Coherent Accounts of Coping with a Chronic Illness: Convergences and Divergences in Family...

Coherent Accounts of Coping with a Chronic Illness: Convergences and Divergences in Family Measurement Using a Narrative Analysis

BARBARA H. FIESE, Ph.0.t FREDERICK S. WAMBOLDT, M.D.$

Researchers and clinicians have shown increasing interest in family narratives as an avenue for accessing the family meaning-making process. In this study, we examine the convergences and diuergences between narrative assessment, family self- report, and verbal accounts of family climate. Sixty-two families with a child with pediatric asthha were interviewed about the impact that asthma had OR family life: These interviews were coded for narratiue coherence, relation sh ip expec tu t io ns, and engagement with the interuiewer. Primary cinegivers were also inkrviewed using the Five Minute Speech Sample (FMSS) and completed self-report assessments of family functioning (Family Assessment Device [FAD]; Impact on the Pamily Scale [IOFII. Contrary to prediction, norratiue coher-

Portions of this research-were supportd, in part, by grants from the National Institutes of Health (ROl hlH51771-01) and W. T. Grant Foundation to the first author, and the National Institutes of Health (ROl-HL53391 and hiOl-RR0051) to the see- ond author. Address all correspondence to the fitst author at 430 Huntington Hall. Department of Psy- chology, Syracuse University, Syracuse, NY, 13244. Email: bhfics@psych .syr.edu t Barbarn H. Fiese is at thc Department of Psy-

chology, Syracuse University, Syracuse, NY. $ Frederick S. Womboldt i s a t the National Jew&

hledicol Research Center, Umvcrsity of Colorado HeaIth Sciences, Denver, Colorado.

ence was higher in those cases where Emotional Over-involuement (EOIl uas present on the FMSS. Narrative coherence and engagement with the interviewer were positively related to self-report of family problem solving, communication, and afi fective responsiveness qs measured on the FAD. Diuergences and cQnuergences between different types of family measurement are discussed in light of meaning making processes associated with coping with a chronic illness.

Fam Proc 42r439-452, 2003

ms BEEN a growing interest in 1 family narratives by researchers

and clinicians alike. Whereas clinicians have been primarily interested in narratives as a therapeutic Framework and guide for undeistanding a family's unique experience (White & Epston, 199O), researchers have focused their efforts p i - manly on developing reriable ways to in- vestigate narratives as a window into psy- chological processes such as defining the self (McAdams, 1993). Thorough analyses of narratives collected via semi-structured interviews have revealed the relation between coherent stories told about personal experiences and satisfaction with close relationships (Main & Gold-

439 Family Process, Uol. 42, No. 4, 2003 o FPI, Inc.

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wyn, 1984; Veroff, Sutherland, Chadiah, & ortega, 1993). Although narratives about f d y experiences pmvide rich clinical descriptions, the degree to which they are consistent with more standard assessments of family functioning has re- ceived relatively little empirical atten- tion. The purpose of this study is to examine the m y in which narratives may coo- verge a$ well as diverge from more traditional keasures of family functioning. Because narratives are told about specific, meaningful experiences, it is important to consider the context in which they are conveyed. For @e purposes of this article, we focus on stories told about famiiy exqe,riences related to coping with a pediatric chronic illness.

FAht I LY PROCESS

Multidimensional Codlng of Family Narratives

Narratives are complex productions that convey meaning on multiple levels. Linguists suggest that in order to inter- pret meaning in a story it is essential to consider how it is constructed, its content, and how relationships are depicted (Hal- liday, 1973). The FNC, method involves multidimensiond coding along three analogous dimensions (Fiese, Sameroff, Grotevant, et al., 1999). Narrative Coher- ence reflects hoy individuals organize and construct a story. The content-of family stories includes reflections on relationships and whether relationships are depicted as trustworthy or as sources of dis- content, referred to as Relationship Be- liefs. A third aspect of family narratives is the act of storyte1fl"ng. For some families there is an easy give-and-take in constructing a familiar tale, but for others, painstaking efforts are taken to keep in- timate details of family life private and closely guarded. How family members connected with the interviewer was la- beled Znterciewer Intimacy. These three dimensions were identified in a confirma- tory factor analysis described in Fiese et al.. 1999.

