Interpersonal expectations and adjustment to depression a dissertation presented

Interpersonal Expectations and Adjustment to Depression A Dissertation Presented by Susanne Katharina Triesch to The Graduate School in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy in Clinical Psychology State University of New York at Stony Brook August, 2001 State University of New York at Stony Brook The Graduate School Susanne Katharina Triesch We, the dissertation committee for the above candidate for the Doctor of Philosophy degree, hereby recommend acceptance of this dissertation. ___________________________ Ronald Friend, Ph. Professor, Department of Psychology ___________________________ John Neale, Ph. Professor, Department of Psychology ___________________________ Susan O’Leary, Ph.

Professor, Department of Psychology ___________________________ Arnold Jaffe, Ph. Associate Professor, Department of Family Medicine Stony Brook University Hospital This dissertation is accepted by the Graduate School ___________________________ Dean of the Graduate School ii Abstract of the Dissertation Interpersonal Expectations and Adjustment to Depression by Susanne Katharina Triesch Doctor of Philosophy in Clinical Psychology State University of New York at Stony Brook 2001 Major depression places considerable burdens on patients and their interpersonal relations with friends and family members. This study explored patient perceptions of being unable to meet the expectations of significant others in several domains related to depression. It tested the hypothesis that perceived inability to meet expectations leads to poorer adjustment and examined whether perceived expectations are derived from unrealistic demands by others or from patient perfectionism.

Forty-five clinically depressed patients were assessed prospectively for perceptions of family and friends expectations, socially prescribed perfectionism, depression, optimism, and quality of life. Significant others were asked about their expectations for patients. Patient neuroticism, perceived criticism, social support, and social desirability were also assessed as control variables. Results showed that perceived expectations reflected the actual expectations reported by family members and were a stronger and more consistent predictor of adjustment than social support, perceived criticism, or socially prescribed perfectionism.

iii Patients who viewed themselves as unable to meet the expectations of others were initially more depressed and less optimistic and reported a lower quality of life. These patients continued to be more severely depressed three months later. Additionally, changes in perceived expectations over time were associated with changes in depression, quality of life, and optimism. Mediational analyses indicated that neither family expectations nor perfectionism explained the relationship between perceived expectations and adjustment.

The results of the study suggest that interpersonal perceptions are an important predictor of adjustment in depression. However, the source of these perceptions remains unclear and requires further study. Developing interventions to prevent or reduce miscommunication between patients and their family members may be effective in improving patient adjustment. iv Table of Contents List of Tables.78 v List of Tables Table 1.60 vi Introduction The study of interpersonal relationships has long been an important focus of research on the etiology and course of major depression.

Over the last several decades, a substantial number of studies have demonstrated that depression leads to significant problems in social and family functioning. For example, Weissman and Paykel (1974) reported that depressed women experienced more friction and arguments with their husbands and children, had difficulty performing housework and other tasks, and showed decreased social activity and contact with friends when compared with nondepressed control women. More recent studies using varied patient populations and assessment procedures have continued to find that families of depressed patients experience significant difficulties during the acute phase of the illness. Moreover, these families continue to experience more problems than nonclinical families even after the diminution of depressive symptomatology (see review by Keitner, Miller, Epstein, & Bishop, 1990).

Problematic family relationships have themselves been shown to contribute to the onset of depression and to influence the course of depressive illness. Interpersonal stressors significantly increase the risk of developing clinical depression (Paykel et al., 1969) and studies of depressed women in discordant marriages have shown that marital discord tends to precede the development of depression rather than vice versa (Beach & Cassidy, 1991). Among depressed patients, conflict with friends and family members has a detrimental effect on the course of the illness (Finch & Zautra, 1992). Conversely, patients who report high levels of social support have less severe symptoms (Lara, Leader, & Klein, 1997), are more likely to recover from a depressive episode (Goering, Lancee, & Freeman, 1992; Keitner et al., 1995; Keitner, Ryan, Miller, & Norman, 1992), 1 and have a lower rate of relapse compared to those with few supportive relationships (Keitner & Miller, 1990).

The evidence for a reciprocal relationship between depressive symptoms and interpersonal relations may best be explained by an interactive, mutually reinforcing process. While the emergence of major depression is facilitated by disturbed marriages and family environments, depressive illness itself creates significant problems for those living with a depressed patient. If friends and family members do not have an effective way of dealing with the problems of depression, then the illness can be significantly prolonged and worsened (Keitner, Miller, Epstein, & Bishop, 1990). Family members may be particularly likely to aggravate the situation with unsuccessful attempts to influence the behavior and feelings of the patient.

Although these attempts may be motivated by a sincere desire to alleviate the suffering of the patient, they are often carried out in ways that complicate and unwittingly worsen the depression (Coates & Wortman, 1988). At the same time, patients themselves may actively contribute to the escalation of interpersonal conflict and depressed mood by seeking support from their social environment with symptomatic behaviors that have the unintended effect of eliciting rejection from others and confirming negative beliefs about the self (Coyne, 1976). An interactional view of depression maintenance is consistent with calls for a situational perspective that does not place blame on either patients or relatives, but attempts to understand the problems that occur in the coordination of mutual needs and concerns among families with depressed patients (Coyne, Ellard, & Smith, 1990). From this perspective, it is particularly important to identify the nature of interpersonal 2 conflicts that reduce support from significant others and contribute to the escalation of depressive symptoms.

