symbiosis and confirmation between the parents of the schizophrenic

Fam Proc 20:319-330, 1981

Symbiosis and Confirmation Between the Parents of the SchizophrenicFrank Summers, PH.D.a

Froma Walsh, PH.D.b

aDirector, Research and Training, Institute of Psychiatry, Northwestern Memorial Hospital, and Assistant Professor, Department ofPsychiatry and Behavioral Sciences, Northwestern University Medical School, Chicago, Illinois 60611.bCenter for Family Studies, Institute of Psychiatry, Northwestern Memorial Hospital, and Assistant Professor, Department of Psychiatryand Behavioral Sciences, Northwestern University Medical School, Chicago, Illinois.

Parents of schizophrenics (N = 17) were compared with parents of nonschizophrenic hospitalized patients (N = 14)and parents of normals (N = 15) on the degree of symbiotic enmeshment and confirmation of individuality in theparental relationship. Symbiosis was divided into six component variables: undifferentiation, dependency, intervention,disapproval of other relationships, separation difficulty, and injunctions. Confirmation was bifurcated intoacknowledgment and accommodation. Projective tests (TAT and Make-A-Picture-Story) and interviews were used tomeasure both variables. The results suggest that mothers of schizophrenics tend to be symbiotically attached to theirhusbands and view their husbands as forming the same type of attachment to them. Fathers of schizophrenics do nottend to be symbiotically involved with their wives but fail to confirm them. The implications of the results for the familysystem of the schizophrenic are discussed.

Despite current focus on genetic and biochemical determinants in the etiology of the schizophrenias, the search forunderstanding of the family constellation continues. Although evidence for genetic determinants exists (3), such factorscannot by themselves explain the appearance of schizophrenia. Previous studies have found evidence that the relationshipsbetween each parent and the schizophrenic young adult are markedly different from the relationships between other youngadults (both mentally ill and normal) and their parents (10, 11). The mother-schizophrenic relationship appears to becharacterized by a symbiotic bond, whereas the father evinces a failure to accommodate to his schizophrenic offspring. Thenature of the evidence suggests that these characteristic relationships between parents and schizophrenic may play acausative role in the onset of the latter's illness. These findings raise the question of what the nature of the relationshipbetween the two parents may be. If each parent is engaged in a particular form of difficult relationship with theschizophrenic, one may wonder to what degree these characteristics may imbue the relationship between the parents.

Although research on families of schizophrenics has focused on the relationships between parents and the ill offspring,previous efforts have been made to characterize the mother-father relationship. Perhaps the most well known of thesecharacterizations is Lidz' dual typology of "schism" and "skew" (5). The "schismatic" marriage is conflictual, with neitherpartner maintaining dominance. In the "skewed" relationship, one partner is clearly dominant and the other, dependent.According to Wynne (12), a "pseudomutual" relationship may obtain in which the parents give the appearance ofcooperation to mask the hostility and conflict between them. Role conflict has also been found to pervade all members ofthe family of the schizophrenic (4, 7). Fleck (1) has stressed the role rigidity of such families. Wynne (13) suggested theconcept of the "rubber fence" to describe his observation that the family boundaries of the schizophrenic do not allow forseparation.

These observations suggest that the relationship between the parents of the schizophrenic may be marked by a rigidity ofexpectations. Furthermore, previous reports of the mother-schizophrenic and father-schizophrenic dyads (10, 11) raise thequestion of the extent of fusion and recognition of differences in the mother-father relationship. The evidence previouslyreported concerning this relationship would fit with a symbiotic, nonconfirming relationship but do not necessarily implythat such is the case.

These reports suffer from their reliance on informal observation. The current study attempted to determine the extent ofsymbiosis and confirmation in the relationship of the parents of the schizophrenic in an objective, verifiable manner. It thusseeks to complement previous reports that attempted this task for the mother- and father-schizophrenic dyads (10, 11). Bymeasuring the degree to which the characteristics previously found in the mother- and father- schizophrenic dyads obtain inthe mother-father relationship, the current study completes a systematic investigation of the degree of differentiation in thefamily system of the schizophrenic. The current study thus adds new understanding to the previous findings regarding theparent-schizophrenic dyads by indicating what the parental relationship is like while each parent is engaged in his or herunique relationship with the schizophrenic patient.