A multi-site study was conducted in which family narratives were analyzed in relation to early couple formation (Warn- boldt, 19991, famiIy routines (Fiesc & Marjinsky, 19991, openness in adoption [Grotwant, Fravel, Gorall, & Piper, 1999 1, and maternal depression (Dick- stein, St. Andre, Sameroff, Seifer, & Schiller, 1999). Relationship beliefs were related, &self-report measures of relationship satisfaction (Wamboldt, 1999) and patterns of directly observed family interaction (Dickstein et al., 1999; Fiese & Marjinsky, 1999). Scores on the Narra- tive Coherence dimension distinguished between groups that varied in terms of

Definlng Family Narratives

Before considering how to evaluate family narratives, it is important to dis- tinguish between what they are and what they are not. Family stories may include a recital told over and over again in a particular family (Bjmg-Hall, 1988; Fiese, Hooker, Kotary, Schwagler, & Rimmer, 19951, the mappihg of relationships over time [Buehlman, Gottman, & Katz?1992; Veroff et al., 1993). or the imparting of personal, family. or cultura1 values (Emde, 1994: hIiller, Wiley. Fung, & Li- ang, 1997). We follow the MqArthur Family Narrative Consortium (FNC, def- inition of family stories as verbal accounts of personal experiences that are important to the family, and typically involve the creation and maintenance of relationships, depict rules of interaction, and reflect beliefs about family relationships (Fiese & Sameruff, 1999). Multiple members of the family may present a narrative to an inten-iewer or the s t o q may be an individual's recounting of how a particular experience affects the collective work- ings of the family.

FIESE nnd \YAMBOLDT

psychiatric status (Dickstein et al., 1999) and Ievels of openness in adoption (Gro- tevant et al., 1999). The family's interaction with the interviewer was significantly related to how the family inter- acted as a group during routine mealtimes IDickstein e t al., 1999; Fiese & Majinsky, 19991, suggesting a concordance between how the story is told and whole family processes.

These preliminary studies suggested that there is cross-domain consistency between narrative accounts and other measures of family functioning either through self-report or directty observed behavior. There are several limitations that require further investigation. First, although there was cross-domain consistency, whether the narratives gathered in an interview setting would be related to other verbal and language-based phenomena was not considered. It is important to address this limitation for both rnethodolog- ical and theoretical reasons. Methodolog ically, it is important to consider whether any aspect of language production is related to overall famiIy functioning. Are the FNC narrative dimensions distinct from other language-based assessments of family relationships such as Expressed Emotion (Magaiia, Goldstein, Karno, et aI., 1986)? If the FNC dimensions are distinct from other language-based measures, is each aspect differentially related to family functioning? We propose that the coherence of the narrative should be related to overall family functioning, whereas how relationships are depicted in the narratives should be related to how we11 the family has coped with specific challenges, such as chronic illness. We reason that narrative coherence is a n enduring characteristic reflecting personal meaning-making across contexts (Gro- tevadt, 1993; McAdams, 19931, and thus may frame ovarall family functioning. How r.elationships are depicted may be

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subject to situational stressors (Patterson & Garwick, 1994).

Second, aithough there were reports of the relation between the narrative codes and interview-based assessment of family functioning, there was no report of the link between .self-report measures of cur- rent family functioning and narrative coherence or relationship beliefs. In es- sence, this second issue pertains to ex- tending the validity of the narrative procedure in relation to more firmly es- tablished methods of family assessment.

