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The coping process of a parent who has an adult child with schizophrenia 1996

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THE COPING PROCESS OF A PARENT WHO HAS AN ADULT CHILD WITH SCHIZOPHRENIA by ROSE TERESA DALLA LANA A., The U n i v e r s i t y of B r i t i s h Columbia, 1992 THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE FACULTY OF GRADUATE STUDIES S c h o o l of F a m i l y and N u t r i t i o n a l S c i e n c e s We accept t h i s t h e s i s as conforming t o the re q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA March, 1996 (c) Rose Teresa D a l l a Lana, 1996 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Dejaartment of • » g > ^ The University of British Columbia Vancouver, Canada Date DE-6 (2/88) 1 1 Abstract This exploratory study investigated the coping process of parents who have adult sons or daughters with schizophrenia. The inquiry was framed by i n d i v i d u a l stress and coping theory with attention to family context. I t investigated p r e d i c t i v e r e l a t i o n s h i p s among i l l n e s s c h a r a c t e r i s t i c s , demographics, i n d i v i d u a l and family l e v e l resources, s i t u a t i o n a l appraisals, and coping strategies. The sample was comprised of 109 mothers and 32 fathers recruited through notices i n newspapers and the Schizophrenia newsletter, and through personal appeals to support groups. Questionnaires, along with stamped, self-addressed, return envelopes, were dis t r i b u t e d personally or by mail. Either the mother or the father of a person with schizophrenia was considered e l i g i b l e for p a r t i c i p a t i o n . Measures used for assessment were those with established psychometric properties. A c o r r e l a t i o n s matrix was examined to i d e n t i f y those variables that were s i g n i f i c a n t l y associated with the dependent variables of i n t e r e s t . The relationships among these relevant variables were further analyzed using a standard multiple regression procedure. The r e s u l t s showed support for the chosen t h e o r e t i c a l perspective. A parents' coping process was shown to be multi- determinant and i n t e r a c t i v e . Both i l l n e s s c h a r a c t e r i s t i c s and demographics were predictive of primary appraisals (perceptions of how the i l l n e s s affected the parent's l i f e ) and of coping stra t e g i e s ; i n d i v i d u a l and family resources predicted primary appraisals, secondary appraisals of c o n t r o l l a b i l i t y , and ways of coping; pr e d i c t i v e relationships also existed among primary appraisals, secondary appraisals, and ways of coping. The I l l i m p o r t a n c e o f a d i r e c t i n f l u e n c e o f f a m i l y members o n t h e p a r e n t a l c o p i n g p r o c e s s was i n d i c a t e d . i v Table of Contents Page Abstract i i Table of Contents i v L i s t of Figures v i L i s t of Tables v i i Acknowledgements x Chapter I. Introduction 1 Purpose 3 I I . Schizophrenia and the Family: A Study of Div e r s i t y 5 V a r i a b i l i t y i n Perceptions: H i s t o r i c a l Overview.. 5 Diver s i t y within the I l l n e s s 14 Family Diversity 17 I I I . Theoretical Framework: Stress and Coping 21 C l a r i f i c a t i o n of Concepts 25 IV. Review of Empirical Findings 49 Limitation of Past Research 66 Methodological Issues i n Stress Research 69 V. Study Rationale 74 Study Inquiry 77 VI. Method 81 Sample Characteristics 82 Analysis Strategy 96 VII. Results 98 Univariate Analyses 98 V Chapter Page Multivariate Analyses 104 VIII. Discussion 119 Limitations 144 Strengths 149 Implications 151 Conclusion 157 References 159 Appendices 175 Appendix A Definitions 175 Appendix B Questionnaire 17 6 Appendix C Sub-scales 191 Appendix D Shapes of Value D i s t r i b u t i o n s . . . . 195 Appendix E Figures 197 Appendix F Tables 2 03 v i L i s t of Figures Figure Page E l . A Model of Family Stress, Coping, and Adaptation 197 E2. A Representation of the Coping Process 198 E3. I l l n e s s Characteristics as Predictors 199 E4. Demographic Characteristics as Predictors 200 E5. Individual and Family Resources as Predictors 201 E6. The Predictive Power of Primary and Secondary Appraisals 202 V l l L i s t of Tables Table Page F l . C h a r a c t e r i s t i c s of Parents 203 F2. C h a r a c t e r i s t i c s of Daughters and Sons 204 F3 . R e l i a b i l i t i e s of Measure 205 F4. Functioning Level of Daughters and Sons: Means and Standard Deviations of L i f e S k i l l s 206 F5. Means, Standard Deviations, and S i g n i f i c a n t Differences of Resources and Appraisals for Mothers and Fathers... 2 07 F6. Means, Standard Deviations, and S i g n i f i c a n t Differences of Ways of Coping for Mothers and Fathers 208 F7. Means, Standard Deviations, and S i g n i f i c a n t Differences i n Parents' appraisals and coping by "Sex of C h i l d " and "Family Influence" 209 F8. Means, Standard Deviations, and S i g n i f i c a n t Differences i n Parents' appraisals and coping by "Have Other C h i l d with D i s a b i l i t y and "Marital Status of Parent" 210 F9 . Correlations Among Demographic Variables 211 F10. Variables S i g n i f i c a n t l y Correlated with Measures of Primary Appraisal 212 F l l . Variables S i g n i f i c a n t l y Correlated with Measures of Secondary Appraisal 213 F12. S i g n i f i c a n t correlations of Demographic, Resource, and I l l n e s s Variables with Ways of Coping 214 F13. S i g n i f i c a n t correlations of Primary and Secondary Appraisals with Ways of Coping 215 V l l l Table Page F14. Standard Multiple Regression of Variables on the Primary Appraisal "Lack of Information" 216 F15. Standard Multiple Regression of Variables on the Primary Appraisal "Relations with the Community" 217 F16. Standard Multiple Regression of Variables on the Primary Appraisal "Relations within the Family" 218 F17. Standard Multiple Regression of Variables on the Primary Appraisal "Problems i n Daily Functioning" 219 F18. Standard Multiple Regression of Variables on the Primary Appraisal "Worry about the Future" 220 F19. Standard Multiple Regression of Variables on a Secondary Appraisal of the Situation as "Changeable" 221 F20. Standard Multiple Regression of "Self-Esteem" on a Secondary Appraisal of the Situation as "Having to be Accepted" 222 F21. Standard Multiple Regression of a "Lack of Information" on a Secondary Appraisal of the Situation as "Needing to Know More" 223 F22. Standard Multiple Regression of Variables on a Secondary Appraisal of the Situation as "Having to Hold Back"... 224 F23. Standard Multiple Regression of Demographic and Appraisal Variables on "Confrontational" Coping 225 F24. Standard Multiple Regression of Demographic, Resource, and Appraisal Variables on "Distance" Coping 226 F25. Standard Multiple Regression of Demographic, Resource, and Appraisal Variables on "Self-Control" Coping 227 ix Table Page F2 6. Standard Multiple Regression of Demographic, Resource, and I l l n e s s Variables on Coping by "Seeking Social Support" 228 F27. Standard Multiple Regression of Demographic, Resource, I l l n e s s , and Appraisal Variables on Coping by "Accepting Responsibility" 229 F28. Standard Multiple Regression of Demographic, Resource, I l l n e s s , and Appraisal Variables on "Escape-Avoidance" Coping 230 F29. Standard Multiple Regression of Demographic, Resource, and Appraisal Variables on "Planful Problem-Solving".. 231 F30. Standard Multiple Regression of Demographic, I l l n e s s , and Appraisal Variables on Coping by "Positive Reappraisal" 232 X Acknowledgements I wish to express my gratitude to the supervisor of my thesis committee, Dr. Brian de Vries, for h i s valuable guidance and h i s enthusiastic support of my work. I also thank the other members of my thesis committee, Dr. Margaret Arcus and Dr. Bonita Long, for t h e i r h e l p f u l suggestions and recommendations for the improvement of t h i s study. The supportive atmosphere of the fac u l t y of the School of Family and N u t r i t i o n a l Sciences also encouraged my e f f o r t s . My appreciation i s directed as well to the Schizophrenia Society and the personnel of many heath units who assisted i n the d i s t r i b u t i o n of the questionnaires, and i n very large measure to the parents who so w i l l i n g l y p a r t i c i p a t e d i n t h i s study and so generously shared t h e i r experiences. 1 Chapter I Introduction Schizophrenia i s a fundamental disturbance of personality, the mere mention of which tends to evoke public misapprehension. That the disturbance i s l i t t l e understood i s no wonder; i t s manifestations are diverse and d i f f i c u l t to comprehend. Its most prominent symptoms are formal thought disorder, auditory hallucinations, delusions, and inappropriate or f l a t a f f e c t ; i t s most frequent symptom, noted i n almost a l l persons with the i l l n e s s , i s lack of in s i g h t (Straube & Oades, 1992). Whatever the signs, schizophrenia i s considered to be a devastating disorder. To have a family member with t h i s a f f l i c t i o n has been described as an experience of unresolved, prolonged g r i e f (Schulz, House, & Andrews, 1986), worse than i f that r e l a t i v e had a terminal i l l n e s s (Torrey, 1983). Descriptions of the family ordeal are a l i t a n y of anguish: despair, loss, sadness, pain, g u i l t , anger, and resentment (Creer & Wing, 1974; Wasow, 1985) . The family relationship with schizophrenia, moreover, i s not always regarded with sympathy; perceptions of parental involvement include blame, shame, and dysfunction (Johnson, 1990; Torrey, 1983). Despite t h i s emotional onslaught, parents predominate as caregivers to persons with mental i l l n e s s (Lefley, 1987c; Tausig, Fisher, & Tessler, 1992). The general question prompting t h i s study was, "How do parents cope with such an experience?" Coping i s a process whereby people attempt, through cognitive and behavioural e f f o r t s , to manage demands they 2 perceive to be taxing or exceeding t h e i r resources (Lazarus & Folkman, 1984). Although an assessment of coping focuses on the management of s p e c i f i c demands, such an evaluation also must attend to s o c i a l context and to c l u s t e r i n g of secondary stressors (Pearlin, 1991). In order, then, to respond to the question of parental coping with schizophrenia, one must understand the circumstances within which these coping e f f o r t s transpire. One must appreciate both family resources and the demands of the s i t u a t i o n , including the v a r i a b i l i t y that exists i n family (heterogeneity i n family structure, family type, and family circumstance) and v a r i a t i o n i n i l l n e s s (in stage, course, symptoms, and s e v e r i t y ) . An exploration of t h i s d i v e r s i t y i s required, not to suggest a picture of unpredictable chaos, but to provide a contextual backdrop for possible scenarios of experience within which coping e f f o r t s ensue. It has been suggested that "coping i s best understood when viewed within the larger context of the stress process" (Pearlin, 1991, p. 267). In t h i s study, a dynamic model of family adaptation to stress i s used as a meaningful framework that locates parental coping within a complex stress process and organizes the v a r i a b i l i t y of family circumstance and response noted i n the l i t e r a t u r e . Individual stress and coping theory i s u t i l i z e d to focus on parental coping e f f o r t s and t h e i r correlates. The si g n i f i c a n c e of such information on parental coping becomes apparent when we understand that for many adults with schizophrenia, parents are important caregivers and a 3 main source of s o c i a l support (Lefley, 1987c). Parental coping i n these circumstances has implications for the mental health of a l l family members. Purpose The purpose of t h i s study i s to examine parental coping e f f o r t s and t h e i r relationships to various aspects of family circumstance. Informed by coping l i t e r a t u r e , t h i s study introduces a broadened context within which to consider mothers' and fathers' attempts to manage t h e i r s i t u a t i o n s , l i n k i n g t h e i r endeavors to parental appraisals of demands and resources. To f a c i l i t a t e such an appreciation of parental coping, I present a b r i e f h i s t o r i c a l overview, i n d i c a t i n g the various ways in which the family and schizophrenia have been linked over time. I then address the d i v e r s i t y that i s evident in both family and i l l n e s s . Next, a model of family adaptation to stress i s outlined that i s able to incorporate the relationships that have been found within t h i s d i v e r s i t y and that i s able to situ a t e i n d i v i d u a l coping within the family context. To illuminate the parental coping process and to f a c i l i t a t e a c l a r i f i c a t i o n of concepts, a model of i n d i v i d u a l stress, appraisal, and coping i s employed. The empirical findings i n the l i t e r a t u r e on family response to schizophrenia i s i d e n t i f i e d within t h i s l a t t e r framework. The design of the study then i s detailed along with i t s s p e c i f i c research questions, i t s methodology and i t s r e s u l t s . I address the study's l i m i t a t i o n s and strengths and suggest some interpretations of the findings. Some implications for s o c i a l science and for family support networks are discussed. The conclusion includes suggestions for further research i n t h i s area. 5 Chapter II Schizophrenia and the Family: A Study of D i v e r s i t y Perceptions of schizophrenia, and the family's r e l a t i o n s h i p to the i l l n e s s , have changed dramatically over time. D i v e r s i t y also i s evident i n the i l l n e s s , i t s symptoms and severity, as well as i n families, t h e i r type and structure. Var i a t i o n i n Perceptions: H i s t o r i c a l Overview During c o l o n i a l times, mental disturbance was considered to be punishment for past transgressions (Deutsch, 1949); families were expected to contend with mental i l l n e s s , as with any act of God, with forbearance (Terkelsen, 1990). Family r e s p o n s i b i l i t y for the care of the mentally i l l placed a great s t r a i n on the family uni t which society required to be productive and economically independent (Hatfield, 1987a). During the f i r s t half of the nineteenth century, there was a s h i f t i n s o c i a l perception of mental disturbance. I t was thought to r e s u l t from chaotic s o c i a l conditions rather than divine r e t r i b u t i o n (Terkelsen, 1990). This philosophical s h i f t was accompanied by the establishment of i n s t i t u t i o n s i n which the mentally i l l could be i s o l a t e d and given r e l i e f from s o c i a l stresses. During t h i s period, "the family was looked on as an i n d i r e c t , passive agent to the onset of mental i l l n e s s . If the p r i n c i p l e cause of insanity was the disarray of American society, the family was at f a u l t for not having shielded the patient s u f f i c i e n t l y " (Terkelsen, 1990, p. 6). Family contact was discouraged; 6 the i s o l a t i o n of the patient was deemed important l e s t r e l a t i v e s r e i n f e c t the patient with germs of anxiety. By the twentieth century, the perception of the family's r o l e i n mental i l l n e s s had s h i f t e d from that of passive agent to offending agent. During recent decades, other views of family involvement have arisen as well. A recent search of the s o c i a l science l i t e r a t u r e by Gubman and Tessler (1987) has i d e n t i f i e d three themes i n twentieth century analyses of the family-schizophrenia r e l a t i o n s h i p : family i n t e r a c t i o n and communication as causal agent, family as r e h a b i l i t a t i o n agent, and family as burden-bearer. Family as Causal Agent Psychoanalytically based theories implicated the family i n the etiology of the i l l n e s s . Attention was focused on family in t e r a c t i o n , on mother-child and spousal r e l a t i o n s h i p s . The interaction approach f i r s t appeared i n the l i t e r a t u r e with Hadju-Gines' (1940) description of mothers of schizophrenic women as cold and s a d i s t i c , and continued l a t e r with Fromm-Reichmann's (1948) characterization of them as r e j e c t i n g and schizophrenogetic (Terkelsen, 1990). Unfortunately, the term, "schizophrenogetic mother ...(became) the b a t t l e cry upon which the family was implicated as a major factor i n d r i v i n g family members into the fearsome world of schizophrenia" (Falloon, Boyd, & McGill, 1984, p. 4). Aspects of treatment approaches based on t h i s paradigm are s t i l l prevalent today (Terkelsen, 1983). 7 The work of Lidz, Cornelison, Fleck, and Terry (1957) found families with a schizophrenic member to have d i s t o r t e d r o l e structures, marital discord, and communication d i f f i c u l t i e s . Lidz and his colleagues concluded the severely disturbed marital and parental r e l a t i o n s h i p s contributed to the development of the i l l n e s s (Falloon et a l . , 1984). More recently, Lidz and Fleck (1985) have acknowledged a genetic component to schizophrenia, but regard i t as "a predisposition to symbolic d i s t o r t i o n " (p. 190) that together with i n t r a f a m i l i a l influences, contribute to the etiology of the i l l n e s s . Bowen (1961) also studied interaction patterns i n fami l i e s of patients diagnosed with schizophrenia. He viewed schizophrenia as the manifestation, i n one member, of a process that involved the entire family system. He noted "intense c o n f l i c t and emotional turmoil" i n the family, a state he described as "undifferentiated ego mass" (cited i n Falloon et a l . , 1984, p. 8). Communication theories also have placed emphasis upon family in t e r a c t i o n i n the etiology of schizophrenia. The double bind hypothesis (Bateson, Jackson, Haley, & Weakland, 1956) focussed on the communication patterns i n fam i l i e s that create a special type of learning context for children, requiring them to deny certain aspects of r e a l i t y (Falloon et a l . , 1984). This theory saw schizophrenia as a learned response to incompatible messages and as a s p e c i f i c pattern of communication rather than a mental i l l n e s s . 8 Studies of communication deviance, such as those of Wynne and Singer (1963) focussed attention on abnormal communication styles of parents, that were considered to cause d i f f i c u l t i e s i n a child' s a b i l i t y to focus attention and understand meaning. These d i f f i c u l t i e s were thought to impair the development of e f f e c t i v e r e a l i t y t e s t i n g and perceptual a b i l i t y , thus predisposing the c h i l d to schizophrenia (Falloon et a l . , 1984). This theory of communication deviance saw disordered communication as the core problem of families with mentally i l l r e l a t i v e s (Hatfield, 1987a). More recent genetic and b i o l o g i c a l studies, however, suggest schizophrenia has an inherited component (see Straube & Oades, 1992). Twin and adoptive studies have revealed a d e f i n i t i v e genetic l i n k (Falloon et a l . , 1984), and p h y s i o l o g i c a l investigations have found s t r u c t u r a l and functional brain abnormalities i n persons with schizophrenia (Straube & Oades, 199 2; Torrey, 1983). Currently, the consensus among most schizophrenia experts, i s that a predisposition to interact with the environment i n a special way i s inherited, making the in d i v i d u a l vulnerable to the disorder (Hatfield, 1987a). The i l l n e s s has been characterized as "a dynamic interplay among patient, family, and the flux of l i f e events" (Gottesman, 1991, p. 166). The most e f f e c t i v e means to reduce the r i s k of schizophrenia i n those who are ge n e t i c a l l y predisposed i s considered to be a supportive, nurturing, problem-solving family environment; i n 9 established cases of schizophrenia, the family environment i s thought to influence the course of the condition (Falloon et a l . , 1984). Although the evidence of a genetic basis for schizophrenia may r e l i e v e some families of the g u i l t and shame associated with t h e i r r o l e as causal agents of the i l l n e s s (Terkelsen, 1990), families are s t i l l considered to be responsible for the successful r e h a b i l i t a t i o n of the mentally i l l (Lefley, 1987c). Family as Rehabilitation Agent Research into the b i o l o g i c a l parameters of schizophrenia and the development of neuroleptic drugs have permitted community care of persons with schizophrenia. The family as caregiver to the mentally i l l has been recognized, as supervision of d e i n s t i t u t i o n a l i z e d patients has increasingly f a l l e n upon families (Atkinson, 1986; Schulz et a l . , 1986). Whereas the provision of assistance and support i s a normative family a c t i v i t y , the extraordinary care that i s required by a family member who has schizophrenia c a l l s for great amounts of time and energy i n a caregiving r o l e that i s unanticipated (Biegel, Sales, & Schulz, 1991) and that requires knowledge and support for i t s execution. Professional concern, however, has concentrated more on levels of family stress and emotional expression and t h e i r e f f e c t on the r e h o s p i t a l i z a t i o n of the family member than on the family's need for information and assistance with provision of care (Lefley, 1992). The maintenance on medication of patients i n the community does not preclude a reoccurrence of schizophrenic episodes. A stress v u l n e r a b i l i t y model has been applied to schizophrenia (Goldstein & Strachan, 1987). Investigations into patient relapse have focussed on the negative features of family relationships; the term, expressed emotion (EE) has been used to describe the r e l a t i v e s ' emotional response to the patient, t h e i r expressions of c r i t i c i s m , h o s t i l i t y , and emotional overinvolvement (Falloon & McGill, 1985) . The high-EE of at least one family member has been found to be associated with more frequent relapse of the patient (Lefley, 1992; Vaughn, Snyder, Jones, Freeman, & Falloon, 1984). One very recent examination of the r e l a t i o n s h i p s among the components of expressed emotion and patient symptomatology, however, produced a pattern of r e s u l t s consistent with a more complex perspective of family i n t e r a c t i o n than that provided by the t r a d i t i o n a l d i a t h e s i s / s t r e s s perspective (see Cole, Kane, Zastowny, Grolnick, & Lehman, 1993). Cole et a l . found patient outcome, the number of weeks the patient remained out of h o s p i t a l , to be e s s e n t i a l l y determined by patient function at discharge and not affected by the EE index. The notion that the emotional environment of the family may be hazardous for a person who i s recovering from an episode of schizophrenia i s reminiscent of the above mentioned contagion theory of the early 19th century. I t has led to misapplication i n c l i n i c a l practice (Falloon, 1986) ; emotionally involved families have been viewed as dysfunctional, requiring therapeutic intervention (Johnson, 1990), a perspective which has added to f a m i l i e s ' f e e l i n g s 11 of g u i l t and shame (Torrey, 1983). Falloon and McGill (1985) have suggested that t h i s perception of the family- schizophrenia r e l a t i o n s h i p i s yet another example of a l i n e a r causal hypothesis being applied to a complex i n t e r a c t i o n a l variable. A recent consideration of the concept, expressed emotion, has queried i t s application to whole fa m i l i e s , as well as i t s t r a i t versus state nature, and has questioned the a d v i s a b i l i t y of a focus on relapse as the sole outcome variable, ignoring the patient's s o c i a l functioning and qu a l i t y of l i f e (see Lefley, 1992). Lefley asserts that l i t t l e i s known of the correlates of low leve l s of expressed emotion. I t may r e f l e c t tolerance and patience; however, i t also may indicate excessive permissiveness or apathy r e s u l t i n g i n understimulation and s o c i a l withdrawal. I t has been suggested there may be antecedent differences i n patients that are correlates of both r e l a t i v e s ' expressed emotion and patient predisposition to relapse (Lefley, 1992), and that high levels of expressed emotion may be an understandable f a m i l i a l reaction to extremely d i f f i c u l t s i t u a t i o n s and behaviors (Lamb, 1990). Although parental overinvolvement may worsen the course of schizophrenia, the enduring p o s i t i v e interest of r e l a t i v e s i s thought to prevent the a f f e c t i v e blunting and s o c i a l withdrawal of the patient (El-Islam, 1979), and the stimulation of high-EE households may be considered a contribution to his/her s o c i a l r e h a b i l i t a t i o n (Falloon & McGill, 1985). This perception of re c i p r o c a l influence i n the f a m i l y - i l l n e s s 12 r e l a t i o n s h i p highlights the consideration of family as burden bearer. Family as Burden Bearer The d i f f i c u l t i e s experienced by families caring for a member with schizophrenia were long i n being recognized, p a r t l y because of the i s o l a t i o n and stigmatization of the mentally i l l and t h e i r r e l a t i v e s , as well as the misinterpretation of the family theories of i l l n e s s etiology (Katschnig & Konieczna, 1987). Introducing the concept of "family burden" i n the community care of persons with schizophrenia, Grad and Sainsbury (1963) found family members to experience severe problems of management, with s o c i a l and work interference and negative e f f e c t s on health and f i n a n c i a l status (Thompson & Doll, 1982). Recognizing that families also suffered an emotional t o l l , Hoenig and Hamilton (1966) distinguished between objective and subjective burden. They defined.subjective burden as what r e l a t i v e s f e l t about the patients' presence i n the home and t h e i r feelings of being burdened. The families that were studied reported greater objective burden (80%), defined as general household disruption and f i n a n c i a l loss, than subjective feelings of being burdened (60%). Many investigations of the family experience with schizophrenia have u t i l i z e d t h i s subjective/objective d i s t i n c t i o n , with a further delineation of the a f f e c t i v e aspects of the subjective dimension (Thompson & D o l l , 1982). Emotional reactions of family members have been found to include anxiety, g u i l t , depression, i r r i t a t i o n , and anger (Creer & 13 Wing, 1974). The subjective burden of parents with adult child r e n who have schizophrenia has been compared to that of adult children with parents who have Alzheimer's disease (see Lefley, 1987b; Wasow, 1985). Both include f e e l i n g s of "despair, loss, sadness, pain, exhaustion, p i t y , g u i l t , resentment, helplessness, embarrassment, fear, and chronic sorrow" (Wasow, 1985, p. 714). Other studies have found that families dealing with schizophrenia l i v e with "severe physical and psychological drain" (Hatfield, 1978, p. 358), household disruption, and tense family relationships (Falloon, Hardesty, & McGi l l , 1985), and i n t r a f a m i l i a l c o n f l i c t (Creer & Wing, 1974) . Thompson and Dol l (1982) found the most common items having to do with f a m i l i e s ' objective burden r e f l e c t e d the inconveniences of the care-giving role, whereas feel i n g s of overload, embarrassment, and entrapment expressed the subjective dimension. These authors concluded that there i s a universal experience of s o c i a l and emotional costs for fami l i e s coping with the mentally i l l . I t i s inter e s t i n g to consider that while the family unit, by d e f i n i t i o n , contains the family member with the i l l n e s s , studies of the family and schizophrenia generally exclude t h i s person. One inclusive study found a difference between attitudes of well family members and patients; 92% of parents compared to 25% of patients i d e n t i f i e d schizophrenia as a disorder associated with extreme burden (Schulz et a l . , 1982). Such a d i s p a r i t y i n perceptions 14 might warrant further investigation since i t would seem to have implications for "family" coping. Although the psychosocial costs may be universal, the family experience i s not uniform; within surveys, a considerable range of responses to questions of burden i s apparent (Johnson, 1990). Between surveys, as well, the o v e r a l l perceptions of burden vary from "generally mild to moderate" (Crotty & Kulys, 1986) to "considerable" (Winefield & Harvey, 1993). It would be useful to consider the circumstances under which greater burden i s perceived. V a r i a b i l i t y of Circumstance Both "family" and "schizophrenia" are terms that include a wide range of v a r i a b i l i t y . The investigations into family burden need to account for the stage and course of the i l l n e s s (Gubman & Tessler, 1987; Rolland, 1989), the severity of the i l l n e s s (Falloon et a l . , 1984), and the heterogeneity of families (McFarlane, 1990). Diversity within the I l l n e s s Schizophrenia i s an i l l n e s s that varies i n onset, symptoms, course, and severity. Its most predictable aspect i s age of onset. Three-quarters of a l l cases begin i n the 16 to 2 5 age group with onset approximately 5 years e a r l i e r for men than for women (Torrey, 1983). I t i s important to note, however, that v u l n e r a b i l i t y for schizophrenia extends throughout the l i f e course (Cohler & Ferrono, 1987). Two syndromes of schizophrenia can been distinguished, the acute syndrome with f l o r i d or p o s i t i v e symptoms and the chronic syndrome with negative or d e f i c i t symptoms, each 15 with i t s own c h a r a c t e r i s t i c s and implications for course and outcome (Wing, 1987b). Positive symptoms include delusions, hal l u c i n a t i o n s , and thought interference; negative symptoms include emotional withdrawal, blunting of a f f e c t , poverty of thought and speech, apathy, and underactivity (Falloon, McGill, & Hardesty, 1985). The syndromes can appear separately or together and i n varying degrees of severity. The i l l n e s s more often begins i n s i d i o u s l y with negative symptoms that are d i f f i c u l t to distinguish from exaggerations of normal, adolescent and adult f e e l i n g s and behaviours (Hardesty, Falloon, & Sh i r i n , 1985; Torrey, 1983) . Acute onset with f l o r i d symptoms i s easier to recognize. Schizophrenia symptoms vary i n severity; they can be s l i g h t l y , moderately, severely, or absolutely d i s a b l i n g (Gottesman, 1991). One cannot speak about the "natural" course of schizophrenia (Wing, 1987a). A great variety of developmental courses can be encountered, although i t i s most t y p i c a l l y one of remission and exacerbation (Falloon & McGil l , 1985). In most cases, a chronic onset i s followed by a more chronic course and an acute onset with a more fl u c t u a t i n g course, but many variations have been observed (Straube & Oades, 1992). Longitudinal studies of patient outcome vary i n reported recovery rates according to the kinds of patients selected for follow-up. Generally i t i s thought that one- t h i r d of a l l patients diagnosed with schizophrenia w i l l completely recover, one-third w i l l improve but not 16 completely recover, and the f i n a l t h i r d w i l l not improve (Torrey, 1983). Research data suggest schizophrenia i s a chronic i l l n e s s that may remit or ameliorate over time (Harding, 1991). A review of six major long-term studies has shown that one-half or more of the patients s i g n i f i c a n t l y improve and/or recover, while the i l l n e s s has an episodic nature i n the other half (Harding, 1991). I t has been suggested, however, that those patients considered recovered may not return to a l e v e l of predisease functioning (Gottesman, 1991), and even a restoration of patients to t h e i r premorbid levels of functioning may leave gross d e f i c i t s i n s o c i a l role performance (Falloon, M c G i l l , & Hardesty, 1985). Some writers take issue with the concept of c h r o n i c i t y (see Jimenez, 1988). Although such a conception may be accurate for some people with schizophrenia, "the assumption of c h r o n i c i t y accompanying a diagnosis of severe mental disorder, p a r t i c u l a r l y schizophrenia, c a r r i e s with i t an i n e v i t a b l e sense of hopelessness and diminished expectation....(It) precludes the notion of recovery and therefore has c r i t i c a l implications for practice and p o l i c y " (Jimenez, 1988, pp. 628-629). I t could be suggested that such an assumption also would have implications for parental response to a diagnosis of schizophrenia i n an adult c h i l d . This heterogeneity of symptoms, course of i l l n e s s , and outcome has prompted the unanswered question of whether schizophrenia i s one disease or a group of loosely connected diseases (Straube & Oades, 1992). It i s generally believed, 17 however, to be e s s e n t i a l l y one entity with a whole continuum of manifestations (Gottesman, 1991). I t can be seen that the consequences of the disorder for the family would d i f f e r according to the d i f f e r e n t manifestations of the i l l n e s s (Cole et a l . , 1993; Gubman & Tessler, 1987). Family Diversity Even with s i m i l a r i t i e s i n the degree and type of objective burden, families have been seen to respond d i f f e r e n t l y , an observation that i s not surp r i s i n g considering the heterogeneity of families (McFarlane, 1990). The family system can be defined very broadly with extensive boundaries including many generations. In t h i s l i t e r a t u r e review, family w i l l be r e s t r i c t e d to parents and s i b l i n g s of the person with schizophrenia. Interestingly, a study including data from epidemiological f i e l d surveys and c l i n i c a l interviews found that of a l l r e l a t i v e s (parent, spouse, c h i l d , s i b l i n g , and extended family member) of persons with mental health problems, the highest measures of depression and anxiety, although not of psychosocial dysfunction, were reported by parents (see Arey & Warheit, 1980). Because of probable age of onset of schizophrenia, family members coping with f i r s t symptoms and diagnosis, e s p e c i a l l y that of young men, are most often those of family of o r i g i n (Falloon et a l . , 1984). Because an i l l n e s s such as schizophrenia reduces a person's p r o b a b i l i t y of marriage, parents and/or s i b l i n g s may remain the family caregiving unit for those with early onset, whether or not residence i s 18 shared (Carpentier, Lesage, Goulet, Lalonde, & Renaud, 1992; Torrey, 1983). These families vary i n form and across time. Only a singl e versus dual-parent d i s t i n c t i o n has been u t i l i z e d i n the l i t e r a t u r e on family response to schizophrenia; separated, divorced, and remarried family forms, each with i t s p a r t i c u l a r i n t e r a c t i o n a l dynamics, have not been d i f f e r e n t i a t e d . These families of o r i g i n may be composed of m i d - l i f e parents with other school-aged children, those with other children who have been "launched", or older parents coping with issues of t h e i r own aging. Because family r o l e r e l a t i o n s h i p s vary at these d i f f e r e n t l i f e stages, adaptation problems and coping resolutions also w i l l d i f f e r (Biegel et a l . , 1991). At any stage of family development, however, adaptation to s t r e s s f u l l i f e events may be mediated by personal c h a r a c t e r i s t i c s of family members as well as by family strengths (McCubbin & McCubbin, 1991). Some family types are considered to be more r e s i l i e n t to external demands. McCubbin and McCubbin (1991, p. 6) define a family's typology as "a set of basic attributes about the family system which characterizes and explains how a family system t y p i c a l l y appraises, operates and/or behaves". Olson, Lavee, and McCubbin (1988) have developed the Circumplex Model of Family Systems based on three major family dimensions: cohesion, adaptability or f l e x i b i l i t y , and communication. Cohesion i s defined as the emotional bonding that family members have toward one another; f l e x i b i l i t y i s 19 defined as the a b i l i t y of the family system to adapt to changing r o l e relationships and relat i o n s h i p r u l e s ; communication i s considered to be a f a c i l i t a t i n g factor i n the family's movement along the dimensions of cohesion and f l e x i b i l i t y . Families can be categorized into four types depending on t h e i r l e v e l s of cohesion and f l e x i b i l i t y : (a) f l e x i b l e - separated - high i n adaptability and low on cohesion, (b) structured-separated - low in both adaptability and cohesion, (c) flexible-connected - high i n a d a p t a b i l i t y and cohesion, (d) structured-connected - low i n a d a p t a b i l i t y and high i n cohesion (Lavee & Olson, 1991). These family types are considered to d i f f e r i n the resources avai l a b l e for response to s t r e s s f u l l i f e events and normative t r a n s i t i o n s (Olson et a l . , 1988). Families also vary i n socio-economic status, e t h n i c i t y , and experience, a l l of which w i l l a f f e c t the influence of the i l l n e s s on the family. In addition, a family i s not an amorphous mass with a u n i f i e d reaction to a stimulus. The schizophrenia of a family member w i l l be experienced d i f f e r e n t l y according to d i f f e r e n t family r o l e r e l a t i o n s h i p s , that i s , mother, father, or s i b l i n g (Gubman & Tessler, 1987; Lefley, 1993). Before examining some empirical support for the rela t i o n s h i p s within t h i s v a r i a b i l i t y , i t would be h e l p f u l to consider t h e o r e t i c a l approaches to the study of stress and coping on both the individual and family l e v e l s . Such a consideration w i l l provide a th e o r e t i c a l focus for study. This digression hopefully w i l l add c l a r i t y through an understanding of the coping process and a d e f i n i t i o n of concepts. Stress and coping theory offers a language for a discussion of the l i t e r a t u r e i n a t h e o r e t i c a l relevant way, allows for a meaningful organization of empirical findings, situates i n d i v i d u a l coping within the family context, and i d e n t i f i e s some areas of weakness i n past research. 