Following the previous studies (10, 11), the concepts of symbiosis and confirmation were operationalized into testablecomponent variables and measured on both projective tests and interviews. Mothers and fathers were investigated withboth modes of measurement and compared with two control groups, one consisting of nonschizophrenic mental patients

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and the other of the parents of normal young adults. The perceptions of both members of the mother-father dyad wereelicited for both sides of the relationship.

"Symbiosis" is defined here as it was in the previous studies: a dyadic relationship in which two parties do not feelthemselves to be separate, distinct individuals (10, 11). Each person perceives the other as part of his or her own being. Apartner in a symbiotic relationship is dependent upon the other and is likely to be threatened by attempts at independence bythe other, possibly to the point of taking action against this tendency. Thus, six characteristics of symbiotic relationshipshave been defined previously (9):

1. Undifferentiation: Difficulty in distinguishing one's own desires, views, and interests from those of the other, asevidenced by resistance to perceiving the other as different or by the presumption that whatever is true of oneself istrue of the other.

2. Dependency: Need for the other to do or be something for one; it may be a direct request for help, advice, or comfortor be indirectly expressed in subtle threats to the other's independence.

3. Intervention: Acting for the other who is seen as in need of one's help in making decisions or in functioning; takingresponsibility for the other's well-being by attempting to solve the other's problems.

4. Disapproval of other relationships: Resistance to outside relationships to the point of expressing discomfort,anxiety, or depressionor even to interfering overtly with friendships.

5. Separation difficulty: Intolerance of the ending of the relationship or of temporary separations, expressed bynegative reactions that may involve discomfort, anxiety, depression, or any difficulty in functioning without the otherperson.

6. Injunctions: Expectations of the other to be or act in a given manner; demands that the other fulfill one's desires.(The demands tend to be rigid and do not change according to circumstances).

"Confirmation" refers to a relationship in which each person recognizes and accommodates to the viewpoint of the other.The parties to the relationship are able to recognize the other's differences for what they are and make accommodations tothem without giving up their own viewpoints. Accordingly, "confirmation" has been bifurcated into two componentvariables (11):

1. Acknowledgment: Recognition of what the other thinks, feels, or says, as evidenced by empathy and respect for theother's views, or simply by any indication of listening to the other.

2. Accommodation: Adaptation of one's own behavior in accordance with the other's desires and needs. It includes anytype of doing for the other, such as the giving of advice, support, or nurturance, provided it is in accordance with thewishes of the other.

Method

SubjectsEach family met the following criteria: (a) child between 18 and 26 years of age; (b) presence of a functional psychiatric

disorder in the child; (c) willingness to participate; (d) ability of the patient to participate; and (e) intact family. The patientswere at Michael Reese Hospital (N = 29) or Illinois State Psychiatric Institute (N = 2) and were seen toward the end oftheir hospitalization. The first seventeen families of patients with a diagnosis of schizophrenia composed the ExperimentalGroup Families (EGFs), and the first fourteen families of patients with functional non-schizophrenic disorders made up theHospitalized Comparison Group Families (HCGFs). For the EFGs, 9 index subjects were males, and 8 were females. FiveHGGF index subjects were males and 9 females. Average educational level was 14 years for the EGFs and 13.6 for theHGGFs. Index subjects averaged 22.4 years of age for the EGFs, and 22.0 for the HCGFs. Fathers of both groups wereemployed predominantly in professional and white collar occupations.

Diagnosis of the patient offspring (Table I) were derived from the larger project and were determined on the basis of apsychiatric interview involving a discussion of symptoms, reasons for hospitalization, course of the disorder, and a briefreport of personal and family history; hospital records were also reviewed and the final determination made by three trainedclinicians. Average length of hospitalization was longer for schizophrenics (150 days) than for nonschizophrenics (101days), but lengthy for both groups.

