of responsibly, and thefamily's help in decision making when ill, mayall play a role in the favorable course observedfor Mexican Americans with schizophrenia.

Like many Latinos, the tradition of mostAsian and Pacific cultures also places great

emphasis on the family (rather than the in-dividual) as the central unit. Japanese fami-lies are also believed to have a strong moralcode to care for their ill. Munakata (1989) re-ported that even when alternatives are read-ily available,Japanese rarely leave their men-tally ill to the care of psychiatric hospitals.Chinese American families also tend to putoff psychiatric treatment and hospitalization.T. Lin and M. Lin (1978) found that, relativeto Caucasians, Chinese American familieswere much more likely to resort to intrafa-milial coping. S. Sue and Morishima (1982)suggested that one reason for the favorablemental health generally reported for Asiansis that family ties enable the individual toshare problems, to have affective needs satis-fied, and to have a sense of belongingnessand community.

In Far Eastern societies the pressure re-quiring Asian families to look after their sick(including the mentally ill), sometimes ex-tends beyond the social arena (Munakata,1989). UnderJapan's Mental Health Acts, forexample, guardians (usually families) are re-quired to have their sick members receivetreatment, to supervise them so that they willnot injure themselves, and to help managetheir assets. Professionals also frequently at-tempt to ease the family's emotional burdenof caring for an ill loved one by purposely dis-guising certain severe or stigmatizing disor-ders. In Japan, for instance, psychotic disor-ders are often disguised as neurasthenia byphysicians. This term is similar to the Mexi-can American concept of nervios. Likenervios, neurasthenia is considered to be a"legitimate" and curable illness of the ner-vous system; hence, neurasthenia labels re-duce family culpability and allow ill individu-als to adapt to the normal sick role withoutthe stigma of mental illness.

Waxier (1984) reported that in Sri Lankaand Mauritius (countries demonstrating acomparatively mild course for schizophre-nia), mental illness is also associated with arelative lack of stigma, close family involve-ment, and reasonable expectations of re-

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sponsibility in the community for the afflict-ed person. Lefley (1987) and Waxler bothcontended that developing countries offergreater availability of meaningful roles in thefamily and community, as well as unbur-dened love. Less technologically advancedsocieties can provide occupational choicesand roles for the ill individual that can beadapted to realistic expectations of perfor-mance, and that do not necessarily insult for-mer levels of aspiration. For the most part,there are no artificially createdjobs in agrar-ian societies, as in many Western vocationalrehabilitation projects, which the individualmay recognize as below his or her compe-tence level. In developing societies the ill in-dividual is generally able to return quickly tovillage life and to relatively normative occu-pational roles, with flexible demands gearedtoward his or her level of capacity.

Lefley (1987) further maintained thatthis circular reinforcement pattern strength-ens the coping resources of both the indi-vidual and the family. Offering realistic,low-expectancy but normative occupationalroles likely gives the individual a niche inthe community, enhancing his or her self-esteem, and reducing dependency on thenuclear family. Freed from the nagging bur-dens of support and attention, the family maybe better able to respond with unhamperedcaring.

Returning to the discussion of expressedemotion, the finding of a lower prevalence ofhigh levels of criticism and hostility amongfamilies of both developing countries andtraditional ethnic groups in the UnitedStates, lends additional support to the hy-pothesis that intrafamilial behaviors may ac-count for different schizophrenic outcomesin different cultures. Leff (1981) proposedthat the extended family structures commonin developing countries may serve to dilutethe deleterious effects of high-EE. Specifical-ly, he argued that in developing countrieswith large extended networks, individuals areless likely to be alone with any one particularperson in the family; thus, the deleterious ef-fect of a critical or hostile relative may be at-

tenuated by more supportive interactionswith other family members.

In line with Leff (1981), Lefley (1987)suggested that extended kinship networkscharacteristic of developing countries pro-vide a qualitatively larger support system tothe ill individual and family. This, Lefley be-lieved, assists in both physical and psycho-logical survival. By sharing the burden ofcaretaking, attention giving, and housing,the family is better able to sustain low-EE,genuine concern, and greater tolerance ofaberrant behavior. In contrast, the typical in-dustrialized family in the United States is typ-ically nuclear. Given this arrangement,Lefley maintained, it is almost impossible tocare for physically or psychologically dis-abled family members at home. With twoadults at most to take roles of major respon-sibility in the home, there seems to be littlemargin for "shock absorption."