21 Chapter III Theoretical Framework: Stress and Coping The focus of t h i s study i s coping. As Pe a r l i n (1991) advises, coping i s best understood when viewed within the stress process. The relationships that have been found empirically to exis t within the v a r i a b i l i t y of family and i l l n e s s , therefore, may be most meaningful when organized by stress and coping theory. Although the concept of stress i s widely used, i t has been defined variously as stimulus and as response (Monat & Lazarus, 1985). This study follows the d e f i n i t i o n of Lazarus and Folkman (1984, p. 19), that s p e c i f i e s psychological stress to be "the relationship between the person and the environment that i s appraised by the person as taxing or exceeding his or her resources and endangering hi s or her well-being." Lazarus and Folkman conceptualize coping as a person's e f f o r t s to manage such stress. The family coping response i n instances of a young c h i l d ' s physical i l l n e s s or d i s a b i l i t y , and caregiving i n aging, have been widely investigated (for reviews see Horowitz, 1985; Knafl & Deatrick, 1987), and a number of stress and coping models have been applied to caregiver experience (see Biegel et a l . , 1991; Lefley, 1990; Pea r l i n , Mullan, Semple, & Skaff, 1990). These various models have agreed on many of the relevant concepts. When choosing a theoreti c a l model, i t i s important to keep i n mind the purpose for which i t i s intended. This study required a model that would s a t i s f y a double purpose: 22 (a) to organize and make more comprehensible the v a r i a b i l i t y that i s apparent i n the l i t e r a t u r e on the family response to schizophrenia, and (b) to locate i n d i v i d u a l coping within the family context. The Resiliency Model of Family Stress, Adjustment, and Adaptation (McCubbin & McCubbin, 1991) i s able to incorporate, within a developmental framework, much of the v a r i a b i l i t y that has been found to be relevant to the family experience with schizophrenia. This model i s compatible with the theorizing of scholars who focus on i n d i v i d u a l stress and coping. It attends to the appraisal of demands and resources featured by Lazarus and Folkman (1984) i n t h e i r work, and accommodates the p i l e up of demands and secondary stressors a r i s i n g from the s i t u a t i o n a l context that i s emphasized by Pearlin (1989). P a r t i c u l a r l y , i t places the i n d i v i d u a l within the family context with i t s important r o l e relationships, v u l n e r a b i l i t i e s , and strengths. The fundamental assumptions of family l i f e upon which t h i s model i s based are the following: (1) families face hardships and changes as a natural and predictable aspect of family l i f e over the l i f e cycle; (2) families develop basic strengths and c a p a b i l i t i e s designed to foster the growth and development of family members and the family u n i t and to protect the family from major disruptions i n the face of family t r a n s i t i o n s and changes; 23 (3) families develop basic and unique strengths and c a p a b i l i t i e s designed to protect the family from unexpected or non-normative stressors and st r a i n s and to foster the family's adaptation following a family c r i s i s or major t r a n s i t i o n and change; and (4) families benefit from and contribute to the network of relationships and resources i n the community, p a r t i c u l a r l y during periods of family stress and c r i s e s (McCubbin & McCubbin, 1991, p. 3) . The Resiliency Model of Family Stress, Adjustment, and Adaptation (McCubbin & McCubbin, 1991) attempts to describe the family experience of stress at two phases of response: the i n i t i a l adjustment period and the l a t e r adaptation phase. In t h i s way the model not only integrates the heterogeneity of families and t h e i r s i t u ations, and the in t e r a c t i o n among these factors, but also accommodates the v a r i a b i l i t y of these components over time. The model i l l u s t r a t e s that family adjustment and adaptation to a s t r e s s f u l s i t u a t i o n (X) i s determined by the i n t e r a c t i o n among the pile-up of demands (A) and family v u l n e r a b i l i t y (V), family type (T), available resources (B), s i t u a t i o n a l appraisals (C) and adaptive, problem solving coping (PSC) (see Figure E l ) . The model indicates a highly i n t e r a c t i v e process with r e c i p r o c a l influences among the components. Adaptation at time one can become a strength or a v u l n e r a b i l i t y at time 24 two. I t has been cautioned elsewhere, however, that any model of the stress process should be regarded as "an h e u r i s t i c device rather than as a l i t e r a l r e f l e c t i o n of r e a l i t i e s and the pathways that j o i n them, many of which are s t i l l unclear" (Pearlin et a l . , 1990, p. 591). The Resiliency Model of Family Stress, Adjustment, and Adaptation (McCubbin & McCubbin, 1991) addresses the d i s t i n c t i o n between individual as opposed to family group resources, perceptions, and responses. I t values both le v e l s of response and sees them, i n a systems perspective, as i n e x t r i c a b l y linked. Elsewhere, as well, family stress theory attends to the importance of both i n d i v i d u a l and family l e v e l s of demands and c a p a b i l i t i e s (see Boss, 1988; Patterson & Garwick, 1994). This model, therefore, can be considered a useful framework within which to view the family experience with schizophrenia, a framework which i s able to locate individual and family coping e f f o r t s within a complex, in t e r a c t i v e stress response. As mentioned above, the work of McCubbin and McCubbin (1991) on stress and coping i s compatible with that of other scholars. Although each approach has a d i f f e r e n t focus, together they share many similar concepts. I suggest through my study that these d i f f e r e n t approaches can be seen to inform and enrich one another. The work of these other scholars, therefore, i s included i n order to f a c i l i t a t e conceptual c l a r i f i c a t i o n . 25 C l a r i f i c a t i o n of Concepts P e a r l i n (1985) asserts that our inte r e s t i n coping f a r exceeds our knowledge about i t . He suggests that because i t has been approached from a variety of perspectives and d i s c i p l i n e s , the knowledge gained has not been cumulative. As an example of conceptual difference, consider the following. Haan (.1985) distinguishes coping as an.ego process separate from defense mechanisms and evaluates i t more favorably; White (1985) views coping and defense both as legitimate but separate strategies of adaptation under d i f f i c u l t conditions; whereas Lazarus and Folkman (1984) perceive defense as one of many coping strategies. In t h e i r theorizing about the coping process, McCubbin and McCubbin (1991) include areas of emphasis s i m i l a r to and compatible with those found i n the social-psychological approach of Lazarus and Folkman (1984), i n the s o c i o l o g i c a l perspectives of Pearlin (1989a), and Pea r l i n and Schooler (1978), and i n the work of other family t h e o r i s t s . I t would be h e l p f u l , then, to examine the concept of coping at both the i n d i v i d u a l and family levels, as i t i s explicated by these scholars. An attempt w i l l be made to c l a r i f y the concept by examining d e f i n i t i o n s , functions, and assessment of coping. Coping: Compatible Definitions Lazarus and Folkman (1984, p. 141) define i n d i v i d u a l coping as "constantly changing cognitive and behavioral e f f o r t s to manage s p e c i f i c external and/or i n t e r n a l demands that are appraised as taxing or exceeding the resources of 26 the person". In "unpacking" t h i s d e f i n i t i o n , the above authors note the following c h a r a c t e r i s t i c s : (a) coping i s a process that changes i n response to the s i t u a t i o n , (b) coping i s a deliberate a c t i v i t y with a s p e c i f i c focus rather than a generalized automatic response, and (c) coping i s any attempt to manage the si t u a t i o n and i s not to be confounded with outcome or mastery. In t h i s respect, coping can include "minimizing, avoiding, t o l e r a t i n g , and accepting the s t r e s s f u l conditions" as well as attempts to master them (Lazarus & Folkman, 1984, p. 142). This d e f i n i t i o n of coping i s comparable to that of McCubbin and McCubbin (1991, p. 22) i n which coping behavior i s seen as "a s p e c i f i c e f f o r t (covert or overt) by which an in d i v i d u a l (or a group of individuals such as the family) attempts to reduce or manage a demand on the family system". Si m i l a r l y , family system theorists, Patterson and Garwick (1994, p. 137), define family coping as "a s p e c i f i c e f f o r t by an in d i v i d u a l or family that i s directed at maintaining or restoring the balance between demands and resources." They see coping behaviours, along with resources, as family c a p a b i l i t i e s . These scholars do not perceive coping to be stressor s p e c i f i c . They see fa m i l i e s continuously managing a pileup of demands with not a single source responsible for the imbalance between demands and resources, even though one source may be most prominent and the one that i s appraised as the problem. Boss (1988, pp. 60-61) defines family coping as "the cognitive, a f f e c t i v e , and behavioral process by which 27 indi v i d u a l s and t h e i r family system as a whole manage rather then eradicate s t r e s s f u l events or s i t u a t i o n s . " She i n s i s t s that to be considered coping or management, t h i s process must have no detrimental effects on any family member. In t h e i r investigation of ind i v i d u a l s ' coping responses to normative life-problems, Pearlin and Schooler (1978, p. 3) define coping as "any response to external l i f e - s t r a i n s that serves to prevent, avoid, or control emotional d i s t r e s s . " Coping responses may be either i n d i v i d u a l s ' actions or t h e i r perceptions, elements of which may be s o c i a l l y learned (Pearlin, 1989a). Integral to these d e f i n i t i o n s of coping are the concepts of demands or stressors, resources, and appraisal. Demands/Stressors Lazarus and Folkman (1984) consider a stressor to be any environmental s i t u a t i o n or event that i s construed by the i n d i v i d u a l as taxing or overwhelming h i s or her resources and endangering his or her well-being. For these scholars, not a l l demands are stressors. They must be perceived as such by the in d i v i d u a l . One's perception or appraisal of the situ a t i o n , therefore, i s a c r i t i c a l factor. P e a r l i n and Schooler (1978, p. 3) consider stressor and s t r a i n to be interchangeable concepts that indicate "those enduring problems that have the potential for arousing threat." P e a r l i n (1989a) addresses two types of stressors: undesired, non-normative events, and chronic s t r a i n s . He emphasizes the s o c i a l character of eventful stress, pointing out that many s t r e s s f u l events are rooted i n a person's 28 s o c i a l and economic status. He defines chronic s t r a i n s as those enduring problems, c o n f l i c t s , and threats that people face i n t h e i r d a i l y l i v e s . He asserts that these l a t t e r s t r a i n s , which occur within s o c i a l roles, a f f e c t people because the roles themselves are important. He suggests that these primary stressors r a r e l y occur singly; one event or s t r a i n tends to trigger other secondary s t r a i n s . Clusters of stressors may develop. Irt addition, stressors experienced by one person can become problems for others who share the same role sets. This s o c i o l o g i c a l approach i s compatible with that of family-stress theorists (see Boss, 1988; McCubbin & McCubbin 1991; Patterson & Garwick, 1994). McCubbin and McCubbin (1991) assert that there are at least f i v e broad types of stressors which contribute to a p i l e up of demands on the family system and to family v u l n e r a b i l i t y : (a) the i n i t i a l s tressor and i t s hardships, (b) normative t r a n s i t i o n s , including family l i f e cycle changes, (c) p r i o r s t r a i n s , (d) the consequences of family e f f o r t s to cope, and (e) both intra-family and s o c i a l ambiguity. Social ambiguity i s thought to r e s u l t from an absence of s o c i a l programs and p o l i c i e s that guide family response i n s t r e s s f u l s i t u a t i o n s . In t h e i r family systems approach to chronic i l l n e s s , Patterson and Garwick (1994) see similar demands a r i s i n g from four aspects of the intersection of i l l n e s s and family systems. (a) There are the c h a r a c t e r i s t i c s of the chronic condition: the degree and type of incapacitation, the degree of v i s i b i l i t y of the condition, the prognosis and course of 29 the i l l n e s s , and the amount of d i s t r e s s experienced by the person who i s i l l . (b) There are demands a r i s i n g from the impact of the i l l n e s s on the family: f i n a n c i a l s t r a i n s , losses of family privacy and family time, problems with service providers, and caregiver s t r a i n s . (c) There are demands associated with developmental interactions. Chronic i l l n e s s can a f f e c t the developmental course of i n d i v i d u a l s within the family and of the family as a whole. (d) There also can be stress a r i s i n g from other family sources that creates d i f f i c u l t i e s i n managing the chronic i l l n e s s . These d i f f e r e n t approaches have i n common the importance of the environment, or context, i n the i d e n t i f i c a t i o n of stressors. There are s i m i l a r i t i e s , as well, i n the ways that resources have been conceptualized. Resources Lazarus and Folkman (1984) consider resources to be something one draws upon and uses to counter demands. They categorize resources into those of the person and those of the environment. Personal resources can be physical (health and energy), psychological (positive b e l i e f s , such as p o s i t i v e thinking and an internal locus of c o n t r o l ) , and competencies (problem-solving and s o c i a l s k i l l s ) . Resources of the environment are such things as s o c i a l support and material resources. The a v a i l a b i l i t y of resources i s considered to influence one's appraisal of the s i t u a t i o n as well as one's choice of coping response. Pe a r l i n and Schooler (1978) also d i s t i n g u i s h between s o c i a l resources and psychological resources, and also 30 define resources not as what people do, but as what i s av a i l a b l e to them in developing t h e i r coping repe r t o i r e s . They see s o c i a l resources represented by people's interpersonal networks which may be pot e n t i a l sources of support. "Psychological resources are the personality c h a r a c t e r i s t i c s that people draw upon to help them withstand threats posed by events and objects in t h e i r environment" (Pearlin & Schooler, 1978, p. 5). In t h e i r analysis, these authors focus on the personality c h a r a c t e r i s t i c s of s e l f - esteem, self-denigration, and mastery. Family-stress theorists consider resources to be i n d i v i d u a l and c o l l e c t i v e strengths or assets that can be drawn upon i n response to a demand or to multiple stressors (see Boss, 1988; McCubbin & McCubbin, 1991; Patterson & Garwick, 1994). They are obtainable from three p o t e n t i a l sources: i n d i v i d u a l family members (for example, i n t e l l i g e n c e , self-esteem, and sense of mastery), the family unit (communication s k i l l s , cooperation, f l e x i b i l i t y , cohesion), and the community (supportive r e l a t i o n s h i p s ) . Relevant to a conceptualization of family l e v e l resources i s the above discussion of family type. Family cohesion has been i d e n t i f i e d as an important dimension of family dynamics (Olson et a l . , 1988) with implications for family response to stressors. In a n o n - c l i n i c a l population, more cohesive families have been found to have lower l e v e l s of s t r a i n and higher levels of well-being than do separated fa m i l i e s (Olson et a l . , 1988). F l e x i b i l i t y , by i t s e l f , has not been found to have di r e c t influence on family 31 r e s i l i e n c y ; an interaction effect, however, has been found between f l e x i b i l i t y and cohesion. Connected fa m i l i e s with low f l e x i b i l i t y and separated families with high f l e x i b i l i t y have been seen to be more vulnerable to stress (Olson et a l . , 1988). Stress v u l n e r a b i l i t y also i s seen to be influenced by one's s o c i a l support system. Because s o c i a l support i s considered to be a highly important resource, s p e c i a l attention to i t i s warranted. Social support. Social support i s generally d i f f e r e n t i a t e d from s o c i a l network. Whereas s o c i a l network i s concerned with numbers and patterns of s o c i a l r e l a t i o n s h i p s , s o c i a l support implies a q u a l i t a t i v e d i s t i n c t i o n . Lazarus and Folkman (1984) emphasize that to be considered a resource, the nature of the s o c i a l r e l a t i o n s h i p i s important. I t must be perceived as h e l p f u l ; i t also must be u t i l i z e d . These scholars have shown that type of support-seeking changes from one stage to another of a s t r e s s f u l encounter, from i n i t i a l information seeking to l a t e r emotional support seeking. P e a r l i n (1989) acknowledges the d i s t i n c t i o n between one's t o t a l i t y of potential s o c i a l resources and one's s o c i a l support, seeing s o c i a l support as the s o c i a l resources that one actually uses i n dealing with l i f e problems. He stresses the importance, however, of l i n k i n g the study of s o c i a l supports more clos e l y to the study of s o c i a l networks, and of considering i t s i n t e r a c t i o n a l nature. 32 P a r t i c u l a r l y i n families such attention i s warranted. Family members generally are important sources of support to each other and yet they often are exposed to the same s t r e s s f u l circumstances. Revenson (1994, p. 123), i n her discussion of marital coping with chronic i l l n e s s , c a l l s attention to the reciprocal relationship of husband and wife. "One must look not only at the passive reaction of one spouse to the other's coping behavior, but at how each spouse d i r e c t l y or covertly influences the other spouse's cognitions, emotions, and actions. For example, i t i s not enough to know that one partner was tr y i n g to be supportive; i t i s also c r i t i c a l to whether that support was perceived as he l p f u l by the reci p i e n t " . Eckenrode (1991, p. 5) suggests there may be "a certain degree of synchrony or orchestration that takes place as each person seeks to cope with a common stressor." Gottlieb and Wagner (1991, pp. 167-168) describe coping and support e f f o r t s i n close relationships when both partners have been exposed to the same stressor: Both the supporter and the would-be r e c i p i e n t become involved i n the process of comparing t h e i r emotional reactions to the event and responding to one another's coping e f f o r t s . They must concurrently deal with the demands imposed by the stressor and those imposed by each other's coping responses. Each faces the challenge of modulating his/her own ways of coping i n order to avoid disrupting the partner's coping e f f o r t s and to gain his/her support. At the same time, as 33 providers of support, each must be c a r e f u l not to allow his/her own needs for emotional regulation to d i c t a t e the types of support extended to the r e c i p i e n t . Appraisal S i t u a t i o n a l appraisal i s an element of the stress process that i s deemed to be highly important i n both i n d i v i d u a l and family stress theory. Although d i f f e r e n t stress t h e o r i s t s assign various terms to t h i s concept, such as, perception, appraisal, d e f i n i t i o n , or assessment, Boss (1988) suggests that a l l terms indicate the meaning of the event or s i t u a t i o n for an individual or family. The concept of appraisal has been c l a r i f i e d most thoroughly by Lazarus and Folkman (1984). These scholars consider i n d i v i d u a l cognitive appraisal to be "an evaluative process that determines why and to what extent a p a r t i c u l a r transaction or series of transactions between the person and the environment i s s t r e s s f u l " (1984, p. 19). They d i s t i n g u i s h between two types of cognitive appraisal: primary appraisal, that evaluates the s i g n i f i c a n c e of the person-environment relationship, and secondary appraisal, that assesses one's resources and options available to change i t . Primary appraisals that i d e n t i f y s t r e s s f u l s i t u a t i o n s include those of harm/loss, where the damage has already occurred; those of threat, which concern anticipated harms or losses; and those of challenge, which include a p o t e n t i a l for gain or growth. These appraisals are accompanied by 34 c h a r a c t e r i s t i c emotions. "Harm/loss appraisals ... can generate feelings of sadness, anger, g u i l t , and r e l i e f , depending on the meaning of the harm or loss to the i n d i v i d u a l . Threat appraisals can generate feelings of worry, fear, and anxiety. Challenge can generate f e e l i n g s of eagerness, hopefulness, and excitement" (Folkman et a l . , 1991, p. 241). These appraisals are not mutually exclusive; the same s i t u a t i o n may be perceived as both a loss or threat and a challenge. With such complex appraisals, people are l i k e l y to report c o n f l i c t i n g emotions. Whether a stressor i s perceived as a loss, a threat, or a challenge, has been shown to have a s i g n i f i c a n t e f f e c t on the choice of coping strategy (McCrae, 1984). Reappraisals occur with a changing s i t u a t i o n or the receipt of new information. A secondary appraisal " i s a complex evaluative process that takes into account which coping options are a v a i l a b l e , the l i k e l i h o o d that a given coping option w i l l accomplish what i t i s supposed to, and the l i k e l i h o o d that one can apply a p a r t i c u l a r strategy or set of strategies e f f e c t i v e l y " (Lazarus & Folkman, 1984, p. 35). The meaning and emotional qu a l i t y of every encounter or s i t u a t i o n i s shaped by the convergence of primary appraisal and secondary appraisal (Folkman et a l . , 1991). " D e f i n i t i o n of the s i t u a t i o n " i s at the heart of the perspectives on which family stress theorists have b u i l t (Hansen & Johnson, 1979). H i l l (1971) was the f i r s t family t h e o r i s t to focus on the "meaning of the event" and l a t e r Reiss (1981) highlighted the family's "construction of 35 r e a l i t y " (Boss, 1988). Al t e r n a t i v e l y , family t h e o r i s t s (see Reiss & O l i v e r i , 1983) have suggested the family's subjective d e f i n i t i o n of an event should be replaced by that of the community within which the family l i v e s . S i m i l a r l y , Boss (1988, p. 19) stresses that "diverse backgrounds give us diverse perceptions." She asserts that the meaning families give to an event i s the key to t h e i r appraisals of the sit u a t i o n , influencing both t h e i r v u l n e r a b i l i t y and t h e i r responses. Boss contends that family perceptions frequently d i f f e r from those of i n d i v i d u a l family members and i n s i s t s that an appreciation of both i s necessary to understand family stress. McCubbin and McCubbin (1991) include family appraisals on three l e v e l s : (a) the family's appraisal of the s p e c i f i c stressor, (b) s i t u a t i o n a l appraisals that include the family's assessments of t h e i r demands r e l a t i v e to t h e i r c a p a b i l i t i e s , and (c) global appraisals, a more stable assessment of how the family views i t s i n t e r r e l a t i o n s h i p s among family members, as well as i t s r e l a t i o n s h i p to the larger community. At the f i r s t l e v e l , family appraisal i s the d e f i n i t i o n the family makes of the seriousness of the stressor. I t i s "the family's subjective d e f i n i t i o n of the stressor, accompanying hardships and t h e i r e f f e c t on the family (McCubbin & McCubbin, 1991, p. 11). This family outlook can vary from seeing a stressor as a challenge to be met or as an uncontrollable s i t u a t i o n . At the t h i r d l e v e l , a global appraisal, or family schema, i s a family's set of b e l i e f s or assumptions about how i t s members r e l a t e to one 36 another and to the community. McCubbbin and McCubbin assert that although appraisals are held i n d i v i d u a l l y , they can be shared by a group and, similar to Reiss and O l i v e r i (1983) above, believe they are formed and shaped by the s o c i a l context. More recently, McCubbin, Thompson, Thompson, Elver, and McCubbin (1994) have drawn up a h i e r a r c h i c a l ordering of f i v e l e v e l s of appraisal processes for families i n c r i s i s . Level 5. Family schema. An overarching, generalized informational structure of shared values, b e l i e f s , goals, expectations, and p r i o r i t i e s through which experiences are f i l t e r e d . Level 4. Family coherence. A d i s p o s i t i o n a l world view that expresses the family's confidence that the world i s comprehensible, manageable, and meaningful [following Antonovsky (1979, 1987)]. I t shapes the degree to which the family i s able to u t i l i z e i t s potential resources. Level 3. Family paradigms. B e l i e f s and expectations shared by the family that guide i t s patterns of functioning i n s p e c i f i c domains of family l i f e . Level 2. S i t u a t i o n a l appraisal. The family's shared d e f i n i t i o n of the stressor, i t s associated hardships, and the demands for change placed upon the family system. Level 1. Stressor appraisal. The family's d e f i n i t i o n of the stressor and i t s severity. McCubbin et a l . (1994) suggest that generally f a m i l i e s respond to s t r e s s f u l situations by r e l y i n g upon t h e i r family paradigms, or usual patterns of functioning. In c r i s i s 37 sit u a t i o n s , however, a l l levels of appraisal are activated to promote changes i n routines, roles, and expectations, and to attach to the experience a sense of meaning. Patterson and Garwick (1994) emphasize three l e v e l s of family meanings, representing three l e v e l s of abstraction and s t a b i l i t y , that shape family response. They suggest that " f a m i l i e s , as a whole, construct and share meanings about (a) s p e c i f i c s t r e s s f u l situations, (b) t h e i r i d e n t i t y as a family, and (c) t h e i r view of the world" (p. 138). On the f i r s t l e v e l , "the meanings the family ascribes to what i s happening to them (demands) and to what they have for dealing with i t (capabilities) are c r i t i c a l factors i n achieving balanced functioning" (p. 1 3 2 ). Individual family members, the family as a whole, as well a"s the community, are sources of demands and c a p a b i l i t i e s and together shape the meaning of a si t u a t i o n . In h i s s o c i o l o g i c a l perspective of stress, P e a r l i n (1989) attests to the importance of meanings attached to circumstances that render them powerful stressors for some ind i v i d u a l s but not others. He believes that a person's values shape the importance and meaning of an experience. In other words, an experience i s perceived to be a threat when i t attacks what one defines "as important, desirable or to be cherished" (Pearlin, 1989, p. 2 4 9 ) . Influences on appraisal. Lazarus and Folkman (1984) suggest two, personal factors that influence one's appraisal: commitment, or what i s important to an i n d i v i d u a l , and b e l i e f s (similar to Pearlin's, 1989, values 38 and s o c i a l r o l e importance). B e l i e f s about personal control are s a i d to be generally stress reducing and " e x i s t e n t i a l b e l i e f s enable people to create meaning and maintain hope i n d i f f i c u l t circumstances" (Lazarus & Folkman, 1984, p. 80). Family t h e o r i s t s and s o c i o l o g i s t s consider s o c i a l values and b e l i e f systems to be highly i n f l u e n t i a l i n shaping the meaning of the s i t u a t i o n (see Boss, 1988; P e a r l i n , 1989a). One's values and b e l i e f system are thought to be influenced by one's membership in a s o c i a l group (Boss, 1988; McCubbin & McCubbin, 1991; Pearlin, 1989a; Reiss & O l i v e r i , 1983). Relevant s i t u a t i o n a l factors influencing appraisal are the novelty, p r e d i c t a b i l i t y , and p r o b a b i l i t y of the event, the temporal factors of imminence and duration, the ambiguity of the event/situation, and i t s timing i n r e l a t i o n to the l i f e cycle (Lazarus & Folkman, 1984). Hansen and Johnson (1979), i n t h e i r reconceptualization of family stress theory, assert that the cognitive and/or evaluative uncertainty i n situations i s among t h e i r most s t r e s s f u l q u a l i t i e s . Some i n i t i a l stress experienced by family members i n d i f f i c u l t situations can r e s u l t from such ambiguity precluding consistent coping e f f o r t s (Boss, 1988; McCubbin & McCubbin, 1991). Lazarus and Folkman (1984), however, suggest that ambiguity within a s i t u a t i o n has a dual nature; i t can i n t e n s i f y one's anxiety but also can be used to reduce threat by allowing d i f f e r e n t interpretations of a s i t u a t i o n . 39 Appraisal operationalized. Boss (1988) asserts that although the family's perception of the s i t u a t i o n i s the most important part of the stress equation, i t has been the l e a s t studied. I t may be helpful to consider the ways i n which the concept of appraisal has been operationalized by various scholars. Folkman, Lazarus, Dunkel-Schetter, DeLongis, and Gruen (1986) operationalize primary appraisal as "the stakes a person has i n a s t r e s s f u l encounter." From a review of subjects' responses to open-ended questions (see Folkman & Lazarus, 1980) and a review of the l i t e r a t u r e , s i x primary appraisal factors are i d e n t i f i e d : (a) threats to s e l f - esteem, (b) threats to loved one's well being, (c) the threat of not achieving an important goal at work, (d) harm to one's own health, safety, or physical well-being, (e) f i n a n c i a l s t r a i n , and (f) losing respect for someone else. Secondary appraisal i s operationalized by Folkman et a l . as "coping options." Subjects indicate the extent to which they perceive the s i t u a t i o n to be one that they (a) could change or do something about, (b) had to accept, (c) needed to know more before they could act, or (d) had to hold back from doing what they wanted to do. This operationalization then, attempts to capture the individual's perceptions of the c o n t r o l l a b i l i t y of the s i t u a t i o n . Walker (1985, p. 832) asserts "those who study family stress continue to postulate the existence and importance of the family's d e f i n i t i o n of the event, even though i t has yet to be operationalized or measured." There have, however, 40 been some recent attempts i n t h i s regard. For example, McCubbin and McCubbin (1991) discuss the family's d e f i n i t i o n of the seriousness of the stressor i n terms of " p o s i t i v e appraisal" or "reframing." Yet there appears to be some conceptual overlap because coping scales developed by McCubbin and colleagues include items such as "reframing", and "maintaining an optimistic d e f i n i t i o n of the s i t u a t i o n . " Patterson and Garwick (1994), as well, i n a q u a l i t a t i v e analysis of families and chronic i l l n e s s , speak of the family's a t t r i b u t i o n of meaning i n terms of s e l e c t i v e attention to p o s i t i v e aspects of the s i t u a t i o n , while minimizing l i m i t a t i o n s or problems. There does not appear to be the maintenance of a clear d i s t i n c t i o n between the concepts of appraisal and coping. At the more abstract levels of family appraisal, McCubbin and McCubbin (1991), McCubbin et a l . (1994), and Patterson and Garwick (1994), following Antonovsky (1979, 1987), discuss "sense of coherence." Sense of coherence at the i n d i v i d u a l l e v e l has been operationally defined by Antonovsky (1979) as (a) comprehensibility (a predictable environment), (b) manageability (available resources), and (c) meaningfulness (demands worthy of engagement). In a study of army famili e s ' adaptation to relocation, Lavee, McCubbin, and Patterson (1985) operationalized coherence as a composite of family members' commitment to the Army mission, t h e i r sense of p r e d i c t a b i l i t y , and the perception of " f i t " between the family and the Army l i f e s t y l e . Family coherence also has been operationalized as the degree to 41 which fa m i l i e s c a l l upon t h e i r appraisal s k i l l s (in terms of acceptance, refraining, and b e l i e f i n God) to manage s t r e s s f u l events and situations (McCubbin, Larsen, & Olson, 1982) . In t h e i r work on families and chronic i l l n e s s , Patterson and Garwick (1994) have attempted through q u a l i t a t i v e methods to understand the meanings that family members share about the i l l n e s s and i t s impact on t h e i r l i v e s . These scholars point out the need for new methods to operationalize family system variables. They mention the work of Reiss, Steinglass, and Howe (1993) i n which "family paradigm" i s operationalized through family i n t e r a c t i o n i n a laboratory, problem-solving task. They assert we need further studies of how families share and construct meanings about i l l n e s s and d i s a b i l i t y . This assertion i s not f a r removed from that of Walker (1985, p. 833) who stresses that "what i s important i s not the 'family's ' d e f i n i t i o n of the stressor but an understanding of i n d i v i d u a l perspectives regarding s t r e s s f u l situations, how these perspectives r e l a t e to behavior, and the influences of members' perspectives i n combination." This b r i e f overview indicates that both i n d i v i d u a l and family stress t h e o r i s t s have attempted to capture s i t u a t i o n a l appraisal, at one l e v e l or another, through perceptions of demands and resources, perceptions of c o n t r o l l a b i l i t y , and attention to meanings. Whereas the operationalizations of appraisal by Folkman et a l . (1986) and Antonovsky (1979) maintain the d i s t i n c t i o n between the 42 concepts of appraisal and coping, other operationalizations appear to contain some conceptual overlap. Coping Compatible d e f i n i t i o n s of coping were reviewed at length above. Attention now i s directed to coping functions, assessment methods, and outcomes. Coping Functions. In t h e i r study of responses to normative l i f e - s t r a i n s , Pearlin and Schooler (1978) i d e n t i f i e d categories of coping d i f f e r e n t i a t e d by the nature of t h e i r function. They noted three d i f f e r e n t functions of coping responses: (a) those that were aimed at modifying the s i t u a t i o n , (b) those that were intended to control the meaning of the problem, and (c) those responses that functioned to control the emotional response to the s i t u a t i o n , "to accommodate to existing stress without being overwhelmed by i t " (Pearlin & Schooler, 1978, p. 7). These coping functions are present i n the coping e f f o r t s described by McCubbin and McCubbin (1991) and Patterson and Garwick (1994). Five examples are given of these problem-solving e f f o r t s : (a) d i r e c t action to reduce demands, (b) d i r e c t action to acquire additional resources, (c) maintaining and r e a l l o c a t i n g e x i s t i n g resources (maintaining and enriching s o c i a l networks), (d) managing the tension associated with ongoing stra i n s , and (e) reappraising a s i t u a t i o n in order to make i t more manageable (lowering performance expectations). Lazarus and Folkman (1984) agree that an important d i s t i n c t i o n i n the functions of coping i s between the 43 e f f o r t s that are directed at managing or a l t e r i n g the problem (problem-focussed coping) and those e f f o r t s aimed at regulating one's emotional response to i t (emotion-focussed coping). Strategies of emotion-focussed coping can be cognitive (a deliberate reappraisal of the situation) or behavioural (exercise or seeking information and s o c i a l support). Problem-focussed coping i s sim i l a r to, but greater than, problem solving (Lazarus & Folkman, 1984) . I t includes strategies that are directed at both the environment and the s e l f . An example of the l a t t e r i s cognitive change that a s s i s t s the ind i v i d u a l i n managing the problem. Folkman et a l . (1991) note that i n general, problem-focussed coping i s appropriate i n situ a t i o n s that have a pot e n t i a l for change, whereas emotion-focussed coping i s more appropriate i n situations with l i t t l e c o n t r o l l a b i l i t y . In h i s discussion of family coping, K l e i n (1983) also suggests problem solving and coping d i f f e r mainly i n degree. Whereas a family solves i t s problems by eliminating or completely overcoming them, a family copes with more severely s t r e s s f u l situations by accepting and managing them. Coping Assessment. Some coping scales are designed for wide a p p l i c a b i l i t y , whereas others are intended to measure coping only within a p a r t i c u l a r context (Cohen, 1987). Lazarus and Folkman (1984) developed a Ways of Coping Checklist containing 67 general coping items that indicate what an in d i v i d u a l thinks, fe e l s , or does i n response to a 44 s p e c i f i c s i t u a t i o n . Factor analysis by Folkman et a l . (1986) has yielded the following eight scales d i f f e r e n t i a t e d by type of response: confrontive coping, distancing, s e l f - control, seeking s o c i a l support, accepting r e s p o n s i b i l i t y , escape-avoidance, planf u l problem solving and p o s i t i v e reappraisal. Some investigators have added items to the Ways of Coping Scale to more accurately assess coping strategies within a p a r t i c u l a r context (Cohen, 1987) . P e a r l i n and Schooler (1978) examined 17 coping strategies, representing the three functions mentioned above, i n the four role areas of marriage, parenting, household economics, and occupation. Although the functions of coping were found to be the same in a l l areas, the strategies used and t h e i r effectiveness varied according to s o c i a l context. For example, whereas the manipulation of goals and values was an e f f e c t i v e coping strategy i n the occupational and economic areas, i t was not so i n the area of family relationships. In marriage and parenthood, a continuing commitment and involvement i n these r e l a t i o n s h i p s i s less l i k e l y to r e s u l t i n d i s t r e s s . McCubbin and colleagues have developed inventories for the assessment of family coping in s p e c i f i c s i t u a t i o n s . These measures concentrate on coping strategies i n c r i s e s , i n cases of serious c h i l d i l l n e s s , or i n spousal separation. Because of t h e i r s p e c i f i c i t y , they are not as widely applicable to a variety of situations. Thoits (1991) gives us a good example of the way i n which the work of various stress theorists can be brought 45 together to f a c i l i t a t e a more complete understanding of a phenomenon. Thoits has examined coping through subjects' written descriptions of t h e i r responses to emotional experiences, accounts which were coded according to a model of coping the author developed. Flowing from the work of P e a r l i n and Schooler (1978) and Lazarus and Folkman (1984) , coping responses are seen to be either cognitive or behavioural. Also borrowing from these scholars, the model distinguishes between responses that are problem-focussed and emotion-focussed. Therefore her model d i f f e r e n t i a t e s coping responses on two dimensions, the mode of response (behavioural or cognitive), and the target of the response (situation-focussed or emotion-focussed). Based upon Thoits' (1984) work on the nature of emotion, the emotion- focussed strategies are further divided into those concerned with phy s i o l o g i c a l changes, expressive gestures, and emotional labels. Thoits (1991) points out t h i s model i s able to accommodate a l l the coping strategies that have been i d e n t i f i e d i n previous research, and has been shown to be useful i n comparing gender differences i n coping. Coping Outcomes. In her overview of the measurement of coping, Cohen (1987) i d e n t i f i e s three areas of outcome e f f e c t s : psychological, s o c i a l , and p h y s i o l o g i c a l . The psychological e f f e c t s are emotional reactions, general w e l l - being, and task performance; s o c i a l outcomes include changes i n interpersonal relationships and s o c i a l r o l e performance; and p h y s i o l o g i c a l effects vary from short term p h y s i o l o g i c a l reactions to long term health changes. Cohen points out 46 that a p a r t i c u l a r coping mode can have d i f f e r e n t e f f e c t s i n the three outcome domains. Si m i l a r l y , Lazarus and Folkman (1984) i d e n t i f y three basic adaptational outcomes: s o c i a l functioning, morale, and somatic health. They see s o c i a l functioning as both the manner i n which an individual f u l f i l l s his or her s o c i a l r o l e s , and also as one's s a t i s f a c t i o n with interpersonal r e l a t i o n s h i p s . Morale i s considered to be a multidimensional concept that i s concerned with how people see themselves and t h e i r conditions of l i f e . The l i n k between coping and health i s based on the premise that appraisals of situations as s t r e s s f u l are accompanied by strong emotional states. These intense emotions are assumed to be causal factors i n i l l n e s s . P e a r l i n (1989) i d e n t i f i e s multiple indicators that have been chosen as outcome measures in s o c i o l o g i c a l studies of the stress process: physical health, a variety of dimensions of mental health, s o c i a l r ole functioning, and the maintenance of s o c i a l relationships. Pearlin (1991) c a l l s attention to the d i s t i n c t i o n between d i r e c t and i n d i r e c t e f f e c t s of coping. He states that generally, researchers look at the dependent variable, such as depression, to ascertain coping effectiveness. Pearlin (1991) points out that i f coping e f f o r t s i n h i b i t the development of other, secondary stressors, they can i n d i r e c t l y influence t h i s depression. He suggests that by r e s t r i c t i n g our focus to d i r e c t e f f e c t s of coping, we may miss an accurate assessment of coping e f f i c a c y . 