Third, we wanted to expand the previous work to include a new sample with a focus on narratives and coping with a chronic illness. The clinical literature suggests that families struggle with making sense of a chronic illness and how it affects daily life (McDaniel, Hepworth, & Doherty, 1997.; Patterson & Garwick, 1994; Reiss, 1981). By including a multidimensional narrative assessment of the imRact of a chronic illness on family life we sought to document in B more systematic fashion the meaning-making process and its relation to coping with a chronic illness. Thus, we had three objectives in this

study. Our first goal was to compare the narrative codes to other language-based measures of family process. We chose to examine the relation between Expressed Emotion (EE) as measured through the Five Minute Speech Sample (FMSS) and the narrative codes. EE is proposed& be indicative of the affective climate of family relationships CLeff & Vaughn, 1985) and has been used reliably in the study of pediatric chronic illness (Wamboldt, O'Connor, Wamboldt, Gavin, & Klinnert, 2000). We expect that verbal accounts collected through the FMSS would be consistent with whether families depicted re- Iationships as trustworthy during a semi- structured interview conducted sepa- rately from the FMSS. Furthermore, we

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eqect that the coherence of the narrative would be negatively related to the amount of criticism evident in the FMSS. A high- criticism EE profile includes a lack of perspective-tahg in reference to the target child's characteristics, and coherence includes mding for flexibility and multiple perspectives b a family issue.

Oar second objective was to examine the relation between the narrative codes and a standard self-report measure of family functioning. We chose to use the F d y Assessment Device (FAD 1 because of its wide use in the family research field (Sawin, Harrigan, & Woog, 1995). Al- though we mgnize that there is some controversy regarding the use of the FAD subscales (Miller, Ryan, Keitner, Bishop, 4k Epstein, 2000; Ridenour, Daley,. & Reich, 20001, we chose to use the six scales consistent with other reports of families with a child with a chronic illness flVamboldt et al., 2000).

Our third objective was to determine whether coping with a chronic illness was related to hosv relationships were de pi& in the narratives. We reasoned that families who reported that they were able to cope with the illness would be more likely to talk aboGt family relationships in a positive way, reflecting less of a negative impact-of the illness on the family. We did not have specific predictions about how the family connected with the intersyewer in relation to self-report measures: Although the- ways in which the f d y engages with the interviewer may be reflective of overall patterns of interaction, this study was limited to only examining the family's-report on oserall functioning and did not ina3de a direct obser- vation of interaction patterne. Thus, we conducted exploratory analyses on the relation between how the story was told to the interviewer and the self-report measures of family fuactioning.

FAMILY PROCESS

METHOD

Participants Sixty-two families drawn from a larger

study on the effects ofpediatric asthma on families were included in these analyses. The subsample of 62 families was selected to be representative across race and socio- economic status. The subsample did not differ from the larger sample in regard to illness severity, child gender, or marital status. Thirty-three of the children in the sample were girls, approximately 13% were African American, 11% Hispanic, and 73% Caucasian. Mothers ranged in education from 7 to 18 years with an average of 14 y e k of education. The major- ity of parents were married to the biolog- ical parent of the child in the study (65%) with the remainder single (24%) or re- married (10%). The children were on average 9 years of age and had, on average, been diagnosed with asthma for 5 '/2

years. We restricted our analysis to interviews conducted with the primary care- taker. Although therewere seven families in the larger sample that included both mothers and fathers, we excluded these couple interviews because of the small number and because previous research has indicated that presence of spouse can affect the overall coherence of the narrative (Grotevant et al., 1999).

Procedure

Families were recruited through a health maintenance organization (HMO) and area public schools. The HMO pro- vided names of patients with asthma, and nurses within the school system sent postcards to all children with asthma en- rolled in the school. Children were excluded if they had been hospitalized in the past 6 months or were receiving steroid treatments (criteria adopted in the larger study). All of the children were .on sched- uled anti-inflammatory medications. Of the families eligible to participate, 87%

FIESE and WAMBOLDT

completed the first laboratory visit. Fam- ilies were interviewed and, completed questionnaires in a ‘laboratory setting. The Asthma Impact Interview (MI; Wam- boldt & O’Connor, 1997) was-conducted with the primary caregiver, asking him or her to tell the story of how asthma had affected their family. Following a procedure reported in previous studies (Oppen- heim, Wamboldt, Gavin, & Renouf, 1996), caregivers were asked to teIl the story a6 if they were talking to a friend over a cup of coffee. The interview began with a question about the time the child was diagnosed with asthma, followed by questions about how the family handled chal- lenging situations associated with asthma care, and how asthma has affected each member of the family. On average, the interviews lasted approximately 20 minutes and were transcribed verbatim.