Table 1Diagnoses of Patients

SCHIZOPHRENICS

Acute 2

Chronic 8

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Acute-chronic 1

Schizo-affective 2

Paranoid 4

Total 17

NONSCHIZOPHRENICS

Depression 7a

Manic-depressive 1

Adolescent adjustment reaction 1

Narcissistic character disorder 1

Sociopathic character 2

Borderline personality 2

Total 14* Four suicidal

The Normal Comparison Group Families (NCGFs) were 15 intact families who responded to an advertisement and whohad a child between 18 and 26 years of age with no history of emotional disorder and a MMPI profile between the 50th and70th percentiles. Seven index subjects were males; 8 were females. Average educational level was 13.5 years. NCGF indexsubjects averaged 20.8 years of age. Fathers were employed predominantly in professional and white collar occupations.

Mothers in all three groups had an average age of about 49 years; fathers in the EGFs, 53 years; and about 50 years inthe other two groups. As judged by the Hollingshead-Redlich Index of Social Position (2), all families were middle class.Consequently, the findings may not be applicable to other socioeconomic groups.

There were no significant differences between groups on any demographic variables.

MeasuresThe projective measures consisted of TAT cards 2 and 10 and a scene from the Make-A-Picture Story (MAPS) (8)

constructed for the study. The MAPS scene consisted of a backdrop of a living room with a door open and three figuresstanding in front; a "brash young man" gesturing furtively outside stands between an older man with his hands in hispockets and an older woman with one hand to her face.

Each of the three scenes contained one older-woman-older-man relationship, designated "mother-father" for the purposeof the study. All variables were scored "present" or "absent" on each side of the relationship. The three "mother-to-father"scores for each variable were summed to produce the score for that side of the relationship, and the same operation wasperformed on the opposite side of the dyad.

For purposes of computer feasibility and scoring ease, possible scores ranged from 2 to 5. If a variable was not presenton any of the three "mother-to-father" scenes, it received a score of 2. Each scene in which a variable was scored "present"increased its score by one point to a maximum of five for a variable depicted on all "mother-to-father" or "father-to-mother"dyads. The summation of all symbiosis variable scores produced a Total Symbiosis score for each side of the mother-fatherrelationship.

Before presentation of each projective battery, the Murray (6) TAT instructions were read.The second instrument was an open-ended interview. Each parent was interviewed separately and asked the following:

So that I may get an idea of the relationship between (mother) and (father), please describe this relationship as(index subject) was growing up. How did you two feel about and act toward each other?

Those aspects of symbiosis and confirmation not mentioned spontaneously were asked for. The interview data werecoded on a scale of 1 to 5.

A two-coder system was used. One coder listened to the tape of each interview and listed all the remarks pertaining toeach "half-dyad" variable, omitting references that would indicate identity or diagnosis. A second rater, using thosecomments, assigned the numerical value to each half-dyad variable.

CodingDefinitions of the components of symbiosis and confirmation delineated above served as guidelines for the coding. For

projective coding, however, additional distinctions were made:

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1. Intrusiveness-Behavioral: Evidence of acting for the other, taking responsibility for solving the other's problems.Intrusiveness-Nonbehavioral: Feeling that the other is in need of one to function, without sign of overt interference;concern about the other's ability to function independently, including worries or expressions of fear but not action.

2. Separation Difficulty for Self: Concern for one's own ability to get along after separation and expression of concernfor one's own well-being in response to separation. Difficulty for Others: Expression of concern for other's ability toget along following separation, including worry about the other's safety and security.

3. The category of Injunctions was measured by coding both Injunctions and their fulfillment. Injunctions: Anyexpressed expectations for the other to behave in a given manner, including proscriptions or prescriptions for theother. Injunctions Fulfilled: Carrying out the other's injunctions.

These three distinctions, along with the Total Symbiosis score and the original six component variables, yield a total of10 symbiosis variables that combined with the two Confirmation variables and Total Confirmation score, result in 13dependent variables in the projective data, each of which was scored on both sides of the mother-father relationship for atotal of 26 variables.