47 The McCubbin and McCubbin (1991) model views family adjustment and adaptation as outcomes over time of family e f f o r t s , i n a s t r e s s f u l s ituation, to achieve a "new l e v e l of balance and f i t " between demands and c a p a b i l i t i e s (McCubbin & McCubbin, 1991, p. 15). When in t e r a c t i o n of the relevant components re s u l t s i n productive problem solving, successful family adaptation to the s t r e s s f u l s i t u a t i o n r e s u l t s (restored functional s t a b i l i t y and/or improved family s a t i s f a c t i o n ) ; when the family i s unable to respond i n a constructive manner, a c r i s i s s i t u a t i o n ensues. These authors emphasize that "a family *in c r i s i s ' does not carry the stigmatizing value judgement that somehow the family has f a i l e d , i s dysfunctional, or i s i n need of professional counseling" (McCubbin & McCubbin, 1991, p. 14). Patterson and Garwick (1994) also conceptualize the outcome of family e f f o r t s to achieve balanced functioning as family adjustment and adaptation. They see good outcomes r e f l e c t e d i n (a) p o s i t i v e physical and mental health of family members, (b) optimal role functioning of family members, and (c) the maintenance of a family unit that can accomplish i t s l i f e cycle tasks. The t h e o r e t i c a l overview above f a c i l i t a t e s a c l e a r comprehension of what i s meant by the key concepts, " s t r e s s " and "coping"; i t gives a shared language for a meaningful discussion of the empirical l i t e r a t u r e . The overview with i t s integration of various t h e o r e t i c a l approaches, has shown that d i f f e r e n t theorists discuss the stress process i n compatible ways. I t has shown that whether the approach i s 48 social-psychological ( i . e . , Lazarus & Folkman, 1984), s o c i o l o g i c a l ( i . e . , Pearlin, 1989; Pear l i n & Schooler 1978), or s p e c i f i c a l l y family focussed ( i . e . , Boss, 1988; McCubbin & McCubbin, 1991; Patterson & Garwick, 1994), th e o r i z i n g about coping i n s t r e s s f u l situations categorizes s i g n i f i c a n t elements of the process as demands, intervening constructs, and outcome. Such a categorization i s able to accommodate the relevant factors i d e n t i f i e d by the l i t e r a t u r e on family response to chronic i l l n e s s (see Biegel et a l . , 1991; Cole & Reiss,1993; H a t f i e l d , 1987b; Johnson, 1990; Rolland, 1989). i 49 Chapter IV Review of Empirical Findings As previously mentioned, a t h e o r e t i c a l understanding of the stress process enables us to appreciate the empirical r e l a t i o n s h i p s found within the v a r i a b i l i t y of family and i l l n e s s . A t h e o r e t i c a l focus also a l e r t s one to research l i m i t a t i o n s . Applying stress and coping theory to the family experience with schizophrenia, I categorized the v a r i a b i l i t y as follows: 1. Demands (a) s i t u a t i o n a l stress (b) s o c i e t a l stress (c) iatrogenic stress 2. Intervening Constructs (a) caregiver c h a r a c t e r i s t i c s : i n d i v i d u a l and family (b) c h a r a c t e r i s t i c s of person with schizophrenia (c) s o c i a l support and community resources (d) family and ind i v i d u a l perceptions of schizophrenia (e) the coping e f f o r t s of family members - attempts to manage the si t u a t i o n 3. Outcome (a) physical and mental health, s o c i a l functioning 4. Limitations of past research Demands Lefley (1990) conceptualizes three main sources of cumulative stress i n families of persons with schizophrenia: s i t u a t i o n a l , s o c i e t a l , and iatrogenic. She sees the 50 v a r i a b i l i t y of context as an important influence on family response. S i t u a t i o n a l Stress In assessing family response to stress, "the s t a r t i n g point ... i s not the occurrence of a stressor event but the seemingly normal state of family disorder" (Lavee, McCubbin, & Olson, 1987, p. 871). Against t h i s "background noise" (Aldous & Klein, 1988) of normative t r a n s i t i o n s and events, fa m i l i e s of persons with schizophrenia may experience ongoing problems i n the areas of employment, housing, health, childrearing, and marriage (McGill, 1990) that together with the i l l n e s s , contribute to the demands upon the family. Other s i t u a t i o n a l stress may r e s u l t from the i n t e r s e c t i o n of the i l l n e s s with the developmental stage of the family. The onset of chronic i l l n e s s can cause a "permanent stuckness" at the phase of development at which i t occurs (Rolland, 1989, p. 449). Expectations are that young adults w i l l not only establish t h e i r independence, t h e i r own source of income and coherent set of values, but also prove able to get along with others, e s t a b l i s h intimacy, and develop a s o c i a l network (Ireys & Burr, 1984). The onset of schizophrenia early i n adulthood, interrupts t h i s developmental trend. While continuing to desire independence, persons with schizophrenia f i n d i t d i f f i c u l t to i n t e r a c t with others and to maintain employment (Torrey, 1983) . They remain dependent upon others, often parents and/or s i b l i n g s , both f i n a n c i a l l y and emotionally, whether 51 or not they remain i n the parental home. Parents are required to readjust t h e i r expectations for t h e i r son or daughter and negotiate new role relationships (Ireys & Burr, 1984), working to establish a balance between stimulation and passive acceptance (Falloon, McGill, & Hardesty, 1985). At the same time, they must negotiate l i m i t s on behaviour. Middle-aged parents may be required to resume an active parenting r o l e at a time when perhaps they were a n t i c i p a t i n g freedom from the r e s p o n s i b i l i t i e s of caring for o f f s p r i n g , a circumstance that may create d i f f i c u l t i e s for parents i n r e l a t i n g to t h e i r peers (Hatfield, 1987b). Mothers i n p a r t i c u l a r have expressed concern and disappointment over the lack of independence of t h e i r mentally i l l adult child r e n (Cook, 1988). M i d - l i f e parents may f i n d themselves caught between the continued dependence of these childr e n and r e s p o n s i b i l i t i e s to elderly parents (Hatfield, 1990). A study of persons with schizophrenia i n 1956 showed that three-quarters of parental caregivers were over the age of 60 and 40% over the age of 70 (Wing, 1987a). Although older parents may have adjusted to the continued dependence of an adult c h i l d with schizophrenia, they are "at a time i n l i f e when they have the least energy to invest i n t h i s type of emotionally and physically draining e f f o r t . This demand may be an unrecognized mental health r i s k for older persons" (Lefley, 1990, p. 146). An assessment of burden f e l t by e l d e r l y r e l a t i v e s of persons with schizophrenia has shown a dependence on parents of pensionable age, with considerable f i n a n c i a l and emotional burden (Stevens, 1972). In 52 addition, older parents may be p a r t i c u l a r l y concerned about who w i l l provide care and support to the son or daughter with schizophrenia when they, themselves, are gone (Grunebaum, 1986; H a t f i e l d , 1987b; Lefley, 1987b). Despite the i l l n e s s of an adult c h i l d , family members continue to have t h e i r own needs that must be met. Studies have shown d i v i s i v e e f f ects of schizophrenia on the family, with c o n f l i c t s , jealousy, and divided l o y a l t i e s among family members and strained spousal relationships (Creer & Wing, 1974; Vaughn et a l . , 1984). Siblings must deal with the confusion, fear, and fee l i n g s of entrapment re s u l t i n g from a diagnosis of schizophrenia i n a s i s t e r or brother ( C a r l i s l e , 1984). They have s p e c i f i c needs that may d i f f e r from those of other family members (Landeen et a l . , 1992), developmental needs that often are not being met ( C a r l i s l e , 1984). Young s i b l i n g s s t i l l at home have been found to be affected i n d i f f e r e n t ways by the mental i l l n e s s of a brother or s i s t e r ; some f e l t more focus and expectations from parents, others f e l t neglected and lonely, while the majority reported they took sides and s h i f t e d allegiances i n the i n e v i t a b l e c o n f l i c t s ( C a r l i s l e , 1984). They have expressed embarrassment at the peculiar behaviours of the mentally i l l s i b l i n g and fear for t h e i r own mental health (Torrey, 1983). The impact of schizophrenia on adult s i b l i n g s ' l i v e s has been found to range from pervasive to discrete, with three patterns of s i b l i n g response: ongoing collaboration with other family members, c r i s i s oriented, and detached 53 (Gerace, C a m i l l e r i , & Ayres, 1993). Older married s i b l i n g s have registered concern about the hereditary r i s k for t h e i r own children; they desire information about the prognosis of schizophrenia, and express concerns over the s i b l i n g ' s a b i l i t y to l i v e independently and to have an adequate l e v e l of f i n a n c i a l support (Landeen et a l . , 1992). Their concerns appear to be well founded for i t has been shown that s i b l i n g s replace parental caregivers over the l i f e course (Horwitz, 1993) . In her description of l i v i n g with a s i s t e r who has schizophrenia, Margaret Moorman (1992) reveals her feeli n g s of hopelessness i n achieving any balance between her s i s t e r ' s consuming need and that of the family. She eloquently speaks of her deep sadness and fear as her "private iceberg." Other aspects of s i t u a t i o n a l stress vary according to the stage and severity of the i l l n e s s and types of symptoms expressed. Some family members report finding a gradual, insi d i o u s onset greatly d i s t r e s s i n g ( C a r l i s l e , 1984; Moorman, 1992), whereas research on family experience of f i r s t episode schizophrenia has i d e n t i f i e d f l o r i d symptoms associated with high levels of distress (McCreadie et a l . , 1987) . Reviews of research on family burden show i t to be strongly related to the l e v e l and type of symptomatology (for reviews see Biegel et a l . , 1991; Johnson, 1990). Some studies reviewed found greater family d i s t r e s s to be associated with bizarre thought and behaviour, and 54 aggressive, uncooperative behaviour, and other research showed negative symptoms of s o c i a l withdrawal to be of more concern. Other reports suggest that the u n p r e d i c t a b i l i t y of patient responses, p a r t i c u l a r l y those of an offensive or threatening nature are most d i f f i c u l t to t o l e r a t e (Gibbons, Horn, Powell, & Gibbons, 1984; Falloon & McGill, 1985). Runions and Prudo (1983) found that by far the most frequent problems were those concerned with negative symptoms (f l a t t e n i n g of a f f e c t , poverty of speech, loss of v o l i t i o n ) , whereas the problems most d i f f i c u l t to manage included those with i n s i g h t compliance and p o s i t i v e symptoms (delusions, ha l l u c i n a t i o n s , thought disorder). Interestingly, differences i n perceptions of most bothersome behaviours were noted between family caregivers and mental health professionals; although nurses perceived s u i c i d a l behavior to be most di s t r e s s i n g to f a m i l i e s , the fam i l i e s themselves indicated the r e l a t i v e ' s i n a b i l i t y to achieve h i s or her potential to be of most concern (McElroy, 1987) . Evidence for the e f f e c t of duration of i l l n e s s i s also equivocal with some studies showing decreasing l e v e l s of burden over time and others indicating that burden continues and stress levels increase (Gibbons et a l . , 1984; Johnson, 1990). A l l studies indicate that whatever the symptoms, t h e i r number and severity strongly predict l e v e l s of family burden. Possibly connected to the severity and course of the i l l n e s s i s residence of the person with schizophrenia. At the time of onset, most young people l i v e with t h e i r 55 f a m i l i e s ; i f r e j e c t i o n by the parents occurs, i t i s usually a f t e r several episodes of i l l n e s s and associated behaviour disturbance (Falloon et a l . , 1984). Parents f e e l a burden of care, however, whether or not the son or daughter resides with them. In fact, one study reported that more behavioral problems and greater need for services was expressed by parents whose offspring l i v e d outside the home (Carpentier et a l . , 1992). Other research found that patients who had moved out of the home and who l i v e d alone continued to be a burden for the family whereas those patients who were i n supervised accommodations presented no problems (Grad & Sainsbury, 1963). Despite the heterogeneity i n type and amount of family contact, most people with schizophrenia r e l y on the family of o r i g i n for a sense of connectedness and belonging (Doane, 1991), as well as a sense of l i f e purpose and protection (McGlashan, 1987); they maintain considerable face-to-face contact, and often overwhelm parents' a b i l i t y to cope (Carpentier et a l . , 1992). So c i e t a l Stress Lefley (1990) considers s o c i e t a l stress to come from c u l t u r a l attitudes toward mental i l l n e s s , stigma, and negative expectancies of recovery. I t has been suggested that general ignorance i n society about schizophrenia leads to s o c i e t a l fear of persons connected with t h i s i l l n e s s (Dearth, Labenski, Mott, & P e l l e g r i n i , 1986). I s o l a t i n g and d e b i l i t a t i n g e f f e c t s of the stigma of mental i l l n e s s on f a m i l i e s are widely reported (McFarlane et a l . , 1993; Steinwachs et a l . , 1992; Wahl & Harman, 1989; Wasow, 1983). 56 Three-quarters of a l l members of the National A l l i a n c e for the Mentally 111 i d e n t i f i e d stigma as having a large unfavorable impact on t h e i r mentally i l l r e l a t i v e s , and one- h a l f of the members believed families i n general were negatively affected (Wahl & Harman, 1989). Although one- h a l f to three-quarters of them f e l t i t had l i t t l e or no impact on aspects of t h e i r own l i f e , awareness of negative public reactions to t h e i r i l l r e l a t i v e could be construed as a s o c i e t a l contribution to the concerns of the family. Less i n d u s t r i a l i z e d cultures are thought to be more accepting of mental patients, not to blame them for t h e i r condition, and to accommodate them more r e a d i l y within society; China, which has very strong stigma attached to the mentally i l l and t h e i r families, i s one exception (Lin & Kleinman, 1988; Torrey, 1983). Cultures that stress the interdependence rather than the independence of family members are thought to influence parents' expectancies for o f f s p r i n g , with implications for family adjustment to schizophrenia. Such interdependent families are more l i k e l y to accept the need of the patient for a safe haven, either at home or i n other community care, and less l i k e l y to entertain the high-expectancy objective of independent l i v i n g , an expectation that may exacerbate the f e e l i n g s of anxiety so central to the i l l n e s s (Lefley, 1987a). Iatrogenic Stress Much of the thinking and language of the "new" family therapies seems to be mired down in older theories that have presumably been discredited (Hatfield, 1987a). C l i n i c i a n s 57 s t i l l perceive families within a d e f i c i t framework; i f patient relapse occurs, families are blamed and made to f e e l g u i l t y (Johnson, 1990; Lefley, 1990). Misunderstanding the complex interactions of the family, some therapeutic approaches erode the overburdened family system with recrimination rather then supporting i t with assistance (Lefley, 1990). C l i n i c a l experience has led Terkelsen (1983) to reconceptualize the communicational aberrations, noted i n families of persons with chronic schizophrenia, as adverse e f f e c t s of family therapy. Family s a t i s f a c t i o n with mental health providers i s low; family members do not f e e l they are receiving enough information, support, or p r a c t i c a l management techniques to enable them to cope with caregiving (Brooker, Ta r r i e r , Barrowclough, Butterworth, & Goldberg, 1992; Hanson & Rapp, 1992; H a t f i e l d , 1979; Johnson, 1990; McElroy, 1987). Intervening Constructs Caregiver c h a r a c t e r i s t i c s , both i n d i v i d u a l and family, along with community services, s o c i a l support, and perception of the si t u a t i o n interact with the coping e f f o r t s of family members and influence t h e i r experiences with schizophrenia. As well, c h a r a c t e r i s t i c s of the person with schizophrenia have been found to be an important influence on the family experience. Caregiver Characteristics: Individual l e v e l Caregiver demographics and personality c h a r a c t e r i s t i c s have been included as independent variables i n research on the family experience with schizophrenia. A random sample 58 of 125 families who had a post-hospital member at home found caregiver burden to be unrelated to s o c i a l c l a s s , race, education, and the age or sex of the r e l a t i v e (Thompson & Do l l , 1982). Data from large epidemiologic surveys and c l i n i c a l interviews, however, showed race, sex, and s o c i a l c l a s s to be relevant to caregiver experience; blacks and females scored higher on the various symptom scales, and r e l a t i v e s i n low socioeconomic groups were three times more prevalent i n the high range of depression, anxiety, and psychosocial dysfunction (Arey & Warheit, 1980). F i n a n c i a l costs incurred by the family can be considerable. Families low on the socioeconomic scale are espe c i a l l y vulnerable to t h i s type of stressor (Glynn & Liberman, 1990). In a small study of 3 0 households, parents were found to be acutely aware and concerned with the downward mobility of t h e i r mentally i l l sons and daughters (Gubman & Tessler, 1987) . Considering the p o s s i b i l i t y of higher expectations i n parents of higher socioeconomic standing, d i s t r e s s over the offspring's f a i l u r e to f u l f i l l h is or her p o t e n t i a l could be greater for these parents, although the c a p a b i l i t y of providing f i n a n c i a l assistance would be less of a problem. The a b i l i t y of the parents to develop r e a l i s t i c expectations for the functional capacities of t h e i r children with schizophrenia i s considered to be a protective factor i n s h i e l d i n g them against stress (Glynn & Liberman, 1990). Other protectors, i d e n t i f i e d by r e l a t i v e s of persons with schizophrenia, are personal physical health, energy, optimism, a b i l i t y to maintain outside i n t e r e s t s , and sense 59 of humour (Dearth et a l . , 1986). Because of the genetic component i n schizophrenia, v u l n e r a b i l i t y i n a small percentage of r e l a t i v e s can come from a coinherited predisposition to mental i l l n e s s (Glynn & Liberman, 1990). Personality c h a r a c t e r i s t i c s of family members do seem to influence t h e i r experience with the i l l n e s s . Research has found that the personal attribute of r e s i l i e n c e acts as a protective factor i n r e l a t i v e s of persons who have psychotic disorders (Lefley, 1990). Because education about schizophrenia and information about medication and the health status of the r e l a t i v e are considered by caregivers to be highly important (Atkinson, 1986; H a t f i e l d , 1990; P a t r i l a & Sadoff, 1992; Torrey, 1983), the a b i l i t y and i n c l i n a t i o n of a family member to seek out t h i s information could be considered a resource. Chronic s t r a i n does appear to be s i g n i f i c a n t l y related to distress among caregivers r e l a t i v e l y low i n mastery (Lefley, 1987b). A s i g n i f i c a n t c o r r e l a t i o n also has been found between the related concept, locus of control, and r e l a t i v e s ' expressions of c r i t i c a l comment (Lefley, 1992). Relatives who were more c r i t i c a l of the patient tended to believe i n the importance of i n t e r n a l factors i n c o n t r o l l i n g events and behaviors; they believed i n the patients' a b i l i t y to control t h e i r symptoms and would pressure them accordingly. Knowledge about the i l l n e s s , r e f l e c t e d i n r e l a t i v e s ' expectations and a t t r i b u t i o n s for patient behavior, could be considered an important coping resource. 60 Caregiver Characteristics: Family Level P r e - c r i s i s l e v e l of family functioning appears to be a factor c e n tral to a family's a b i l i t y to cope with schizophrenia. Not only the absence of negative attitudes but also e f f e c t i v e communication, problem-solving s k i l l s , and f l e x i b l e r o l e relationships, are considered to be b e n e f i c i a l strengths (Biegel et a l . , 1991; Falloon & M c G i l l , 1985). Recent interventions with families have focused on e f f o r t s to bolster family resources by increasing family knowledge about schizophrenia and promoting e f f e c t i v e communication, problem-solving, and coping s k i l l s (see Bentley, 1990; Cole et a l . , 1993; Falloon, Hardesty, & Mc G i l l , 1985; H a t f i e l d , 1990; MacFarlane et a l . , 1993) with salutary impact on both the patient and the family. Both Bentley (1990) and Doane (1991) have advised, however, that increased interpersonal contact for disengaged (separated) families may increase stress, and for these families an intensive intervention schedule may not be appropriate. Family structure also i s relevant to the caregiver experience (Lefley, 1992). Single parents have been found to experience greater burden of care and be i n greater need of services and support than married parents (Carpentier et a l . , 1992; Falloon et a l . , 1984). Ch a r a c t e r i s t i c s of the Person with Schizophrenia There i s a lack of information on the association between family burden and sex of the mentally i l l person. Johnson's (1990) review of research found only three studies 61 reporting on t h i s relationship: Grad and Sainsbury (1963) and Thompson and Doll (1982) found no sex differences i n l e v e l of burden, whereas Hoenig and Hamilton (1969) found that male patients presented a greater burden to the family. A more recent study by Winefield and Harvey (1993) has reported greater di s t r e s s i n those caring for females with schizophrenia. Findings may be confounded by the fa c t that r e l a t i v e s surveyed are the spouses and the parents of persons with schizophrenia. Family support of female patients i s more l i k e l y to be spousal or s i b l i n g whereas family support of males i s more often parental (Atkinson, 1986). Spouses and parents may perceive burden d i f f e r e n t l y . Seeman's (1986) review of the l i t e r a t u r e found that daughters with schizophrenia, rather than sons, tend to be less aggressive, less l i k e l y to commit suicide, less l i k e l y to be involved with the law, and more l i k e l y to adhere to a treatment regime. Seeman's inquiry found that for women, frequency of acute episodes i s lower, duration of h o s p i t a l i z a t i o n i s shorter, and quality of remission i s superior. The relapse rate for men has been found i n other research to be more than t r i p l e the rate for women (Vaughn et a l . , 1984). These differences would seem to lighten the burden for parents of daughters with schizophrenia. So c i a l Support and Community Services Diminished self-worth leaves one es p e c i a l l y vulnerable to experiencing symptoms of stress; interventions of coping assistance and s o c i a l support bolster s e l f esteem and help prevent t h i s negative experience (Pearlin, Lieberman, 62 Menaghan, & Mullan, 1981). The s o c i a l stigma and community neglect perceived by families of the mentally i l l can be i s o l a t i n g and stress promoting. Parents often f i n d i n s e l f - help/mutual support groups the informational and emotional s o c i a l support that they require (Atkinson, 1986; Biegel & Yamatami, 1986; Johnson, 1990). Multigroup, supportive, psychoeducation interventions, p a r t i c u l a r l y those with a problem-solving component, also have proven h e l p f u l to fa m i l i e s (Cole et a l . , 1993; McFarlane et a l . , 1993). In addition to family s o c i a l support, the e x t r a f a m i l i a l s o c i a l support network of the family member with schizophrenia i s related to family well-being; a s i g n i f i c a n t r e l a t i o n s h i p has been found between the a v a i l a b i l i t y of a confidant for that person and lower family perceptions of burden (Crotty & Kulys, 1986). Families look to the care- giving system to provide comprehensive, long-term, affordable treatment and r e h a b i l i t a t i o n programs for r e l a t i v e s with schizophrenia (Glynn & Liberman, 1990). Unfortunately, an essential, yet often overlooked ingredient i n these community care programs i s the nurturance of the patients' support systems (Falloon et a l . , 1984). Family and Individual Perceptions of Schizophrenia "A family's b e l i e f s about i l l n e s s and about what constitutes an appropriate response also serve to shape i t s actions" (Cole & Reiss, 1993, p. x i ) . As mentioned above, the onset of schizophrenia i s often d i f f i c u l t to recognize and i t s symptoms extremely diverse. This ambiguity makes 63 the development of an ef f e c t i v e , consistent response d i f f i c u l t f or the family (Cole et a l . , 1993). Once a diagnosis of schizophrenia has been made, the family perception of the si t u a t i o n w i l l depend upon the c u l t u r a l milieu (Lefley, 1987c; Reiss, 1981), and the family's p r i o r and ongoing experience with mental i l l n e s s (Terkelsen, 1987). As previously mentioned, the s o c i a l context within which the family interacts w i l l influence the appraisals made and shared by family members. Because of the genetic component to schizophrenia, the family may have had another r e l a t i v e with the i l l n e s s . Knowledge about schizophrenia and impressions gained from t h i s past experience w i l l a f f e c t the family's perspective of t h e i r present s i t u a t i o n , as w i l l the extent to which the family has been able to cope with the exacerbations and remissions i n the i l l n e s s over time. The family's perception of the si t u a t i o n , then, could be considered a process of appraisal and reappraisals. Coping E f f o r t s Coping strategies that families exhibit are both cognitive and behavioral; they include accepting, distancing, and setting l i m i t s (Spaniol, 1987). Relatives learn to accept the limi t a t i o n s and adjust t h e i r expectations for the person with schizophrenia, s t r i v i n g to achieve an adaptive balance of stimulation and l a i s s e z - f a i r e ; they separate themselves from behaviors they cannot change and learn not to argue about the delusions; they set firm l i m i t s around behaviors they do not l i k e , knowing that 64 structure can communicate caring (Spaniol, 1987; Wing, 1987a). These coping s k i l l s are acquired gradually, often through t r i a l and error, sometimes through support group in t e r a c t i o n , other times through education programs i n problem-solving techniques. H a t f i e l d (1990) suggests that i n addition to behavioral solutions to deal with objective burden, intrapsychic coping i s required to come to terms with the pa i n f u l f e e l i n g s associated with subjective burden. Pos i t i v e coping strategies include the protection by family members of t h e i r own and each others' physical health and emotional w e l l - being, and t h e i r procurement of empathic support from professionals and others i n similar circumstances. Outcomes As has been shown, the family experience with schizophrenia w i l l depend upon a variety of personal and s i t u a t i o n a l c h a r a c t e r i s t i c s . Research has investigated r e l a t i o n s h i p s between these s i t u a t i o n a l determinants and various outcome measures, such as in d i v i d u a l f e e l i n g s of being burdened (Potasznik & Nelson, 1984; Thompson & D o l l , 1982), measures of anxiety and depression (Abramowitz & Coursey, 1989; Arey & Warheit, 1980; Mattlin, Wethington, & Kessler, 1990), negative affect, and comprehensive measures of physical and emotional well-being (Winefield & Harvey, 1993) . Social functioning i n families of the mentally i l l has long been scrutinized. H o s t i l i t y , anger, and c o n f l i c t have been generally noted, as well as s t r u c t u r a l change. Creer and Wing (1974) found, i n some cases, t o t a l breakup of 65 family unity, while other families seemed able over time to devise a regime within which the patient could function and the family could achieve r e l a t i v e s t a b i l i t y . In one of the few studies to focus on coping i n fami l i e s of the mentally i l l , H a t f i e l d (1981) rated family coping effectiveness through three component factors: (a) emotional mastery ( a b i l i t y to manage emotions with minimal d i s t o r t i o n of r e a l i t y ) , (b) cognitive s k i l l ( r e a l i s t i c appraisal, information seeking, and capacity to manage disturbing s i t u a t i o n s ) , and (c) need f u l f i l l m e n t (adequate s o c i a l involvement). Her data suggested a p o s i t i v e association between e f f e c t i v e coping and caregiving mothers' being older and better educated. An adaptive framework from stress and coping theory leads to d i f f e r e n t interpretations of behavior i n families of the mentally i l l from that of dysfunction (Hatfield, 1990). C r i t i c a l remarks and h o s t i l i t y noted i n the, EE research can be viewed as legitimate reactions to disruptive and embarrassing behaviors (Lefley, 1992). Emotional overinvolvement, overprotection, and focusing on the patient to the exclusion of the rest of the family members, can be regarded as adaptive strategies employed i n highly s t r e s s f u l conditions (Cook, 1988; Lefley, 1987a). Physical and/or psychological separation of family members from the patient can be seen as a sur v i v a l mechanism whereby the family seeks to maintain i t s i n t e g r i t y i n the face of overpowering demands (Spaniol, 1987). 66 Limitations of Past Research L i t t l e past research on families and schizophrenia has a s p e c i f i c coping focus; studies that have considered the family response to the disorder have ignored the family context and/or not been grounded i n stress and coping theory. Many investigations have been directed to expressed emotion and caretaker burden. Pertaining to these investigations, the l i t e r a t u r e has pointed to a number of problems and omissions. It has indicated the need f o r longitudinal designs involving larger and more representative samples, u t i l i z i n g measures with established r e l i a b i l i t y and v a l i d i t y (Biegel et a l . , 1991); the importance of greater attention to theory (Goldstein & Strachan, 1987); the need for comparative studies to contrast the impact of mental i l l n e s s with other types of d i s a b i l i t i e s (Gubman & Tessler, 1987); and the necessity for control groups and for baseline rates of family i n t e r a c t i o n (Helmersen, 1983). Scholars have suggested that i n q u i r i e s include the p o s i t i v e dimensions of the family experience: the p o s i t i v e q u a l i t i e s of intimate support (Falloon & McGill, 1985; Spaniol, 1987), the good times as well as the bad (Gubman & Tessler, 1987), the positive contributions of the patient to family functioning (Falloon, Hardesty, & McGill, 1985; Stevens, 1972), and the fe e l i n g of closeness and s o l i d a r i t y i n the family that can re s u l t (Dearth et a l . , 1986). Assumptions of homogeneity have pervaded many investigations into the family experience with schizophrenia 67 (Steinwachs et a l . , 1992). I t has been proposed that a consideration of the family response to schizophrenia should attend to the family's coping strengths (Gubman & Tessler, 1987; H a t f i e l d , 1987b; Lefley, 1987a; Wasow, 1983) and be informed by family l i f e course s o c i a l science (Cook & Cohler, 1986; Ireys & Burr, 1984) . Levels of Analysis F i n a l l y , there has been confusion of l e v e l of analysis i n research on the family experience with schizophrenia. Whereas much of the l i t e r a t u r e speaks of "family" burden, "family" coping, and "family" response, assessments have been e l i c i t e d at the individual l e v e l . The question a r i s e s as to whether there i s such a phenomenon as "family" coping or i s i t simply a c o l l e c t i o n of individuals who are coping i n various degrees of synchronism? As previously discussed, family stress scholars assert that "family" coping includes both i n d i v i d u a l and group aspects. Boss (1988, p. 60) c l a r i f i e s t h i s issue by s t a t i n g "the cognitive appraisal of a s t r e s s f u l s i t u a t i o n or event, the emotional reaction to i t , and the behavioral responses to both the appraisal and the emotion a l l happen within the i n d i v i d u a l family member, a l b e i t within a systems context." S i m i l a r l y , Antonovsky (1994), i n a discussion of "sense of coherence" at the c o l l e c t i v e l e v e l , suggests that whereas we can be aware of the influence of the c o l l e c t i v e on one's sense of coherence, i t i s a d i f f e r e n t matter to speak of a c o l l e c t i v e as perceiving the world as coherent. 68 Family stress theory i s a multi-leveled approach that sees r e c i p r o c a l influences between i n d i v i d u a l and family. Explorations of family stress and coping require assessment of d i s t i n c t but i n t e r r e l a t e d levels of analysis (Menaghan, 1983; Walker, 1985). Certainly, i f one were interested i n the group l e v e l of analysis, a family stress model such as that of McCubbin and McCubbin (1991) would be appropriate. In addition, i f one were to assess outcome measures of psychological, s o c i a l , and physical well-being (at the i n d i v i d u a l l e v e l ) , attention to the t o t a l number of family stressors would be valuable. The focus of t h i s study, however, i s the parental coping process. This s p e c i f i c focus requires close attention to i n d i v i d u a l appraisals and coping strategies i n response to a p a r t i c u l a r stressor, a l b e i t within a family context. In t h i s study, then, the r e s i l i e n c y model of family stress, adjustment, and adaptation (McCubbin & McCubbin, 1991) i s employed as a useful framework with which to set that context, i . e . , within which to place the t o t a l i t y of the family experience with schizophrenia, as i t appears i n the l i t e r a t u r e ; i n t h i s study, the McCubbins' model also i s used to locate parental coping within the broader context of the family stress process. As parental coping i s embedded within the family context, so i n d i v i d u a l coping theory can be seen to f i t within family stress theory. It has been shown above that the concept of coping as explicated at the i n d i v i d u a l l e v e l by Lazarus and Folkman (1984) i s compatible with that of 69 family stress scholars. A l l define demands, resources, s i t u a t i o n a l appraisals, coping, and outcomes i n congruent terms. Unlike other theorists, however, Lazarus and Folkman not only emphasize the importance of s i t u a t i o n a l appraisal, but also attend to i t s operationalization and measurement at the i n d i v i d u a l l e v e l , keeping i t conceptually d i s t i n c t from coping. In i t s attention to s i t u a t i o n a l appraisal, therefore, t h i s study of the coping e f f o r t s of i n d i v i d u a l mothers and fathers w i l l follow Lazarus and Folkman. To r e i t e r a t e , t h i s appraisal at the i n d i v i d u a l l e v e l w i l l been considered within i t s s o c i a l context of family and community. Methodological Issues in Stress Research Further discussion i s required concerning methodological issues i n the u t i l i z a t i o n of stress and coping theory. Attention w i l l be directed toward the problem of c i r c u l a r i t y and/or redundancy of variables and to the d i s t i n c t i o n between mediating and moderating functions of variables. C i r c u l a r i t y Lazarus, DeLongis, Folkman, and Gruen (1985) have examined the problem of confounding and c i r c u l a r i t y i n stress research. These authors discuss the question of redundancy/confounding among variables. They address the emphasis of Dohrenwend, Dohrenwend, Dodson, and Shrout (1984) on the value of treating stressors as environmental inputs that are independent of the psychological response or appraisal of the person, i n order that the same process i s 70 not being measured i n both independent and dependent variables. Lazarus et a l . (1985, p. 776) respond "that stress i s best regarded as a complex rubric, l i k e emotion, motivation, or cognition, rather than as a simple v a r i a b l e . " They acknowledge that stress i s an "unclean" variable that depends on a person-environment interaction. They suggest the c i r c u l a r i t y that i s inevitable with a r e l a t i o n a l d e f i n i t i o n of stress can be limited through an understanding of antecedents and consequences of s i t u a t i o n a l appraisals. Person variables such as, values and b e l i e f s , self-esteem, and sense of control, interact with the environmental s i t u a t i o n to generate appraisals of harm/loss, threat, or challenge; i n turn, these appraisals generate consequent responses. A s i m i l a r discussion exists i n the caregiving l i t e r a t u r e . I t has been suggested that caregiver burden, as a stressor, and caregiver well-being are t a u t o l o g i c a l l y linked (see George, 1994; George & Gwyer, 1986). S t u l l , Kosloski, and Kercher (1994), however, have empirically shown that measures of caregiver well-being and caregiver burden, u t i l i z e d either as predictor or outcome variables, tap d i f f e r e n t domains of experience. Other confounding of variables i s addressed by Thoits (1982) who c a l l s attention to the int e r a c t i o n e f f e c t s of l i f e events and s o c i a l support. She points out that support and l i f e events have reciprocal effects on each other, even that "support ... may be a product of - i f not, i n some cases, operationally i d e n t i c a l with - the occurrence of 71 c e r t a i n types of l i f e events" (p. 148). As Thoits suggests, lon g i t u d i n a l research i s needed to disentangle t h e i r influence. Mediators and Moderators In discussions of the stress process, those constructs that are considered to intervene between the demands and outcomes of a s i t u a t i o n have been labeled variously as mediators and/or moderators. Pearlin (1989a, pp. 149-150) ref e r s to intervening constructs c o l l e c t i v e l y as mediators because "they have been shown to govern (or mediate) the e f f e c t s of stressors on stress outcomes." McCubbin and McCubbin (1991) ref e r to family resources and c a p a b i l i t i e s as factors that play a role i n "buffering the negative impact of change or unexpected l i f e events" (p. 3) and mention that s o c i a l support i s most often viewed as "one of the primary buffers or mediators between stress and health breakdown" (p. 19). Frese (1986) maintains that coping can function as both a moderator and a mediator depending upon the nature of i t s relationship with both stressor and stress reaction. Baron and Kenny (1986) point out that although i t i s not uncommon for s o c i a l psychological researchers to use the terms moderator and mediator interchangeably, i t i s important to d i s t i n g u i s h between moderator and mediator functions of t h i r d variables. These authors d i f f e r e n t i a t e between "(a) the moderator function of t h i r d variables, which p a r t i t i o n s a f o c a l independent variable into subgroups that e s t a b l i s h i t s domains of maximal effectiveness i n 72 regard to a given dependent variable, and (b) the mediator function of a t h i r d variable, which represents the generative mechanism through which the f o c a l independent variable i s able to influence the dependent variable of i n t e r e s t " (Baron & Kenny, 1986, p. 1173). They state that moderators explain when certain effects w i l l hold whereas mediators t e l l us why and how they occur. Baron and Kenny further c l a r i f y that "moderator variables always function as independent variables, whereas mediating events s h i f t roles from e f f e c t s to causes, depending on the focus of the analysis" (p. 1174). Folkman and Lazarus (1988) agree that moderator variables are antecedent conditions that i n t e r a c t with other independent variables to produce some outcome whereas a mediator i s considered to arise during the encounter and influence the relationship between the antecedent and outcome variable. The mediator-moderator d i s t i n c t i o n i s important s t a t i s t i c a l l y as well as conceptually. With moderation, the re l a t i o n s h i p between two variables changes as a function of the moderating or t h i r d variable. S t a t i s t i c a l analyses, therefore, must include the interaction e f f e c t s of the predictor and the moderator on the outcome variable. A mediating variable functions as a pathway between the predictor and outcome variables. A s t a t i s t i c a l analysis of mediation e f f e c t s would include a series of regression equations to determine (a) that the independent variable a f f e c t s both the mediator and the dependent variable, and (b) t h a t t h e m e d i a t o r a l s o i n f l u e n c e s t h e d e p e n d e n t v a r i a b l e . 