Special Section: A Memorial Tribute: Prosocial Family Processes and the Quality of Life of Persons With Schizophrenia

The data are from the third wave of a longitudinal survey of 295 aging families of adults with schizophrenia. Families were recruited through community support programs, the local media, and the National Alliance on Mental Illness. Mothers were the primary family respondent and were asked to participate if they met three criteria: the mother was aged 55 years or older, the mother reported that her son or daughter had been diagnosed by a psychiatrist as having schizophrenia or schizoaffective disorder, and the mother provided at least weekly assistance with a major activity of daily living to her son or daughter with mental illness. Mothers completed a two-hour in-home interview and self-administered questionnaire. With the mother's consent, the son or daughter was asked to complete a self-administered questionnaire. Data from the adult child was collected within three weeks, on average, after the mother's interview. Informed consent was obtained for all study participants. The institutional review board of the University of Wisconsin-Madison approved all the procedures for the protection of human subjects.

Table 2 reports the correlations between the three measures of prosocial family variables and the life satisfaction of the adult with schizophrenia. All three indicators of prosocial family processes were significantly correlated with the life satisfaction of the adult with schizophrenia, with maternal warmth having the strongest correlation with life satisfaction.

The results of the regression analyses are shown in Table 3 . Because the control variables were entered on the first step, the coefficients for these variables are similar across the three models, which differ only with respect to the prosocial family measure entered on the second step. As shown in step 1, adults with schizophrenia who self-reported more depressive symptoms had significantly lower levels of life satisfaction. In addition, adults who had more close friends had significantly higher levels of life satisfaction. The adult's level of functioning, gender, and age were unrelated to the adult's life satisfaction.

As shown in Table 3 in models 1, 2, and 3, all three prosocial family processes were significantly related to higher levels of life satisfaction when the analysis controlled for the adult's gender, age, level of depressive symptoms, functional status, and number of close friends. The expression of greater warmth by the mother during the FMSS was associated with higher levels of life satisfaction among adults with schizophrenia (see model 1). Warmth contributed an additional 3 percent of the variance in life satisfaction above and beyond the variance explained by the gender, age, level of depressive symptoms, functioning, and number of close friends of the adult with schizophrenia. Similarly, as shown in model 2, higher levels of maternal praise were related to greater life satisfaction among adults with schizophrenia. Entering maternal praise into the model explained an additional 3 percent of the variance in the adult's life satisfaction. Finally, as shown in model 3, adults with schizophrenia had significantly higher levels of life satisfaction when their mothers reported that they shared a close and mutually supportive relationship. The quality of relationship between the mother and adult child explained an additional 2 percent of the variance in life satisfaction.

Lopez and colleagues ( 2 ) were among the first to search for family prosocial behaviors that promoted the well-being of persons with mental illness. In the tradition of research on expressed emotion, they focused on the role of these prosocial processes in reducing relapse among persons with schizophrenia. Our findings point to the promise of extending this work on the effects of these prosocial processes to recovery-oriented outcomes, such as the life satisfaction of individuals with serious mental illness.

Adults with schizophrenia reported a higher quality of life when their mothers displayed higher levels of warmth and their mothers described them in a more affirming and validating way. When parents provide a nurturing environment and offer praise, the child is encouraged to view himself or herself more positively ( 9 ). The importance of parental warmth and positive parental appraisals may be even more significant for adults with severe mental illness, who often confront acts of stigma or discrimination on a daily basis. Our findings as well as past research on the contributions of persons with mental illness to their family ( 29 ) suggest that when family members are able to look beyond their relative's deficits and recognize and affirm the relative's strengths, not only is their own burden reduced ( 30 ) but they also may contribute to the overall quality of life of their loved one. However, many families struggle with their relative's mental illness and may have difficulty stepping back to reflect on their relative's positive attributes without the encouragement of mental health clinicians. Falloon and colleagues ( 31 ) have developed a behavioral family therapy intervention that incorporates therapeutic strategies for strengthening prosocial family processes. The intervention involves individual and family sessions, in which information about mental illness is shared, and communication and problem solving skills are taught in an effort to help family members support and affirm the positive qualities in one another.