The symbiosis scoring was based on a manual that defines the scores for each variable (9). Data on confirmation werescored by use of a similar manual.1

ReliabilityOf the 138 protocols collected for the total family study, a random sample of fourteen were coded blindly by two raters to

establish interrater reliability. For the projective tests, there was agreement on 91.6 per cent, with rates varying from 80.2per cent to 100 per cent. For the interviews, the coefficients of correlation ranged from .79 to .94 except for Dependency,which had a coefficient of correlation of only .52, rendering this category unusable for interview coding.

Intercorrelations of VariablesThe correlations of the nine component measures of symbiosis on the projective tests varied from .04 to .47, and

three-fourths (12 or 16) were between .21 and .39. The five measures of symbiosis on the interviews ranged from .31 to.56. The two confirmation measures correlated .59 on the projective tests and .57 on the interviews. The componentvariables of both symbiosis and confirmation are sufficiently independent of each other to justify their treatment as separatevariables.

Results

Interviews

Mothers. Of the twelve symbiosis variables in the interview data, three clearly distinguished mothers of schizophrenicsfrom both other groups of mothers. As shown in Table II, for the father-to-mother side of the relationship, Intrusiveness andTotal Symbiosis were significantly more prevalent in the protocols of mothers of schizophrenics compared with the othertwo groups, and Expectations was nearly so. Mothers of schizophrenics, more than other mothers, perceived their husbandsas intrusive and likely to be symbiotically involved with them in some way. Mothers of schizophrenics also tended toperceive their husbands as expecting more of them than other mothers did. As to their own side of the relationship, TableIII indicates that mothers of schizophrenics were clearly differentiated from other groups on Total Symbiosis but not on anyparticular component of symbiosis. Mothers of schizophrenics saw themselves as more likely than other mothers to formsome type of symbiotic attachment to their husbands.

Table 2Symbiosis in the Interviews for Father to Mother: Mothers

Group

Experimental Group Families Hospitalized ComparisonGroup Families

Normal Comparison GroupFamilies

Variable F-Ratio

Mean S.D. Mean S.D. Mean S.D.

Dedifferentiation 1.54 1.00 1.73 1.36 1.23 0.80 0.62

Intrusivenessa 2.39 1.60 1.73 1.29 1.00 0.00 4.14*

Separations 1.23 0.80 1.36 0.77 1.23 0.80 0.10

Other Relationships 1.23 0.80 1.00 0.00 1.00 0.00 0.92

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Expectations 1.54 1.00 1.00 0.00 1.00 0.00 3.14

Total Symbiosisb 8.17 2.70 6.82 2.59 5.46 1.60 3.88** p < .05a t-test between EGF and NCGF= 3.00, p < .05; t-test between EGF and NCGF= 2.00, p < .05b t-test between EGF and NCGF= 2.95, p < .05; t-test between EGF and HCGF= 2.35, p < .05

Table 3Symbiosis in the Interviews for Mother to Father: Mothers

Group



Variable F-Ratio



Intrusiveness 1.77 1.19 1.36 1.15 1.31 0.72 0.70

Separations 1.46 0.84 1.36 0.77 1.54 0.93 0.12


Expectations 1.92 1.27 1.27 0.86 1.31 0.61 1.69

Total Symbiosisa 9.50 2.36 7.09 2.39 7.46 2.41 3.20** p < .05a t-test between EGF and NCGF = 2.05, p < .05;b t-test between EGF and HCGF = 2.32, p < .05

The results of the interviews indicate that from the viewpoint of the mother of the schizophrenic, her husband intrudesupon her autonomy and has a generally symbiotic involvement with her. This attachment is not one-sided, however. Themother of the schizophrenic also sees herself as forming an unspecified symbiotic attachment to her husband. It appearsthat from the viewpoint of the mother of the schizophrenic, her relationship with her husband is characterized by a mutual,non-specific sense of symbiotic entanglement, but the husband is especially intrusive toward her, indicating that sheperceives a greater investment on his part in the symbiotic bond.