74 Chapter V Study Rationale The purpose of t h i s study i s to examine, within t h e i r s i t u a t i o n a l context, the coping e f f o r t s of mothers and fathers who have an adult c h i l d with schizophrenia, and to determine what factors are predictive of d i f f e r e n t coping choices. Rather than taking a c l i n i c a l approach or perceiving these families i n terms of dysfunction, i t w i l l embrace a "salutogenic" (Antonovsky, 1987) o r i e n t a t i o n that looks instead at individual and family strengths and resources as coping mechanisms that enable one to withstand adversity. Rather than being a study of caregiving and i t s burden, i t i s a study of the coping process and i t s c o r r e l a t e s . With i t s basis i n family studies, my inquiry acknowledges the permanence of the parental r o l e and the influence of the family system upon i n d i v i d u a l family members. I consider the coping responses of mothers and fathers who have a c h i l d with schizophrenia as parental e f f o r t s to manage a s i g n i f i c a n t family stressor. Informed by stress and coping theory, t h i s study includes a broad context within which to consider mothers' and fathers' management of t h e i r situations. I draw upon l i t e r a t u r e from three areas that inform and enrich each other. Family stress theory emphasizes the importance of family system variables within whose influence the i n d i v i d u a l family member operates. Individual stress and coping theory explicates the appraisal and coping 75 process and how i t i s related to demands and resources i n various types of situations. The l i t e r a t u r e on family response to schizophrenia informs us of the d i v e r s i t y that can e x i s t within t h i s one s i t u a t i o n . Thus, parental coping can be investigated by drawing on a model of i n d i v i d u a l stress and coping theory that i s enriched by an attention to family context. The purpose of the above discussion of coping and i t s r e l a t e d constructs was intended to explicate and c l a r i f y the coping process as i t i s envisioned by scholars i n associated f i e l d s of study. To f a c i l i t a t e an understanding of the constructs as they are u t i l i z e d i n t h i s study, a l i s t of d e f i n i t i o n s i s presented i n Appendix A. As discussed above, i t i s considered important to d i s t i n g u i s h between mediators and moderators i n discussions of the stress process. Generally, what has been investigated i n previous studies are the mediating e f f e c t s of appraisal and coping on some outcome c r i t e r i o n , such as well-being. This exploratory study attempts to understand what factors are important i n predicting a parent's s i t u a t i o n a l appraisals and coping choices. Thus, the d i s t i n c t i o n between mediation and moderation i s not a s a l i e n t point that i s included i n the study design. Unlike many investigations that consider appraisal and coping i n d i f f e r e n t types of s t r e s s f u l s i t u ations, t h i s study s p e c i f i e s the situation, namely, having an adult c h i l d with schizophrenia; i t suggests that the v a r i a b i l i t y within t h i s circumstance permits a variety of s i t u a t i o n a l 76 appraisals and coping responses. This study investigates these appraisals and coping strategies and t h e i r c o r r e l a t e s . Moreover, t h i s study seeks to place t h i s coping process within the family context. Following McCubbin and McCubbin (1991), important family system variables are considered to influence parental perceptions and coping responses; therefore, t h i s study investigates parental perception of such influence. To t h i s end, the v a r i a b i l i t y of the i l l n e s s , along with demographics and resources at both the i n d i v i d u a l and family system l e v e l s , are considered to be associated with a parent's primary and secondary s i t u a t i o n a l appraisals, and to be pr e d i c t i v e of parental coping strategies. This process i s represented in Figure E2. Through such an application of theory, I hope to contribute to a more complete understanding of the parental coping process through an investigation of the question, "How i s the v a r i a b i l i t y of the situ a t i o n related to the coping e f f o r t s of parents who have an adult c h i l d with schizophrenia?" P a r t i c u l a r l y , t h i s study investigates r e l a t i o n s h i p s among (a) personal and s i t u a t i o n a l variables, (b) parental perceptions of what i s at stake (primary appraisal), (c) perceptions of c o n t r o l l a b i l i t y (secondary appraisal), and (d) coping strategies. Although i t i s assumed that there are outcome variables i n the coping process (personal w e l l - being and s o c i a l functioning, as well as feedback from coping to the primary stressor, to resources, and to 77 s i t u a t i o n a l appraisals), i t i s beyond the scope of t h i s study to assess such influence. As previously mentioned, the aim of t h i s study i s to inquire into predictors of parental coping; i t s purpose i s not to evaluate coping effectiveness. The above review of stress and coping l i t e r a t u r e has shown that a number of scholars share the t h e o r e t i c a l perspective that one's coping strategies are influenced by a var i e t y of personal and s i t u a t i o n a l factors. There i s also agreement that coping strategies focus either on the problem, or on the way one feels about the problem. Although coping theory may not be developed s u f f i c i e n t l y f or the generation of formal propositions and s p e c i f i c hypotheses, the above review of stress and coping theory suggests some questions to be addressed concerning the associations of s i t u a t i o n a l variables with coping choices. I t i s not clear how these predictors of coping might be inter c o r r e l a t e d , and which variables have the strongest re l a t i o n s h i p s with coping strategies. Study Inquiry Based upon the the o r e t i c a l and empirical l i t e r a t u r e reviewed above, parental coping strategies can be considered to be associated with the following factors: (a) c h a r a c t e r i s t i c s of the i l l n e s s , (b) demographic c h a r a c t e r i s t i c s (e.g., parent's marital status, f i n a n c i a l status, age, sex, number of dependents; c h i l d ' s sex, age, place of residence), (c) individual and family resources (parental mastery and self-esteem, family cohesion and 78 a d a p t a b i l i t y , s o c i a l support), (d) primary appraisals (perceptions of what i s at stake), and (e) secondary appraisals (perceptions of c o n t r o l l a b i l i t y ) . This study investigates the intercorrelations among these variables as well as the relationships between them and the various forms of coping. The following general questions are proposed with examples of study expectations given the foregoing empirical and t h e o r e t i c a l review. Study Questions Question 1. How well do i l l n e s s c h a r a c t e r i s t i c s predict parental appraisals of the s i t u a t i o n and parental coping strategies? Empirical studies would lead me to expect that greater symptom severity would be associated with "more at stake" and would be related p o s i t i v e l y to emotion-focussed coping strategies. These studies also would suggest that time since onset of i l l n e s s would be p o s i t i v e l y related to a secondary appraisal of the s i t u a t i o n as "one that must be accepted" and negatively r e l a t e d to the number of coping strategies u t i l i z e d . Question 2. What demographic c h a r a c t e r i s t i c s p r e d i c t parental appraisals and coping? From my understanding of the l i t e r a t u r e , I expect that (a) age of the parent w i l l be p o s i t i v e l y related to a primary appraisal of "worry about the future", (b) sex of the c h i l d w i l l be p o s i t i v e l y r e l a t e d to primary stressor "manifestations of the i l l n e s s " , that i s , daughters w i l l have higher levels of l i f e s k i l l s , and (c) parental co-residence with c h i l d w i l l be p o s i t i v e l y 79 r e l a t e d to primary appraisals of "problems i n d a i l y functioning" and "poor relationships within the family." Question 3. What individual and family resources predict parental appraisals and coping strategies? The o r e t i c a l l y , i n d i v i d u a l personal and family system c h a r a c t e r i s t i c s along with the a v a i l a b i l i t y of s o c i a l support are generally presumed to af f e c t one's response to a s t r e s s f u l s i t u a t i o n . I expect that parental mastery and self-esteem w i l l be p o s i t i v e l y related to a secondary appraisal of the s i t u a t i o n by parents as one they can "change or do something about." I expect that family cohesion and f l e x i b i l i t y w i l l be negatively related to "problems i n d a i l y functioning" and "poor r e l a t i o n s h i p s within the family." Question 4. What predictive relationships e x i s t among primary appraisals (what i s at stake), secondary appraisals ( c o n t r o l l a b i l i t y of the sit u a t i o n ) , and coping strategies? Theory would suggest that a secondary appraisal of the s i t u a t i o n as one that can be changed w i l l be p o s i t i v e l y r e l a t e d to problem-focussed coping strategies, whereas a secondary appraisal of the si t u a t i o n as one that has to be accepted w i l l be p o s i t i v e l y related to emotion-focussed strategies. Questionnaire A questionnaire was assembled i n order to respond to these queries (see Appendix B). Following Damrosch and Lenz (1984), demographic items were divided into subsections i n 80 order to avoid an appearance of over intrusiveness. The categories were as follows: 1. Demographics of the person with schizophrenia 2. The functioning l e v e l of the person with schizophrenia 3. Primary appraisal (how the i l l n e s s has influenced the parent's l i f e ) 4. Secondary appraisal ( c o n t r o l l a b i l i t y ) 5. Parent's ways of coping 6. Overt influence of family members on parent's appraisals and coping strategies. 7. Demographics of the parent 8. Personal resources (mastery and self-esteem) 9. Soc i a l support 10. Family cohesion and f l e x i b i l i t y 81 Chapter VI Method Recruitment Respondents were recruited through notices i n the newsletter of the Schizophrenia Society, i n one of the major Vancouver newspapers, i n two community newspapers, and v i a the Schizophrenia information noticeboard on the internet. A d d i t i o n a l l y , requests for participants were made by telephone to coordinators of mental health f a c i l i t i e s i n large and small urban centers i n the province of B r i t i s h Columbia, and some personal presentations were made to support groups for families who are dealing with schizophrenia. Requests were made to both mothers and fathers, asking for the p a r t i c i p a t i o n of either parent of a person with schizophrenia. Approximately 3 00 questionnaires, which included assurances of c o n f i d e n t i a l i t y , were distributed along with stamped, addressed, return envelopes. Respondents were offered the opportunity of obtaining an account of the main conclusions of the study through the separate return of a self-addressed postcard. A t o t a l of 149 questionnaires were completed and returned, for a return rate of approximately 50%, along with 83 requests for study conclusions. Of these l a t t e r requests, 80 were from B r i t i s h Columbia, 1 from Ontario, and 2 from the United States. Of the 149 questionnaires, 8 could not be included i n the analyses; 1 respondent was not a parent, 1 adult c h i l d was diagnosed with bi-polar 82 disorder, and 6 questionnaires contained substantial missing data. Sample Characteristics The sample of 141 parents i s described i n Table F l along with means and standard deviations of parental c h a r a c t e r i s t i c s , separated by sex of parent where s i g n i f i c a n t differences were noted. Parental age was f a i r l y normally d i s t r i b u t e d and a l l marital categories were represented. Years of formal education of these parents also approximated a normal d i s t r i b u t i o n . As can be seen, there was also a broad representation of family incomes. These parents i d e n t i f i e d t h e i r e t h n i c / c u l t u r a l backgrounds as B r i t i s h , including I r i s h and Scottish (36%), European (12%), Canadian (26%), Asian (5%) and Other (5%). The 'Other' category included Syrian, Ukrainian, East Indian, Jewish, and Dukhobors. For almost 10% of these parents, the c h i l d with schizophrenia was an only c h i l d , but most parents had between 1 and 3 other children (76%). Approximately 18% of other children l i v e d i n the parental home. Of p a r t i c u l a r note, 23% of parents said that i n addition to t h e i r son or daughter with schizophrenia, they had another c h i l d with a physical or mental d i s a b i l i t y or i l l n e s s ; 12% of parents s p e c i f i e d additional dependents. Considerable v a r i a b i l i t y also was found i n the c h a r a c t e r i s t i c s of the person with schizophrenia (displayed i n Table F2). Ages of the sons and daughters were f a i r l y normally d i s t r i b u t e d (M = 32.7 years, SD = 7.6). Time since the onset of the i l l n e s s ranged from less than one year (2%) 83 to 35 years (.7%). The mean length of i l l n e s s was 12.4 years ( SD = 7.9 ); the median was 10 years. The reported number of h o s p i t a l i z a t i o n s varied from a minimum of 0 to a maximum of 20 (M = 4.6, SD = 4.1). The vast majority of these adult children were b i o l o g i c a l o f f s p r i n g (95%) and had never been married (88%). I t i s of inte r e s t that the only s i g n i f i c a n t difference (at p_ < .001 level) i n the c h a r a c t e r i s t i c s of sons and daughters was found i n marital status, as noted i n Table 2, with sons much more l i k e l y to have never been married. Thirty-two percent of these adult children l i v e d with the parent, 31% l i v e d on t h e i r own, 19% l i v e d i n a co-op or group housing arrangement, and 5% were p s y c h i a t r i c inpatients; only 1.4% l i v e d with a spouse. F i n a n c i a l l y , almost half of these persons with schizophrenia r e l i e d on s o c i a l assistance and/or d i s a b i l i t y income (48%), 5.6% had some type of employment, 5.6% were f i n a n c i a l l y supported only by the parent, and 3 6% received income from another source i n addition to parental f i n a n c i a l support. Measures In addition to demographics, the factors investigated were the following: (a) the functioning l e v e l of the person with schizophrenia; (b) resources (e.g., esteem, mastery, family cohesion and adaptability, and s o c i a l support); (c) primary appraisal, operationalized as the impact of the i l l n e s s on the respondent's l i f e ; (d) secondary appraisal or the c o n t r o l l a b i l i t y of the s i t u a t i o n ; and (e) coping, the strategies used to manage either the s i t u a t i o n or the way the respondent f e l t about the si t u a t i o n . The measures 84 chosen to assess these variables were selected on the basis of t h e i r broad a p p l i c a b i l i t y as well as t h e i r psychometric properties, to be appropriate for use i n a va r i e t y of family s i t u a t i o n s . Table F3 l i s t s these measures and t h e i r r e l i a b i l i t i e s ; Appendix C l i s t s the questionnaire items categorized by sub-scale. Demands The severity of the primary demand, the i l l n e s s , was assessed by the L i f e S k i l l s P r o f i l e , LSP (Rosen, Hadzi- Pavlovic, & Parker, 1989). The LSP i s a measure developed to assess general lev e l s of function and d i s a b i l i t y i n persons with schizophrenia. I t i s b r i e f and i s composed of s p e c i f i c , jargon-free items, assessing d i s t i n c t behaviours, and therefore i s capable of being completed by family members as opposed to persons with c l i n i c a l t r a i n i n g . I t has 39 items that comprise 5 f a c t o r - a n a l y t i c a l l y derived sub-scales, namely, self-care, nonturbulence, s o c i a l contact, communication, and r e s p o n s i b i l i t y . One of these items (r e f e r r i n g to the child's offensive smell) was deleted for t h i s study i n consideration of parents' s e n s i b i l i t i e s . These Likert-type scales have been labeled i n p o s i t i v e terms i n the b e l i e f that a focus on strengths as opposed to d e f i c i t s would be more helpful to subjects. The response categories range from "not true" (1) to "very true" (4). Rosen et a l . (p. 333) stress that "since the measure was not designed to assess schizophrenic features, per se, ... very few items ... have any d i s t i n c t s p e c i f i c i t y to 85 schizophrenia." This aspect of the scale contributes to the wide a p p l i c a b i l i t y for which t h i s study i s s t r i v i n g . Rosen et a l . (1989) report that each sub-scale score i s moderately and p o s i t i v e l y associated with each other; they considered these scales to be cumulative, reporting a t o t a l scale score that indicated a person's general l e v e l of functioning, with a higher score indicating higher function. For the most part, t h i s study also found a moderate, p o s i t i v e association between sub-scales; l e v e l s of association ranged from r = .27 ( r e s p o n s i b i l i t y and s o c i a l contact) to r = .75 ( r e s p o n s i b i l i t y and nonturbulent behaviour). The int e r n a l consistency of each scale was found to be high with Cronbach's Alpha values as follows: s e l f - c a r e .72, nonturbulence .81, s o c i a l contact .70, communication .72, and r e s p o n s i b i l i t y .77 (comparable to the findings of Rosen et a l . of .88, .85, .79, .67, and .77, r e s p e c t i v e l y ) . Internal consistency for the t o t a l scale was .90. Rosen et a l . have suggested the scale's v a l i d i t y i s indicated by the scale's s e n s i t i v i t y to c l i n i c a l r e a l i t i e s (a negative association between age and both turbulent behaviour and i r r e s p o n s i b i l i t y ) , as well as an association between high scale scores and s t a b i l i t y i n l i v i n g arrangements. Resources Mastery and self-esteem. Mastery and self-esteem have long been considered by stress and coping t h e o r i s t s to be relevant to one's coping response. These constructs have been widely used i n various caregiving contexts. Pertinent 86 to t h i s study, Lefley (1987b, 1990, 1992) has noted t h e i r influence on r e l a t i v e s ' reactions to the mental i l l n e s s of a family member. Mastery was measured with a scale developed by P e a r l i n and Schooler (1978) for use with a community adult sample. The 7-item scale assesses the extent to which one regards one's l i f e chances as being generally under one's control or as f a t a l i s t i c a l l y determined. In a study by Folkman, Lazarus, Gruen, and DeLongis (1986) the i n t e r n a l consistency of the scale (alpha) was .75. The present study found a Cronbach's Alpha figure of .69. Self-esteem was measured with a 6-item scale also developed by Pea r l i n and Schooler (1978), following Rosenberg (1965), for use with a community adult sample. In the present study, i t s internal consistency was found to be .75. In other studies, measures of s e l f esteem and mastery have been found to be highly correlated (r = .65) (Folkman, Lazarus, Gruen, & DeLongis, 1986). In t h i s study, however, a moderate co r r e l a t i o n (r = . 45) was found between esteem and mastery. In both scales, respondents indicated the extent to which they agreed with statements, using response categories ranging from "strongly disagree" (1) to "strongly agree" (6), with higher scores indicating greater l e v e l s of esteem and mastery. Family adaptability and cohesion. Family cohesion and ad a p t a b i l i t y are considered important stress r e s i s t a n t resources both t h e o r e t i c a l l y (e.g., Biegel et a l . , 1991; 87 McCubbin & McCubbin, 1991) and empirically (e.g., Falloon & McG i l l , 1985). This study assessed parental perceptions of family ad a p t a b i l i t y and cohesion using FACES II (Olson, Portner, & B e l l , 1982). This measure i s the second version i n a ser i e s of scales developed by David Olson and h i s colleagues to measure family cohesion and a d a p t a b i l i t y . Adaptability, with i t s 14 items, assesses the extent to which the family system i s f l e x i b l e and able to change i t s power structure and role relationships i n response to s i t u a t i o n a l and developmental stress. The 16-item Cohesion scale measures the degree to which family members are connected i n terms of emotional bonding. Respondents were asked to indicate the extent to which items applied to t h e i r family, with response categories ranging from "almost never" (1) to "almost always" (5). Both scales are scored i n the p o s i t i v e d i r e c t i o n with higher scores i n d i c a t i n g higher l e v e l s of cohesion and adaptability. FACES II (Olson, Portner, & B e l l , 1982) has been used i n a national survey of over 1000 "non-problem" couples and fa m i l i e s across the family l i f e cycle. In a FACES II update, Olson and T i e s e l (1991) affirm the l i n e a r nature of FACES II scores. Olson, B e l l , and Portner (n.d.) report the following psychometric properties: Cronbach Alpha figures of .87 for cohesion, and .78 for adaptability; t e s t - r e t e s t r e l i a b i l i t i e s (4-5 weeks) of .83 for cohesion, and .80 for a d a p t a b i l i t y ; and a co r r e l a t i o n between cohesion and ad a p t a b i l i t y of .65. Olson et a l . found t h i s c o r r e l a t i o n between the two dimensions not to be problematic. They 88 combine cohesion and adaptability scores i n a unique way to a r r i v e at a "family type." Concurrent v a l i d i t y i s said to have been demonstrated. Olson and his colleagues report that the dimensions of FACES II (Olson, Portner, & B e l l , 1982) have been found to correlate highly with a global measure of family health assessed by the Dallas Self-Report Family Inventory (Hampson, Hulgus, & Beavers, 1991): cohesion (.93) and adaptability (.79). The present study found very high i n t e r n a l consistencies for both cohesion and adaptability scales with Cronbach's Alpha = .91 (cohesion) and alpha = .87 (ada p t a b i l i t y ) , as well as a very high c o r r e l a t i o n (r = .82) between the two dimensions. Although t h i s study considers cohesion and adaptability to be separate important dimensions of family strength, t h e i r high c o r r e l a t i o n precluded the inclusion of both i n the analyses. I decided not to consider them to be simply cumulative for two reasons: (a) t h i s study wished to honor the requirements of Olson et a l . (1982) i n the application of t h e i r measure, and (b) I wished to r e t a i n the more widely comprehensible dimensions of cohesion and adaptability that have been noted i n the l i t e r a t u r e , rather than specify a "family type". A number of respondents (those parents who l i v e d alone) noted d i f f i c u l t y i n responding to some items of the a d a p t a b i l i t y scale. Also, adaptability was correlated more strongly than cohesion with the in d i v i d u a l resources of esteem and mastery that were included i n the analyses. 89 Based upon these e t h i c a l and methodological concerns, cohesion was chosen as a family resource variable. S o c i a l Support. Social support i s a ubiquitous concept i n applications of stress and coping theory. I t i s considered a p a r t i c u l a r l y h e l p f u l resource i n si t u a t i o n s that are characterized by feelings of confusion, i s o l a t i o n , and misunderstanding (Atkinson, 1986; Johnson, 1990). The measure of expressive s o c i a l support used i n t h i s study i s one of multiple measures developed by P e a r l i n et a l . (1990) from t h e i r conceptual scheme for the study of caregiver stress. Their framework i s a product both of many years of research into the stress process and of considerable exploratory research among family caregivers. The measures were constructed from a multiwave study of 555 caregivers that began with open-ended exploratory interviews out of which a structured questionnaire was formed, pretested, and revised. The manner i n which the measures were developed as well as t h e i r psychometric properties provide an o v e r a l l sense of confidence that they are serviceable and r e l i a b l e (Pearlin et a l . , 1990). This expressive s o c i a l support measure, i n a Likert-type response format, i s composed of 8 items that tap the perceived a v a i l a b i l i t y of a person who i s caring, trustworthy, u p l i f t i n g , and a confidant. Respondents were asked for the extent of t h e i r agreement with the statements using response categories ranging from "strongly disagree" (1) to "strongly agree" (4), with higher scores r e f l e c t i n g perceptions of more s o c i a l support. The internal r e l i a b i l i t y of the 90 scale was high (alpha = .87), matching that reported by P e a r l i n et a l . . No v a l i d i t y data are available. Following Pearlin et a l . (1990) the a v a i l a b i l i t y of informational and instrumental support was measured by a 4- item index. These 4 items inquire about the a v a i l a b i l i t y of (a) support programs/groups for the parent, (b) information about the i l l n e s s for the parent, (c) a confidant/support person for the adult c h i l d with schizophrenia, and (d) a day program for the adult c h i l d . The responses to these items, with t h e i r coding i n brackets, was: yes (2), no or I don't know (1). A higher index score was considered to indicate a greater amount of instrumental support from the community. Primary Appraisal Whereas Folkman, Lazarus, Dunkel-Schetter, et a l . (1986) developed a scale to investigate subjects' primary appraisals i n a variety of s t r e s s f u l encounters, I investigated appraisals within a s p e c i f i c s i t u a t i o n . As previously mentioned, a premise of t h i s study i s that the v a r i a b i l i t y that i s apparent i n the i l l n e s s and within the family context may r e s u l t i n d i f f e r e n t s i t u a t i o n a l appraisals. S i m i l a r l y to Folkman, Lazarus, Dunkel-Schetter, et a l . (198 6), primary appraisal was assessed with items that i d e n t i f y what the respondent considers to be at stake i n the s t r e s s f u l s i t u a t i o n . These items, which evaluate the impact of the i l l n e s s on the respondent's l i f e , were assessed by a questionnaire developed as part of a large cross-national study of s e l f - h e l p groups (Chesler, Chesney, Gidron, 91 Hartman, & Sunderland, 1988). I t followed from e a r l i e r studies examining the impact of a c h i l d ' s chronic i l l n e s s on parents. I t i s reported to overlap with most of the domains addressed by subjective burden scales for families of the mentally i l l , f or example those of P i a t t (1985) and Potasznik and Nelson (1984). In a study by Gidron (1991), the 24-item scale was factor analyzed with only items loading near or above .50 being retained. The retained 21 items loaded onto 5 factors: (a) lack of information and problems i n communication, (b) relationship with the community environment, (c) problems i n d a i l y functioning, (d) r e l a t i o n s h i p s within the family, and (e) worry about the future. Gidron did not report r e l i a b i l i t i e s for these sub- scales. For t h i s study, the item "reactions of society towards mental i l l n e s s and my family" (loading onto " r e l a t i o n s h i p with the community environment") has been separated into the following three items: (a) reactions of society toward schizophrenia, (b) reactions of society toward my family, and (c) reactions of society toward my son/daughter. These separate items were presumed to load onto the same factor as the o r i g i n a l item. In addition, two new items were added: (a) loss of time and energy at work (presumably loading onto "problems i n d a i l y functioning"), and (b) r e l a t i o n s with spouse or former spouse (presumably loading onto "relationships within the family"). Respondents were asked to indicate, on a 6-point, Likert-type scale (strongly 92 disagree = 1, strongly agree = 6) , the extent to which each item was one of concern, with higher scores i n d i c a t i n g higher l e v e l s of concern. In t h i s study, i n t e r n a l r e l i a b i l i t i e s for the factor-analyzed sub-scales were as follows: r e l a t i o n s with the community, 5 items (alpha = .72); r e l a t i o n s within the family, 4 items (alpha = .66); problems functioning, 6 items (alpha = .75); lack of information, 7 items (alpha = .79); and worry about the future, 2 items (correlation = .41); t o t a l aggregate scale, 24 items (alpha = .90). Secondary Appraisal Secondary appraisal was assessed with four d i s c r e t e items that describe coping options. These items, which are t h e o r e t i c a l l y based, were o r i g i n a l l y developed by Lazarus and Launier (1978) and f i r s t used by Folkman and Lazarus (1980) with a yes/no format. Folkman, Lazarus, and t h e i r colleagues have u t i l i z e d t h i s secondary appraisal assessment multiple times on large study samples, changing the response format to a 5-point L i k e r t scale, scored i n the p o s i t i v e d i r e c t i o n . As previously mentioned, these items assess the extent to which respondents saw the s i t u a t i o n as one "that you could change or do something about," "that you had to accept," " i n which you needed to know more before you could act," and " i n which you had to hold yourself back from doing what you wanted to do" (Folkman, Lazarus, Dunkel-Schetter, et a l . , 1986). This study u t i l i z e d a 6-point response category from "strongly disagree" (1) to "strongly agree" (6). Of these single item appraisals, only two were found 93 to be s i g n i f i c a n t l y correlated. Seeing the s i t u a t i o n as one i n which "I needed to know more before I could act" was s i g n i f i c a n t l y correlated with "having to hold myself back from doing what I wanted to do" (r = .32, p_ < .001) . Ways of Coping Because of i t s generality, the Ways of Coping (WOC; Lazarus & Folkman, 1984) can be used to assess coping i n any s t r e s s f u l circumstance (Tennen & Herzberger, 1985). Three separate factor analyses of a revised WOC by Folkman, Lazarus, Dunkel-Schetter, et a l . (1986) produced s i m i l a r factor patterns (alpha scores i n brackets): confrontive coping (.70), distancing (.61), s e l f - c o n t r o l l i n g (.70), seeking s o c i a l support (.76), accepting r e s p o n s i b i l i t y (.66), escape-avoidance (.72), planful problem-solving (.68), and p o s i t i v e reappraisal (.79). In a c r i t i q u e of the WOC scale, Tennen and Herzberger (1985) note that a number of investigations have demonstrated the scale's internal consistency, construct, and concurrent v a l i d i t y . These authors point out that t e s t - r e t e s t r e l i a b i l i t y may not be appropriate for a measure of a coping process that i s seen to change according to s i t u a t i o n a l demands and previous coping e f f o r t s . Also because the scale i s a self-report measure, Tennen and Herzberger suggest that i n t e r - r a t e r r e l i a b i l i t y estimates cannot be obtained. In some studies, investigators have added items to the WOC to assess coping more accurately i n a p a r t i c u l a r i l l n e s s context (Cohen, 1987). This study included items, noted i n 94 the l i t e r a t u r e , that describe p a r t i c u l a r ways that r e l a t i v e s cope with an i l l n e s s of a family member. These items are: "talked to someone i n a similar s i t u a t i o n " (presumably loading onto "seeking s o c i a l support"); "made arrangements for the future" and "read books and a r t i c l e s to learn more about the s i t u a t i o n " (presumably loading onto "planful problem-solving"); and "adjusted my expectations for the future," "concentrated on the child' s p o s i t i v e contributions to the family," and "we grew or changed as a family i n a good way" (presumably loading onto "positive r e a p p r a i s a l " ) . This l a t t e r item p a r a l l e l s an item already i n the WOC (Folkman, Lazarus, Dunkel-Schetter, et a l . , 1986) that reads "I changed or grew as a person in a good way." This study found the following internal r e l i a b i l i t i e s for these sub- scales (alpha scores i n brackets): confrontive coping, 6 items (.49), distancing, 6 items (.56), s e l f - c o n t r o l l i n g , 7 items (.52), seeking s o c i a l support, 7 items (.79), accepting r e s p o n s i b i l i t y , 4 items (.32), escape-avoidance, 8 items (.61), planfu l problem-solving, 8 items (.70). and p o s i t i v e reappraisal, 10 items (.79). A l l the coping scales were scored i n the positi v e d i r e c t i o n . I had considered the p o s s i b i l i t y of combining the sub- scales into two aggregate scales representing problem- focussed versus emotion-focessed coping. Similar to findings of a previous study on maternal coping (see Seltzer, Greenberg, & Krauss, 1995), the i n d i v i d u a l forms of coping appeared to have unique re l a t i o n s with the independent variables; these important associations might be 95 masked by composite scoring. Therefore, i n d i v i d u a l sub- scale scores were analyzed. Parents were instructed as follows: "We come now to the part of the questionnaire i n which we ask you to indicate the various ways i n which you presently cope with your s i t u a t i o n . The word coping use here refers to any attempt to manage your sit u a t i o n , as you have described i t above, whether or not you f e e l t h i s e f f o r t i s successful. Please c a r e f u l l y read each item and indicate, by c i r c l i n g the appropriate category number, the extent to which you have used i t within the past three months". The responses for t h i s 4-point L i k e r t scale range from "not used" (1) to "used a great deal" (4). Overt Family Influence In accord with recent l i t e r a t u r e on spousal influence on coping and family contextual variables (e.g. G o t t l i e b & Wagner, 1991), an inquiry was directed to overt influence of family members on appraisal and coping i n order to f a c i l i t a t e an interpretation of parents' choices of coping strategies. F i r s t , respondents were asked to respond Yes (1) or No (2) to the question, "Have any family members influenced your views of your s i t u a t i o n or your coping responses?" Next, i n an open-ended response format, respondents were asked to indicate i n two or three sentences (a) "which family members have done or said something to influence either the way you see your s i t u a t i o n or the way you choose to cope with i t " , and (b) "how your views of your situation and/or your coping responses have changed because 96 of what they have done or said". Responses to part "b" were then content coded into the following s i x categories: (a) f e e l i n g closer to family members, (b) accepting advice and/or encouragement, (c) being pushed to action, (d) r e a l i z i n g personal growth, (e) achieving a r e a l i s t i c acceptance, and (f) experiencing c o n f l i c t / a disruption of family r e l a t i o n s h i p s . Analysis Strategy In order to respond to the study questions and to determine the predictive relationships among the many variables assessed, I decided upon the following analysis strategy. My intent was to re t a i n as much v a r i a b i l i t y as possible while eliminating any redundant or nonsignificant variables from the f i n a l analytic procedures. The analyses would proceed i n a series of steps. To begin with, I would examine a large c o r r e l a t i o n matrix containing a l l the continuous variables assessed. Variables that could be considered redundant would be eliminated; variables showing s i g n i f i c a n t associations with the dependent variables of in t e r e s t would be retained for further analysis. Next, t - tests would be run to determine s i g n i f i c a n t associations between categorical variables and dependent variables of in t e r e s t . F i n a l l y , those variables i d e n t i f i e d as s i g n i f i c a n t i n the above procedures would be entered into standard multiple regression equations with the dependent variab l e s . These regressions would i d e n t i f y those variables among i l l n e s s c h a r a c t e r i s t i c s , demographics, resources, and 97 appraisals that could be designated as predictors within the coping process. 98 Chapter VII Results Univariate Data Analyses Missing Values Univariate analyses were conducted to assess scale d i s t r i b u t i o n s , and to i d e n t i f y missing or outlying values. For the most part, missing values appeared to be randomly d i s t r i b u t e d . Missing values on sub-scale items were replaced with the mean score for the remainder of the sub- scale. This procedure was not appropriate for two sub-scales of primary appraisal, "problems i n d a i l y functioning" and "worry about the future". Each sub-scale had one item with a considerable number of missing responses. In the former sub-scale, there were 52 missing cases attached to the item "I worry about my spouse's health ( i f applicable)." An in v e s t i g a t i o n showing these missing cases attached to both married and unmarried respondents, suggested t h i s item may have been unclear. Deletion of t h i s item from the sub- scale, "problems i n d a i l y functioning," resulted i n a 6-item scale with improved r e l i a b i l i t y . The item "Relations with own parents/spouse's parents have worsened" was missing 28 cases. According to Gidron (1991), t h i s item contributed to the 3-item sub-scale "worry about the future." I found, however, that the item was not applicable to many older respondents whose own parents were no longer a l i v e . I t was inappropriate to replace t h i s item with the mean score on the other two items because of the great difference i n means 99 ( 1 . 8 8 for the problem item versus 5 . 