Harriet P. Lefley

Family burden and family stigma in major mental illness.

Mental illnesses are unique in their etiological attributions. They are categories of disorder treated by medical means but viewed as induced by the behavior of others. Despite increasing evidence of diathesis, on the one hand, and on the other, a wide range of nonfamilial environmental stressors that may trigger decompensation (Day et at., 1987), families continue to be viewed as primary toxic agents, particularly in schizophrenia. The hard data emerging from the replications of the expressed emotion (EE) research (Vaughn, Snyder, Jones, Freeman, & Falloon, 1984) and the documented success of correlative psychoeducational interventions (Hogarty et al., 1986) have shifted the emphasis from etiology to potential precipitants of relapse. The EE investigators have cautioned that their research neither implies causality nor explains the decompensation of patients who have little or no contact with families, so that extrafamilial environmental events must be explored (Vaughn et al., 1984). Indeed, many families are perturbed by the implication that, as primary targets of EE research and behavioral training, they may be viewed as the major caregivers of deinstitutionalized patients (Hatfield, 1987). This is an undesired social role with the potential for creating an at-risk population among aging parents, young children, and other relatives whose mental health may be affected by living with the stresses and sorrows occasioned by the psychotic disorder of a family member (Lefley, 1987b). The question of predictive deviance in families of persons with schizophrenia continues to be an issue (Goldstein, 1985) although the research data invariably demonstrate that investigator-defined patterns of deviance are in no way modal or normative in this population. In the EE research, moreover, the calm, benign affects of low EE rather than the critical overinvolvement of high EE are the prevailing worldwide norms among families of schizophrenic individuals (Jenkins, Karno, de la Selva, & Santana, 1986; Left& Vaughn, 1985), a finding that tends to contradict stereotypes of schizophrenogenesis. Over the years, numerous authors have cautioned that deviance in families, when observed, might be reactive to the experience of living with an individual who has a psychotic disorder. The reactive viewpoint, however, has focused largely on sympathetic or isomorphic responses to the cognitive deficits and aberrant communicative styles of the schizophrenic family member, rather than on the catastrophic impact of mental illness on the family system. Although there are claims ofepistemological confusion among those who infer directionality from systems-orielated approaches (Dell, 1980), the organizational/systems model, when contrasted with the biologically based stress/ vulnerability paradigm (Rohrbaugh, 1983), nevertheless assigns a functional value to the patients symptoms and views them as precipitated and maintained for familial homeostasis. In contrast, a conceptualization of families of the mentally ill in terms of a model of stress, coping, and adaptation (Hatfield & Lefley, 1987) views familial behaviors as coping strategies. These represent modes of adjustment, both positive and negative, to the chronic strain of long-term psychosis and its attendant patterns of crises and remissions.

Impact of mental illness in families of mental health professionals.

Family burden and coping strategies were investigated in 84 experienced mental health professionals with family members suffering from chronic major mental illnesses. The sample was nationally recruited from ads in professional journals. Personal reactions of respondents involved cognitive and attitudinal changes in conceptions of psychotic disorders and guarded relations with colleagues with respect to self-disclosure and case involvement. Financial and emotional burdens were substantial, with ongoing stressful life events, aversive patient behaviors, and poor treatment histories. In rating family coping strategies, mental health professionals showed a high degree of concordance with nonprofessional family members in assigning priority to education on symptoms, medications, and patient management techniques. Involvement with self-help groups and physical separation from patients were rated higher than individual or family therapy as aids in coping for families of the mentally ill.

Future involvement of siblings in the lives of persons with mental illness

Siblings are considered logical replacements for aging parental caregivers of persons with severe mental illness. For workshops on future planning conducted with 400 elderly parents, 60 siblings answered a survey regarding their future caregiving expectations, anticipated difficulties, and need for help. Nearly all expected to be involved, but were more likely to provide social and emotional support than the instrumental support offered by their parents. Nearly half indicated that the consumer’s hostility and lack of cooperation were major barriers to effective care. It was suggested that siblings need education and help from professionals in assessing behaviors, interacting appropriately, and conferring control of their own lives to their ill relatives. For consumers, social skills and self-esteem training in psychiatric rehabilitation programs should address the area of sibling relationships and reciprocity. Such issues should be dealt with early, rather than later in the course of illness

Public-academic linkages for culturally sensitive community mental health

AbstractsThis paper traces the sixteen year history of a unique community mental health center which has combined academic and service provider roles in delivery of culturally appropriate care. Initially an arm of a department of psychiatry and derived from an anthropological research project, the center model was based on seven teams serving discrete ethnic communities, with subsequent development of a network of neighborhood-based “mini-clinics” as well as centralized aftercare facilities. The team staff-social scientists, clinicians, and paraprofessionals all of matching ethnicity to the populations served-became a core of “culture brokers” with a service, teaching, and research role at the interface of the university, medical center, and community. Subsequently the university was funded for a cross-cultural training institute for mental health professionals. Center staff extended training in culturally appropriate care to 174 mental health professionals from 97 facilities throughout the nation, as well as other spinoffs improving cultural expertise of staff in public sector agencies. Data on effectiveness of services and training are given and significant findings are discussed. The description includes the impact of historical shifts in funding, the effects of external events on community mental health center structure, and the current state of cross-cultural training and public-academic linkages in this particular program.