With regard to the confirmation variables, Table IV shows that in the father-to-mother vector, Acknowledgment andTotal Confirmation differentiated mothers of schizophrenics from both other groups of mothers. Mothers of schizophrenics,more than other mothers, tended to view their husbands as failing to confirm them, and the difference was attributableprimarily to the perception of the husbands' failure to recognize their wives' point of view. As mothers of schizophrenicswere not clearly unique in their perceptions of their husbands' accommodation to them, the perceived failure of the husbandto confirm the wife seems to be attributable to the tendency of the wife to see her husband as failing to recognize her pointof view.

Table 4Confirmation in the Interviews for Father to Mother: Mothers

Group



Variable F-Ratio


Acknowledgmenta 2.17 1.21 3.50 0.96 3.69 1.20 1.62*

Accommodation 2.46 1.55 2.92 1.26 3.54 1.15 1.97

Total Confirmationb 4.65 3.31 6.42 4.32 7.23 3.03 6.05** p < .05a t-test between EGF and NCGF= 3.30,p < .01; t-test between EGF and HCGF= 2.86, p < .01b t-test between EGF and NCGF= 2.83, p < .01; t-test between EGF and HCGF= 2.00, p < .06

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As to her own side of the relationship, Table V indicates that schizophrenics reported themselves to be significantly lessconfirming of their husbands than other mothers were. Accommodation also differentiated the three groups but onlydistinguished mothers of schizophrenics from mothers of normals in the paired groups comparisons. Thus, althoughmothers of schizophrenics were no more likely than other mothers to report failure in acknowledgment or accomodation,they were unique in their tendency to report either of these types of failure in their relationship with their husbands. It maybe said that mothers of schizophrenics tend to report themselves as failing to confirm their husbands in some respect.

Table 5Confirmation in the Interviews for Mother to Father: Mothers

Group



Variable F-Ratio


Acknowledgment 3.00 1.47 3.33 1.18 3.92 1.07 1.62

Accommodationa 2.62 1.27 3.25 1.42 4.00 0.68 4.26*

Total Confirmationb 5.62 2.50 6.58 3.04 7.92 2.06 6.72** p < .05a t-test between EGF and NCGF = 3.32, p < .05b t-test between EGF and NCGF = 4.04, p < .05; t-test between HCGF and NCGF = 2.30, p < .05.

According to the reports of mothers of schizophrenics, they and their husbands engage in a mutual failure to confirm theviewpoint of the other. This is most marked for the husband in his perceived lack of acknowledgment of his spouse, but thetendency to fail in either acknowledgment or accommodation is perceived by the mother as mutual in her relationship withher spouse.

Fathers. None of the measures of symbiosis differentiated the fathers of schizophrenics from both other groups of fatherson either side of the relationship. Fathers of schizophrenics did tend to perceive their wives as more symbioticallyenmeshed with them than fathers of normals did, but they were not differentiated from fathers of nonschizophrenics in thisregard. The reports of fathers of schizophrenics are different from those of the mothers, who are clearly differentiated fromboth other groups of mothers by their description of symbiotic attachment to their husbands.

The confirmation variables show strikingly different results. Both component variables and the Total Confirmationscores clearly differentiated fathers of schizophrenics from both other groups of fathers in the father-to-mother side of therelationship, as shown in Table VI. Fathers of schizophrenics report themselves as failing to acknowledge andaccommodate to their wives. The data fit the reports of the mothers who describe their husbands as lacking inacknowledgment and confirmation in general. As indicated in Table VII, however, for the mother-to-father side of therelationship, fathers were different only from normals on Total Confirmation. They were not significantly differentiatedfrom both other groups of fathers on any of the confirmation variables. The parents of the schizophrenic agree that the wifedoes not fail to confirm her husband.

Table VIConfirmation in the Interviews for Father to Mother: Fathers

Group



Variable F-Ratio


Acknowledgmenta 2.58 1.19 3.89 0.74 3.79 1.32 7.92*

Accommodationb 1.92 1.19 3.00 1.25 3.79 1.14 4.63*

Total Conformationc 4.60 2.54 6.89 2.60 7.58 3.37 6.59** p < .05a t-test between EGF and NCGF= 2.33, p < .05; t-test between EGF and HCGF= 2.76, p < .05b t-test between EGF and NCGF= 3.92, p < .05

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c t-test between EGF and NCGF= 3.29, p < .05; t-test between EGF and HCGF= 2.35, p < .05