1 4 for the other two items). This item also was deleted r e s u l t i n g i n a sub-scale with only two items. D i s t r i b u t i o n s Preliminary analysis revealed that variables, f o r the most part, were normally distributed. Some scales evidenced s l i g h t skewness and/or kurtosis. The scale that assessed a parent's worry about the future exhibited the most s i g n i f i c a n t skewness (Skewness - -1.39,.SE Skewness = . 2 0 ) . A l a t e r check of the scatterplot of residuals against predicted DV scores did show that i n some instances, the assumptions of the regression analyses, s p e c i f i c a l l y normality and homoscedasticity, were not met. No transformations of data were undertaken, however. Tabachnick and F i d e l l (1989) acknowledge that data transformations are not universally recommended because transformed variables are sometimes more d i f f i c u l t to i n t e r p r e t . They also point out that f a i l u r e to meet assumptions of multiple regression does not i n v a l i d a t e the analysis so much as weaken i t . The shapes of the d i s t r i b u t i o n s of scale values are discussed at length i n Appendix D. The range, means, and standard deviations of scales are reported i n Table F4 (Functioning Level of Daughters and Sons), and i n Table F5 and F6 (Resources, Appraisals, and Coping of Mothers and Fathers). I t i s of i n t e r e s t to note that the forms of coping most often reported by t h i s group of parents were seeking s o c i a l support, p l a n f u l problem-solving, and p o s i t i v e reappraisal. 100 They reported less use of confrontational coping, a type of coping that would correspond to the "expressed emotion" that i s mentioned i n the l i t e r a t u r e as detrimental to the w e l l - being of persons with schizophrenia. Multivariate Analyses Correlations The questions posed by t h i s study concerned the i d e n t i f i c a t i o n of i l l n e s s , demographic, and resource variables that were predictive of appraisals and coping. The analysis strategy mentioned above was followed i n the service of t h i s e f f o r t . A correlation matrix was examined to investigate interrelationships among the variables i n order (a) to eliminate redundant variables and, (b) to choose from among those t h e o r e t i c a l l y relevant variables, the ones that were s i g n i f i c a n t l y correlated with measures of appraisal and coping. In addition, t-tests were conducted to investigate the associations of categorical variables (gender, marital status, residence of c h i l d , overt family influence, and having another c h i l d with d i s a b i l i t i e s ) with measures of i l l n e s s , resources, appraisals, and coping. S i g n i f i c a n t r e s u l t s for these categorical variables are reported i n Tables F4 to F8. Table F9 shows s i g n i f i c a n t correlations that were noted among some of the demographic variables designated f o r further analysis. S i g n i f i c a n t i n t e r r e l a t i o n s h i p s can be noted among "age of parent," "age of c h i l d , " and "time since onset of the i l l n e s s , " with the levels of s i g n i f i c a n c e ranging from r = .60 to r = .81. In order to eliminate any 101 redundancies, "age of parent" was chosen as a representative va r i a b l e that would capture these i n t e r r e l a t e d c h a r a c t e r i s t i c s of the s i t u a t i o n . Table F10 i d e n t i f i e s those variables s i g n i f i c a n t l y associated with primary appraisals. Correlation c o e f f i c i e n t s with levels of significance are included; for each categorical variable, values displayed are the differences i n means between the groups, along with the 2- t a i l e d l e v e l s of significance. It i s of i n t e r e s t to note the absence of variables whose associations with primary appraisals might have been expected according to the l i t e r a t u r e reviewed above, for example, primary appraisals were not s i g n i f i c a n t l y associated with either the parent's education, marital status, or family income. Table F l l i d e n t i f i e s those variables that were s i g n i f i c a n t l y associated with secondary appraisals. Most of the variables l i s t e d were i d e n t i f i e d as s i g n i f i c a n t correlates of a secondary appraisal of the s i t u a t i o n as one i n which parents f e l t they had to hold back from doing what they wanted to do. It can be noted, however, that of the f i v e sub-scale measures of the son's/daughter's l e v e l of functioning, only nonturbulent behaviour and r e s p o n s i b i l i t y had t h i s i d e n t i f i c a t i o n . I t can be seen that the variables l i s t e d were associated in d i f f e r e n t ways with the other measures of secondary appraisal. For example, mastery, expressive support, and relationships within the family were correlated with seeing the s i t u a t i o n as one that could be changed, whereas only self-esteem had a s i g n i f i c a n t 102 r e l a t i o n s h i p with an appraisal of the s i t u a t i o n as one that must be accepted. Logically, a secondary appraisal of needing to know more before acting was s i g n i f i c a n t l y associated with a primary appraisal of a lack of information and problems i n communication. Tables F12 and F13 i d e n t i f y those variables that were s i g n i f i c a n t l y associated with a parent's coping strategies. I t can be seen that demographics, resources, primary appraisals, and secondary appraisals were correlated d i f f e r e n t l y with d i f f e r e n t types of coping; the greatest number and strength of associations existed between these variables and various forms of emotion-focussed coping, such as, s e l f - c o n t r o l , seeking s o c i a l support, and escape- avoidance strategies. Interestingly, parent's marital status (married = 1, not married = 2), which was found above to be nonsignificantly associated with measures of s i t u a t i o n a l appraisal, was seen to be s i g n i f i c a n t l y correlated with various types of coping. Age of the parent, which was noted above to be strongly correlated with time since onset of i l l n e s s , generally had stronger associations with aspects of coping than did the l a t t e r v a r i a b l e . With distance strategies, however, the time since onset was found to have the stronger association and therefore was the variable considered to be more appropriate for further analysis of t h i s form of coping. To r e i t e r a t e , these s i g n i f i c a n t associations helped i d e n t i f y those variables that were appropriate choices for regression analyses. 103 Some in t e r e s t i n g observations are apparent from Tables F10 to F13. Certain variables are seen to reoccur as s i g n i f i c a n t correlates of both appraisals and coping, namely, sex of the parent, the r e s p o n s i b i l i t y and nonturbulent behaviour of the daughter/son, and the resources of esteem, mastery, and expressive support. Other variables are more s p e c i f i c in t h e i r associations. For example, parent's marital status i s s i g n i f i c a n t l y correlated only with coping, not with appraisals, whereas the resource, cohesion, i s seen only to be s i g n i f i c a n t l y associated with appraisals. I t i s also interesting to note those appraisals and forms of coping that most frequently are correlated with other factors. Four of the f i v e primary appraisals, have s i g n i f i c a n t associations with demographics, c h i l d ' s l i f e s k i l l s , and resources. One secondary appraisal, the perception of having to hold back, also has multiple associations that reach levels of s i g n i f i c a n c e . As well, c e r t a i n forms of coping, p a r t i c u l a r l y accepting r e s p o n s i b i l i t y and escape-avoidance, are s i g n i f i c a n t l y correlated with demographics, resources, c h i l d ' s l i f e s k i l l s , and both primary and secondary appraisals. An absence of p a r t i c u l a r s i g n i f i c a n t associations also i s notable. Unlike the other four primary appraisals, worry about the future has no s i g n i f i c a n t associations with c h i l d ' s l i f e s k i l l s . Each of two secondary appraisals, namely, viewing the s i t u a t i o n as one that must be accepted and needing to know more before acting, has only one 104 s i g n i f i c a n t c o rrelation, with self-esteem and a lack of information respectively. Certain forms of coping, as well, lack s i g n i f i c a n t associations i n p a r t i c u l a r areas. For example, confrontive coping and p o s i t i v e reappraisal are not correlated s i g n i f i c a n t l y with any resource factor; distance coping, seeking s o c i a l support, and p o s i t i v e reappraisal have no s i g n i f i c a n t associations with measures of primary appraisal; and seeking s o c i a l support (unlike other forms of coping) i s not s i g n i f i c a n t l y correlated with any of the four secondary appraisals. Multiple Regression To assess relationships among variables, and answer the basic question of multiple correlation, the standard form of multiple regression i s the method advised by Tabachnick and F i d e l l (1989). Independent variables, retained from the above analyses, were entered simultaneously into multiple regression equations to provide a more accurate assessment of t h e i r associations and to indicate t h e i r p r e d i c t i v e power. Three series of multiple regressions were conducted to c l a r i f y the following: (a) the amounts of variance i n primary appraisals that can be attributed to demographics and resources, (b) the variance i n secondary appraisals that i s a t t r i b u t a b l e to demographics, resources, and primary appraisals, and (c) the accountability of demographics, resources, primary appraisals, and secondary appraisals for the variance i n coping. Whereas the independent variables are designated as predictors, no causal inference i s intended or indeed i s possible. For an accurate assessment 105 of the importance of the independent variables, attention must be given to the intercorrelations among them, as well as t h e i r Beta values and levels of s i g n i f i c a n c e . Multiple regression series 1. Tables F14 through F18 display the r e s u l t s of regression equations i n which demographic, resource, and i l l n e s s ( l i f e s k i l l s ) variables were regressed on each of the f i v e primary appraisals. Generally, at least four of the f i v e l i f e s k i l l s measures were candidates for entry into each of the equations, along with other variables. These l i f e s k i l l s sub-scales, however, were moderately to highly inte r c o r r e l a t e d ; f o r example, the c o r r e l a t i o n of nonturbulence and r e s p o n s i b i l i t y was r = .75. The cumulative l i f e s k i l l s measure was u t i l i z e d , therefore, to capture the range of l i f e s k i l l s influence while avoiding the m u l t i c o l l i n e a r i t y of the sub- scales. The tables display the correlations between the variables, the unstandardized regression c o e f f i c i e n t s (B), the standardized regression c o e f f i c i e n t s (Beta), F values and the s i g n i f i c a n c e of F for each predictor, as well as R, R squared, adjusted R, F, significance of F, and degrees of freedom for each equation. In equation number one (see Table F14), I entered demographics [age and sex of parent (male = 1, female = 2), sex of c h i l d (male = 1, female = 2 ) ] , l i f e s k i l l s of the c h i l d , and resources (esteem, mastery, cohesion, and community support) as predictors of a primary appraisal of a lack of information and problems i n communication. Altogether 32% (adjusted 28%) of the v a r i a b i l i t y i n t h i s 106 primary appraisal was predicted by knowing the scores on the eight independent variables. R for regression was s i g n i f i c a n t l y d i f f e r e n t from zero, F = 7.65, p_ < .001. Only two of the independent variables contributed s i g n i f i c a n t l y to the variance explained, chil d ' s l i f e s k i l l s (Beta = -.21) and community support (Beta = -.19). Both higher l e v e l s of c h i l d ' s l i f e s k i l l s and greater a v a i l a b i l i t y of community support predicted less parental concern over a lack of information and problems in communication. Although the other IVs had been shown independently to be s i g n i f i c a n t l y associated with the DV, when entered i n combination with other i n t e r r e l a t e d variables, t h e i r s i g n i f i c a n c e was diminished. In the second equation (Table F15), sex of parent, c h i l d ' s l i f e s k i l l s , and the resources of esteem, mastery, cohesion, and community support, were regressed on the primary appraisal, concern over r e l a t i o n s with the community. Variance explained was 27% (adjusted 24%). Multiple R was s i g n i f i c a n t l y d i f f e r e n t from zero, F = 8.36, p_ < .001. Again, child's l i f e s k i l l s was the strongest predictor (Beta = -.21), followed by mastery (Beta = -.19) and sex of parent (Beta = .18). Less parental concern over r e l a t i o n s with the community, therefore, was predicted by higher l e v e l s of c h i l d ' s l i f e s k i l l s , higher l e v e l s of parental mastery, and by being the father of the person with schizophrenia. Table F16 displays the results of the t h i r d equation i n which the l i f e s k i l l s and sex of the c h i l d , resources, and 107 having another c h i l d with a d i s a b i l i t y , accounted f o r 38% (adjusted 34%) of the v a r i a b i l i t y i n the primary appraisal, concern over r e l a t i o n s within the family. The regression c o e f f i c i e n t was s i g n i f i c a n t l y d i f f e r e n t from zero, F = 10.09, p_ < .001. Of the eight I V s entered into the equation, only three were s i g n i f i c a n t predictors. Lower le v e l s of parental concern over r e l a t i o n s within the family were predicted by higher levels of mastery (Beta = -.33), higher l e v e l s of chil d ' s l i f e s k i l l s (Beta = -.24), and higher l e v e l s of family cohesion (-.19). A f u l l 46% (adjusted 43%) of the variance of the primary appraisal, problems i n d a i l y functioning, was explained by equation four (Table F17). The multiple R of .68 was s i g n i f i c a n t l y d i f f e r e n t from zero, F = 16.38, p_ < .00. Four of the seven IVs entered were s i g n i f i c a n t predictors of fewer problems i n d a i l y functioning: higher l e v e l s of mastery (Beta = -.36), increased age of parent (Beta = -.23), higher levels of esteem (Beta = -.16), and higher l e v e l s of chil d ' s l i f e s k i l l s (Beta = -.14). Only 18% (adjusted 16%) of the variance i n the primary appraisal, worry about the future, was explained by equation f i v e (Table F18). R for regression was s i g n i f i c a n t l y d i f f e r e n t from zero with F = 7.38, p_ < .001. Interestingly, the presence of overt family influence was the strongest predictor (Beta = -.24). Having a family member who says or does something to change the way the parent views or copes with the s i t u a t i o n i s predictive of higher l e v e l s of worry about the future (p_ < .001). Lower leve l s of self-esteem 108 (Beta = -.18) and being a mother (Beta = .17) also s i g n i f i c a n t l y contributed to higher le v e l s of t h i s concern. The data i n the tables reviewed so far show that between 18% and 4 6% of the v a r i a b i l i t y i n primary appraisals can be attributed to demographics, i l l n e s s c h a r a c t e r i s t i c s ( l i f e s k i l l s ) , and both individual and family resources. The i n t e r c o r r e l a t i o n s among the independent variables are such that when regressed simultaneously on each dependent variable, t h e i r levels of significance are reduced. Each equation i d e n t i f i e s between two and four variables that r e t a i n t h e i r levels of significance and emerge as s i g n i f i c a n t predictors. Resource variables are the most frequent predictor of primary appraisals; i l l n e s s c h a r a c t e r i s t i c s are predictive of a l l primary appraisals excepting for worry about the future. Multiple regression series 2. Tables F19 through F22 show the r e s u l t s of regression equations i n which demographic, resource, and primary appraisal variables were regressed on secondary appraisals. In equation number 6 (Table F19), three IVs accounted for 15% (adjusted 14%) of the variance of the secondary appraisal, "the s i t u a t i o n i s one I can change or do something about" (F = 8.36, p_ < .001). Only mastery, however, with a Beta value of .21, retained a l e v e l of significance less that .05. Higher l e v e l s of mastery, then, predicted a stronger perception of the s i t u a t i o n as one that the parent could change or do something about. 109 The regression of the ind i v i d u a l resource self-esteem on the secondary appraisal, "the s i t u a t i o n i s one I have to accept," was the weakest equation of t h i s group (Table F20). The sin g l e independent variable that had been i d e n t i f i e d previously as s i g n i f i c a n t l y associated with t h i s secondary appraisal, accounted for only 5 % (adjusted 4 %) of the variance i n the secondary appraisal, with an F value of 6.90, p_ < 01. Higher levels of self-esteem were p r e d i c t i v e of a stronger perception of the sit u a t i o n as one that had to be accepted. The secondary appraisal, "I needed to know more before I could act" also had only one IV regressed upon i t (Table F21). This predictor, a primary appraisal of a lack of information and problems i n communication accounted for the 12% (adjusted 11%) of variance explained, with an F value of 18.86, p. < .001. A greater concern over a lack of information, then, predicted a stronger perception of needing to know more. By contrast, Table F22 shows there were eight IVs, previously i d e n t i f i e d as s i g n i f i c a n t , entered into the equation explaining 33% (adjusted 29%) of the variance of the secondary appraisal, "I had to hold back from doing what I wanted to do" (F = 8.14, p_ < .001). Among these variables were demographics, resources, l i f e s k i l l s and primary appraisals. A l l the primary appraisals were candidates for entry because of s i g n i f i c a n t associations with the dependent vari a b l e ; moderate to high i n t e r c o r r e l a t i o n s among them, generally between r = .50 and r = .70, made t h i s i n c l u s i o n 110 inadvisable. Rather, the aggregate measure of primary appraisal was u t i l i z e d . Of the variables entered, only the aggregate primary appraisal measure emerged as a s i g n i f i c a n t predictor (Beta = .36, p_ < .001). The i n t e r r e l a t i o n s h i p s between t h i s s i g n i f i c a n t contributor and the other IVs entered (resources, demographics, and l i f e s k i l l s ) had been demonstrated i n the previous set of equations. This equation showed that a higher l e v e l of concern over the ways the i l l n e s s had affected the parent's l i f e predicted a stronger perception of the s i t u a t i o n as one i n which the parent had to hold back from doing what was wanted. In the equations investigating the predictors of secondary appraisals, the variance explained ranges from only 5% to 33%. S i g n i f i c a n t predictors of secondary appraisals are resources (self-esteem and mastery) and primary appraisals. Only a secondary appraisal of the s i t u a t i o n as one i n which the parent had to hold back had s i g n i f i c a n t associations with multiple variables. Multiple regression series 3. Results of the regression of i l l n e s s , demographic, resource, and appraisal variables on each of the measures of coping are displayed i n Tables F2 3 through F3 0. Amounts of variance explained range from 13% to 42%. Five IVs including demographics, two primary appraisals, and a secondary appraisal, were regressed on confrontive coping (Table F23), accounting for 14% (adjusted 11%) of the variance i n the DV (F = 4.46, p_ < .001). Only marital status contributed s i g n i f i c a n t l y to confrontive I l l coping with a Beta value of .18 and a si g n i f i c a n c e l e v e l of P < .03. Being never married, separated, divorced, or widowed predicted a greater use of confrontive coping. Equation number 11 (Table F24) demonstrated that two IVs, increased time since i l l n e s s onset (Beta = .22) and a stronger secondary appraisal of having to hold back (Beta = .17), emerged as the s i g n i f i c a n t predictors of a greater use of distance coping. Four IVs were regressed on the DV accounting for 13% (adjusted 11%) of i t ' s v a r i a b i l i t y (F = 5.26, p_ < .001) . Table F25 shows marital status again to be a s i g n i f i c a n t predictor of coping. Being not married (never married, separated, divorced, or widowed) predicted greater use of coping through s e l f - c o n t r o l . Although seven IVs were regressed on s e l f - c o n t r o l coping, only marital status contributed to the 24% (adjusted 20%) of variance explained with a si g n i f i c a n c e l e v e l less or equal to .05. The F value for the regression equation equalled 5.72 with a si g n i f i c a n c e l e v e l of p < .001 Coping by seeking s o c i a l support i s shown i n Table F26 to have a number of s i g n i f i c a n t predictors. Altogether, 27% (adjusted 24%) of the v a r i a b i l i t y i n seeking s o c i a l support was predicted by knowing the a v a i l a b i l i t y of expressive support (Beta = .38), the marital status of the parent (Beta = .20), the l i f e s k i l l , nonturbulent behaviour, of the c h i l d (Beta = -.20), and the age of the parent (Beta = -20). F for regression was 9.92, p_ < .001. A greater use of coping through seeking s o c i a l support, therefore, was associated 112 with an increased a v a i l a b i l i t y of expressive support, being younger and not married, and having a c h i l d with more turbulent behaviour. In equation 14 (Table F27), more parental coping by accepting r e s p o n s i b i l i t y was predicted by a stronger secondary appraisal of having to hold back from doing what the parent wanted to do (Beta = .22) and by a lower l e v e l of the c h i l d ' s l i f e s k i l l , nonturbulence (Beta = -.19). The amount of variance explained was 26% (adjusted 23%) with F = 7.81, p_ < . 001. Although eight IVs were regressed on escape-avoidance coping, the variance was explained s i g n i f i c a n t l y by three predictors. Table F28 demonstrates that 42% (adjusted 39%) of the variance could be predicted by knowing the scores on the aggregate primary appraisal measure (Beta = .27), the l e v e l of mastery (Beta = -.22), and the age of the parent (Beta = -.19). Interestingly, both mastery and primary appraisals were s i g n i f i c a n t predictors despite t h e i r i n t e r c o r r e l a t i o n of -.50. Being older, having higher l e v e l s of mastery, and having lower levels of concerns predicted less use of escape-avoidance strategies. F for regression equalled 11.97, p_ < .001. Table F29 shows that 25% (adjusted 21%) of the variance i n coping through planful problem-solving i s accounted for i n equation 16 (F = 7.16, p_ < .001). There are four s i g n i f i c a n t predictors of a greater use of p l a n f u l problem- solving: a greater a v a i l a b i l i t y of expressive support (Beta - .24), , being not married (Beta = .20), a greater worry 113 about the future (Beta = .18) and a stronger secondary appraisal of needing to know more (Beta = .23). A l l s i x IVs entered into equation 17 were demonstrated to be s i g n i f i c a n t predictors of coping through p o s i t i v e reappraisal (Table F30), with 31% (adjusted 28%) of the variance explained. The parent's greater use of coping through p o s i t i v e reappraisal was associated with (a) being a mother (Beta = .24), (b) being not married (Beta = .19), (c) higher l e v e l s of the child's l i f e s k i l l , s o c i a b i l i t y (Beta = .20), and (d) three separate secondary appraisals, a greater need to know more before acting (Beta = .22), a stronger perception of the s i t u a t i o n changeable (Beta = .22), and a stronger view of the si t u a t i o n as one that must be accepted (Beta = .18). F for regression equalled 10.04 with a l e v e l of s i g n i f i c a n c e , p_ < .001. The equations just reviewed reveal that predictors of coping are multiple and varied; demographics, i l l n e s s c h a r a c t e r i s t i c s , resources, primary appraisals, and secondary appraisals account for between 13% and 42% of the v a r i a b i l i t y i n d i f f e r e n t forms of coping. I t i s of i n t e r e s t that the demographic, marital status of parent (married = 1, not-married = 2), which has not been s i g n i f i c a n t l y associated with any type of s i t u a t i o n a l appraisal, i s demonstrated to be a s i g n i f i c a n t predictor of many forms of coping. 114 L i f e S k i l l s . Demographics, Resources, and Appraisals as Predictors In order to respond most d i r e c t l y to the questions posed by t h i s study, however, a s l i g h t reorientation toward the regression r e s u l t s i s required. Rather than focussing on i d e n t i f y i n g the predictors of various appraisals and forms of coping, study responses must be directed toward determining the predictive power of i l l n e s s c h a r a c t e r i s t i c s , demographics, resources, and appraisals. Figures E3 through E6 i l l u s t r a t e , using Beta values, the d i r e c t i o n and strength of the p r e d i c t i v e power of i l l n e s s , demographic, resource, and appraisal variables, respectively. The r e l a t i o n s h i p s diagrammed are those that retained a l e v e l of s i g n i f i c a n c e less or equal to .05 within the regression equations. They are diagrammed in accordance with the stress and coping model reviewed above. The diagrams w i l l be b r i e f l y described i n response to the study questions. Question 1. How well do i l l n e s s c h a r a c t e r i s t i c s predict parental appraisals of the s i t u a t i o n and parental coping strategies? Figure E3 shows that l i f e s k i l l s of the son or daughter with schizophrenia are predictive of primary appraisals and of coping (Beta values i n brackets), but not of secondary appraisals. The c h i l d ' s nonturbulent behaviour i s negatively predictive of two coping strategies for parents, seeking s o c i a l support (-.20) and acceptance of r e s p o n s i b i l i t y (-.19). Interestingly, higher l e v e l s of a c h i l d ' s s o c i a b i l i t y i s predictive of more parental coping by 115 p o s i t i v e reappraisal (.20). A lower l e v e l of c h i l d ' s l i f e s k i l l s (cumulative) i s predictive of greater parental concern over (a) lack of information and problems i n communication (-.21), (b) rel a t i o n s with the community (- .21), (c) r e l a t i o n s within the family (-.24), and (d) problems i n d a i l y functioning (-.14). Another i l l n e s s c h a r a c t e r i s t i c , greater time since onset, predicts greater use of distance coping (.22). Question 2. What demographic c h a r a c t e r i s t i c s predict parental appraisals and coping? Figure E4 indicates that age and sex of parent (father = 1, mother = 2) are predictive of both primary appraisals and coping. Age i s negatively related to a concern over problems functioning (-.23), and to coping by seeking s o c i a l support (-.20) or by using escape strategies (-.19). Mothers more that fathers perceive concerns i n t h e i r r e l a t i o n s with the community (-.18) and they have higher l e v e l s of worry about the future (.17). Mothers are more l i k e l y than fathers to cope through p o s i t i v e reappraisal (.24). Marital status (1 = married, 2 = not married) i s pr e d i c t i v e of several coping strategies. Not being married (divorced, separated, widowed) i s predictive of more coping through confrontation (.18), s e l f control (.21), seeking s o c i a l support (.20), and planful problem-solving (.20). Demographics do not appear as predictors of secondary appraisals. Question 3. What individual and family resources predict parental appraisals and coping strategies? 116 Figure E5 shows that mastery i s highly p r e d i c t i v e of ce r t a i n primary appraisals. Higher lev e l s of mastery predict lower lev e l s of concern over r e l a t i o n s with the community (-.19), re l a t i o n s within the family (-.33), and problems functioning (-.36). As might be expected, mastery p o s i t i v e l y predicts a secondary appraisal of the s i t u a t i o n as one that you could change or do something about (.21), and i s negatively predictive of coping through escape- avoidance strategies (-.22). Self-esteem, which i s correlated with mastery (r = .46), i s also predictive of problems functioning (-.16), even with both variables entered into the regression equation. Self-esteem also predicts worry about the future (-.18) and a secondary appraisal of the s i t u a t i o n as one that has to be accepted (.22), but has not s i g n i f i c a n t p r e d i c t i v e power d i r e c t l y associated with coping strategies. The a v a i l a b i l i t y of expressive support s i g n i f i c a n t l y predicts coping by seeking s o c i a l support (.38) and by pl a n f u l problem-solving (.24). The sign i f i c a n c e of community support as a predictor i s noted only i n i t s negative r e l a t i o n s h i p with a primary appraisal of lack of information (-.19). The family resource, cohesion, was found independently to be s i g n i f i c a n t l y correlated with several appraisals. In most instances, when regressed on these appraisals i n combination with other int e r r e l a t e d variables, i t s l e v e l s of si g n i f i c a n c e were not retained. In regression with one primary appraisal, however, i t proved to be a s i g n i f i c a n t 117 contributor to the variance explained. Cohesion was found to be negatively predictive of a primary appraisal of concern over r e l a t i o n s within the family (-.19). Overt family influence has been placed a r b i t r a r i l y within the resource category for lack of a more appropriate designation. This variable has been i d e n t i f i e d as a s i g n i f i c a n t p o s i t i v e predictor of a parent's worry about the future (.24) . Question 4. What predictive relationships e x i s t among primary appraisals (what i s at stake), secondary appraisals (the c o n t r o l l a b i l i t y of the s i t u a t i o n ) , and forms of coping? Figure E6 shows that primary appraisals predict both secondary appraisals and coping. Logica l l y , a primary appraisal of lack of information and problems i n communication s i g n i f i c a n t l y predicts a secondary appraisal of the s i t u a t i o n as one i n which one needed to know more before acting (.35), whereas a primary appraisal of worry about the future predicts planful problem-solving (.18). The aggregate primary appraisal measure i s p o s i t i v e l y p r e d i c t i v e of a secondary appraisal of the s i t u a t i o n as one i n which parents f e l t they had to hold back from doing what they wanted to do (.3 6) and of coping through the use of escape-avoidance strategies (.27). Secondary appraisals, more often than primary appraisals, are demonstrated to be s i g n i f i c a n t predictors of coping. A secondary appraisal of the s i t u a t i o n as changeable predicts coping through p o s i t i v e reappraisal (.22); a secondary appraisal of the s i t u a t i o n as one that 118 must be accepted also predicts coping through p o s i t i v e reappraisal (.18). Secondary appraisal of needing to know more before acting predicts both p o s i t i v e reappraisal (.22) and p l a n f u l problem-solving (.23). The remaining secondary appraisal, having to hold back from doing what they wanted, predicts coping by distancing (.17) and accepting r e s p o n s i b i l i t y (.22). 119 Chapter VIII Discussion The genesis of t h i s study was the general question, "How do parents cope when they have a son or daughter with schizophrenia?" A reading of both c l i n i c a l and family studies l i t e r a t u r e revealed considerable v a r i a b i l i t y within t h i s s i t u a t i o n . A review of th e o r e t i c a l frameworks dealing with coping established there were certa i n concepts u t i l i z e d by both i n d i v i d u a l and family coping models that could assess t h i s v a r i a b i l i t y ; there were demands, resources, and appraisals considered integral to the coping process. An inve s t i g a t i o n of t h i s general question, then, needed to attend to these concepts, to operationalize and measure them, along with an assessment of coping strategies, i n a substantial sample of parents. Coping theories have led to the conceptualization of process by way of models but have not led to the derivation of c l e a r hypotheses. In t h i s study, I proposed some exploratory questions which, i f answered, not only might increase our appreciation of parental coping with a c h i l d who has schizophrenia, but also might provide insights into parental coping i n general and perhaps further our global understanding of coping by empirically i d e n t i f y i n g some predictors within the process. Along with these questions, I ventured some expectations of findings based on the t h e o r e t i c a l and c l i n i c a l l i t e r a t u r e review. This i n t e r p r e t a t i o n of the study's r e s u l t s , then, w i l l consider each question that was posed, how i t was answered, and 120 whether my expectations were met; I w i l l venture some explanations for the findings. I w i l l point out important r e l a t i o n s h i p s and patterns of influence that may speak to the coping model that drove the research. The discussion w i l l continue with a consideration of the l i m i t a t i o n s and strengths of the study, and any implications there may be for t h e o r e t i c a l and p r a c t i c a l application. Question 1 Question 1 queried the predictive power of i l l n e s s c h a r a c t e r i s t i c s (child's l i f e s k i l l s and time since onset). Recall that the l i t e r a t u r e showed d i f f e r i n g consequences of the disorder for the family according to d i f f e r e n t manifestation of the i l l n e s s (Cole et a l . , 1993; Gubman & Tessler, 1987), with greater family d i s t r e s s accompanying p o s i t i v e symptoms i n general (Runions & Prudo, 1983), and i n p a r t i c u l a r , symptoms of an offensive or threatening nature (Biegal et a l . , 1991; Gibbons et a l . , 1984; Johnson, 1990). Figure E3 shows that as was expected, l i f e s k i l l s (except for s o c i a b i l i t y ) do predict a l l but one of the parental appraisals of what i s at stake. Cumulatively, they are the strongest predictor of parental concerns about a lack of information and problems i n communication and r e l a t i o n s with the community. P a r t i c u l a r l y , the l i f e s k i l l s of r e s p o n s i b i l i t y and nonturbulence of the c h i l d are i n f l u e n t i a l i n these parental assessments, independently having the highest correlations with primary appraisals as noted i n Table F10. A child's s o c i a b i l i t y , however, has a s i g n i f i c a n t association only with a parent's appraisal of 121 r e l a t i o n s h i p s with the community. Unlike the c h i l d ' s turbulent and irresponsible behaviour, his/her general i n a c t i v i t y with l i t t l e s o c i a l involvement and few friends promotes less disruption i n family relationships and problems i n d a i l y functioning, but s t i l l impacts upon rel a t i o n s h i p s with friends, neighbours, and society i n general. Interestingly, the child's l i f e s k i l l s have no s i g n i f i c a n t relationships with a parent's worry about the future. As we saw above, the sub-scale "worry about the future" was s i g n i f i c a n t l y skewed to the l e f t . For the most part, the parents i n t h i s sample indicated high l e v e l s of t h i s concern. I t appears that regardless of severity of symptoms, the parent i s concerned about the c h i l d ' s future and worried about the e f f e c t on the rest of the family should the parent die. There were few s i g n i f i c a n t associations between i l l n e s s c h a r a c t e r i s t i c s and secondary appraisals, as noted above i n Table F l l . Although nonturbulence was regressed along with other variables on the secondary appraisal, having to hold back, i t did not emerge as a s i g n i f i c a n t predictor. Whereas for the most part the c h i l d ' s l i f e s k i l l s strongly influence a parent's primary appraisals i n s i m i l a r ways, they are independently and less frequently p r e d i c t i v e of coping. As was expected, lower lev e l s of l i f e s k i l l s p r e dict more use of emotion-focussed forms of coping, a f i n d i n g that follows suggestions by Folkman et a l . (1991) that emotion-focussed coping i s appropriate when demands are 122 less amenable to change. For example, a c h i l d ' s turbulent behaviour i s predictive of more parental coping by seeking s o c i a l support, including t a l k i n g to someone to f i n d out more about the si t u a t i o n , and getting professional help. This turbulent behaviour, then, appears to be the more d i f f i c u l t behaviour for parents to understand and to manage. This f i n d i n g corresponds to that of Rosen et a l . (1989) i n which turbulent behaviours were ranked by parents among the highest that were "hard to take". The c h i l d ' s turbulence and i r r e s p o n s i b i l i t y are s i g n i f i c a n t l y related to a parent's coping by accepting r e s p o n s i b i l i t y . Only turbulence, however, i s found to be a s i g n i f i c a n t predictor because of the i n t e r c o r r e l a t i o n (r = .75) between these behaviours. I t i s i n t r i g u i n g to consider the meaning of these s i g n i f i c a n t relationships. Accepting r e s p o n s i b i l i t y by the parent includes coping by s e l f - c r i t i c i s m , by apologizing or doing something to improve a rel a t i o n s h i p , and by resolving that things would be d i f f e r e n t next time. One wonders whether parents f e e l somehow they have f a i l e d , perhaps by not being consistent enough or tough enough, or not setting firm enough guidelines. One wonders i f t h i s could be an expression of the adverse e f f e c t s of family therapy referred to by Terkelsen (1983), or the iatrogentic damage to family members reported by Lefley (1990). A l t e r n a t i v e l y , the l i n k between the ch i l d ' s nonturbulent behaviour and parents' feel i n g s of r e s p o n s i b i l i t y might be confounded by t h e i r j o i n t r e l a t i o n s h i p with problems i n d a i l y functioning. 