Potential risk factors for rape in three ethnic groups

This article describes the frequency of possible risk factors that emerged during a cross-cultural study of psychosocial response to sexual assault among African-American, Hispanic, and non-Hispanic white women presenting for treatment at a major urban rape treatment center. Of 881 victims screened, 51% had no observable risk factors while 49% fell into categories of variables that previous research has associated with increased vulnerability. Included were mental disability (psychiatric or developmental), a prior history of rape or incest, tourist or visitor status (site unfamiliarity), and homelessness. Ethnic groups differed significantly in these categories, suggesting socioeconomic and cultural variables that may affect rape statistics and that should be taken into account in rape prevention programs in the community.

Training professionals to work with families of chronic patients

This paper describes a multidisciplinary (psychiatry, psychology, social work) training program which prepares clinicians to work in a collaborative relationship with families of the chronically mentally ill. Content includes an overview of traditional approaches to family roles in major mental illnesses, research findings on family burden, typology of professional-family interactions, and treatment and outcome issues related to older conceptual models of family-patient relationships. The training model includes a didactic component on relevant research and theory, incorporating social policy and cross-cultural issues and emphasizing the actual experiences of patients and families within a framework of coping and adaptation. Training in patient and family education, problem management, supportive counseling, and resource knowledge is accompanied by practicum experiences involving longitudinal work with chronic patients and families. Special features in psychiatric residency training are highlighted.

Impact of cross-cultural training on black and white mental health professionals☆

Abstract In a 3-year period, 174 mental health professionals received intensive 8-day cross-cultural/interracial communication workshops involving didactic, transactional, experiential, and cultural immersion techniques. Comprehensive evaluation strategies investigated changes in social distance, attitudes, and values comprehension, as well as improvement in therapeutic performance. Comparison of 68 white and 54 black clinical practitioners indicated significant differences in impact, with the former more oriented toward cognitive and attitudinal change, and the latter toward insight into personal identity and role conflict. Among white trainees, increased values comprehension, increased agreement with preferential treatment for minorities, and decreased social distance to tri-ethnic (black, Hispanic, white) stimulus figures at three socioeconomic status (SES) levels, were associated with improved therapeutic skills with a poor black client. Among black trainees, self-distancing responses to social, attitudinal, and values items which implied both acknowledgment and rejection of “black professional” identity, were associated with highly significant improvement in therapeutic performance with a poor black client. In addition to demonstrated efficacy in building knowledge and skill, cross-cultural training appears to be a consciousness-raising process for minority professionals conflicted about culture-abandonment and irrelevancies in clinical training.

Training professionals to work with the chronically mentally ill

The community mental health movement in recent years has not only lost much of the magic of the 60s but ironically has been accused of the same failures that plagued the state hospital movement of the nineteenth century. Although the success or failure of the movement depends to some extent on ones point of view, any social reform movement can only be as effective as the quality of its human tools. The movement began with great expectations that somehow severely mentally ill people could be removed from hospitals and treated in the new community mental health centers. However, no one prepared the mental health centers for what they were supposed to be doing and no one prepared the staff of those centers with skill, attitude, and knowledge bases that fit the needs of the target population. Although the federal government had lists of vaguely structured mandated services, such as outpatient, inpatient, day treatment, and 24 hour emergency service, to be provided to certain population groups, no one in the 1960s had any idea of the sorts of support elements that might be necessary to work with severely mentally disabled individuals in the community. It

Etiological and prevention views of clinicians with mentally ill relatives.

In a survey of 84 experienced mental health professionals with family members suffering from long-term psychotic disorders, more than 70% ranked biogenetic variables as primary, regardless of familial relationship to the patient. Family interactions and parenting were minimized as etiological factors. Biochemical/genetic research, psychopharmacological research, and research on high-risk children were the highest ranked prevention priorities.

Social and familial correlates of self esteem among American Indian children

Children. CHrLD DEVELOPMENT, 1974, 45, 829-833. Social and familial correlates of selfesteem (SE), in relation to tribal acculturation, were investigated in 72 American Indian reservation children who had shown highly significant negative SE relative to Anglo norms. Ss were 34 Miccosukee and 38 Seminole children and their mothers (N = 32), all of the same ethnolinguistic group. Results indicated that although the tribes did not differ in socialization practices, both mothers and children in the less acculturated, more socially intact tribe (Miccosukee) had significantly higher SE than more acculturated (Seminole) counterparts. Across tribes, (a) girls were significantly higher in SE and perceived parental love than boys, and (b) daughters SE was positively correlated with maternal SE, and sons SE with perceived parental love. Findings were discussed in terms of the interaction of familial and sociocultural variables.