Table VIIConfirmation in the Interviews for Mother to Father: Fathers

Group



Variable F-Ratio


Acknowledgment 3.08 1.32 3.56 1.17 3.79 1.21 1.23

Accommodation 2.75 1.48 3.00 1.16 3.43 1.35 0.92

Total Confirmationa 5.83 2.89 6.56 2.91 7.22 2.34 4.43** p < .05a t-test between EGF and NCGF= 2.88, p < .05

To summarize, the interview data indicate that the parents of the schizophrenic differ in their view of symbiosis in theirrelationship. The mother sees herself as forming a symbiotic attachment to her husband, but the husband does not concur inthis view. The couple does agree, however, that the husband fails to confirm the viewpoint of his wife, who does notreciprocate this failure.

Projective Tests.

Mothers. Of the 20 symbiosis variables on both sides of the "mother-father" relationship, only Total Symbiosis in the"father-to-mother" vector distinguished the protocols of the mothers of schizophrenics from the data of the other two groupsof mothers (see Table VIII). It appears that mothers of schizophrenics tended to perceive "husbands" as more likely topossess some characteristic of symbiotic enmeshment with "wives" than other mothers did. That was not true of the"wife-to-husband" vector. This result suggests that mothers of schizophrenics view "husbands" as evincing some form ofsymbiotic attachment to "wives" but do not see the "wives" as reciprocating in this bond. There is no definite characteristicof their perception. The confirmation variables did not distinguish the groups of mothers in any respect on either side of the"husband-wife" dyad.

Table 8Symbiosis on the Projective Tests for "Husband to Wife": Mothers

Group



Variable F-Ratio



Intrusiveness Nonbehavioral 1.11 0.31 1.08 0.27 1.00 0.00 0.78

Intrusiveness Behavioral 1.11 0.23 1.00 0.00 1.08 0.25 0.78

Negative Reactions for Selfto Separation

1.11 0.31 1.00 0.00 1.00 0.00 1.54

Dependency 1.26 0.41 1.08 0.27 1.07 0.25 1.66

Injunctions 1.11 0.31 1.08 0.27 1.00 0.00 0.78

Injunctions Fulfilled 1.00 0.00 1.00 0.00 1.00 0.00 0.00


Negative Reactions for Otherto Separation

1.05 0.22 1.00 0.00 1.00 0.00 0.73

Total Symbiosisa 16 1.31 9.23 0.58 9.33 0.47 4.76*a t-test between EGF and NCGF = 2.23, p < .05; t-test between EGF and HCGF = 2.33, p < .05

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* p < .05

Fathers. The projective tests of the fathers indicated that none of the 20 symbiosis variables clearly differentiated fathersof schizophrenics from both other groups of fathers. Total Symbiosis differentiated fathers of schizophrenics from fathers ofnormals on the "husband- to wife" vector but did not distinguish the former group from fathers of other hospitalized mentalpatients. Fathers of schizophrenics are more likely than fathers of normal young adults to perceive "husbands" assymbiotically involved in some way with "wives" but not more likely to do so than fathers of other mental patients.Confirmation variables did not distinguish the groups of fathers in any respect for either side of the "husband-wife" dyad.

The results of the projective tests for the fathers are similar to the mothers' data. Neither parent of the schizophrenicperceives a specific characteristic of symbiotic enmeshment at the projective test level between "husband" and "wife."Mothers do tend to view "husbands" as likely to form some aspect of a symbiotic relationship with "wives," but theirhusbands are not clearly distinguishable from fathers of other mental patients in this regard. Neither parent saw failure toconfirm as a characteristic of the "husband-wife" relationship.

It appears the relationship between the parents of schizophrenics is most clearly different from the other two groups ofparents in the interviews. At the self-report level, the mother of the schizophrenic views the parental relationship asmutually symbiotic and lacking in confirmation. She sees her husband as being more intensely involved in this relationshipthan she is, but clearly reports these trends as occurring on both sides of the relationship. The father does not concur in thisreport. He sees no symbiotic attachment in the mother-father dyad, but he does report himself as failing to confirm his wife.It appears that the mother of the schizophrenic reports less differentiation and confirmation in the relationship, especially inher own relationship to her husband.