123 Parent's acceptance of r e s p o n s i b i l i t y may be directed toward these d a i l y hassles. These relationships do appear to v e r i f y the extension of an active parental r o l e beyond the ch i l d r e a r i n g years referred to i n the l i t e r a t u r e (e.g., Ascher-Svanum & Sobel, 1989; Hatfie l d , 1987b; Ireys & Burr, 1984) . Other i l l n e s s c h a r a c t e r i s t i c s that independently are pr e d i c t i v e of coping are the child's s o c i a b i l i t y , and time since onset of the i l l n e s s . A higher l e v e l of s o c i a b i l i t y (child's) i s predictive of a parent's greater use of coping through p o s i t i v e reappraisal of the s i t u a t i o n , including such strategies as believing the family has changed i n a good way, adjusting expectations for the future, and concentration on the child' s contribution to the family. Perhaps the c h i l d ' s warmth and s o c i a l contact enables the parent to more re a d i l y construct the s i t u a t i o n within a p o s i t i v e frame. Interestingly, the l a s t item mentioned encouraged some volunteered comments that ranged from "You've got to be kidding" and "(my daughter's contribution is) my granddaughter" to the poignant "I thought that i f he had died, there would be an emptiness in.my world." This l a t t e r comment reinforces the report by Greenberg, Greenley, and Benedict (1994) that persons with mental i l l n e s s contribute p o s i t i v e l y to t h e i r families by providing companionship, l i s t e n i n g to problems, and providing news about family and friends. Time since onset of the i l l n e s s i s the strongest predictor of parental use of distance coping, being 124 p o s i t i v e l y related to such strategies as, ignoring the s i t u a t i o n , refusing to get too serious about i t , and t r y i n g to look on the bright side of things. Spaniol (1987) reports that parents learn by t r i a l and error what works to manage t h e i r situations, and notes that distancing i s a coping s k i l l parents u t i l i z e . Perhaps the p a r t i c i p a n t s of t h i s study have learned over time that distancing techniques are ways of coping they f i n d most appropriate. Folkman, Lazarus, Pimley, and Novacek, (1987) i n comparing age differences i n coping, also found older p a r t i c i p a n t s to use more distancing strategies i n response to t h e i r appraisals of t h e i r situations as less changeable. I t makes one suspect that a variety of l i f e experience may lead one to the recognition that some situations are either not amenable to change or too d i f f i c u l t to change; i n such circumstances, distancing, and other emotion-focussed strategies, might be the most adaptive forms of coping (Lazarus & Folkman, 1984). Participants write of caring for themselves by keeping busy p h y s i c a l l y and mentally. One mother mentioned that she f i n a l l y r e a l i z e d she could not change her son but she could change herself; another commented that at f i r s t she joined the Schizophrenia Society to learn about the i l l n e s s and to share her experience with others, but now p a r t i c i p a t e s i n other a c t i v i t i e s that maintain her own mental health. These comments f i t with the findings of H a t f i e l d (1981) that of family members caring for the mentally i l l , those who were older tended to have greater need f u l f i l l m e n t i n terms of an 125 adequate personal l i f e with ego-involving tasks. Parental s e l f - c a r e may be a way i n which the parent distances her or him-self from the i l l n e s s and i t s impact, and works with what i s con t r o l l a b l e . Both i n t h i s study and i n the c l i n i c a l l i t e r a t u r e , parents report that over time, they manage to come to a r e a l i s t i c acceptance of the i l l n e s s ; they r e a l i z e the l i m i t a t i o n s i t has for t h e i r offspring and they adjust t h e i r expectations accordingly. One parent reported that, "As h i s mother, I wanted him 'well' again. Now I accept the patient, my son, the way he i s and enjoy what I can and empathize with him." Other comments, as well, speak to a " r e a l i z a t i o n that the outcome of the i l l n e s s may not be to my l i k i n g " and "an acceptance of a 'new' i l l person." Contrary to my expectations, however, there was no s i g n i f i c a n t relationship between time since onset of the i l l n e s s and a parent's secondary appraisal of the s i t u a t i o n as one that must be accepted. There appears, then, to be an important difference between acceptance of the i l l n e s s with i t s l i m i t a t i o n s for t h e i r c h i l d and acceptance of the s i t u a t i o n i n i t s t o t a l i t y , as captured i n t h i s study by parents' primary appraisals, for example, by a lack of information, relationships within the family, and so f o r t h . In sum, i l l n e s s c h a r a c t e r i s t i c s ( l i f e s k i l l s ) are pr e d i c t i v e of a l l but one of the primary appraisals, no secondary appraisals, and three separate ways of coping. Nonturbulence and r e s p o n s i b i l i t y are the c h i l d ' s l i f e s k i l l s with the strongest and most frequent influence upon parental 126 appraisals and coping, a finding that i s i n accord with previous studies i n which offensive and uncooperative behaviour was p o s i t i v e l y related to higher l e v e l s of family d i s t r e s s . Time since onset of the i l l n e s s i s the strongest predictor of distance coping. In accord with my p r i o r expectations, lower levels of l i f e s k i l l s are associated with emotion-focussed rather that problem-focussed strategies. Question 2 Question 2 considered the predictive power of demographic c h a r a c t e r i s t i c s (Figure E4). This study shows that parent's age, sex, and marital status are s i g n i f i c a n t predictors of primary appraisals and coping, but not of secondary appraisals. Age of the parent i s negatively r e l a t e d to a primary appraisal of problems i n d a i l y functioning, problems such as concern over one's own physical, mental, and f i n a n c i a l health, and d i f f i c u l t y keeping up with work and home chores. Perhaps t h i s i s because l a t e r i n l i f e , there tends to be a reduction i n family, work, and f i n a n c i a l hassles (Folkman et a l . , 1987). In addition, i t i s important to remember that age of parent and time since onset of the i l l n e s s are highly correlated (r = .60). The gradual acceptance of the ch i l d ' s i l l n e s s and the parental attention to t h e i r own care that was mentioned above may bode well for the parents' concerns over t h e i r own mental and physical condition. Comments volunteered by parents i n t h i s study speak to t h e i r gradual adjustment to t h i s i l l n e s s with i t s uncertainties and disruption, while 127 they continue to experience a profound sadness at the emptiness i n the c h i l d ' s l i f e . Parent's age i s negatively predictive of coping by seeking s o c i a l support or by using escape-avoidance strategies, such as wishing the s i t u a t i o n would go away, fantasizing, or t r y i n g to f e e l better by eating, drinking, and so f o r t h . Less seeking of s o c i a l support by older persons was also noted by Folkman et a l . (1987) i n t h e i r study of age differences i n coping. Age related differences must be interpreted cautiously because the differences noted may be cohort related (Folkman et a l . , 1987). I would suggest, however, that i n t h i s study, the common factors of the i l l n e s s and the parental role, along with the time rel a t e d adjustment of family members that has been noted i n the empirical l i t e r a t u r e , would take precedence over h i s t o r i c a l differences i n cohorts. Contrary to my expectations, age of parent was not p o s i t i v e l y related to a primary appraisal of worry about the future. Although the age range of the parents encompassed four decades, worry about what would happen to family members when the parent was gone appeared to be as great a concern to the younger parents as to those whose deaths would normatively be considered to be "on time" (see Hagestad & Neugarten, 1985). This high l e v e l of concern could be attributed to the salience of the parental r o l e with i t s norms of protection and support. Although sex of the parent was s i g n i f i c a n t l y associated with most of the primary appraisals and forms of coping 128 (with mothers' higher scores indicating greater concern and more frequent use of coping strategies), when multiple, i n t e r r e l a t e d variables were entered into the regression equations, sex of parent emerged as a s i g n i f i c a n t predictor of only two primary appraisals and one coping strategy. Mothers were shown to have s i g n i f i c a n t l y higher concerns over r e l a t i o n s with the community and worry about the future, and to use posi t i v e reappraisal as a coping strategy more often than fathers. Lazarus and Folkman (1984) suggest that one's appraisals are influenced by what i s important to an i n d i v i d u a l ; Pearlin (1991) emphasizes the importance of s o c i a l r o l e s . Women's s o c i a l i z a t i o n , and p a r t i c u l a r l y the mother r o l e , require a responsiveness to others' needs (Gore & Colten, 1991) . Caregiving to mentally i l l adults extends t h i s c u l t u r a l l y prescribed nurturant r o l e beyond the c h i l d - rearing years (Ascher-Svanum & Sobel, 1989). One mother commented that she was glad her daughter l i v e d with her because she was able to t a l k her out of her delusional state; another mentioned she was attempting to decrease her son's dependency upon her because she was worried what would happen when she was gone; yet another wrote that u n t i l her husband r e t i r e d , she f e l t that coping with her son's i l l n e s s was mainly her r e s p o n s i b i l i t y . I t can be seen that parents, and p a r t i c u l a r l y mothers, continue to play an active parenting r o l e with t h e i r adult offspring and are concerned who i s going to provide for the child's needs when the parent i s gone. 129 Mothers more than fathers coped by p o s i t i v e reappraisal; they used such techniques as prayer, changing something about themselves, believing they have benefitted from the experience, and concentrating on the c h i l d ' s contributions to the family. One mother volunteered that she learned to admire the courage of persons with schizophrenia, saying i t strengthened her love and admiration for her daughter. Parent's marital status was predictive only of coping strategies. Being married or remarried (as opposed to separated, divorced, widowed and never married) predicted less use of f i v e coping strategies: confrontation, s e l f - control, seeking s o c i a l support, planful problem solving, and p o s i t i v e reappraisal. I t i s i n t e r e s t i n g to speculate on the reason for t h i s finding. I t does not appear that a married parent has less with which to cope, for there i s no r e l a t i o n s h i p between marital status and primary appraisals of what i s at stake. Could i t be that a married parent r e l i e s on a spouse for some of the coping that i s needed to manage the s i t u a t i o n ; or perhaps through day-to-day spousal i n t e r a c t i o n , married parents gain from one another s o c i a l support and/or problem solving opportunities? An intimation of t h i s mutual help i s suggested i n written comments by the p a r t i c i p a n t s who mention that with t h e i r spouse, "we t a l k things over and make decisions together" and "we're a team, we t a l k the problems out together". Certainly, i n response to the inquiry into overt family influence, spouses were often mentioned as being supportive as well as being 130 i n f l u e n t i a l i n changing a participants views or ways of coping. Single parents are without t h i s p o t e n t i a l coping assistance. This interpretation would f i t with observations that a marital disruption i s not only the d i s s o l u t i o n of a dyadic r e l a t i o n s h i p but also the loss of a s o c i a l support system (Lin & Westcott, 1991), and I would suggest i t also may be the loss of a potential management partner. My other expectations regarding the p r e d i c t i v e power of demographics were not f u l f i l l e d . In accord with the l i t e r a t u r e , I had expected that daughters would have higher l i f e s k i l l s scores, p a r t i c u l a r l y higher l e v e l s of nonturbulent behaviour and r e s p o n s i b i l i t y (e.g., Seeman, 1986) ; on the contrary, daughters' scores were s l i g h t l y but not s i g n i f i c a n t l y lower than sons' scores. Considering that family support of females i s more l i k e l y to be spousal (Atkinson, 1986), daughters with parental support i n t h i s study may be those whose severity of symptoms caused the d i s s o l u t i o n of t h e i r marriage and t h e i r subsequent return to parental care. The data show that daughters were more l i k e l y to have been married. The daughters with schizophrenia i n t h i s study, therefore, may not be representative of most women with schizophrenia. Another u n f u l f i l l e d expectation was that parental co- residence with c h i l d was not s i g n i f i c a n t l y related to primary appraisals as I had expected; i t was not associated with more concern over relationships within the family or problems with d a i l y functioning. The l i t e r a t u r e was equivocal on t h i s issue. Arey and Warheit's (1980) study of 131 family support of persons with mental i l l n e s s found higher l e v e l s of anxiety and depression i n family members when there was co-residence; a l t e r n a t i v e l y Carpentier et a l . (1992) found that psychological di s t r e s s i n family members did not d i f f e r s i g n i f i c a n t l y whether the patient l i v e d at home or not. Falloon et a l . (1984), however, suggest that o f f s p r i n g with schizophrenia may be excluded from the household following disruptive episodes. In t h i s study, the lack of an association between co-residence and problems i n d a i l y functioning may have been found because dis r u p t i v e o f f s p r i n g had already been asked to leave the family residence. Those adult children remaining i n the household may have been those who were more amenable. Question .3 Question three inquired whether in d i v i d u a l and family resources would s i g n i f i c a n t l y predict appraisals and coping (see Figure E5). Mastery, self-esteem, community support, and cohesion were a l l s i g n i f i c a n t predictors of primary appraisals. Interestingly, mothers and fathers did not d i f f e r s i g n i f i c a n t l y on any of the resource measures. Higher lev e l s of mastery predicted less concern over r e l a t i o n s with the community, relations within the family, and problems i n d a i l y functioning; a view of the s i t u a t i o n as "one that could be changed" (as had been expected); and less use of escape-avoidance coping strategies. Mastery concerns the extent to which people regard t h e i r l i f e chances as being under t h e i r own control as opposed to being f a t a l i s t i c a l l y determined (Pearlin & Schooler, 1978) . High 132 l e v e l s of mastery include strong b e l i e f s , such as "what happens i n the future mostly depends on me" and "there are things I can do to change many of the important things i n my l i f e . " I t i s reasonable to assume that these b e l i e f s would enable parents to view aspects of t h e i r s i t u a t i o n s as manageable and to r e l y less on coping by using avoidance strategies, such as wishing the s i t u a t i o n away. Of i n t e r e s t i s the p o s i t i v e c o r r e l a t i o n found between the nonturbulent behaviour of the c h i l d and the parent's l e v e l of mastery (r = .32). The most probable d i r e c t i o n of influence would be from behaviour to mastery, that i s , the c h i l d ' s offensive and reckless behaviour would aff e c t the parental b e l i e f s of c o n t r o l l a b i l i t y . Higher lev e l s of self-esteem predicted less concern over problems i n d a i l y functioning and less worry about the future; i t predicted a stronger perception of the s i t u a t i o n as one that had to be accepted (contrary to my p r i o r expectations). Self-esteem refers to p o s i t i v e b e l i e f s about oneself, such as "I f e e l I have a number of good q u a l i t i e s " and " I am able to do things as well as most people" (Pearlin & Schooler, 1978). I t suggests a c e r t a i n contentment with the s e l f , a contentment that somehow enables one to accept the si t u a t i o n . As previously noted, self-esteem i s correlated with mastery (r = . 4 6 ) , but unlike mastery, i t i s associated with the s o c i a b i l i t y of the son or daughter (r = .27). Again a reasonable assumption would be for the d i r e c t i o n of influence to flow from the c h i l d ' s behaviour to parental self-esteem. 133 Higher lev e l s of the family resource, cohesion, predicted less concern over r e l a t i o n s within the family (in accordance with e a r l i e r expectations). Parents who perceive t h e i r f a m i l i e s to have greater emotional bonding express fewer worries over how the s i t u a t i o n i s a f f e c t i n g the other child r e n and over a lack of time and energy for the family. Cohesion i s weakly associated with both esteem (r = .29) and mastery (r = .25). Like mastery, i t i s associated with the nonturbulent behaviour of the c h i l d (r = .28). I t i s apparent from the responses to the inquiry into family influence that parents' perceptions of the cohesiveness of t h e i r f amilies have been affected both negatively and p o s i t i v e l y by the impact of the i l l n e s s . Parents write that the c r i t i c i s m of family members and t h e i r r e f u s a l to accept the i l l n e s s has distanced them from one another; parents also indicate that the support and encouragement given by family members makes them f e e l loved. This acknowledgement highlights the issue of r e c i p r o c a l influence. One wonders about the d i r e c t i o n of influence between l e v e l s of resources and r e l a t i o n s within the family. Do resources f a c i l i t a t e family functioning or does disruption within the family deplete resources? The cross- se c t i o n a l design of t h i s study precludes t h i s determination. I t would seem, however, that by c o n t r o l l i n g for time since the onset of the i l l n e s s , t h i s study might a r r i v e at a more accurate understanding of the interaction. Data show, however, that the associations between time since onset and other relevant variables were ne g l i g i b l e . Correlations with 134 time since onset were as follows: mastery (r = .01), esteem (r = .10), cohesion (r = .05), re l a t i o n s within the family (r = -.05). The two s o c i a l support resources, expressive and community support, behaved d i f f e r e n t l y as predictors. Community support was s i g n i f i c a n t l y related to a primary appraisal of a lack of information and problems i n communication, with higher levels of support pr e d i c t i n g less of t h i s concern. The community support measure assessed the a v a i l a b i l i t y of organized support and information group a c t i v i t y ; i t i s g r a t i f y i n g that t h i s information access appeared to predict improved communication. A l t e r n a t i v e l y , expressive support was related to two d i f f e r e n t coping strategies, with greater a v a i l a b i l i t y of support p r e d i c t i n g greater use of coping through seeking s o c i a l support and p l a n f u l problem-solving. The l i n k between s o c i a l support and problem-solving can be noticed i n the narratives of the parents. With various family members they speak of t a l k i n g things over, accepting advice, making decisions together, and acting on suggestions regarding al t e r n a t i v e housing, r e s p i t e care, and day programs for t h e i r son or daughter. They also mention sharing and learning from the experiences of parents i n l i k e - s i t u a t i o n s . Incidentally, self-esteem and the a v a i l a b i l i t y of expressive support were correlated (r = .30). This relationship may validate the assertion of P e a r l i n et a l . (1981) that s o c i a l support bolsters s e l f - esteem; a l t e r n a t i v e l y i t may show that indi v i d u a l s with higher self-esteem seek more emotional support or that such 135 support i s volunteered more often to individ u a l s with high self-esteem (Dunkel-Schetter, Folkman, & Lazarus, 1987). Overt family influence was allocated to the resource category for want of a more appropriate designation. Interestingly, parents' perceptions that a family member has done or said something to change the way they view or cope with t h e i r s i t u a t i o n predicts a higher l e v e l of worry about the future. This family influence appears to be not always reassuring, a finding that corresponds to the observations of G o t t l i e b and Wagner (1991) mentioned previously. Many respondents reported that family members helped them to a r e a l i s t i c acceptance of the i l l n e s s ; t h i s may have been accompanied by r e a l i s t i c a l l y decreased expectations for the c h i l d ' s future independence. Other parents mention being urged to make alternative housing arrangements for the c h i l d ; yet others report receiving c r i t i c i s m , lack of support, and a discounting of the i l l n e s s by family members. One mother mentioned her other children have made i t c l e a r they w i l l not provide her l e v e l of support for the s i b l i n g when the parent i s gone. These accounts are s i m i l a r to those of other studies i n which there was found to be an ongoing collaboration of s i b l i n g s with other family members (see Gerace et a l . , 1993) and in which parti c i p a n t s expressed concerns over the future independence and f i n a n c i a l support of t h e i r s i b l i n g (see Landeen et a l , 1992) . Worry about the future may be a response to such influence. These findings seem to indicate that through overt family influence, family members negotiate new 136 " d e f i n i t i o n s of the s i t u a t i o n " (Menaghan, 1983). Such negotiations may speak to the issue raised by Patterson and Garwick (1994) of the need for studies on how fa m i l i e s share and construct meanings about i l l n e s s . Both money and knowledge are resources that can a f f e c t one's options for coping (Folkman et a l . , 1991). As noted above, there was a wide range of both income and education. The data showed that many parents assisted t h e i r sons and daughters f i n a n c i a l l y ; one mother shared her sense of hurt that she was unable to help her son i n t h i s way. Just over 50% of respondents agreed to some degree that the i l l n e s s has created f i n a n c i a l problems for the family. Yet su r p r i s i n g l y , neither family income nor parent's l e v e l of education were s i g n i f i c a n t l y related to any of the appraisals or to coping. One wonders i f t h i s f i n d i n g would hold were there not the existing system of health and s o c i a l services i n B r i t i s h Columbia, a system that has been found to of higher qu a l i t y than that of any of the American states (Torrey, Bigelow, & Sladen-Dew, 1993), a l b e i t less than some might wish. In sum, there are six individual and family resources that are pr e d i c t i v e of appraisals and coping: mastery, s e l f - esteem, expressive support, community support, cohesion, and overt family influence. Mastery and self-esteem each predict multiple primary appraisals and one secondary appraisal. The other resources are more s e l e c t i v e i n t h e i r influence, predicting either primary appraisals or coping. Interrelationships were noted among the resource variables 137 and between parental resources and some l i f e s k i l l behaviours of the c h i l d . Question 4 Question four inquired into s i g n i f i c a n t r e l a t i o n s h i p s among primary appraisals, secondary appraisals, and coping (see Figure E6). Secondary appraisals, more often than primary appraisals, were demonstrated to be s i g n i f i c a n t predictors of coping. There were fewer l i n k s between secondary appraisals and coping, however, than theory would lead us to expect. Individually, the primary appraisal, worry about the future, d i r e c t l y predicted greater use of p l a n f u l problem- solving, including such strategies as concentrating on what to do next, reading books or a r t i c l e s to learn more about the s i t u a t i o n , and making some arrangements for the c h i l d ' s future. This r e l a t i o n s h i p i s p a r t i c u l a r l y understandable i n the context of the above discussion of family influence. I t indicates that whereas these data r e f l e c t the i n t r a f a m i l i a l c o n f l i c t found i n other studies (Creer & Wing, 1974; Falloon, Hardesty, & McGill, 1985), they show that i n t r a f a m i l i a l influence, though not always reassuring, can move parents to action. The primary appraisal, lack of information, i n i t i a t e s a process that could be described as a cognitive or information chain. A lack of information predicts a secondary appraisal of needing to know more, which i n turn predicts coping by pl a n f u l problem-solving and p o s i t i v e reappraisal. Positive reappraisal includes b e l i e v i n g 138 oneself or one's family has benefitted from the experience, adjusting expectations for the future, and concentrating on the c h i l d ' s contributions to the family. I t ' s i n t e r e s t i n g to consider the l i n k between an appraisal of needing to know more, and coping through p o s i t i v e reappraisal. I t may r e f l e c t the observation by Lazarus and Folkman (1984) that ambiguity i n situations can be used to reduce threat by allowing d i f f e r e n t interpretations of a predicament. Folkman, Lazarus, Dunkel-Schetter, et a l . (1986) found that i n encounters appraised as requiring more information, subjects also used planful problem-solving, i n addition to seeking more s o c i a l support, and using more s e l f - c o n t r o l . Cumulatively, primary appraisals predicted a secondary appraisal of having to hold back from what one wants to do. This secondary appraisal predicted coping by distancing and accepting r e s p o n s i b i l i t y . Distancing techniques, such as refusing to get too serious about the s i t u a t i o n , appear to be very d i f f e r e n t from accepting r e s p o n s i b i l i t y by doing something to improve a relationship or promising oneself things would be d i f f e r e n t next time. The age of the parent could influence his/her choice of coping strategy. Age of parent has been seen to be p o s i t i v e l y related to time since the onset of the i l l n e s s (and i n d i r e c t l y to distance coping), and negatively related to problems i n d a i l y functioning. Older parents, therefore, might more r e a d i l y choose distance coping whereas younger parents might accept r e s p o n s i b i l i t y for t h e i r d a i l y hassles. Folkman, Lazarus, Dunkel-Schetter, et a l . (1986) also found subjects to use a 139 v a r i e t y of techniques i n response to an appraisal of having to hold back; they used more confrontational coping, s e l f - control, and escape-avoidance. The data i n t h i s study also pointed to a s i g n i f i c a n t relationship between a secondary appraisal of having to hold back and escape-avoidance coping; when entered simultaneously into the equation with the cumulative primary appraisal measure, however, the l a t t e r was i d e n t i f i e d as the more s i g n i f i c a n t predictor. Both secondary appraisals of the s i t u a t i o n as one that could be changed and as one that had to be accepted predicted coping through posi t i v e reappraisal, which according to Lazarus and Folkman (1984), i s an emotion- focussed form of coping. My p r i o r expectations, therefore, were not completely supported. Theory suggests, and I had expected, that seeing the situ a t i o n as one that could be changed would predict some form of problem-focussed coping. Folkman, Lazarus, Dunkel-Schetter, et a l . (1986) also found p o s i t i v e reappraisal, along with confrontational coping and pl a n f u l problem-solving, to be used in encounters appraised as changeable; they found that subjects used distancing and escape-avoidance i n situations appraised as having to be accepted. Interestingly, Carver, Schier, and Weintraub (1989) suggest that po s i t i v e reappraisal (which they c a l l p o s i t i v e r e i n t e r p r e t a t i o n and growth) i s not lim i t e d to managing d i s t r e s s (therefore i s not only emotion-focussed) but should enable the person to continue problem-focussed coping actions. Seltzer, Greenberg, and Krauss (1995) 140 consider i t a problem-focussed form of coping. One might conclude that i t s status i s i n question. In accord with t h e o r e t i c a l projections, viewing the s i t u a t i o n as changeable had a s i g n i f i c a n t negative c o r r e l a t i o n with escape-avoidance coping (r = -.22) but because of i t s i n t e r c o r r e l a t i o n with other variables, p a r t i c u l a r l y mastery, i t was not found i n the regression equation to be a s i g n i f i c a n t predictor of t h i s form of coping. Overall, the l i n k s between appraisals and coping were fewer than theory would suggest. Folkman, Lazarus, Dunkel- Schetter, et a l . (1986) had found, each of the assessed stakes (primary appraisals) and coping options (secondary appraisals) to have s i g n i f i c a n t coping correlates. In t h e i r analyses, however, the procedure used was a multivariate analysis of variance for repeated measures, to compare coping scores i n several encounters for each p a r t i c u l a r stake and each coping option. In t h i s present study, the stakes (primary appraisals) and coping options (secondary appraisals) were regressed on ways of coping simultaneously with other variables (e.g., chil d ' s l i f e s k i l l s , demographics, resources). These data show two of the primary appraisals independently to have p r e d i c t i v e r e l a t i o n s h i p s , one with a secondary appraisal and one with coping. Cumulatively, primary appraisals predict one secondary appraisal and one form of coping. Each secondary appraisal has a predictive relationship with one or more forms of coping. I t i s important to r e i t e r a t e that many 141 r e l a t i o n s h i p s between the relevant variables l o s t s i g n i f i c a n c e i n the standard multiple regression procedure because of the intercorrelations of the independent variab l e s . Summary of Findings To summarize these findings, some general patterns can be noted i n the presence and absence of s i g n i f i c a n t p r e d i c t i v e relationships. Whereas cumulatively, a c h i l d ' s l i f e s k i l l s are predictive of a parent's primary appraisals, r e s p o n s i b i l i t y and nonturbulence appear to be the more i n f l u e n t i a l behaviours. L i f e s k i l l s , however, are notably absent as predictors of the primary appraisal, worry about the future. Of the demographic variables, age and sex of parent predict both primary appraisals and coping, whereas the p r e d i c t i v e power of parent's marital status i s directed only towards coping strategies. Mastery and self-esteem are the resources that were found to be p r e d i c t i v e of several primary and secondary appraisals, retaining t h e i r s i g n i f i c a n c e i n equations with other variables. As well, mastery predicted one form of coping. Of the secondary appraisals, only viewing the s i t u a t i o n as one i n which you had to hold back was s i g n i f i c a n t l y i n t e r r e l a t e d with demographics, resources, l i f e s k i l l s , and primary appraisals; the other secondary appraisals had fewer associations. They each were predictive of at l e a s t one form of coping. In addition to the variables that were i d e n t i f i e d as predictors, i t i s important to attend to the s i g n i f i c a n t relationships noted i n the c o r r e l a t i o n matrix, 142 the s i g n i f i c a n c e of which diminished i n the regression equations because of the m u l t i c o l l i n e a r i t y of the v a r i a b l e s . Previously i t was mentioned that no c a u s a l i t y can be a t t r i b u t e d to these predictive relationships, and above there was a b r i e f discussion of d i r e c t i o n of influence. Yet again, caution i s advised i n the interpretation of the data. For example, i t was shown that higher l e v e l s of mastery predict less concern over relations within the family and problems i n d a i l y functioning. I t also could be said that fewer problems and concerns are related to a greater perception of mastery. Coping theory acknowledges a "network of r e c i p r o c a l e f f e c t s " (Pearlin & Schooler, 1978, p. 18) that requires longitudinal studies to disentangle. I choose to interpret the predictive relationships according to the t h e o r e t i c a l model of coping reviewed above i n which demands and resources are considered important influences upon appraisals and coping, while at the same time I remain aware that coping i s an ongoing process of r e c i p r o c a l influence and reappraisal. There appears to be a reasonable f i t between the model and the data gathered i n t h i s study. The data show that i n some instances, more than one-third of the v a r i a b i l i t y i n appraisals and coping was attributed to demands and resources ( i l l n e s s c h a r a c t e r i s t i c s , demographics, i n d i v i d u a l and family l e v e l resources). The amounts of v a r i a b i l i t y explained range from a low of 5% to a high of 46%; of the other percentages, 5 were between 11% and 19%, 5 ranged between 20% and 29%, 4 were between 30% and 39%, and 1 was 143 42%. Although these amounts of variance are not comparable because they have d i f f e r e n t predictors, the majority of these percentages are acceptable amounts of variance for s o c i a l science research with i t s complex multivariate nature. In addition to amounts of v a r i a b i l i t y explained, the the multi-determinant nature of the model of stress and coping i s able to account for multiple sources of t h i s v a r i a b i l i t y . Folkman et a l . (1991, p. 242) assert that "appraisals ... are influenced by psychological, s o c i o l o g i c a l , health, and contextual variables" and that coping i s influenced by available resources ( s o c i a l , psychological, physical, i n s t i t u t i o n a l , c u l t u r a l , p o l i t i c a l ) and also i s determined by the person's appraisal of the demands of a p a r t i c u l a r s i t u a t i o n . The data show support for t h i s multi-determinant model. With simultaneous entry into multiple regression equations, the interrelationships among the independent variables often resulted i n t h e i r loss of s i g n i f i c a n c e with the dependent variable of interest. P a r t i c u l a r l y , the l i n k s between secondary appraisals and coping, which had been s i g n i f i c a n t , were eclipsed by other stronger r e l a t i o n s h i p s . Whereas secondary appraisals were s i g n i f i c a n t l y associated with a l l but one forms of coping, they were i d e n t i f i e d as p r e d i c t i v e of only four of the eight strategies. I l l n e s s c h a r a c t e r i s t i c s , demographics ( p a r t i c u l a r l y marital status), and resources were a l l i d e n t i f i e d as other s i g n i f i c a n t predictors of coping strategies. 144 Much of the v a r i a b i l i t y , however, was not explained. Obviously, there were many i n f l u e n t i a l factors t h i s study could not incorporate. An in-depth q u a l i t a t i v e inquiry with probing questions might help solve t h i s puzzle of unexplained variance. Limitations and Strengths Limitations This study dealt with a complex coping process of multiple concepts and reciprocal influences, yet i n i t s cross-sectional design i s a mere snapshot of t h i s ongoing process; as such, i t i s unable to f u l l y capture i t s richness or understand i t s complexity. Folkman, Lazarus, Dunkel- Schetter, et a l . (1986) caution that whereas i t i s tempting to i n f e r , as theory suggest, there i s a temporal ordering i n the coping process, a cross-sectional study design precludes such an assumption. Additionally, while attempting to increase our understanding of the correlates of s i t u a t i o n a l appraisals and coping strategies, t h i s study i s l i m i t e d i n the number of variables i t considers, and i s unable to investigate a l l of the interactions among them. Many important factors and interrelationships have been necessarily excluded. A l i m i t a t i o n of t h i s study i s i t s s e l f - s e l e c t e d nature. Although a s p e c i f i c e f f o r t was made to include p a r t i c i p a n t s of d i f f e r e n t cultures, i t was r e s t r i c t e d to those parents who could read and write English. The majority of parents were contacted though support groups or through t h e i r associations with mental health units. Those mothers and 145 fathers who responded to the request for pa r t i c i p a n t s might be an unrepresentative group of parents who have an adult c h i l d with schizophrenia. Inferences from the sample s t a t i s t i c s to the population therefore are not possible or are tenuous at best. The unequal number of sons (111) and daughters (30) requires an attempt at explanation. Schizophrenia a f f e c t s males and females with equal frequency but males are more l i k e l y to be younger and single at f i r s t diagnosis (Cetingok, Chu, & Park, 1990). As mentioned above, the daughters i n t h i s study were much more l i k e l y than sons to have been married. When a c h i l d marries, the parent-child r o l e r e l a t i o n s h i p changes (Greene & Boxer, 198 6). S o c i a l expectations are for the parent to re l i n q u i s h control (Aldous, 1978); the spousal unit becomes the primary source of mutual support. It would be l o g i c a l to venture that more daughters with schizophrenia would be l i v i n g with t h e i r spouses and no longer considered the primary r e s p o n s i b i l i t y of parents. The unequal numbers of mothers (109) and fathers (32) i n t h i s inquiry i s common to studies of families of the mentally i l l (see Arey & Warheit, 1980; Tausig et a l . , 1992) . As noted above, the care of mentally i l l o f f s p r i n g i s often regarded by mothers as a natural extension of t h e i r parental r o l e . The series of multiple regressions necessitated by the multiple dependent variables increases the l i a b i l i t y of committing a Type I error, that i s , relationships may be 146 shown to be s i g n i f i c a n t merely by chance. One might decide to lower the significance l e v e l to avoid t h i s problem. Because of the exploratory nature of t h i s study, however, t h i s danger must be balanced against the problem presented by a Type II error i n which important re l a t i o n s h i p s might be disregarded. A significance l e v e l of p_ <, .05 was retained. As mentioned above, not a l l of the.variables, independently and/or i n combination, met the assumptions of multiple regression of normality, l i n e a r i t y , and homoscedasticity. The analyses, therefore, are weakened. Again caution i s advised i n the interpretation of the study r e s u l t s . The study attempted to use measures with established r e l i a b i l i t y and v a l i d i t y . There i s the issue, however, of operationalization of the constructs. There was an explanation given above regarding the choice of resources to be assessed; i t was based upon those resources that were t h e o r e t i c a l l y and empirically considered to be relevant to the coping process. Following Folkman, Lazarus, Dunkel- Schetter, et a l . (1986), secondary appraisals were assessed with singe items. One can not be assured that the p a r t i c i p a n t s had a similar understanding of the phrasing of the appraisal questions. For example, when they were asked indicate t h e i r l e v e l of agreement with the statement "my s i t u a t i o n i s one that I have to accept", did they have a shared understanding of "situation?" Although my ins t r u c t i o n s had included the explanation that i t was "your s i t u a t i o n , as you have described i t above," they may have 147 been considering d i f f e r e n t aspects of t h i s s i t u a t i o n when they r e p l i e d to the question. The operationalization of primary appraisals, as well, needs to be addressed. Folkman, Lazarus, Dunkel-Schetter, et a l . (1986) considered primary appraisals to be "what was at stake i n a s t r e s s f u l encounter". They assessed s i x factors: (a) threats to self-esteem (6 items), (b) threats to loved one's well-being (3 items), and four single items, (c) not achieving an important goal at work, (d) harm to own health or physical well-being, (e) a s t r a i n on your f i n a n c i a l resources, and (f) losing respect for someone else. I could f i n d no mention of i n t e r r e l a t i o n s h i p s among these items, although these relationships can be seen to be possible. In my study, I wished to assess what was at stake i n the s t r e s s f u l s i t u a t i o n of having a son or daughter with schizophrenia. I t seemed l o g i c a l to assess the ways i n which the i l l n e s s had affected d i f f e r e n t aspects of t h e i r l i v e s , what Pearl i n (1989) would c a l l secondary stressors. The scale chosen assessed f i v e factors, each with multiple items: (a) lack of information, (b) r e l a t i o n s h i p with the community, (c) relationships within the family, (d) problems i n d a i l y functioning, and (e) worry about the future. These f i v e factors were inter r e l a t e d . The data show that f o r most parents there were multiple stakes within t h e i r s i t u a t i o n s . While t h i s scale may accurately represent parents' s i t u a t i o n s , one wonders i f i t i s true to the concept of primary appraisal as i t i s conceived i n Lazarus and Folkman's (1984) model of coping. 