I 443 the different parts of the narrative are integrated. At the high end of the scale, personalized examples are synthesized throughout. At the low end of the scale, there are multiple contradictions. Organi- zation refers to the management of the narrative and how thoughts are put together to form a whole. At the high end of the scale, the story is put together in a direct cmd succinct manner. At the low end of the scale, the story is scattered and there are ambiguous referents. Flexibility refers to the degree to which the narrative includes mpltiple perspectives. At the high end ’of the scale, multiple perspectives are integrated. At the low end of the scale, the indfiridual strongly adheres to one perspective, Congruence of Atrect and Content refers to the match between the content of the narrative and the storytell- ers’ affect during the recounting of the story. At the high end of the scale, affect it3 appropriately modulated. At the low end of the scale, there are multiple mis- matches between the content of the stoty and the displayed affect. Average intra- class correlations across all raters for Narrative Coherence was .72.

The ReIationship Ekpctation scale assesses whether the family views relationships as manageable, safe, and reliable. At the low end of the scale relationships are expected to be unrewarding and po- tentially a source of hostility. At the higher end of the Scale’reIetionships are rewarding and sources of pleasure. Aver- age intra-class correlatians across raters for Relationship Expectations was .80.

The interviewer Intimacy scale assesses how the family connects with the interviewer, At the low end of the scale, families may give very few details about their family and provide short and appar- ently well-rehearsed answers. Faqilies ab the higher end of the scale readily engage with the interviewer and o h n pull the interviewer into the conversation. The av- eragehtra-class correlation across raters

Measures Family Narrative Consortium Coding

Scheme. Three independent raters di- verse in ethnicity (African American, Caucasian, & Hispanic) and naive to the purposes of the study were trainedain the FNC coding scheme. Individual paired ratings were used to calculgte interrater reliability. In the event of disagreement, consensus was reached through discussion. Consensus codes across the three raters were used in this analysis. Each narrative was coded for Narrative Cohr - ence, Relationship Expectations, and In- teruieurer Intimacy, using the FNC scales (Fiese et al., 1999). Each scale is rated from 1 to 5 , with lower scores indicating poorer coherence or more hostile relationships.

Narrative Coherence refers to how well the individual is able to construct and organize a story. Four scales are summed to create the Narrative Coherence score. Internal Consistency reflects the com- pleteness of the narrative and. how dell

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for Intenriewer Intimacy was -81. Copies of the coding manual are available from the first author.

Five Minute Sr>eech Sample for Ex- pressed I Emotion (FMSS; Magaa et al., 1986). Speech samples were collected from parents during a family testing ses- sion. Parents were asked to speak, unin- t e m p @ for 5 minutes, stating their thoughts and feelings about their child, what kind of person their-child is, arid how they get along with the child. The speech samples were then transcribed and coded according to the most recent manual (Magana, ,19931. Two raters, sep- amte from the FNC raters, were trained in reliability. We followed the procedures for coding and establishihg reliability as outlined by Magaiia- Critical comments were scnred as outlined in the most recent manual whereby the presence of a statement refieding a negative relationship, a criticism of the child, or a negative initial statement were classified as Critical. Two scores were generated for Emotional Over-involvement (EOI). The standard scoring system was used to generate the first EOI score whereby aEMSS was classified as EOI if one of the following wa6 present: Self-sacrificing/Overpro~tive statement, or Statement of Attitude and 2 5 Positive remarks; an Emotional Display, or Statement of Attitude and Ex- cessive Detail. There is evidence to support, hmw-er, a revised EOI score for use in samples of families with young children. %irnboldt and colleagues Warn- boldt et al. 2000) have proposed that the presence of positive remarks and statement of attitude (“I love him very much”) is. developmentally appropriate in families with young children in contrast to families who are dealing with an adult schizophrenic offspring. In this regard, the scoring of emotional over-involvement requires an adjustment such that norma- tive levels of positive remarks can be taken into account. Thus, we also in-

FAMILY PROCESS

cluded the Revised EOl scoring whereby any speech sample rated as EOI under the original coding rules would be classified as EOI except those speech samples achieving high EOI solely on the basis of one or more Statement of Attitudes and five or more positive remarks.