On the projective tests, only the mother's perception of aspects of symbiosis likely to be found in her husband'sattachment to her distinguished the mother of the schizophrenic from both other groups of mothers. At the fantasy level, themother of the schizophrenic does not perceive the symbiotic attachment of her husband that was reported in the interviews.Similarly, the failure of the father to confirm the mother reported by both parents in the interviews does not appear on theprojective tests. It seems that unique characteristics of the relationship between the parents of the schizophrenic exist at thelevel of self-report but not on the less conscious, fantasy level.

To assess the possible influence of gender on the results, EFGs were divided into parents of males (N = 9) and parents offemales (N = 8). There were no significant differences between the groups on any dependent variables. However, the smallnumbers in the two groups made the achievement of statistical significance difficult, and it is possible that the groups couldbe differentiated with larger numbers.

DiscussionThe first issue of interpretation, as in the previous papers (9, 10), is the validity of the inferential step from

projective-level perceptions and reports of past relationships to the reality of those relationships. The argument for thevalidity of the step was made in those papers and needs only to be restated briefly here. Symbiosis and confirmation aredefined by the feelings and perceptions of the parties to the relationship. People who feel undifferentiated are, for thatreason, symbiotically bound. Similarly, to feel and perceive oneself as acknowledged and responded to by another is to beconfirmed by the other. There is not a great inferential leap from the interview and projective test data to the reality of therelationship.

The only finding revealed on both the projective tests and interviews is the mother's perception of the father assymbiotically bound to her. That finding is the strongest and clearest result of the current investigation. The evidenceindicates that the mother of the schizophrenic sees her husband as failing to differentiate himself from her. Since the fathers'perceptions did not differentiate the groups at either data level on symbiosis, it is clear that fathers of schizophrenics do notconcur in their wives' judgments of their symbiotic enmeshment.

Similarly, the wives perceive themselves to be symbiotically attached to their husbands who do not concur in thisperception. It appears that the perception of symbiosis on both sides of the relationship belongs to the mother. It is she whoviews both her husband and herself as symbiotically attached to the other. Her husband does not perceive symbioticenmeshment. The mother's perception of her own symbiotic bond is, by definition, a lack of differentiation between herselfand her husband. Thus, the evidence indicates that the mother's perception of her husband as symbiotically attached to heris most likely a projection of her own symbiotic bond to her husband. That is the most likely explanation for the finding thatthe mother perceives a mutually symbiotic bond, whereas the father sees the relationship as differentiated.

The parents are in agreement on the failure of the father to confirm his wife. Both parents perceive that pattern but onlyat the self-report level. It may be said that there is evidence that the father of the schizophrenic does not confirm theviewpoint of his wife, but it is not supported by evidence from the projective tests.

The only finding supported, in fact, by the projective tests is the mother's perception of her husband as symbioticallybound to her. That result would seem to have the most support from the data. This perception, which is most likely a

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projection, appears to be the most clear and convincing single way in which the relationship between the parents of theschizophrenic differs from other parental relationships.

The results, taken as a whole, seem to indicate that the mother of the schizophrenic is enmeshed in a symbiotic bond withher husband and projects this attachment onto his relationship to her. The husband fails to confirm the wife, indicating alack of recognition of her. The mother of the schizophrenic is enmeshed in a complex symbiotic bond with her husband,who seems not to take cognizance of her. The mother seems involved to the extent of undifferentiation, whereas the father isonly minimally involved. A "skewed" pattern seems evident (5). Perhaps the mother is attached to her husband in such aburdensome manner that the latter withdraws his attention from her. In any event, it seems fair to conclude that the parentsperceive their relationship in strikingly different ways. It is as though each parent lives in a different relationship. Althoughthe evidence from the present study is not conclusive, it does indicate a possibly distinct pattern in the marriage of theparents of the schizophrenic that is not found in other marriages. The results of two previous studies (10, 11) fit theseresults. Evidence was found in those investigations to support the hypothesis that the mother's need for symbioticenmeshment with her child and the father's failure to confirm the child both play a contributive role in the etiology ofschizophrenia. It may be that each parent reproduces to a mild extent in the parental relationship the type of relationship heor she has with the child. The mother's symbiotic enmeshment is greatest with the child but also exists with the father; thefather's failure to confirm is most marked in his relationship with his schizophrenic child but is present also in hisrelationship with his wife.