The parenting literature suggests that a supportive relationship between the parent and adult child has a modest but significant effect on the psychological well-being of adult children ( 32 ), which is similar to the pattern found here. Mental health researchers have devoted considerable effort toward identifying factors that promote friendships because of the importance of these relationships to the quality of life of persons with schizophrenia ( 33 ). However, little is known about the factors that promote close relationships between adults with schizophrenia and their parents. Identifying these factors is a necessary first step toward the goal of developing interventions to strengthen these family bonds. The current practice of including clients in multiple-family groups might be encouraged in all family psychoeducation programs, as it provides an opportunity for adults with mental illness and their family members to work together to form a more supportive and understanding relationship ( 34 ).

We conducted an exploratory qualitative post hoc analysis of the FMSS transcripts in an effort to identify specific prosocial maternal behaviors associated with high levels of life satisfaction among individuals with schizophrenia. We compared 20 mother-adult child dyads: ten dyads in which the mother had high scores on the indicators of prosocial family processes and the adult with schizophrenia reported high levels of life satisfaction and ten dyads who had low scores on these measures. This analysis revealed three types of prosocial behaviors associated with high levels of client life satisfaction. First, mothers in the high prosocial group initiated activities that supported their son or daughter's sense of being a competent adult. These activities were ones that their son or daughter enjoyed and could do well, such as gardening, playing board games, or engaging in a sports activity. Second, mothers in the high prosocial group were more likely to acknowledge and affirm small steps that their son or daughter made toward recovery, even when the adult fell short of the goal. For example, one mother spoke of the courage and determination her son showed in making attempts to return to school after experiencing several setbacks. Third, mothers in the high prosocial group were less reactive to displays of negative symptoms (for example, lack of conversation and detached behavior). Whereas mothers in the low prosocial group expressed their frustration and desire to change negative symptoms, mothers in the high prosocial group were more accepting of these symptoms. For example, a mother in the high prosocial group responded sympathetically when her son was feeling stressed by the stimulation at a large family dinner and wanted to return to his room. In contrast, a mother in the low prosocial group reacted to a similar situation by becoming quite upset with her son for wanting to retreat to his room.

On a related note, mothers who displayed high levels of prosocial behavior seemed able to separate the person from the illness. In the words of one mother, "He's a very gentle person, but the illness, when it manifests itself, it makes him into somebody completely different … angry, hostile, somebody who is ruled by voices." Mothers in the low prosocial group had great difficulty separating the symptoms from the person. They were more likely to perceive symptoms as willful and to respond with criticism and anger. This post hoc analysis speaks to the continued need for mental health professionals to educate families about the symptoms of schizophrenia and to teach families more adaptive strategies of coping with behavioral manifestations of the illness. It also reminds us that many families have a great deal of "practice wisdom" and have much to teach mental health providers about how to most effectively intervene with their adult child with schizophrenia.

There are several limitations to this study that should be noted. First, our sample was drawn from clients with schizophrenia or schizoaffective disorder who were living in one Midwestern state and had regular contact with their mothers. Our sample is also limited by its ethnic and racial homogeneity; less than 10 percent of the sample was from an ethnic minority cultural group, which potentially reduced the generalizability of the findings. Second, our attrition analysis suggests that the sample of 122 mother-adult child dyads has a small bias toward the mother's expressing higher levels of warmth and having a better quality of relationship with her adult child. Mothers with these characteristics may possess other traits, such as a high level of motivation or commitment toward helping their adult child, which may influence the strength of the relationship between these prosocial processes and the quality of life of the adult with schizophrenia.