FamiIv Assessment Device (FAD; Ep- stein, Baldwin, & Bishop, 1983; Miller, Epstein, Bishop, & Keitner, 1985). The FAD is a 60-item self-report questionnaire based on the McMaster Moddl of Family Functioning. The questionnaire assesses six dimensions of family func-’ tioning: Problem Solving, Communica- tion, Roles, Mective Responsiveness, Af- fective Involvement, and Behavior Con- trol. In addition, a scale measuring overall General Functioning is included. Higher scores reflect worse family functioning. The FAD hasbeen used exten- sively in research and is applicable for use in families who have experienced a chronic illness (Bishop, Epstein, & Keit- ner, 1986; Wamboldt. et a l , 2000). Coeffi- cient alphas for this sample ranged from

Impact on the Family Scale (IOF; Stein & Riessman, 1980). The IOF is a 24-item scale that yields a total score and 4 sub- scale scores that measure impact on var- ious components of family life: the finan- cial situation, social interaction within and outside the home, subjective distress felt by the parent, and a positive sense of mastery that may emerge from coping with the streis. Higher scores reflect a greater impact on the family. Scores on the IOF were related to caregiver quality of life for parents of childre; with asthma (Juniper, Guyatt. Feeny, et d., 1996). Co- efficient alphas range fiom .60 to .86 with an alpha of -88 for.the total score.

Functional Severity of Asthma (Rosier, Bishop, Nolan, et a]., 1994). The Func- tional Severity ofAsthma scaIe is a 6-item scale completed by parents. Items pertain to how often the child has tightness and

-69 to 37.

FIESE and WAMBOLDT

wheezing, wakes at night, experiences wheezing i n - t h e morning, has attacks that limit speech, and to what extent there are limitations of home and school activities due to wheezing. The scale has proven to be reliable with an internal consistency estimate of .89. Validity was demonstrated through correlations between severity and school days missed and functionaI impairment and visits for medical care.

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found that the narrative scores did not differ by interviewer, Interviewer Inti- macy F (5, 56) = 0.31, ns; Relationship Beliefs (F (5, 56) = 052, ns; Narrative Coherence F (5,561 = 0.92, ns.

To test our first set of hypotheses, we conducted paired t-tests on the narrative measures and EE. Contrary to prediction, we did not find differences on the narrative measures and criticism noted on the EE assessment. We did find, however, that Narrative Coherence and Inter- viewer Intimacy were distinguishable by the revised measure of Emotional Over- involvement. The group classified as emo- tionally over-involved on the basis of the Five Minute Speech Sample was rated as more coherent M = 15.4 (-92) than the other group, M = 13.5 (.28) during the Asthma Impact Interview. Similarly, the. EE over-involved group was rated as more engaged with the interviewer M = 4.2 (.32) than the other group M = 3.52 {.lo) during the Asthma Impact Inter- view.

Our Second set of hypotheses concerned the reIation between responses on the FAD and the narrative measures. The most consistent findings were between Narrative Coherence and the FAD. More coherent narratives were related to more effective problem solving, communication affective responsiveness, and overall general family functioning. A similar pittern was noted with Interviewer Intimacy (see Table 1). Our third set of hypotheses focused on

the impact of the illness on family life and how relationships were portrayed in the interview, We found that when famiry relationships were depicted as trustworthy and rewarding there wks less of an impact of the illness on the family and their coping with the ilhess. There were no significant relations between coherence of the narrative or engagement with the interviewer and impact of the illness on the -family, with the exception of Coping and

RESULTS Prior to testing our hypotheses, we ex-

amined the relation between the narrative scales and demographic and linguistic variables to identi& any possible con- founds. We found that, maternal education was significagtly related to Narrative Coherence, F (62) = .32, p < .01, and that number of words expressed in the interview was related to Inter- viewer Intimacy. t (62) = -39, p < .001. Thus, we used education as a coyariate in analyses examining Narrativ.e Coherence and number of words as a covariap in anaIyses including Interviewer Intimacy. We found that the Relationship Expecta- tions scale was not significantly related to Narrative Coherence, r (62) = .14, or In- terviewer Intimacy, r (62) = .17. Narra- tive Coherence and Interviewer Intimacy were highly related to each other, however, r (62) = .53. Although a statistically significant relation, we opted to examine the pattern of correlations sepa- rately for Narrative Coherence and Intertiewer Intimacy given that a significant amount of the variance between the two is still unaccounted for.