The current results add a new dimension to the previous findings of distinctive relationships in the families ofschizophrenics. The particular quality of the relationships previously detected between mother- and father-schizophrenicappears to imbue the mother-father relationship. The parental relationship fits the aspects of the family system previouslydiscovered. The mother appears to seek symbiotic attachment to both her husband and schizophrenic offspring and isapparently more successful in the latter case. It may be that the result of her thwarted effort for fusion with her husband is asearch for the fulfillment of the same need through the schizophrenic child, with whom reciprocity is achieved. The fatherapparently fails to confirm his wife, just as he fails to recognize the viewpoint of the schizophrenic child. Thus, both aspectsof the unique parent-schizophrenic patterns prevail in the husband-wife dyad.

These considerations may appear to assume a causative role in the relationship between the parents of the schizophrenic.Such an interpretation would be a misconception. The current data cannot lead to a definitive causal inference. It is true thatthe interview data involve reports of the history of the parental relationship. Such data are insufficient, however, for causalinterpretation. It is also true that companion studies have found evidence for causation in the mother- and father-schizophrenic relationships. Nonetheless, the current results do not bear directly on causation. The present studycomplements previous work to add understanding of the system in which the young adult schizophrenic lives. Whether theparental dyad component of this system plays a causal role in the schizophrenic illness is a question for furtherinvestigation.

REFERENCES

1. Fleck, S., "Family Dynamics and the Origin of Schizophrenia," Psychosom. Med., 22, 333-344, 1960. 2. Hollingshead, A. and Redlich, F., Social Class and Mental Illness, New York, Wiley, 1958. 3. Kety, S., Rosenthal, D. and Wender, P., "Mental Illness in the Biological and Adoptive Families of Adopted

Schizophrenics," Amer. J. Psychiat., 128, 302-306, 1971. 4. Lerner, P., "Resolution of Intrafamilial Role Conflict in Families of Schizophrenic Patients. I: Thought

Disturbance," J. Nerv. Ment. Dis., 141, 324-351, 1965. 5. Lidz, T., Cornelison, A., Fleck, S. and Terry, D., "The Intrafamilial Environment of Schizophrenic Patients. II:

Marital Schism and Marital Skew," Am. J. Psychiat., 114, 241-248, 1957. 6. Murray, H., Thematic Apperception Test, Cambridge, Harvard University Press, 1943. 7. Scott, R. and Ashworth, P., "'Closure' at the First Schizophrenic Breakdown: A Family Study," Brit. J. Med.

Psychol., 40, 109-145, 1967. 8. Shneidman, E., Make-A-Picture Story, New York, The Psychological Corporation, 1948. 9. Summers, F., "A Manual for the Measurement of Symbiosis in Human Relationships," Psych. Reps., 43, 663-670,

1978. 10. Summers, F. and Walsh, F., "The Nature of the Symbiotic Bond Between Mother and Schizophrenic," Amer. J.

Orthopsychiat., 47, 136-148, 1978. 11. Summers, F. and Walsh, F., "Symbiosis and Confirmation Between Father and Schizophrenic," Amer. J.

Orthopsychiat., 49, 136-148, 1978. 12. Wynne, L., "Pseudomotuality in the Family Relations of Schizophrenics," in G. Handel (ed.), The Psychosocial

Interior of the Family: A Sourcebook for the Study of Whole Families, Chicago, Aldine, 1967.

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13. Wynne, L. and Ryckoff, I., et al., "The Family Relationships of the Schizophrenics: A Rubber-Fence Hypothesis,"Paper presented at the Annual Meeting, American Psychiatric Association, Chicago, 1956.

1The coding manual for Confirmation is available upon request.

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symbiosis and confirmation between the parents of the schizophrenic

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