The present study focuses on the misunderstandings and misperceptions that may occur among patients and their families as the result of the depression itself. We hypothesize that adjustment to depression may be made more difficult when friends and family members fail to understand the magnitude of the illness and its effects. Family members who do not understand or lack information about the nature of depression are likely to develop expectations about the ability of patients to function and manage their illness that exceed the perceived capabilities of the patients themselves. As a result, patients may perceive that they are unable to meet the expectations of significant others in a number of important areas.

This perception may lead patients to believe that their families and friends do not understand how seriously ill they are (Eitel, Hatchett, Friend, Griffin, & Wadhwa, 1995; Hatchett, Friend, Symister, & Wadhwa, 1997). Over time, perceived inability to meet expectations from significant others and the related feeling of being misunderstood may increase subjective distress and contribute to the maintenance of the depressive episode. These hypotheses emerged from two recent studies that found a strong relationship between perceived expectations and adjustment in renal dialysis patients. Hatchett, Friend, Symister, and Wadhwa (1997) studied patient perceptions of family and medical staff expectations and found that perceived inability to meet the expectations of others predicted changes in depression, optimism, illness intrusiveness, and quality of life over a three month period.

Furthermore, perceived expectations were strongly correlated with patient reports of feeling misunderstood by family members. Although the study did not directly address the origin of the perceived inability to meet family expectations, two 3 alternative explanations were proposed for these results. First, family members may lack knowledge about the nature and course of renal disease and its physical and psychological consequences, resulting in unrealistic and fluctuating expectations for the patient. Alternatively, patients may experience a loss of self-esteem due to their inability to function at a level they of expect of themselves.

As they become frustrated at their own incapacity, they project this anger outward and come to believe that others also hold expectations that they cannot fulfill. These hypotheses were tested in a second study that measured patient self-esteem and also assessed family members regarding their expectations for the patient (Hatchett, 1997). Mediational analyses revealed that high levels of reported expectations on the part of family and friends led to patients perceiving that they were unable to meet these expectations, which in turn predicted patient adjustment. Self-esteem, on the other hand, did not explain the relationship between patient perceptions and adjustment.

Thus, the author concluded that patient perceptions accurately reflected excessive expectations from family members and friends. The theoretical perspective developed by Hatchett and colleagues (1997) and the present study is strongly influenced by the work of Solomon Asch, whose general theory of social psychology centered around the importance of shared psychosocial fields of perceptions, cognitions, and emotions (Friend, Rafferty, & Bramel, 1990). Asch (1952/1987) argued that a consensus of shared perceptions and expectations forms the basis of social relations and plays a central role in making intelligible social action possible. In this context, Asch emphasized the fundamental importance of the object of judgment, arguing that perceptions and attitudes are determined primarily by the specific qualities or properties of the object as they are perceived by the individual.

Shared 4 understanding is the rule because common perceptual processes generally lead to similar perceptions among persons in a given situation. When individual perspectives differ or conclusions are based on inaccurate or incomplete data, however, lack of consensus in perceptions or expectations may result. Given the importance of shared cognitions in regulating social interaction, such disagreements may lead to frustration and the experience of substantial distress (Asch 1952/1987). The present study incorporates the Aschian framework by emphasizing the role of the object of judgment, in this case depression and its symptoms, in characterizing the relationship between patients and their family members and friends.

We propose that interpersonal agreements and disagreements arise from the depression itself as understood or misunderstood by patients and their significant others. Thus, we examine several aspects of depression that may lead to conflicting interpersonal expectations among patients and their friends and family members. Depression is characterized primarily by negative symptoms that are largely continuous with normative behavior and may not be recognized as signs of mental illness by others who lack information about the nature of the disorder (Beck, 1967). These symptoms represent a considerable burden for friends and family members of persons with depression.

Coyne et al. (1987), for example, found that family members of depressed patients were significantly more distressed than those living with recovered patients. Their increased distress was almost completely accounted for by difficulties related to negative symptoms such as fatigue, hopelessness, and lack of energy. Similarly, Fadden, Bebbington, and Kuipers (1987) found that spouses of depressed patients reported substantial problems due to negative symptoms including underactivity, 5 dependence, self-neglect, and indecisiveness.

Unlike positive symptoms such as hallucinations or delusions, negative symptoms were not attributed to the depression by spouses who generally reported that they were unaware of what behavior to expect from patients as a result of the illness. The negative symptoms associated with depression may also make it difficult for patients to carry out the routine functions and activities of daily life. For example, Weissman and Paykel (1974) found that many depressed women in a community sample were unable to manage household or parenting tasks and severely decreased their involvement in social and leisure activities. They depended on their husbands to perform the majority of household chores and to assume responsibility for coordinating the social life of the family.

Although the husbands generally tried to be helpful, most soon became resentful and demanded that their wives resume their normal activities. Consistent with these findings, the family members surveyed by Coyne et al. (1987) also reported significant difficulties related to patient lack of interest in social life and leisure activities.