I t is possible that an interviewer effect could account for any significant findings. Because there were six different inter- viewers invo1ve.d in the study, we conducted ANOVAs comparing scores on the Narrative Coherence, Relationship 'Ex- pectations, and Interviewer Intimacy scores by, interviewer. In all cases, -we

.

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4 4 6 i FILUILY PROCESS

TABLE 1 Comparison of Narmlive Dimensions with Family Based Measures

~~ -~

Narrative Relationship Interviewer Coherence' Erpeaatiane Intirnaeyb

E z p d Emotion critical cammenu Emotional Ch-er-Involvement Emotional Over-hvolvement Rensed

Problem Soh-ing Cammunication ROl= Mective Fkpomiveness Affective Involvement E3ehayior Control General Functioning

Impact on the Family F k c i a l General Impact soda1 Relationships copkg Total Impart

F m d y ilrsessmpnf Deuice

11571 = 1.20 t (57) = 0.18 I (57) = 1.79 t 6 7 ) = 0.59 t ( 5 7 l = 1.98' t (57) = 0.90

r (621 = - 2 5 - r (62) = -27 r (621 = -22 r (621 = -.IS r (621 = - . la

r 162) = -.09 i(62) = -.I7 rf62f = -.I0 r ( 6 2 ) = - 2 3 rt621 = -25' r ( 6 2 ) ' = -.31"

, r (621 = -25'

r (62, = -.33" f (62) = -.06

t (571 = 0.24 f (57) = 1.82 t (571 = 2.07*

r (621 = -.25* r (62) = -.27' r (621 = -.07 r ( 6 2 ) = -.37" r(62) = -.07 r (62) = -.07 r (62) = -.l5

r (62) = .08 r (621-= .09 r ( 6 2 ) = .05

r (62) = .07 r t62t = -.23

Sate: . pnidled for effm of mother education: ' panialled far effect of word count ' p < .05. .'p < -01.

Inteniewer Intimacy. We were concerned that the correspondence between bow relationships were depicted and the impact of the illness on the family was due, in part, to how ill the child was. W e exam- ined t h e correlation between functional severity of the illness and Relationship Expectations and found a modest but statistically significant reIation, r = - .2T, p < -05.

We were concerned that perhaps family members who are more engaging with an interviewer appear to be more coherent to naive raters because of general social impression rather than the ability to create a coherent account afthe impact of illness on family life. We were curious as to whether it is possible to tell a coherent story and not be engaged with the interviewer. Thus, we conducted a cluster analysis to identify subgrohps based on the interactive features of Narrative Co- herence and Inteniewer Intimacy. Using a k-means clustering procedure we set out

to identifj. four groups that would vary on coherence and engagement with the interviewer. We were unabIe to detect a low coherence, high-engaged group and thus reran the analysis distinguishing between Iow, medium, and high coherence. We successfully identified the following groups: Engagemigh Coherence, En- gaged/hledi urn Coherence, Disengaged Medium Coherence, and DisengagedfLow Coherence. Means for the narrative scales are presented in Table 2. Consistent with the correlational findings, we compared the cluster groups on the FAD subscales of Problem Solving, Communication, Af- fective Responsiveness. and General Functioning. Overall, we found that the disengaged low coherence group reported more difficulties in family problem solving, communication, affective responsiveness, and general functioning thari the engaged high coherence and engaged medium coherence groups.