Third, the measurement of prosocial family factors was based on data collected from mothers because of their role as the primary caregiver when this study began. Although sampling the primary caregiver is a common practice in studying families of persons with serious mental illness, future research needs to determine if these prosocial processes have similar effects when enacted by other family members.

Fourth, and most important, given the cross-sectional and correlational nature of the data, causality cannot be established. In this study we focused on the relationship of maternal prosocial processes to the life satisfaction of adults with schizophrenia, in part, because the life satisfaction data were collected from the adult with schizophrenia after the mother's interview, during which the prosocial measures were administered. However, an alternative hypothesis is that clients with higher levels of life satisfaction may interact in ways that evoke more positive responses from their parents. Clearly, the nature and persistence of the client's symptoms and behaviors affect the parent's response to the child, as demonstrated by King and Dixon ( 14 ), who found that maternal criticism was in response to disturbed behavior of the individual with schizophrenia. Goldstein and colleagues ( 10, 15 ) conducted a series of studies showing the complex mutually influencing interplay between the clinical functioning of the adult with schizophrenia and the family's level of expressed emotion. Longitudinal studies are needed to examine the bidirectional relationships between these prosocial family processes and the quality of life of individuals with schizophrenia.

In addition, as suggested by our qualitative analysis, the display of low levels of warmth is often a very understandable family response given the nature of the behavior of the individual with schizophrenia and the family's limited knowledge about the negative symptoms of schizophrenia. We hope that rather than blaming families who are less warm or positive in their interactions, professionals can use their experiences to understand and empathize with these family reactions and help educate the family with the aim of promoting more positive relationships.

Counterbalancing these limitations are several unique strengths and features of this study. The sample captures a diverse group of individuals with respect to age, gender, symptoms, functional status, and physical health. The mother's data were collected three weeks, on average, before the data collection from the son or daughter with schizophrenia, giving us more confidence in the temporal ordering of the relationship between prosocial family processes and client satisfaction. Third, we included three indicators of prosocial processes. The convergence of the findings across the three indicators increases our confidence that the results are robust.

This study speaks to the importance of family support in the lives of individuals with schizophrenia. In the mental health field, the emphasis has been on fixing families, most typically by lowering their expressed emotion, with relatively little emphasis on the families' strengths, in particular the families' role in enhancing the life satisfaction of their loved one by being there as a source of support. As a recovery orientation focuses on the strengths of consumers, it should also focus equally on the supportive presence of families in the lives of many clients. We have much to learn about the effects different prosocial family processes have on the quality of life of persons with serious mental illness and how these positive family processes affect the course of the illness. By identifying these prosocial family processes, researchers can provide clearer guidelines for the development of interventions that promote recovery goals in the care of persons with mental illness.

Support for the preparation of this article was provided by grant R01-MH-55928 from the National Institute of Mental Health (NIMH) and by grant P30-HD-03352 from the National Institute of Child Health and Human Development, both through the Waisman Center at the University of Wisconsin-Madison, by grant T32-MH-065185 from NIMH through the School of Social Work at the University of Wisconsin-Madison, and by grant P30-MH-068579 from NIMH through the Center for Mental Health Services Research at the George Warren Brown School of Social Work, Washington University in St. Louis. The authors also thank Dorothy Edwards, Ph.D., and Mary Ann Test, Ph.D., for comments on early drafts of this article.

Dr. Greenberg and Ms. Aschbrenner are affiliated with the Waisman Center and with the School of Social Work, University of Wisconsin-Madison, 1350 University Avenue, Madison, WI 53706 (e-mail: [email protected]). Dr. Knudsen is with the Office of Program Evaluation and Research, Ohio Department of Mental Health, Columbus, Ohio.This article is part of a special section honoring the memory of three leaders in the psychosocial treatment of patients with severe and persistent mental disorders: Wayne S. Fenton, M.D., Gerard E. Hogarty, M.S.W., and Ian R. H. Falloon, M.D., D.Sc.