There is also much support for the notionthat friends and family network systems havea preventative or curative role in the com-munity. For example, El Islam (1979) re-ported that ill individuals living with their ex-tended families (as is customary in manytraditional societies) fare better on follow-upthan those residing with nuclear families. Inaddition, results from a 2-year follow-up ofindividuals included in the IPSS indicatethat social isolation, and widowed, divorced,or separated marital status are associatedwith a poor schizophrenic outcome (Sarto-rius,Jablensky, & Shapiro, 1978). In develop-ing societies the divorce rate is generally low-er than in industrial countries, and extendedkin networks are much more frequent.

Together these findings suggest that fam-ily/community prognostic differences forschizophrenia among individuals from coun-tries of different developing statuses. It islikely that greater protection available fromnaturally occurring social support systemssuch as extended kinship networks and intactmarriages characteristic of developing coun-tries, may serve as a bastion to protect ill in-dividuals from the consistent stresses of ad-justing to a debilitating illness. Jaco (1959)

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hypothesized that a strongly rooted orienta-tion of familism provides a closely meshedpsychosocial support network that protectsits members against the development of, ordestruction from, psychotic disorders. Hence,a familial attitude of acceptance toward thedisorder coupled with involvement and assis-tance toward the individual might help ex-plain the benign outcome for some culturalgroups.

Conclusion and Future Directions

This article provided a review of numerousstudies and reports with an eye toward un-derstanding cross-cultural prognostic vari-ability observed for schizophrenia. The liter-ature provides evidence that, compared to illindividuals in industrialized societies, indi-viduals with schizophrenia in developingcountries have a more favorable clinicalcourse. My thesis is that in developing coun-tries a social ambience that externalizes cau-sation, stresses mutual family interdepen-dence rather than independence, and allowsfor realistic expectancies regarding ill indi-viduals' performance may result in more sup-portive and healthful family relationships,and consequently, better illness prognosis forrelatives suffering from schizophrenia in de-veloping societies.

Several implications for treatment emergefrom this review. Given that family involve-ment seems to play a curative role for schizo-phrenia in developing cultures, collaborat-ing with family members and enlisting theminto the treatment process may enhanceWestern psychosocial treatments for schizo-phrenia. Intervention programs specificallygeared toward fortifying family members'perceptions of group spirit, unity, and cohe-sion may be one effective means of bufferingthe effects of schizophrenia in the industri-alized West. In addition, the findings relatingrelatives' controllability attributions to theiremotional reactions toward mental illnesssuggest that psychoeducational programsaimed at reframing beliefs regarding the

causes and controllability of schizophreniatoward external factors (e.g., biology, envi-ronmental stress) may be beneficial in re-ducing critical and hostile emotions knownto have a deleterious effect on individualssuffering from schizophrenia.

It is important to address one final point:A few researchers (i.e., Edgerton & Cohen,1994; S. Sue, D. W. Sue, L. Sue, & Takeuchi,1995) have suggested that what appears to bebetter mental health in developing countriesmay actually be an artifact of other factors.Edgerton and Cohen, for example, pointedout that limited resources and inaccessiblepsychiatric facilities may lead to reducedpublic awareness of the extent of psychiatricproblems in developing societies. Similarly,S. Sue et al. suggested that the widespreadnotion of Asian Americans as an emotionallywell-adjusted group may not reflect reality. S.Sue et al. suggested that attempts to deter-mine the exact prevalence rates of mentaldisorders may have been hindered by "non-cultural" characteristics of Asian Americans,such as relatively small sample size, hetero-geneity, and rapid changes in demographics.To date, much of the research regarding theeffect of culture on psychopathology hasbeen anecdotal and qualitative in nature.This research is useful for generating hy-potheses. However, before we can replacethe guesswork with substantive informationregarding the role that culture plays in men-tal illness prognosis, empirical and epidemi-ological studies are needed that operation-alize and directly assess specific sociocul-tural variables hypothesized to influence thecourse of mental illness. Economic and oth-er practical issues that may minimize aware-ness of psychiatric problems in some culturesmust also be carefully examined.

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