FIESE and WMLBOLDT f 447 TABLE 2

Means und Standard Deviations for Narrative Cluster Croups on FAD Subscales

Engaged Engaged! Dicengragd Disengagedl LOW High Medium Medium

Coherence Coberencc Coherence Coherence (EH) CEmlP (DM) (DL)

(N = 18) (N= 211 W = 14) (N = 8) F(S,688) Contrasts Narmtiw Scules

Intenriewcr fntimncy 4.16 1.07) , 4.00 1.07) 2.93 1.081 2.56 (.lo) 86.45**' DL c DhI< EH, EhI Narrative Coherence 16.05 1.26) 13.05 1.24) 13.36(.30) 10.78 f.37) 51.22*09 DL < DhI, EM< EH

Problem Solving 1.87 1.081 1.79 1-06) 2.03 L.09) 2.33 1.111 5-41" DL > EH, Eht Communicn tion 1.85[.09) 1.91(.08) 1.90(.10) 2.16(.12t 6.19'.0 D L > E H . E M , D h I AFcetive Respnsjvencs 1-58 1-09) 1.70 1.08) 1.87 1.10) 2.24 I 13) 6.29"' DL > EH, EM G e n m l Functioning 1.68 L09) 1.69 (.081 1.74 L10) 2.13 1131 3.44. DL > kH, Eh!

FAD

' p < .05. " p < .Ol, * * ' p < ,001.

DISCUSSION

In this study, we sought to examine the relation between narrative accounts of the impact of pediatric asthma on family life and self-report measures of family functioning. Furthermore, we were interested in whether the process of verbal meaning making eyident in an interview is similar to or distinct fmm other linguistic assessments. We found systematic divergences and convergences across narrative and self-report measures. We struc- ture aur discussion focusing on three main points: language-based divergences in family measurement, convergences between self-report and interview-based communications about family life, and narrative meaning-malung in the context of chronic illness.

Contrary to prediction, we found divergences between linguistic measures of EE and Narrative Coherence. Not only was our initial hypothesis not confirmed, but there were significant findings in the op- posite direction, These findngs are consistent, however, with Wamboldt and colleagues' report, fWamboldt et al., 20001. We suspect that during the FMSS an emotional display or statements regarding self-sacrificing behavior may also indicate the degree to which the parent is

directly involved in the care and-monitor- ing of the child's i l1ness.h this tegard, parents who are involved (but not dkces- sarily 'over-involved") in the care of their child are able to create a coherent account of how the illness has influenced the family, providing detailed examples and syn- thesizing statements indicative of a higher coherence score. These findings further support the notion that the construct of emotional over-involvement may not be a developmentally sensitive measure of family climate for families with young children. We found convergences between the

relative coherence of the narrative and the process of engaging with the interviewer in relation to self-report accounts of family functioning. An enduring issue in family assessment is the congruence (or lack 00 between the insider 5 view of family rife. captured in self-report measures of family functioning and the outsider's assessment of famiIy behavior (Hampson, Beavers, & Hulgus, 1989). mically, low congruence between such measures is taken as either a difference in system level measurement (Sigafoos, h i s s , Rich, & Douglas, 1985) or differences in tasks. The lack of the relation between criticism on the FMSS and Nar-

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rative Coherence in the AII may reflect task demands and how the famhily inter- prets the researchers’ intent. In this study, the Au was used as a means to engage parents with .the research team as part o f a larger study. The interview ad- dresses questions about the impact of the illness on the family as a whole and is not necessarily linked to a particular relationship. The FMSS, on the other hand, is specific to the relationship between the parent-and an individual child. In this regard, the family may construe the AII as an opportunity to convey information about multiple aspects of family life whereas in the FhfSS there is an explicit demand characteristic .to focus on an individual, who may, or may not, be worthy of criticism.