148 Self-care for r e l a t i v e s i s an important p r i n c i p l e advocated by support systems for family members coping with schizophrenia (see Alexander, 1991). Parents are advised to take very good care of themselves emotionally and p h y s i c a l l y i n order that they might p a r t i c i p a t e f u l l y i n t h e i r s o c i a l r o l e s and f i n d enjoyment i n l i f e . The Ways of Coping Scale (Lazarus & Folkman, 1984) did not appear to be have a category that adequately captured t h i s aspect of coping. These sorts of strategies, such as exercise, hobbies, and a c t i v i t i e s , have been categorized as " s e l f - d i s t r a c t i o n " (Carver et a l . , 1993), "disengagement" (Carver et a l . , 1989), and "avoidance" (Amirkhan, 1994). None of these categories appear to capture the posi t i v e , active nature of these coping e f f o r t s , that e s s e n t i a l l y bolster or replenish one's personal resources. This deficiency may have r e s t r i c t e d the p a r t i c i p a n t s 7 coping choices. There i s always a concern i n a questionnaire whether the responses accurately r e f l e c t how the p a r t i c i p a n t defines the s i t u a t i o n . For example, one father indicated l i t t l e concern over society's reactions to the i l l n e s s , to the family, or to the c h i l d with schizophrenia; yet he volunteered that the i l l n e s s of his c h i l d i s kept private "so that friends and r e l a t i v e s w i l l not look down on her." This man's e t h n i c i t y brought to the fore China's stigma against mental i l l n e s s . Again i t seems probable that an interview process with probing questions would have yielded valuable information; the father may have been able to c l a r i f y the seeming incongruity of his responses. 149 Strengths This study adopts some of the recommendations noted previously for research i n the area of schizophrenia and the family, namely, that i t should have a t h e o r e t i c a l grounding, address the v a r i a b i l i t y i n family experience with the i l l n e s s , attend to famili e s ' coping strengths, and u t i l i z e measures with established r e l i a b i l i t y and v a l i d i t y . This inquiry i s t h e o r e t i c a l l y grounded i n theory on i n d i v i d u a l stress and coping enriched with the attention to family context that i s afforded by family stress theory. I t attends to the heterogeneity of both family and i l l n e s s ; i t s cent r a l premise i s that v a r i a b i l i t y i n manifestations of the i l l n e s s , i n d i v i d u a l family members, and family contexts, r e s u l t s i n d i f f e r e n t s i t u a t i o n a l appraisals and coping strategies. This study attends to po s i t i v e coping strengths, seeing both individual and family system resources as f a c i l i t a t o r s of the coping process. I t includes p o s i t i v e dimensions of parental experience, accommodating expressions of family s o l i d a r i t y and growth. The measures that were used i n i t s assessments have established r e l i a b i l i t y and v a l i d i t y , with only one i d i o s y n c r a t i c index employed, namely, the index of community support. Another strength of t h i s study i s i t s attention to le v e l s of analysis. Whereas i t does speak of "family" response to schizophrenia when reviewing the empirical l i t e r a t u r e , the study design has an e x p l i c i t focus on the in d i v i d u a l l e v e l of coping. A l l responses are those of the 150 i n d i v i d u a l , but most importantly, the in d i v i d u a l within the family context. Family context i s assessed with demographic variables and ind i v i d u a l perceptions of family strengths and influence. This study attempts to maintain a clear d i s t i n c t i o n among concepts. I t i s suggested here that because i t s focus and outcome of intere s t i s coping, t h i s study w i l l avoid the c i r c u l a r i t y that c r i t i c s have argued i s present when the independent variable i s "burden" and the dependent variable i s "well-being". An additional strength i s i t s integration of l i t e r a t u r e from three d i f f e r e n t but related f i e l d s of endeavor which can inform and enrich each other. The f i r s t area of l i t e r a t u r e drawn upon i s that of schizophrenia and the family. This l i t e r a t u r e informs us of the great d i v e r s i t y i n a l l aspects of the i l l n e s s . I t i s an area of multiple perspectives, one of which dir e c t s attention to a consideration of famili e s ' e f f o r t s to cope with the disorder. Second, family stress theory deals with the stress process i n a l l i t s complexity. I t a l e r t s us to important family system influence such as the strengths and c a p a b i l i t i e s of families, to reciprocal r e l a t i o n s h i p s among variables, and to the feedback over time which i s so important i n the developmental course of many stressors. I t situates individuals within i n f l u e n t i a l and variable family contexts. Third, individual stress and coping theory with i t s c l e a r l y defined concepts, f a c i l i t a t e s a focus on these in d i v i d u a l s , t h e i r s i t u a t i o n a l appraisals, and coping 151 responses. I t has elaborated methods of appraisal assessment, and has demonstrated relationships between these appraisals and coping strategies while keeping the concepts conceptually d i s t i n c t . What promotes an integration of these areas i s a family perspective which i s cognizant of family d i v e r s i t y , the salience of family roles, and the importance of viewing the individual within the family context. This study informs our understanding of coping i n general, v e r i f y i n g the multideterminant nature of the coping model. I t also has implications for coping within the family context, highl i g h t i n g the importance of family system variables. Implications In addition to support for the model of coping as a highly i n t e r a c t i v e multi-determinant process, the data suggest possible implications for a general understanding of coping. I t must be recognized, however, that these data come from parents who were dealing with a s i t u a t i o n that d i r e c t l y affected the whole family. These implications may not apply to coping i n situations where there i s l i t t l e involvement of other family members. The suggestions implied by these data appear to pertain to three somewhat d i f f e r e n t levels of speculation: the i n d i v i d u a l l e v e l of appraisals and coping choices, the family system l e v e l of family structure and i n t r a f a m i l i a l influence, and the s o c i e t a l l e v e l of gender s o c i a l i z a t i o n . 152 1. On the individual l e v e l , a parent's perception of the s i t u a t i o n as changeable was not pre d i c t i v e of problem- focussed coping as theory would suggest, but to increased p o s i t i v e reappraisal (an emotion-focussed strategy according to Folkman & Lazarus, 1984). This may lend support to Carver et a l . ' s (1989) contention that p o s i t i v e reappraisal enables one to undertake problem-focussed coping. 2. At the l e v e l of the family system, both family structure and family dynamics were shown to be i n f l u e n t i a l i n the coping process. Marital status was shown to be an important variable d i r e c t l y a f f e c t i n g one's coping choices, with single parents making more use of multiple forms of coping. In addition, these data show that parents' appraisals and t h e i r coping choices are modified by the d i r e c t influence of a family member. I t may be important to consider t h i s family interaction i f one's coping choices are to be understood. Walker (1985) does suggest that to understand a family's response to stress, we need an understanding of the indi v i d u a l perspectives of family members i n combination. 3. At the s o c i e t a l l e v e l , these data may speak to the ongoing discussion of gender differences i n coping. Thoits (1991) comments that the generally reported higher l e v e l s of psychological d i s t r e s s i n women have been explained i n a number of ways. In addition to women's greater expressivity, the explanations include: (a) women face more stressors i n general (e.g., Aneshensel & Pearlin, 1987), and (b) they lack coping resources, such as high self-esteem and 153 mastery, or appropriate coping responses (Pearlin & Schooler, 1978). I t also has been suggested that women experience uncontrollable s o c i a l forces, such as sexism and lim i t e d access to power that l i m i t t h e i r coping process (e.g., Banyard & Graham-Bermann, 1993). Concerning point (a), both men and women i n t h i s study faced o b j e c t i v e l y the same type of stressor. Within t h i s s i t u a t i o n , however, mothers did perceive higher levels of concern i n four of the f i v e primary appraisals, that i s , mothers perceived more to be at stake than did fathers (see table 5). Both fathers and mothers had similar levels of concern over r e l a t i o n s h i p s within the family, a finding that i s consistent with the discussion by Gore and Colten (1991) i n which they re l a t e d that women were no more reactive than men to the stresses i n family l i f e . There were aspects, however, within t h i s s t r e s s f u l s i t u a t i o n to which mothers were more reactive than fathers, p a r t i c u l a r l y to relationships with the community and worry about the future. The explanation ventured here i s that the gender difference i n levels of concern i s due to s o c i a l r o l e importance. As discussed above, women's s o c i a l i z a t i o n , and p a r t i c u l a r l y the mother rol e , generates a set of values that a l e r t s mothers to concerns that others may not recognize. There were no gender differences i n secondary appraisals. Mothers and fathers did not d i f f e r appreciably i n t h e i r assessments of c o n t r o l l a b i l i t y of the s i t u a t i o n (consistent with the findings of Thoits, 1991). 154 Regarding coping resources, data from t h i s study show no s i g n i f i c a n t differences i n psychological or s o c i a l resources (except for income) for women and men. Mothers did report lower income, but as stated above, income was not shown to be s i g n i f i c a n t l y related to any aspect of appraisal or coping. Corresponding to the findings of Thoits (1991), which showed that women used more coping strategies than men when dealing with d i s t r e s s , t h i s study found that mothers reported greater use of a l l forms of coping, both problem- focussed and emotion-focussed, except for distancing. The differences were s l i g h t but s i g n i f i c a n t . I t has been suggested that women use more strategies because the techniques they use are less e f f e c t i v e (see Pe a r l i n & Schooler, 1978); al t e r n a t i v e l y , I suggest t h e i r greater use might be seen as an appropriate response to mothers' primary appraisals of more at stake. The data from t h i s study, then, showed no gender differences i n the a v a i l a b i l i t y of coping resources, or i n any of the secondary appraisals, such as the c o n t r o l l a b i l i t y of the si t u a t i o n . Mothers perceived more concerns than did fathers and responded with greater use of both problem and emotion-focussed coping st r a t e g i e s . Along with p o s s i b i l i t i e s for a more informed understanding of coping theory, the resu l t s of t h i s study may have implications for parents. These findings might corroborate parents' experiences and may inform the service providers for these families. 155 1. The ch i l d ' s behavioural c h a r a c t e r i s t i c s that have the strongest influence on appraisal and coping were shown to be i r r e s p o n s i b i l i t y and turbulence. Higher l e v e l s of these behaviours were related to higher l e v e l s of concern regarding lack of information, problems with the community, rel a t i o n s h i p s within the family, and problems with d a i l y functioning, and were associated with increased coping by seeking s o c i a l support, accepting r e s p o n s i b i l i t y , and using escape-avoidance strategies. Extra care and services seem warranted for these families. I t may be more d i f f i c u l t f or these parents to cope through p o s i t i v e reappraisal as they might i f t h e i r c h i l d had higher levels of warmth and s o c i a l contact. 2. Self-esteem and mastery appear to be strong coping f a c i l i t a t o r s . With some assistance these resources may be developed by the in d i v i d u a l . Because expressive support has been shown to be p o s i t i v e l y related to self-esteem, and the d i r e c t i o n of influence i s unclear, the a v a i l a b i l i t y of both of these resources could be bolstered. Outreach programs may be advisable for those parents who f e e l d i s i n c l i n e d to attend mutual support groups. 3. Sixty percent of parents reported d i r e c t influence, p o s i t i v e and negative, from family members that affected the ways they viewed and/or coped with t h e i r s i t u a t i o n s . The comments suggested that even i f the influence was c r i t i c a l , the c o n f l i c t often spurred the parent to some p o s i t i v e action. I t may be useful for parents to be aware of such 156 possible outcomes and help f u l for service providers to attend to t h i s family interaction. 4. Service providers might f i n d i t h e l p f u l to take a multi-faceted approach i n t h e i r work with parents, using the f i v e primary appraisals as s p e c i f i c areas of concern that require attention. This approach could follow a model of intervention suggested by Folkman et a l , (1991). They propose that people can be assisted i n t h e i r e f f o r t s to cope with a d i f f i c u l t s i t u a t i o n by separating t h i s s i t u a t i o n , or global stressor, into s p e c i f i c stressors; these can then be categorized into changeable and unchangeable aspects. For example, the global stressor, having a son or daughter with schizophrenia, could be separated into the following concerns: lack of information, problems i n d a i l y functioning, r e l a t i o n s with the community, r e l a t i o n s h i p s within the family, and worry about the future. Other concerns i d e n t i f i e d by the parents could also be included, for example, t h e i r sense of sadness over t h e i r c h i l d ' s q u a l i t y of l i f e . For each of these concerns, parents could be encouraged to i s o l a t e s p e c i f i c aspects they consider important. These could be categorized according to whether they are seen as changeable or unchangeable. Various emotion-focussed strategies might be discussed to manage the s p e c i f i c stressors with l i t t l e p o tential for change; various problem-focussed e f f o r t s could be considered to manage changeable aspects of the sit u a t i o n . By breaking a global stressor down into i t s smaller, more manageable aspects, 157 multiple forms of coping, each with a s p e c i f i c focus, could be u t i l i z e d . Families i n other types of s t r e s s f u l s i t u a t i o n s also might be regarded b e n e f i c i a l l y within a stress and coping framework. The need has been i d e n t i f i e d to examine the ef f e c t s upon family l i f e of a child' s deviant behaviour (Bahr, 1987; Geis & Binder, 1991). Parents with delinquent childre n have experiences that appear to p a r a l l e l those of parents who have offspring with mental i l l n e s s . They must deal with a leg a l system i n which a lack of information and problems i n communication may be a problem; there may be d i f f i c u l t relationships with the community as well as within the family, problems with d a i l y functioning and worry about the future. I r r e s p o n s i b i l i t y and/or turbulent behaviour of the c h i l d might well be i n f l u e n t i a l aspects of the s i t u a t i o n . Parents are often seen to be responsible for t h e i r c h i l d ' s delinquency (Geis & Binder, 1991) and yet juveniles are released into t h e i r parents' custody. Focussing on the coping process of such families might ameliorate t h e i r d i s t r e s s and benefit the c h i l d ' s r e h a b i l i t a t i o n . Conclusion Parents who have an adult c h i l d with schizophrenia have been regarded over time as causal agents, as r e h a b i l i t a t i o n agents, then as burden bearers. This study has viewed these parents as managers of d i f f i c u l t but variable s i t u a t i o n s . In taking t h i s perspective, I found that parents made use of many forms of coping that were related to the v a r i a b i l i t y of 158 t h e i r s i t u a t i o n s . An understanding of t h i s v a r i a b i l i t y may f a c i l i t a t e a better provision of service to these parents. This inquiry found that parents were very w i l l i n g to share t h e i r experiences, adding t h e i r comments to enrich the content and help explain the findings of the study; many expressed gratitude for such an opportunity. Their cooperation leads one to speculate whether a questionnaire was the correct design format. An interview would have given these parents greater opportunities to t e l l t h e i r s t o r i e s . Such a format, however, would have lim i t e d the numbers of participants, and r e s t r i c t e d them to one geographical area. The number of included variables, and therefore the v a r i a b i l i t y , assessed by the study would have been greatly reduced. This study hinted at the power of i n t r a f a m i l i a l influence i n shaping the coping process. This i s an area of family i n t e r a c t i o n for which further study has been recommended (see Patterson & Garwick, 1994; Walker, 1985). Go t t l i e b and Wagner (1991) have such studies planned. I endorse these e f f o r t s and would propose they be conducted within a m u l t i c u l t u r a l context. 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Shaver (Ed.), Review of personality and s o c i a l psychology, Vol. 5 (pp. 219-238). Beverly H i l l s , CA: Sage. Thoits, P. A. (1991). Gender differences i n coping with emotional d i s t r e s s . In J. Eckenrode (Ed.), The s o c i a l context of coping (pp. 107-138). New York: Plenum. Thompson, E. H. J r . , & Do l l , W. (1982). The burden of families coping with the mentally i l l : An i n v i s i b l e c r i s i s . Family Relations, 31, 379-388. Torrey, E. F. (1983). Surviving schizophrenia: A family manual. New York: Harper & Row. Torrey, E. F., Bigelow, D. A., & Sladen-Dew, N. (1993). Quality and cost of services for serio u s l y mentally i l l individuals i n B r i t i s h Columbia and the United States. Hospital and Community Psychiatry. 44, 943-950. Vaughn, C. E., Snyder, K. S., Jones, S., Freeman, W. B., & Falloon, I. R. (1984). Family factors i n schizophrenic relapse. Archives of General Psychiatry, 41. 1169-1177. Wahl, 0, F., & Harman, C. R. (1989). Family view of stigma. Schizophrenia B u l l e t i n , 15, 131-139. 174 Walker, A. J. (1985). Reconceptualizing family s t r e s s . Journal of Marriage and the Family, Nov., 827- 837. Wasow, M. (1983). Parental perspectives on chronic schizophrenia. Journal of Chronic Diseases, 36, 337-343. Wasow, M. (1985). Chronic schizophrenia and Alzheimer's disease: The losses for parents, spouses and children compared. Journal of Chronic Diseases, 38, 711- 716. White, R. W. (1985). Strategies of adaptation: An attempt at systematic description. In A. Monat & R. S. Lazarus (Eds.), Stress and coping: An anthology, 2nd Ed. (pp. 121-144). New York: Columbia University Press. Winefield, H. R., & Harvey, E. J. (1993). Determinants of psychological d i s t r e s s i n r e l a t i v e s of people with chronic schizophrenia. Schizophrenia B u l l e t i n . 19, 619-625. Wing, J. K. (1987a). Psychosocial factors a f f e c t i n g the long-term course of schizophrenia. In J. S. Strauss, W. Boker, & H. D. Brenner (Eds.), Psychosocial treatment of schizophrenia: Multidimensional concepts, psychological, family, and self-help perspectives (pp. 13-29). Lewiston, NY: Hans Huber. Wing, J. K. (1987b). Long-term s o c i a l adaptation i n schizophrenia. In N. E. M i l l e r & G. D. Cohen (Eds.), Schizophrenia and aging: Schizophrenia, paranoia, and schizophreniform disorders i n l a t e r l i f e (pp. 183-199). New York: Guilford. Wynne, L., & Singer, M. T. (1963). Thought disorder and family r e l a t i o n s of schizophrenics, I: A research strategy. Archives of General Psychiatry. 9. 191-198. 175 Appendix A Definitions per Lazarus and Folkman (1984) Stress: The r e l a t i o n s h i p between the person and the environment that i s appraised by the person as taxing or exceeding h i s or her resources and endangering his/her w e l l - being. Coping: Constantly changing cognitive and behavioral e f f o r t s to manage s p e c i f i c external and/or i n t e r n a l demands that are appraised as taxing or exceeding the resources of the person. Demand/Stressor: Any environmental s i t u a t i o n or event that i s construed by the individual as taxing or overwhelming her/his resources and endangering her/his well-being. Resource: Something one draws upon and uses to counter demands. Resources can be categorized into those of the person (positive b e l i e f s and competences) and those of the environment ( s o c i a l support and material resources). Appraisal: An evaluative process that determines why and to what extent a p a r t i c u l a r transaction or s e r i e s of transactions between the person and the environment i s s t r e s s f u l . Primary appraisal: An evaluation of the s i g n i f i c a n c e of the person-environment relationship. Secondary appraisal: A complex evaluative process that takes into account which coping options are available, the l i k e l i h o o d that a given coping option w i l l accomplish what i t i s supposed to, and the l i k e l i h o o d that one can apply a p a r t i c u l a r strategy or set of strategies e f f e c t i v e l y . 176 Appendix B THE COPING PROCESS OF PARENTS WHO HAVE AN ADULT CHILD WITH SCHIZOPHRENIA We require participants for a study of the coping e f f o r t s used by parents who have an adult c h i l d with schizophrenia. Our use of the term "adult c h i l d " i s simply recognition that parents continue to consider t h e i r o f f s p r i n g as t h e i r children regardless of age. Allow us to share with you some objectives of t h i s project. This study i s part of a Master's thesis i n the department of Family Studies at the University of B r i t i s h Columbia. We regard parents who cope with having a son or daughter with schizophrenia as we would parents who deal with any devastating family stressor. By "coping" we mean any attempt to manage a d i f f i c u l t s i t u a t i o n or to manage the feel i n g s aroused by s t r e s s f u l circumstances, regardless of i t s effectiveness. From t h i s study we hope to learn more about the influences upon parental coping e f f o r t s so as to better understand how to off e r coping assistance. This study asks you to express your views of your s i t u a t i o n and the ways in which you respond to i t . We hope your r e f l e c t i o n upon your ways of coping may v e r i f y for you that your e f f o r t s are understandable responses to your p a r t i c u l a r s i t u a t i o n . By providing you an opportunity to receive feedback on the main conclusions of the study, we hope to share with you a greater understanding of coping with s t r e s s f u l situations. Please be assured that as we read your responses to t h i s questionnaire we w i l l have no knowledge of your i d e n t i t y ; your c o n f i d e n t i a l i t y i s assured. At the conclusion of the study a l l data co l l e c t e d w i l l be destroyed. The time needed to complete the questionnaire i s approximately 1 hour. We are very interested i n the ways that you see and respond to your si t u a t i o n , as i t has been within the l a s t three months, so please take your time to c a r e f u l l y respond, on your own, to the questions. As soon as you have completed the questionnaire, please return i t to us i n the large, stamped, addressed envelope. If you wish to receive a b r i e f account of the main findings of t h i s study at i t s completion, please return the enclosed stamped, self-addressed postcard SEPARATELY from the questionnaire. This request attends to our concern to t r e a t your data with c o n f i d e n t i a l i t y . You may decide not to p a r t i c i p a t e . . We hope, however, that you w i l l agree to a s s i s t us i n our e f f o r t s to add to a general understanding of parental coping so as to increase our understanding of e f f e c t i v e coping assistance. The return of t h i s completed questionnaire w i l l assure us of your consent to p a r t i c i p a t e . Rose DallaLana Brian de Vries PhD 177 QUESTIONNAIRE SECTION 1: INFORMATION ABOUT YOUR CHILD To begin, we would l i k e some information concerning your c h i l d who has been diagnosed with schizophrenia. Please check the appropriate answers as they apply to your son/daughter with schizophrenia. 1. Sex of c h i l d . male female 2. Relationship to you. b i o l o g i c a l c h i l d adopted c h i l d s t e p - c h i l d 3. His/her year of b i r t h . 4. His/her marital status. never married married (or common-law) separated divorced widowed 5. Does your c h i l d l i v e with you at present? Yes No If no, please indicate his/her current l i v i n g arrangements. 6. Approximate length of time since onset of i l l n e s s . 7. Number of hospit a l i z a t i o n s since diagnosis. 8. Son's/daughter's source(s) of income. Please check a l l that apply. employment s o c i a l assistance d i s a b i l i t y parent(s) other - please specify 178 S E C T I O N 2: C H I L D ' S GENERAL L E V E L OP FUNCTIONING We would now l i k e you to t e l l us your impressions of your daughter's/son's general levels of functioning as i t has been o v e r a l l within the l a s t three months, to the best of your knowledge. Please respond to the 38 items below, using the categories provided. If you f e e l that the statement i s not true, you would c i r c l e N T ; i f you f e e l that i t i s only s l i g h t l y true, you would c i r c l e S T ; moderately true i s indicated by MT, and very true by V T . Please c i r c l e one response only. N T n o t t r u e S T M T s l i g h t l y t r u e m o d e r a t e l y t r u e V v e r y T t r u e 1. My c h i l d wears clean clothes. NT ST MT VT 2 . He/she i s capable of budgeting. NT ST MT VT 3 . She/he intrudes on other's conversations NT ST MT VT 4. She/he chooses a good diet. NT ST MT VT 5. He/she neglects physical problems. NT ST MT VT 6. He/she has unsociable habits. NT ST MT VT 7. She/he bathes regularly. NT ST MT VT 8. She/he displays reckless behaviour • NT ST MT VT 9. He/she shows violence to others. NT ST MT VT 10. He/she i s capable of employment. NT ST MT VT 11. He/she has problems with other household members. NT ST MT VT 12. Displays offensive behaviour NT ST MT VT 13 . Is capable of food preparation. NT ST MT VT 14. Has been i n trouble with p o l i c e . NT ST MT VT 15. She/he shows warmth to others. NT ST MT VT 16. He/she abuses alcohol and/or drugs .NT ST MT VT 17. She/he i s i n t r u s i v e toward others. NT ST MT VT 179 NT S T M T not true slightly true moderately true V very T true 18. Shows responsible behaviour. NT ST MT VT 19. She/he i s angry toward others. NT ST MT VT 20. He/she has some s o c i a l organization involvement. NT ST MT VT 21. She/he takes offense readily. NT ST MT VT 22 . He/she i s generally active. NT ST MT VT 23 . She/he displays odd ideas in t a l k . NT ST MT VT 24. He/she shows reduced eye contact. NT ST MT VT 25. He/she shows poor compliance with medication. NT ST MT VT 26. She/he i s v i o l e n t to her/himself. NT ST MT VT 27. She/he has friendships. NT ST MT VT 28 . He/she i s well groomed. NT ST MT VT 29. His/her speech i s disordered. NT ST MT VT 30. Has some d e f i n i t e interests. NT ST MT VT 31. She/he uses bizarre or inappropriate gestures. NT ST MT VT 32 . Withdraws from s o c i a l contact. NT ST MT VT 33 . He/she destroys property. NT ST MT VT 34. He/she generally has d i f f i c u l t y with conversation. NT ST MT VT 35. She/he takes others possessions. NT ST MT VT 36. She/he loses personal property. NT ST MT VT 37. She/he i s uncooperative with health workers. NT ST MT VT 38. Is r e l i a b l e with own medication. NT ST MT VT 180 SECTION 3: HOW THE ILLNESS HAS INFLUENCED YOUR LIFE Now we would l i k e you to read c a r e f u l l y the following l i s t of items that describe some concerns that have been i d e n t i f i e d by parents as ways i n which the i l l n e s s of t h e i r c h i l d r e n has influenced various aspects of t h e i r l i v e s . Please c i r c l e only one response indicating the extent to which YOU agree or disagree with each of the following statements. The categories are as follows: 1 2 3 4 5 6 strongly moderately slightly slightly moderately strongly disagree disagree disagree agree agree agree 1. I am concerned about my c h i l d ' s future. 1 2 3 4 5 6 2. I have d i f f i c u l t y accepting the sit u a t i o n . 1 2 3 4 5 6 3. I worry about my spouse's h e a l t h ( i f a p p l i c a b l e ) . 1 2 3 4 5 6 4. The reactions of society toward schizophrenia concern me. 1 2 3 4 5 6 5. I have d i f f i c u l t y keeping up with chores at home. 1 2 3 4 5 6 6. Not knowing who and where to go to for help i s a problem. 1 2 3 4 5 6 7. I worry about the e f f e c t on my other c h i l d ( r e n ) . 1 2 3 4 5 6 8. I am concerned about r e l a t i o n s with my friends and neighbours. 1 2 3 4 5 6 9. I am concerned that i f something happens to me, i t w i l l be d i f f i c u l t for the re s t of my family. 1 2 3 4 5 6 10. Reactions of society toward my family concern me. 1 2 3 4 5 6 11. Lack of understanding of professional language used by service providers i s a problem. 1 2 3 4 5 6 181 1 2 3 4 5 6 s t r o n g l y m o d e r a t e l y s l i g h t l y s l i g h t l y m o d e r a t e l y s t r o n g l y d i s a g r e e d i s a g r e e 12 d i s a g r e e ag ree a g r e e a g r e e Relations with r e l a t i v e s not i n the household are a concern. 1 13. I lack time or energy for the family. 1 2 14. I have g u i l t feelings about my c h i l d . 1 2 15. Relations with professionals are a problem. 1 2 16. I lack time and energy at work. 1 2 17. I am concerned that my c h i l d i s not getting the proper treatment. 1 2 18. I worry about my own mental health. 1 2 19. Relations with my spouse (or former spouse) have suffered. 1 2 20. Lack of information about the i l l n e s s i n general i s a concern. 1 2 21. Relations with public agencies are a source of concern. 1 2 22. I worry about my own physical health. 1 2 23. This i l l n e s s has created f i n a n c i a l problems for our family. 1 2 24. There i s a lack of information about my c h i l d ' s s p e c i f i c condition. 1 2 25. Relations with parents/spouse's parents have worsened. 1 2 26. Reactions of society toward my son/daughter concern me. 1 2 182 SECTION 4: THOUGHTS ABOUT YOUR SITUATION In order to help us more completely understand how you see your s i t u a t i o n , as you have described i t above, would you please indicate your l e v e l of agreement with the following statements. The categories are as follows: 1 2 3 4 5 6 strongly moderately slightly slightly moderately strongly disagree disagree disagree agree agree agree 1. My s i t u a t i o n i s one i n which there are things that I can change or do something about. 1 2. My s i t u a t i o n i s one that I have to accept. 1 3. My s i t u a t i o n i s one i n which I needed to know more before I could act. 1 4. My s i t u a t i o n i s one in which I had to hold myself back from doing what I wanted to do. 1 SECTION 5: YOUR WAYS OF COPING We come now to the part of the questionnaire i n which we ask you to indicate the various ways in which you presently cope with your s i t u a t i o n . The word coping used here r e f e r s to any attempt to manage your situation, as you have described i t above, whether or not you f e e l t h i s e f f o r t i s successful. Please c a r e f u l l y read each item and indicate, by c i r c l i n g the appropriate category number, the extent to which you have used i t within the past three months. The categories are: 1 2 3 not used used used quite somewhat a bit 1. Just concentrated on what I had to do next - the next step. 1 2 4 used a great deal 3 4 2. I did something which I didn't think would work, but at least I was doing something. 1 2 3 4 183 1 2 3 4 n o t u s e d u s e d u s e d q u i t e u s e d a somewhat a b i t g r e a t d e a l 3. Tried to get the person responsible to change. 1 2 3 4 4. Talked to someone to f i n d out more about the s i t u a t i o n . 1 2 3 4 5. C r i t i c i z e d or lectured myself. 1 2 3 4 6. Tried not to burn my bridges, but leave things open somewhat. 1 2 3 4 7. Hoped a miracle would happen. 1 2 3 4 8. Went along with fate; i t ' s just bad luck. 1 2 3 4 9. Went on as i f nothing was wrong. 1 2 3 4 10. Tried to keep my feelings to myself.1 2 3 4 11. I looked for the s i l v e r l i n i n g , so to speak; t r i e d to look on the bright side of things. 1 2 3 4 12. Slept more than usual. 1 2 3 4 13. I expressed anger to the person who caused the problem. 1 2 3 4 14. Accepted sympathy and understanding from someone. 1 2 3 4 15. I was inspired to do something creative. 1 2 3 4 16. Tried to forget the whole thing. 1 2 3 4 17. I got professional help. 1 2 3 4 18. I changed or grew as a person i n a good way. 1 2 3 4 19. I apologized or did something to improve a relationship. 1 2 3 4 20. I made a plan of action and followed i t . 1 2 3 4 21. I l e t my feelings out somehow. 1 2 3 4 22. Realized I brought the problem on myself. 1 2 3 4 184 1 2 3 4 n o t u s e d used used q u i t e u s e d a somewhat a b i t g r e a t d e a l 23. I have benefitted from the experience. 1 2 3 4 24. I talked to someone who could do something concrete about the problem. 1 2 3 4 25. T r i e d to make myself f e e l better by eating, drinking, smoking, using drugs or medication, etc. 1 2 3 4 26. Took a big chance or did something very ri s k y . 1 2 3 4 27. I t r i e d not to act too h a s t i l y or follow my f i r s t hunch. 1 2 3 4 28. Found new f a i t h . 1 2 3 4 29. Rediscovered what i s important i n l i f e . 1 2 3 4 30. Changed something so things would improve. 1 2 3 4 31. I avoided being with people i n general. 1 2 3 4 32. Didn't l e t i t get to me; refused to think too much about i t . 1 2 3 4 33. I asked a r e l a t i v e or friend I respected for advice. 1 2 3 4 34. Kept others from knowing how bad things were. 1 2 3 4 35. Made l i g h t of the s i t u a t i o n ; refused to get too serious about i t . 1 2 3 4 36. Talked to someone about how I was f e e l i n g . 1 2 3 4 37. Stood my ground and fought for what I wanted. 1 2 3 4 38. Took i t out on other people. 1 2 3 4 39. Drew on my past experiences; I was i n a s i m i l a r s i t u a t i o n before. 1 2 3 4 185 n o t u s e d 2 u s e d somewhat u s e d q u i t e a b i t 40. I knew what had to be done, so I doubled my e f f o r t s to make things work. 1 41. Refused to believe that i t was happening. 1 42. I made a promise to myself that things would be d i f f e r e n t next time. 1 4 u s e d a g r e a t d e a l 3 4 3 4 3 4 43. Came up with a couple of d i f f e r e n t ways to deal with the problem. 1 44. I t r i e d to keep my feelings from i n t e r f e r i n g with other things too much. 1 45. I changed something about myself. 1 46. Wished that the s i t u a t i o n would go away or somehow be over with. 1 2 2 3 4 3 3 4 4 47. Had fantasies about how things might turn out. 48. I prayed. 49. I went over i n my mind what I would say or do. l 1 2 2 3 3 4 4 50, 51, 52. 53 I thought about how a person I admire would handle t h i s s i t u a t i o n and used that as a model. We changed or grew as a family i n a good way. Made some arrangements for my c h i l d ' s future. Read books and a r t i c l e s to learn more about the s i t u a t i o n . 1 1 2 2 3 3 4 4 54. Adjusted my expectations fo r the future. 55. Concentrated on child ' s contributions to the family. 1 56. I talked to someone i n a s i m i l a r s i t u a t i o n . 1 186 SECTION 6: FAMILY INFLUENCE Sometimes parents indicate that t h e i r thoughts or f e e l i n g s about a s t r e s s f u l s i t u a t i o n and the ways they choose to respond to i t are influenced by what a family member has done or said. Have any family members influenced your views of your s i t u a t i o n or your coping responses? Yes No I f yes, i n a few b r i e f sentences would you please t e l l us 1) which family member(s) have influenced your views of your s i t u a t i o n and/or your coping responses, and 2) how your views of your situation and/or your coping responses have changed because of what they have done or said. 1) Which family members have influenced your views of your s i t u a t i o n and/or your coping responses? 2) How have your views of your s i t u a t i o n and/or your coping responses changed because of what they have done or said? SECTION 7: INFORMATION ABOUT YOURSELF At t h i s point i t would be helpful for us to understand something about you and your unique personal s i t u a t i o n . Please remember your c o n f i d e n t i a l i t y i s assured. 1. Your year of b i r t h 2. You are: male female 3. Number of years of your formal education 4. To what ethnic or c u l t u r a l group(s) do you belong? 187 5. Your marital status i s : married or common law separated divorced remarried widowed never married 6. Your t o t a l annual family income i s : less than $15,000 $45,001 - $60,000 $15,000 - $30,000 $60,001 - $75,000 $30,001 - $45,000 over $75,000 7. Do you have any other children (other than your c h i l d with schizophrenia)? Yes (please l i s t the age for each below) No Son(s) age(s): Daughter (s) age(s) : If any of the above children/dependents are living with you at the present time, please circle their ages. 8. Do you have another c h i l d with any physical or mental d i s a b i l i t y or i l l n e s s ? Yes No 9. Do you have any other dependents? Yes No Please explain your relationship to these other dependents: 188 S E C T I O N 8: GENERAL B E L I E F S Now we would l i k e you to help us understand your general b e l i e f s about yourself and l i f e . Please indicate the extent to which you agree or disagree with the following statements. The categories are: 1 2 3 4 5 s t r o n g l y m o d e r a t e l y s l i g h t l y s l i g h t l y m o d e r a t e l y d i s a g r e e d i s a g r e e d i s a g r e e ag ree a g r e e 1. I have l i t t l e control over the things that happen to me. 1 2 3 4 E 2. I f e e l that I have a number of good q u a l i t i e s . 1 2 3 4 f 3. There i s l i t t l e I can do to change many of the important things i n my l i f e . 1 2 3 4 £ 4. I am able to do things as well as most other people. 1 2 3 4 f 5 . Sometimes I f e e l that I'm being pushed around i n l i f e . 1 2 3 4 ! 6. What happens to me i n the future mostly depends on me. 1 2 3 4 £ 7. On the whole, I am s a t i s f i e d with myself. 1 2 3 4 £ 8. There i s r e a l l y no way I can solve some of the problems I have. 1 2 3 4 £ 9. I f e e l that I'm a person of worth, at least on an equal plane with others. 1 2 3 4 5 s t r o n g l y a g r e e 10. I often f e e l helpless i n dealing with the problems of l i f e . 1 2 11. I take a p o s i t i v e attitude toward myself. 1 2 12. I can do just about anything I r e a l l y set my mind to do. 1 2 13. A l l i n a l l , I'm i n c l i n e d to f e e l that I'm a f a i l u r e . 