In addition to specific task demands. central to this discussion has been the tenet that families ascribe persona1 meaning to questionnaires and Iaboratoc procedures in ways not always evident to the famiiy researcher. Using a narrative methodology, however, we assume that the family will attempt to make sense of important events and it is the meanirig making process that provides coherence among measures. Reiss (1989) tras proposed that residues of majorshared experiences in the family, such as illness, be- mme conserved over time and influence how the family forms patterns ?f interaction. In this regad the relative coherence of the narrative about the impact of illness on family life may reff ect the distil- lation of the experience over time, which in turn is consistent with how the family acts as a group. Thus, parents who are. able to create a Eoherent account of the illness that includes a clear sense of the order of events surrounding the illness, are able to get their point across in a direct manner, and able tosee that there are multiple perspectives to be integrated are also able to effectively problem solve, communicate, and respond in a regulated

FAMILY PROCESS

manner. In this regard the convergence of the narrative and self-report assessment may indicate the degree to which the family has reached a resolution about the irn- pact of illness and moved on t o a more balanced life (Steinglass, 1998). In our exploratory clus’ter- analysis we

we& able to idenjify groups that vaned in terms of how coherent their stury.was and the degree to which they engaged with the interviewer. IR cases where the respon- dent was disehgaged from the interviewer and struggled with creating a Coherent account of the impact of illness, family communication was reported as prablem- atic. In this regard, the directly observ- able connections made with the outsider and the insiders’ reports of family functioning were consistent. CIinicians have long assumed that families .who have difficulties talking about personal events and remain distant from the therapist may also be experiencing difficulties at home. Our results suggest that there may be concordance between how caregivers engage with an outsider (in this case an interviewer) and family functioning in an- other context. However, given the overlap between coherence and engagement with the interviewer, h t u r e studies need to addregs whether these are ihdeed distinct aspects of the narrative process. There is some concern that rater bias affected these results as well. I t may be that caregivers who appear more engaged with the intemiewer are more sociaIly adept and lead one to believe his or her story is more coherent. It will be important to examine social desirability s\s \*ell as rater bias effects in future studies. haddi t ion, findings from the cIGster analysis should be interpreted cautiously given the small sample sizes in some of the groups.

The stories we colledted in this study focused on the potential influences of-a chronic illness on famiiy life. We found specific .links between how, relationships were depicted in the interview and the

FIESE and WAMBOLM'

impact of the illness on the family. The thematic content of these relationship accounts may reflect the "situated meaning" of the illness (Patterson & Garwick, 1994). The Asthma Impact Jnterview cap- tures how families have faced the challenges of raising a child with a chronic illness. For some families, chronic illness may araw members close together and foster feelings of felt security. For other families, however, the illness may hro- voke conflict and/or avoidance of close personal relationships. On the one hand, some caregivers would recount how i t wasn't possible to trust other family members with their child overnight because the other family members didn't see asthma as a serious condition and would fail to take necessary precautions. On the other hand, some caregivers would de- scribe how different members of the farn- ily took on different roles such as reading to the child when on a nebulizer, bringing home educational information seen at the pharmacy, or having medications available at relatjves' homes in the case of an emergency. These specific events are ac- cessible and repoGable by family members in contrast to narrative coherence, which may be more abstract and related to the family's overarching worldview. Be- cause of the cross-sectional nature of this study, we do not know whether the illness itself creates positive or negative accounts af relationships or whether more positivrr initial relationships minimize the impact of the illness.

There are several limitations to this study that need to be taken into account. We have already mentioned concerns about socia1 impression and its relation to the coherence assessment. This was a correlational study and we are limited in reporting patterns of associations and cannot address direction of effects. Al- though we found significant patterns of correlations across measures, the strength of these statistically significant

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relations are modest. We limited our sample tQ interviews conducted with one primary caregiver rather than the whole family. Previous r e p o h have indicated that the presence of more than one family member may affect narrative coherence (Grotevaat et a]., 1999). This is not just a methodological limitation but also concerns theoretical implications of including a single member's view of family life ver- sus collecting information from multiple members. Future efforts are warrwkd .Qv examine whether similar convergences and divergences would be evident when nariatives are collected as part of a group process.

J u s t as there is no single story to be told about chronic illness and family life, there is no singular way to access meaning- making processes. Literary critics remind us that a good story involves multiple parts including, but not limited to, the actors, the scene, the intent, the resolution, and the overarching affect (Burke, 1950). For families, constructing meaningful accounts of 'stressful events, such as chronic illness, reflects not only the impact of the illness on' family life but the coherent synthesis of family beliefs and practices as well.

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