1 2 189 S E C T I O N 9 : HELP AND SUPPORT Let's turn now to the help and support you get from friends and r e l a t i v e s . Thinking about your friends and family, other than your c h i l d with schizophrenia, please indicate the extent to which you agree or disagree with the following statements. The categories are: 1 2 3 4 s t r o n g l y d i s a g r e e d i s a g r e e a g r e e s t r o n g l y a g r e e 1. There i s r e a l l y no one who understands what I am going through. SD D A SA 2. The people close to me l e t me know that they care about me. SD D A SA 3. I have a f r i e n d or r e l a t i v e i n whose opinions I have confidence. SD D A SA 4. I have someone who I f e e l I can t r u s t . SD D A SA 5. I have people around me who help me to keep me s p i r i t s up. SD D A SA 6. There are people i n my l i f e who make me f e e l good about myself. SD D A SA 7. I have at least one frie n d or r e l a t i v e I can r e a l l y confide i n . SD D A SA 8. I have at least one frie n d or r e l a t i v e I want to be with when I am f e e l i n g down or discouraged. SD D A SA COMMUNITY SUPPORT There are support programs and/or support groups for r e l a t i v e s of persons with schizophrenia a v a i l a b l e . Yes No Don't know 2. There are information and/or education programs ava i l a b l e for r e l a t i v e s of persons with schizophrenia. Yes No Don't know There i s a day program available for my son/daughter. Yes No Don't know 4 . My son/daughter has a confidant/friend or support person. Yes No Don't know know S E C T I O N 1 0 : UNDERSTANDING HOW YOUR FAMILY WORKS You've come to the f i n a l section. Thank you for your perseverance. Over time, families naturally vary i n l e v e l s of togetherness and adaptability. We'd l i k e you to share with us some of your views about how your family presently operates. Please c i r c l e the appropriate number which indicates the extent to which the following items apply to your family. (Note. This assessment was conducted u t i l i z i n g FACES II of Olson, Portner, and B e l l , 1982, which i s not able to be reproduced here). Thank you for your patience and cooperation i n completing the questionnaire. Your help i s very much appreciated. Please check back to make sure you have not l e f t any questions unanswered. If you have additional comments you would l i k e to make on the ways i n which you cope with your s i t u a t i o n , please use the space provided below and the reverse of t h i s page. Some examples are: What has helped you most to cope? How have your coping e f f o r t s changed over time? 191 Appendix C Questionnaire Items Categorized According to Sub-Scale I l l n e s s c h a r a c t e r i s t i c s - L i f e S k i l l s P r o f i l e (Rosen et a l . . 1989) Self-care: Wears clean clothes. Capable of budgeting. Chooses good d i e t . Neglects physical problems. Has unsociable habits. Bathes regularly. Capable of employment. Capable of food preparation. Well groomed. Nonturbulence: Displays reckless behaviour. Shows violence to others. Has problems with other household members. Displays offensive behaviour. Has been i n trouble with the poli c e . Abuses alcohol and/or drugs. Is i n t r u s i v e toward others. Shows responsible behaviour. Is angry toward others. Takes offense r e a d i l y . Is v i o l e n t to her/himself. Destroys property. Sociable: Shows warmth to others. Has some s o c i a l organization involvement. Is generally active. Has friendships. Has some d e f i n i t e interests. Withdraws from s o c i a l contact. Communication: Intrudes on other's conversations. Displays odd ideas i n ta l k . Shows reduced eye contact. Speech i s disordered. Uses bizarre or inappropriate gestures. Generally has d i f f i c u l t y with conversation. Resp o n s i b i l i t y : Shows poor compliance with medication. Takes others possessions. Loses personal property. Is uncooperative with health workers. Is r e l i a b l e with own medication. 192 Primary appraisal - How the i l l n e s s has influenced your l i f e (Gidron, 1991) Lack of information and problems i n communication: Not knowing who and where to go to for help. Lack of understanding of professional language used by service providers. Relations with professionals are a problem. Concern that my c h i l d i s not getting proper treatment. Lack of information about the i l l n e s s i n general. Relations with public agencies are a problem. Lack of information about my child' s condition. Relationship with the community: Reaction of society toward schizophrenia concern me. Relations with my friends and neighbours are a concern. Reaction of society toward my family concern me. Relations with r e l a t i v e not i n the household are a concern. Reactions of society toward my c h i l d concern me. Problems i n d a i l y functioning: D i f f i c u l t y keeping up with chores at home. Have g u i l t feelings about my c h i l d . Lack time and energy at work. Worry about my own mental health. Worry about my own physical health. I l l n e s s has created f i n a n c i a l problems for family. Relations within the family: I have d i f f i c u l t y accepting the si t u a t i o n . Worry about the e f f e c t on my other c h i l d ( r e n ) . Lack time and energy for the family. Relations with my spouse (or former spouse) have worsened. Worry about the future: I am concerned about my child' s future. I am concerned that i f something happens to me i t w i l l be d i f f i c u l t for the rest of my family. Ways of Coping (Folkman, Lazarus, Dunkel-Schetter. et a l . . 1986) Confront: Did something which I didn't think would work, but at lea s t I was doing something. Tried to get the person responsible to change. Expressed anger to the person who caused the problem. Let my feelings out somehow. Took a big chance or did something very r i s k y . Stood my ground and fought for what I wanted. Distance: Went along with fate; i t ' s just bad luck. Went along as i f nothing was wrong. 193 Looked for the s i l v e r l i n i n g , so to speak; t r i e d to look on the bright side of things. Tried to forget the whole thing. Didn't l e t i t get to me; refused to think too much about i t . Made l i g h t of the s i t u a t i o n ; refused to get too serious about i t . S e l f - c o n t r o l ; Tried not to burn my bridges, but leave things open somewhat. Tri e d to keep my feelings to myself. Tried not to act too h a s t i l y or follow my f i r s t hunch. Kept others from knowing how bad things were. Tried to keep my feelings from i n t e r f e r i n g with other things too much. Went over i n my mind what I would say or do. Thought about how a person I admire would handle t h i s s i t u a t i o n and used that as a model. Seek s o c i a l support: Talked to someone to f i n d out more about the s i t u a t i o n . Accepted sympathy and understanding from someone. Got professional help. Talked to someone who could do something concrete about the problem. Asked a r e l a t i v e or f r i e n d I respected for advice. Talked to someone about how I was f e e l i n g . * Talked to someone in a similar s i t u a t i o n . Accept r e s p o n s i b i l i t y : C r i t i c i z e d or lectured myself. Apologized or did something to improve a r e l a t i o n s h i p . Realized I brought the problem on myself. Make a promise to myself that things would be d i f f e r e n t next time. Escape-avoidance: Hoped a miracle would happen. Slept more than usual. T r i e d to make myself f e e l better by eating, drinking, smoking, using drugs or medication, etc. Avoided being with people i n general. Took i t out on other people. Refused to believe that i t was happening. Wished that the s i t u a t i o n would go away or somehow be over with. Had fantasies about how things might turn out. Pl a n f u l problem-solving: Just concentrated on what I had to do next- the next step. Made a plan of action and followed i t . Changed something so things would improve. Drew on my past experiences; I was i n a s i m i l a r s i t u a t i o n before. Knew what had to be done, so I doubled my e f f o r t s to make things work. Came up with a couple of d i f f e r e n t ways to deal with the problem. * Made some arrangements for my chil d ' s future. * Read books and a r t i c l e s to learn more about the s i t u a t i o n . 194 P o s i t i v e reappraisal: Was inspired to do something creative. Changed or grew as a person i n a good way. I have benefitted from the experience. Found new f a i t h . Rediscovered what i s important i n l i f e . Changed something about myself. Prayed. We changed or grew as a family i n a good way. * Adjusted my expectations for the future. * Concentrated on the c h i l d ' s contributions to the family. Esteem (Pearlin & Schooler, 1978) I f e e l that I have a number of good q u a l i t i e s . I am able to do things as well as most other people. On the whole, I am s a t i s f i e d with myself. I f e e l that I'm a person of worth, at least on an equal plane with others. I take a p o s i t i v e attitude toward myself. A l l i n a l l , I am i n c l i n e d to f e e l that I'm a f a i l u r e . Mastery (Pearlin & Schooler, 1978) I have l i t t l e control over the things that happen to me. There i s l i t t l e I can do to change many of the important things i n my l i f e . Sometimes I f e e l that I'm being pushed around i n l i f e . What happens to me i n the future mostly depends on me. There i s r e a l l y no way I can solve some of the problems I have. I often f e e l helpless i n dealing with the problems of l i f e . I can do just about anything I r e a l l y set my mind to do. Note. * indicates idi o s y n c r a t i c items 195 Appendix D The Shapes of Value Di s t r i b u t i o n s Demographics Except for family income, d i s t r i b u t i o n s of values f o r the demographic variables approached normality. Observed values of " t o t a l family income" were s l i g h t l y and s i g n i f i c a n t l y skewed to the r i g h t . Except for a value of 35 years for "formal education" (recoded to one above the next highest value as suggested by Tabachnick and F i d e l l , 1989), there were no o u t l i e r s (defined as 3 SDs above the mean), Level of functioning measures Observed values of "selfcare" and "sociable" sub-scales were approximately normally distributed. D i s t r i b u t i o n s were s i g n i f i c a n t l y skewed to the l e f t i n the sub-scales "nonturbulent behaviour" (Skewness = -.854, SE Skewness = .212), "communication s k i l l s " (Skewness = -.642, SE Skewness = .207), and " r e s p o n s i b i l i t y (Skewness = -.875, SE Skewness = .206), i n d i c a t i n g a " t a i l " towards lower values. Kurtosis values lacked s i g n i f i c a n c e . In t h i s sample then, the greater number of sons and daughters were considered to be responsible, communicative, and calm, whereas the others-were ranked i n varying degrees of lower function. The d i s t r i b u t i o n of observed values for the t o t a l scale, the " L i f e S k i l l s P r o f i l e , " had a small but s i g n i f i c a n t skew to the l e f t (Skewness = -.524, SE Skewness = .220) along with a s l i g h t l y p l a t y k u r t i c shape which lacked s i g n i f i c a n c e . Primary appraisal measures The observed d i s t r i b u t i o n s of four of the primary appraisal sub-scales, namely, "lack of information," "r e l a t i o n s h i p with the community," "problems functioning," and "relationships within the family," displayed nonsignificant p o s i t i v e skewness and nonsignificant negative kurtosis. This pattern was also evident i n the d i s t r i b u t i o n of the cumulative scale " a l l the concerns." The d i s t r i b u t i o n of the sub-scale "worry about the future," however, demonstrated a clear departure from normality. I t had strong negative skewness (-1.387, SE Skewness = .204) and s i g n i f i c a n t p o s i t i v e kurtosis (1.754, SE Kurtosis = .406). The majority of cases were clustered toward the higher values, an i n d i c a t i o n that indeed t h i s was an area of great concern for most of the parents i n the sample. Secondary appraisal D i s t r i b u t i o n s of values for two of the single-item secondary appraisals, "I could change or do something about the s i t u a t i o n " and "I had to hold back from doing what I wanted to do," were negatively skewed (nonsignificant) with s i g n i f i c a n t p l a t y k u r t i c shapes. Kurtosis values for the former were -1.325 with a SE Kurtosis of .406; values for the l a t t e r were Kurtosis = -1.361 with a SE Kurtosis of .408. The negative skew of "I had to accept the s i t u a t i o n " was s i g n i f i c a n t (Skewness = -1.293, SE Skew = .205) but i t s posi t i v e kurtosis was not. D i s t r i b u t i o n of the secondary appraisal, "I needed to know more I could act," was 196 s i g n i f i c a n t l y skewed to the l e f t (-.636, SE Skewness = .206) with a s i g n i f i c a n t negative kurtosis (Kurtosis = -.944, SE Kurtosis = .408) . Resource measures The d i s t r i b u t i o n of values of the "esteem" scale was s i g n i f i c a n t l y skewed to the l e f t (Skewness = -1.526, SE Skewness = .207) with a s i g n i f i c a n t p o s i t i v e kurtosis (Kurtosis = 3.419, SE Kurtosis = .411), indicating a leptokurtic d i s t r i b u t i o n of the observations with a cluster of cases i n the upper values and a " t a i l " toward the lower end of the scale. More respondents i n t h i s sample expressed high levels of "esteem" than would normally be expected. The individual resource, "mastery," however was approximately normally distributed with s l i g h t , negative skew and p l a t y k u r t i c shape, both of which lacked s i g n i f i c a n c e . D i s t r i b u t i o n s of observed values of "expressive support" and "community support" were skewed to the l e f t with s i m i l a r l e v e l s of s i g n i f i c a n c e (3.89 and 3.85). Observations of "cohesion" were d i s t r i b u t e d i n a comparable pattern but with a lower s i g n i f i c a n c e l e v e l for skewness (2.60). Ways of coping scales "Seeking s o c i a l support" and "positive re a p p r a i s a l " were s i m i l a r l y d i s t r i b u t e d with p l a t y k u r t i c shapes that did not reach l e v e l s of sig n i f i c a n c e . Distributions of "distancing," "accepting r e s p o n s i b i l i t y , " and "escape-avoidance" were s i m i l a r with s i g n i f i c a n t l e v e l s of pos i t i v e skewness (Skewness = .736, .602, .786, respectively). The sub-scales, "confront," "plan," and " s e l f - c o n t r o l , " along with the two cumulative scales, "problem-focussed" and "emotion-focussed," were those that most c l o s e l y approached a normally shaped d i s t r i b u t i o n with low, i n s i g n i f i c a n t l e v e l s of skewness and kurtosis. Appendix E 197 Legend (A) pile-up of demands (V) family vulnerability (T) family type (X) family adjustment and adaptation (B) available resources (C) situational appraisal (PSC) problem-solving coping Figure E l . A Model of Family Stress. Coping, and Adaptation (Following McCubbin and McCubbin . 1991) P r i m a r y Figure E2 A Representation of the Coping Process (following Lazarus and Folkman. 1984) Primary Appraisals 199 . 2 1 Life Skills Self-care < CommunicatK Responsibility - Nonturbulence • Sociablility - Time since Onset Lack of Information 21 Relations with community - . 24 I—Relations within Family Worry about the Future . 14 Problems Functioning Coping Confront 7,7^. Distance Self-Control Seek Social Support Accept Responsibility Escape Planful Problem-Solving ° Positive Reappraisal Secondary Appraisals Could Change Situation Had to Accept Situation Needed to Know More Had to Hold Back Figure E3. Illness Characteristics (Life Skills) that Predict Appraisals and Coping. 200 Demographics Age of Parent Sex of Parent Marital Status of Parent Primary Appraisals Lack of Information Relations with Community Relations within Family Problems Functioning Worry about the Future Coping Confront Distance Self-Control Seek Social Support Accept Responsibility Escape Planful Problem-Solving Positive Reappraisal Secondary Appraisals Could Change Situation Had to Accept Situation Needed to Know More Had to Hold Back Figure E4. Demographic Characteristics That Predict Appraisals and Coping 201 Expressive Suppo Community Support Cohesion Overt Family Influence Primary Appraisals — Lack of Information Relations with Community Relations within Family Coping Confront Distance Self-Control £3—Seek Social Support Accept Responsibility - . 22 Escape Planful Problem-Solving Positive Reappraisal Secondary Appraisals Could Change Situation Had to Accept Situation Needed to Know More Had to Hold Back Figure E5. Individual and Family Resources That Predict Appraisals and Coping 202 Secondary Appraisals Can Change Situation—' Have to Accept . 1 8 Situation Primary Appraisals Lack of Information Relations with Community Relations within Family Problems Functioning Worry about Future Self-Control Seek Social Support Coping Confront Distance Accept Responsibility Escape Positive Reappraisal Planful Problem-Solving Figure E6. Predictive Relationships Among Primary Appraisal. Secondary Appraisals and Coping 203 A p p e n d i x F Table F l Demographic Characteristics of Parents Sample Size Mothers 109 Fathers 32 Marital Status Married/Remarried 108 Widowed 13 Divorced/Separated 19 Formal Education (4-22 years) M 13-16 SD 3.06 Number of Other Children (0-8) M 2.97 SD 1.6 Have Other Child with Disability Yes 35 No 106 Have Other Dependents Yes 17 No 122 Missing 2 Characteristics with Significant Differences by Sex of Parent Mothers Fathers t test p < Age (39-88 years) M 59.00. SD9.29 M.66.65 SD9.77 .00 Family Income (a) M 2.93 SD 1.34 M_3.66SD1.47 .01 Note.(a)l=<$15,000, 2=$15,001-30,000, 3=830,001-45,000, 4=545,001-60,000, 5=$60,001-75,000, 6=>$75,000. 204 Table F2 Characteristics of Daughters and Sons with Schizophrenia Sample Size (141) Residence With Parents Elsewhere Marital Status Never Married Other Age (17-51) Time Since Illness Onset (1-35 years) Number Hospitalizations (0- 20) Daughters 30 11 19 22 8 M 33.07 SD7.19 MJ2.90 SD7.41 M 4 . 7 1 SD2.92 Sons 111 35 76 104 7 Significance Chisquare M_32.72 _SD 7.75 M 12.27 SD7.96 M4.52 SD4.22 .60 .00 Significance^ test p<.83 p<.70 E<.82 Table F3 Reliabilities of Measures Scale Number of Items Cronbachs Illness Characteristics Selfcare 9 .72 Nonturbulence 12 .81 Sociability 6 .70 Communication 6 .72 Responsibility 5 .77 Life Skills Profile (cumulative) 38 .90 Resources Self-Esteem 6 .75 Mastery 7 .69 Cohesion 14 .91 Adaptability 16 .87 Expressive Support 8 .87 Primary Appraisal Lack of Information 7 .79 Relations within Family 4 .66 Relations with Community 5 .72 Problems Functioning 6 .75 Worry about the Future 2 Correlation Cumulative Primary Appraisals 24 .90 Ways of Coping Confront 6 .49 Distance 6 .57 Self-Control 7 .52 Social Support 7 .79 Accept Responsibility 4 .32 Escape/Avoidance' 8 .61 Planful Problem Solving 8 .70 Positive Reappraisal 10 .79 Alpha 206 Table F4 Functioning Level of Daughters and Sons: Means. Standard Deviations, and Significant Differences Sub-Scale Range (1-4) Group Daughters Sons Significance (30) (111) Min Max M SD M SD M SD Uestp< Self-care 1.33 3.78 2.62 .59 2.69 .53 2.59 .62 .43 Nonturbulence 1.25 4.00 3.21' .57 3.01 .64 3.23 .57 .05 Social Contact 1.17 4.00 2.46 .68 2.47 .07 2.44 .67 .73 Communication 1.33 400 3.02 .66 2.88 .68 3.06 .66 .20 Responsibility 1.13 3.20 2.54 .67 2.82 .78 3.17 .81 .04 207 Table F5 Means. Standard Deviations, and Significant Differences of Resources and Appraisals for Mothers and Fathers Variable Range Group Mothers Fathers Significance Self-Esteem(l-6) Mastery (1-6) Cohesion (1-5) Espressive Support (1-4) Community Support(4-8) Resources Min Max M SD M 2.33 6.00 5.29 .70 5.34 1.29 6.00 4.09 .90 4.07 22.0 79.0 58.38 11.98 58.21 1.63 4.00 3.38 .54 3.41 4.00 8.00 7.08 .92 7.10 SD .72 .88 12.12 .56 .90 M 5.26 4.24 58.17 3.24 6.97 SD t test p< .54 .63 .97 10.72 .70 .10 .34 .98 .15 .50 Lack of Information 1.00 Relationship with Community 1.00 Relationship with Family 1.00 Problems Functioning 1.00 Worry about the Future 1.00 Primary Appraisal (1-6) 6.00 3.18 1.25 3.29 1.25 2.71 1.16 .02 6.00 3.57 1.13 3.68 1.00 3.16 1.18 .02 6.00 3.34 1.36 3.49 • 1.28 3.12 1.56 .17 5.83 2.98 1.35 3.13 1.30 2.39 1.34 .01 6.00 5.13 1.04 5.25 .96 4.73 1.09 .01 Can Change Situation Have to Accept Situation Need to Know More Have to Hold Back Secondary Appraisals (1-6) 1.00 6.00 3.75 1.85 3.70 1.85 3.94 1.85 .52 1.00 6.00 4.79 1.54 4.89 1.46 4.47 1.76 .18 1.00 6.00 4.22 1.78 4.25 1.78 4.09 1.75 .66 1.00 6.00 3.74 1.87 3.77 1.83 3.28 1.91 .11 Note. Higher scores indicate higher levels of resources, primary appraisal concerns and situational beliefs. 208 Table F6 Means.Standard Deviations, and Significant Differences of Ways of Coping for Mothers and Fathers Way of Coping Range . Group Mothers Fathers Significance Min Max M SD ' M SD M SD ttest p_< Problem Focussed Confront 1.00 3.17 1.97 :48 2.04 .44 1.77 .54 .00 Planful Problem-Solving 1.00 4.00 2.54 .64. '2.72 .52 2.37 .72 .00 Emotion Focussed Distancing 1.00 4.00 1.96 .53 1.97 .52 1.95 .61 .85 Self-Control 1.00 3.71 2.32 .52 2.39 .47 2.14 .61 .02 Seek Social Support 1.00 4.00 2.56 .77 2.73 .71 2.31 .81 .01 Accept Responsibility 1.00 3.25 1.79 .59 1.85 .53 1.59 .72 .03 Escape/Avoidance 1.00 3.38 1.72 .52 1.77 .53 1.55 .46 .08 Positive Reappraisal 1.00 3.90 2.48 .65 2.59 .51 2.12 .76 .00 Note. Higher scores indicate greater use of coping strategy. 209 Table F7 Means. Standard Deviations, and Significant Differences in Parents' Appraisals and Coping by Categorical Variables "Sex of Child" and "Overt Family Influence" Parents' Appraisals and Coping Sex of Child Daughters Sons t-tests_p_ < Primary Appraisal "Lack of Information" M 3.57 3.05 .04 SD 1.32 1.22 Primary Appraisal "Relations Within the Family M 3.86 3.28 .04 SD 1.38 1.32 Secondary Appraisal "Have to Hold Back" M 4.43 3.55 .02 SD 1.65 1.88 "Distance" Coping M 2.15 1.92 .04 SD .58 .52 "Accept Responsibility" Coping M 2.15 1.92 .02 SD .56 .58 Parents' Appraisals and Coping Overt Family Influence Yes No t-tests p< Primary Appraisal "Worry about the Future" M 5.45 4.87 .00 SD .78 1.29 "Self-Control" Coping M 2.41 2.21 .03 SD .53 .49 "Planful Problem-Solving" Coping M 2.74 2.51 .02 SD .53 .63 Note. Significance levels are 2-tailed. 210 Table F8 Means. Standard Deviations, and Significant Differences in Parents' Appraisals and Coping by Categorical Variables "Have otherChild with Disability" and "Marital Status of Parent" Parents' Appraisals and Coping Have Other Child with Disability Yes No t-tests g < Primary Appraisal "Relationships in Family" M 3.86 3.25 .02 SD 1.15 1.39 Parents' Ways of Coping Marital Status of Parent Married Not Married t-test p< "Confrontive" Coping M 1.92 2.17 .01 SD .46 .48 "Self-Control" Coping M 2.27 2.55 .01 SD .52 .42 "Planful Problem-Solving " Coping M . 2.57 2.87 .01 SD ,57 .52 "Positive Reappraisal" Coping M 2.42 2.69 .04 SD .65 .61 "Seek Social Support" Coping M 2.55 2.91 .02 SD .75 .70 Note. Significance levels are 2-tailed. 211 Table F9 Significant Correlations among Demographic Variables Variables 1 2 3 4 5 6 7 8. 1. AgeofParent 1.00 .81** .20 .60** .26 -.04 -.23* -.18 2. Age of Child - — 1.00 .25* .77** .33** -.09 -.26* -.25* 3. Number of Hospitalizations . 1.00 .32** .35** ' .09 -.02 -.14 4. Time Since Onset of Illness 1.00 .32** -.01 -.22* -.21 5. Residence of Child - — 1.00 .11 -.18 -.31** 6. Parents Education Level 1.00 .33** .06 7. Total Family Income 1.00 .26* 8. Number of Other Children at 1.00 Home Note. Residence of child: With parent = 1, Elsewhere = 2. *< .01, **<.001. 212 Table F10 Variables Significantly Correlated with Measures of Primary Appraisal Variables Demographics Sex of Child (a) Age of Parent Sex of Parent (a) Have Other Child with Disability (a) Child's Life Skills Selfcare Sociability Communication Skills Responsibility Nonturbulent Behaviour Life Skills Profile (cumulative) Resources Esteem Mastery Community Support Cohesion Overt Family Influence Lack of Information -.52, p< .04 -.24* .58 p<03 -.28** -.28** -.36** -.33** . 3 7 * * . 3i** -31** -.32** -.28** Primary Appraisals Relation with Community .56 p<.02 -.25* -.26* -.23* -.30** . 3 j * * -.35** -31** -.36** -.23* -.26* Relations with Family -.59, p<.04 .60, p<.02 -31** -.27** -.38** -.38** -.40** -.32** -.49** -.23* -.38** Problems Functioning . 3 3 * * .74 p<.00 -.24* -.22* . 3 4 * * -.33** -.34** -.43** -.53** . 3 2 * * Worry about the Future .52 p<.01 -.25* -.26* .58, p<.00 Note. Dashes indicate non-significant association. (a) values displayed are the differences in means between the groups with a 2-tailed significance level. 2-tailed significance *<01, **<001. 213 Table F l l Variables significantly Correlated with Secondary Appraisals Secondary Appraisals Variables Could Change Have to Accept Need to Know Have to Hold Back Situation Situation More Age of Parent — — ~ -.24* Sex of Child (a) -- - -- -.88,p<.02 Resources Esteem -- .21* - -.25* Mastery .33** — ~ -.35** Expressive Support .22* — . - Community Support ~ ~ — -.26* Cohesion ~ ~ ~ -.24* Child's Life Skills Nonturbulence — — -- -.32** Responsibility - -- - -.31** Primary Appraisals Lack of Information — ~ .35** . 4 4 * * Relations with Community — - — .33** Relations with Family -.29** - -- .41** Problems Functioning ~ - ~ .54** Worry about Future - — ~ .24* Note. Dashes indicate non-significant association. (a) values displayed are the differences in means between the groups with a 2-tailed significance level. 2-tailed significance *<.01, **<.001. 214 Table F12 Significant Correlations of Demographic. Resource, and Illness Variables with Measures of Coping Measures of Coping Variables Confront Distance Self- Social Accept Escape Plan Positive Control Support Responsibility Reappraisal Demographics Age of Parent - - - -.24* -- -.28** Sex of Parent (a) .27 - .25 .42p<.01 .26p<.03 .35 p<.01 .47p<.00 p<.01 p<.02 Time Since Onset ~ .26** Marital Status of -.25 - -.28 -.36 — — -.30 -.27, p<.04 Parent (a) p<.01 p<.01 p<.02 g<.01 Sex of Child (a) — .23p<.04 - — -.28p<.02 .23p<.03 Resources Esteem — — — — -.22* -.36** Mastery — — -.26* — — -.48** Expressive — — — .34** — — .23* Support Community — -.24* — ~ ~ -.25* Support Overt Family - - .20 p< — — — .23 p<.02 Influence (a) .03 Child's Life Skills Nonturbulent ~ - ~ -.22* -.34** -.22* Behaviour Responsibility ~ ~ ~ ~ -.26* Sociability - ~ ~ - — - - .22* Note. Dashes indicate non-significant association. (a) values displayed are the differences in means between the groups with 2-tailed significance level 2-tailed significance level * < .01, ** < .001; 215 Table F13 Significant Correlations of Primary and Secondary Appraisals with Measures of Coping Measures of Coping Variables Confront Distance Self- Social Accept Escape Plan Positive Control Support Responsibility Reappraisal Primary Appraisals Lack of Information .23" .30* .39* Relations with Community .34* Relations with Family .26* .29* .50* Worry About the Future .24* .30* .23* Problems Functioning .23" .35" .39* .60* Secondary Appraisals Can Change Situation -.24* .25* Have to Accept Situation .23" Need to Know More .29* Have to Hold Back .24* .21* .28* .40* .42" Note. Dashes indicate non-significant association. 2-tailed significance level *<.01, **<.001. 216 Table F14 Standard Multiple Regression of Demographic. Resource, and Life Skills Variables on Primary Appraisal. "Lack of Information and Problems in Communication Correlation Variables 1 2 3 4 5 6 7 8 9 1. Lack of Information 1.00 .17 -.23 .19 -.40 -.29 -.33 -.33 -.27 2. Sex of Child ----- 1.00 -.01 -.09 -.09 -.18 -.11 -.09 -.12 3. Age of Parent 1.00 -.31 .12 .15 .04 .04 .08 4. Sex of Parent ----- 1.00 -.10 .04 -.02 .06 .00 5. Life Skills Profile 1.00 .21 .30 .38 .22 6. Esteem 1.00 .45 .20 .29 7. Mastery ----- 1-00 .25 .24 8. Community Support 100 .20 9. Cohesion 1 0 0 Equation Number 1 . Dependent Variable"Lack of Information" Variables Entered B Beta F Significance F Cohesion -.01 -.11 1.99 .16 Sex of Parent .43 .14 3.39 .07 Sex of Child .31 .10 1.83 .18 Community Support -.25 -.19 5.36 .02 Age of Parent -.02 -.14 3.24 .07 Mastery -.17 -.12 2.14 .15 Life Skills Profile -.51 -.21 6.43 .01 Esteem -.17 -.09 1.18 .28 : 7.65 Significance F = .00 R = .32 DFRegression 8 Adjusted R = .28 Residual 132 R=.56 217 Table F15 Standard Multiple Regression Of Demographic. Resource. And Life Skills Variables On Primary Appraisal "Relations With The Community" Correlation Variables 1 2 3 4 5 6 7 1. Relations with Community(PA) 1.00 .21 -.37 -.30 -.37 -.25 -.26 2. Sex of Parent 1.00 -.10 .04 -.08 .06 .00 3. Life Skills Profile 1.00 .21 .30 .38 .22 4. Esteem 1.00 .45 .20 .29 5. Mastery 1.00 .25 .24 6. Community Support 1.00 .20 7. Cohesion 1.00 Equation Number 2 Dependent Variable"Relations With The Community" Variables Entered B Beta F Cohesion -.01 -.11 2.06 Sex of Parent .48 .18 5.69 Community Support -.10 -.08 .906 Esteem -.21 -.12 2.17 Life Skills Profile -.48 -.21 6.62 Mastery -.24 -.19 5.04 F = 8.36 Significance F = .00 DFRegression 6 Residual 134 Significance F .15 .02 .34 .14 .01 .03 R=.27 Adjusted R_= .24 R = .52 218 Table F16 Standard Multilple Regression Of Demographic. Resource. And Life Skills Variables On Primary Appraisal "Relations Within The Family" Correlation Variables 1 2 3 4 5 6 7 8 9 1. Relations Within the Family 1.00 .18 -.19 -.41 -.33 -.49 -.27 -.24 -.37 2. Sex of Child - — 1.00 .02 -.09 -.18 -.11 -.18 -.09 -.12 3. Other Child With Disability - — 1.00 .13 .03 .12 .10 -.03 .29 4. Life Skills Profile ----- LOO .21 .30 .16 .38 .22 5. Esteem ----- 1 00 .45 .30 .20 .29 6. Mastery ----- 1-00 .29 .25 .24 7. Expressive Support 1 00 .24 .42 8. Community Support — - 100 .20 9. Cohesion 100 Equation Number 3 Dependent Variable "Relations Within the Family" Variables Entered B Beta F Cohesion -.02 -.19 5.27 Sex of Child .28 .08 1.43 Community Support -.01 -.01 .01 Other Child with Disability -.21 -.07 .84 Mastery -.50 -.33 17.04 Life Skills Profile -.63 -.24 9.39 Expressive Support -.04 -.02 .04 Esteem -.10 -.05 .41 Significance F .02 .23 .92 .36 .00 .00 .85 .52 10.09 Significance F_= .00 R = .38 DF Regression 8 Adjusted R = .34 Residual 132 R=.62 219 Standard Multiple Regression Of Demographic. Resource. And Life Skills Variables On Primary Appraisal "Problems Table F17 in Daily Functioning" Correlation Variables 1 2 3 4 5 6 7 8 1. Problems Functioning 1.00 -.34. .23 -.35 -.43 -.53 -.26 -.31 2. AgeofParent 1.00 -.31 .12 .15 .04 .06 .08. 3. Sex of Parent ----- 1.00 -.10 .04 -.08 .12 .00 4. Life Skills Profile - — 1-00 .21 .30 .16 .22 5. Esteem ----- 1-00 .45 .31 .29 6. Mastery ----- 1 00 .29 .24 7. Expressive Support 1 0 ° -42 8. Cohesion 1 0 0 Equation Number 4 Dependent Variable "Problems Functioning" Variables Entered B Beta F Significance F Cohesion -.01 -.11 2.45 .12 Sex of Parent .42 .13 3.58 .06 Life Skills Profile -.37 -.14 4.21 .04 Esteem -.32 -.16 4.71 .03 AgeofParent -.03 -.23 11.39 .00 Expressive Support -.10 -.04 .374 .54 Mastery -.53 -.36 22.72 .00 F_= 16.38 Significance F = .00 R = .46 DF Regression 7 Adjusted R = .43 Residual 133 R_= .68 220 Table Fl8 Standard Multiple Regression of Demographic and Resource Variables on Primary Appraisal "Worry About the Future" Correlation Variables 1. Worry About the Future (PA) 2. Sex of Parent 3. Esteem 4. Mastery 5. Family Influence 1 1.00 .21 1.00 -.24 .04 1.00 -.27 -.07 .45 1.00 -.27 -.16 -.04 .07 1.00 Equation Number 5 Dependent Variable "Worry About the Future Variables Entered B Beta F Significance F Family Influence -.51 -.24 8.75 .00 Esteem -.29 -.18 4.24 .04 Sex of Parent .44 .17 4.46 .04 Mastery -.19 -.15 3.01 .09 F_= 7.38 Significance F = .00 R=.18 DF Regression 4 Adjusted R = .16 Residual 132 R=.43 Standard Multiple Regression of Resource and Primary Appraisal Variables on Secondary Appraisal "Situation is One 221 Table F l 9 I Could Change Or Do Something About" Correlation Variables 1 2 3 4 1. Could Change Situation (SA) 1.00 .33 .24 -.31 2. Mastery 1.00 .29 -.49 3. Expressive Support 1.00 -.26 4. Relations Within Family (PA) 1.00 Equation Number 6 Dependent Variable "Situation is One I Could Change Or Do Something About" Variables Entered B Beta F Significance F Relations Within Family -.24 -.18 3.69 .06 Expressive Support .40 .13 2.37 .13 Mastery .43 .21 5.20 .02 F = 8.36 Significance E - 00 R = . 15 DF Regression 3 Adjusted R = .14 Residual 137 R=.39 Note. PA indicates Primary Appraisal; SA indicates Secondary Appraisal Standard Multiple Regression Of The Resource "Self-Esteem" On Secondary Appraisal "Situation Is One I Have To 222 Table F20 Accept" Correlation Variables 1 2 1. Have to Accept Situation (SA) 1.00 .22 2. Esteem 1.00 Equation Number 7 Dependent Variable "Situation Is One I Have To Accept" Variables Entered B Beta F Significance F Esteem .49 .22 6.90 .00 F = 6.90 Significance F = .01 R=.05 DF Regression 1 Adjusted R_= .04 Residual 139 R=.22 Note. SA indicates Secondary Appraisal 223 Table F21 Standard Multiple Regression Of Primary Appraisal "Lack Of Information And Problems In Communication" On Secondary Appraisal "Needed To Know More Before I Could Act" Correlation Variables 1. Needed To Know More (SA) 2. Lack Of Information (PA) 1 1.00 .35 1.00 Equation Number 8 Dependent Variable "Needed To Know More Before I Could Act" Variable Entered Lack Of Information B .49 Beta .35 F 18.86 Significance F .00 18.86 Significance F = .00 DF Regression 1 Residual 139 R=.12 Adjusted R = .11 R=.35 Note. PA indicates Primary Appraisal; SA Indicates Secondary Appraisal 224 Table F22 Standard Multiple Regression O f Demographic. Resource. Life Skills And Primary Appraisal Variables On Secondary Appraisal. "Had To Hold Back From Doing What I Wanted To Do" Correlation Variables 1 2 3 4 5 6 7 8 9 1. Had To Hold Back (SA) 1.00 -.24 .19 -.24 -.36 -.27 -.24 -.33 .53 2. Age of Parent 1.00 -.02 .15 .04 -.03 .08 .22 -.27 3. Sex of Child 1.00 -.18 -.11 -.09 -.12 -.16 .16 3. Esteem 1.00 .45 .20 .29 .19 -.40 4. Mastery 1.00 .25 .24 .34 -.50 5. Community Support 1.00 .20 .35 -.21 6. Cohesion 1.00 .27 -.34 7. Nonturbulence 1.00 -.42 8. Cumulative PA 1.00 Equation Number 9 Dependent Variable "Had To Hold Back From Doing What I Wanted To Do" Variables Entered B Beta F Significance F Cumulative P A .65 .36 15.03 .00 Sex of Child .47 .10 1.98 .16 Age of Parent -.03 -.13 2.93 .09 Community Support -.23 -.11 2.06 .15 Cohesion -.01 -.04 .25 .62 Esteem .10 .04 .20 .65 Nunturbulent Behaviour -.15 -.05 .33 .57 Mastery -.25 -.12 1.85 .18 F = 8.14 Significance F_= .00 R = .33 DF Regression Residual 132 Adjusted R = .29 R=.58 Note. PA indicates Primary Appraisal; SA indicates Secondary Appraisal 225 Table F23 Standard Multiple Regression Of Demographic and Appraisal Variables On "Confrontive" Coping Correlation Variables 1 2 3 4 5 6 1. Confrontive Coping 1.00 .24 .22 .22 .21 .23 2. Sex of Parent - — 1.00 .22 .19 .23 .13 3. Marital Status of Parent 1.00 .07 .03 -.02 4. Lack of Information (PA) 1.00 .61 .44 5. Problems Functioning (PA) 1.00 .54 6. Had to Hold Back (SA) - — 1.00 Equation Number 10 Dependent Variable "Confrontive" Coping Variables Entered B Beta F Significance F Had to Hold Back (SA) .04 .16 2.67 .11 Marital Status of Parent .21 .18 5.02 .03 Sex of Parent .17 .15 3.29 .07 Lack of Information (PA) .03 .09 .76 .39 Problems Functioning (PA) .01 .04 .11 .74 F_= 4.46 Significance F = .00 R = . 14 DF Regression 5 Adjusted R_=. 11 Residual 135 R=.38 Note. PA indicates Primary Appraisal; SA indicates Secondary Appraisal 226 Table F24 Standard Multiple Regression Of Demographic. Resource. And Appraisal Variables On "Distance" Coping Correlation Variables 1 2 3 4 5 1. Distance Coping 1.00 .20 .18 -.22 .21 2. Time Since Onset 1.00 .03 -.03 -.16 3. Sex of Child - — 1.00 -.09 .19 4. Community Support 1.00 -.27 5. Had to Hold Back (SA) 1.00 Equation Number 11 Dependent Variable "Distance" Coping Variables Entered B Beta F Significance F Had To Hold Back (SA) .05 .17 4.11 .05 Time Since Illness Onset .02 .22 7.05 .01 Sex of Child .16 .12 2.15 .15 Community Support -.09 -.16 3.64 .06 F = 5.26 Signif icance^ .00 R = .13 JDF Regression 4 Adjusted R =. 11 Residual 136 R=.37 Note. SA indicates Secondary Appraisal 227 Table F25 Standard Multiple Regression of Demographic. Resource. And Appraisal Variables On "Self-Control" Coping Correlation Variables 1 2 3 4 5 6 7 8 1. Self-Control Coping 1.00 .22 .24 -.28 .25 .35 -.19 .30 2. Sex of Parent 1.00 .22 -.07 .21 .22 -.16 .12 3. Marital Status pf Parent 1.00 .06 .05 .05 -.07 -.00 4. Mastery 1.00 -.27 -.53 .07 -.35 5. Worry about the Future(PA) 1.00 .46 -.27 .23 6. Problems Functioning (PA) 1.00 -.07 .52 7. Overt Family Influence 1.00 -.08 8. Had to Hold Back (SA) 1.00 Equation Number 12 Dependent Variable 'Self-Control" Coping Variables Entered B Beta F Had to Hold Back(SA) .04 .15 2.69 Marital Status of Parent .26 .21 7.26 Overt Family Influence -.12 -.12 2.07 Sex of Parent .10 .08 1.03 Mastery -.08 -.14 2.33 Worry about the Future (PA) .03 .06 .39 Problems Functioning (PA) .05 .14 1.57 Significance F .10 .01 .15 .31 .13 .53 .21 5.72 Significance F = .00 DF Regression Residual 129 R = .24 Adjusted R = .20 R=.49 Note. PA indicates Primary Appraisal; SA indicates Secondary Appraisal 228 Table F26 Standard Multiple Regression Of Demographic. Resource. And Life Skills Variables On "Seek Social Support" Coping Correlation Variables 1 2 3 4 5 6 1. Seek Social Support 1.00 -.22 .24 .20 .34 -.22 2. Age of Parent - — 1.00 -.31 .08 .06 .22 3. Sex of Parent - — 1.00 .22 .12 -.16 4. Marital Status of Parent 1.00 -.03 -.10 5. Expressive Support 1.00 .15 6. Nonturbulent Behaviour — 1.00 Equation Number 13 Dependent Variable "Seek Social Support "Variables Entered B Beta F Significance F Nonturbulent Behaviour -.26 -.20 6.95 .01 Marital Status of Parent .35 .20 6.61 .01 Expressive Support .48 .38 25.32 .00 Age of Parent -.02 -.20 6.02 .02 Sex of Parent .09 .05 .42 .52 F = 9.92 Significance F = .00 R_= .27 DF Regression 5 Adjusted R = .24 Residual 135 R=.51 229 Table F27 Standard Multiple Regression Of Demographic. Resource. Life Skills. And Appraisal Variables On "Accepting Responsibility" Coping Correlation Variables 1 . 2 3 4 5 6 7 1. Accept Responsibility Coping 1.00 .19 .20 -.21 -.35 .38 .41 2. Sex of Parent 1.00 -.09 .04 -.16 .23 .13 3. Sex of Child 1.00 -.18 -.16 .14 .19 4. Esteem 1.00 .19 -.43 -.24 5. Nonturbulent Behaviour 1.00 -.33 -.33 6. Problems Functioning (PA) 1.00 .54 7. Had to Hold Back (SA) 1.00 Equation Number 14 Dependent Variable "Accept Responsibility" Coping Variables Entered B Beta F Significance F Had to Hold Back (SA) .07 .22 6.10 .02 Sex of Parent .15 .11 1.90 .17 Sex of Child .15 .11 1.94 .17 Esteem -.04 -.04 .27 .60 Nonturbulent Behaviour -.19 -.19 5.53 .02 Problems Functioning (PA) .06 .13 1.85 .18 7.81 Significance F = .00 DF Regression Residual 134 R = .26 Adjusted R = .23 R=.51 Note. PA indicates Primary Appraisal; SA indicates Secondary Appraisal 230 Table F28 Standard Multiple Regression Of Demographic. Resource. Life Skills. And Appraisal Variables On "Escape- Avoidance" Coping Correlation Variables 1 2 3 4 5 6 7 8 9 1. Escape/Avoidance 1.00 -.28 -.37 -.48 -.25 -.22 .55 -.22 .42 2. Age of Parent 1.00 .15 .04 -.04 .22 -.27 -.12 -.24 3. Esteem — 1.00 .45 .20 .19 -.40 .12 -.24 4. Mastery 1.00 .25 .34 -.50 .33 -.36 5. Community Support 1.00 .35 -.29 .16 -.27 6. Nonturbulent Behaviour 1.00 -.42 -.08 -.33 7. Cumulative PA's 1.00 -.19 .53 8. Could Change Situation (SA) 1.00 .07 9. Had to Hold Back (SA) 1.00 Equation Number 15 Dependent Variable "Escape-Avoidance" Coping Variables Entered B Beta F Had to Hold Back (SA) .04 .15 3.12 Could Change Situation (SA) -.03 -.09 1.56 Age of Parent -.01 -.19 6,93 Esteem -.07 -.09 1.24 Community Support -.05 -.09 1.53 Nonturbulent Behaviour .09 .10 1.61 Mastery -.13 -.22 6.35 Cumulative PA's .14 .27 8.57 Significance F .08 .22 .01 .27 .22 .21 .01 .00 E = 11.97 DF Significance JL= .00 Regression 8 Residual 132 R=.42 Adjusted R = .39 R=.65 Note. PA indicates Primary Appraisal; SA indicates Secondary Appraisal 231 Table F29 Standard Multiple Regression O f Demographic. Resource. And Appraisal Variables On "Planful Problem-Solving" Coping" Correlation Variables 1 2 3 4 5 6 7 1. Planful Problem-Solving 1.00 .26 .21 .24 .24 -.20 .23 2. Sex of Parent 1.00 .22 .13 .21 -.16 .02 3. Marital Status of Parent 1.00 -.04 .05 -.07 -.07 4. Expressive Support 1.00 -.07 -.06 .00 5. Worry About the Future (PA) 1.00 -.27 .07 6. Overt Family Influence 1.00 .02 7. Need to Know More (SA) 1.00 Equation Number 16 Dependent Variable "Planful Problem-Solving" Variables Entered B Beta F Significance F Need to Know More (SA) .08 .23 8.98 .00 Expressive Support .24 .24 9.6 .00 Overt Family Influence -.13 -.11 1.82 .18 Marital Status of Parent .27 .20 6.27 .01 Sex of Parent .18 .13 2.43 .12 Worry About the Future (PA) .10 .18 4.84 .03 F = 7.16 Significance F = .00 E_= .25 DF Regression 6 Adjusted R = .21 Residual 130 R = .50 Note. PA indicates Primary Appraisal; SA indicates Secondary Appraisal 232 Table F30 Standard Multiple regression Of Demographic. Illness. And Appraisal Variables On "Positive Reappraisal" Coping Correlation Variables 1 2 3 4 5 6 7 1. Positive Reappraisal 1.00 .31 .18 .22 .25 .22 .30 2. Sex of Parent 1.00 .22 .02 -.05 .11 .04 3. Marital Status of Parent 1.00 -.10 -.05 -.11 -.06 4. Sociability of Child 1.00 .14 -.03 .01 5. Could Change Situation (SA) 1.00 -.03 .16 6. Have to Accept Situation (SA) 1.00 .20 7. Need to Know More (SA) 1.00 Equation Number 17 Dependent Variable "Positive Reappraisal" Coping Variables Entered B Beta F Significance F Need to Know More (SA) .08 .22 9.12 .00 Sociability of Child .19 .20 7.54 .01 Sex of Parent .37 .24 10.46 .00 Could Change Situation (SA) .08 .22 8.57 .00 Have to Accept Situation(SA) .08 .18 6.00 .02 Marital Status of Parent .29 .19 6.22 .01 F = 10.04 Significance F_= .00 R = .31 DF Regression 6 Adjusted R = .28 Residual 133 R=.56 Note. SA indicates Secondary Appraisal.

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