conceptualizing family members of violent mentally ill individuals as a vulnerable population

Issues in Mental Health Nursing, 28:943–975, 2007Copyright c© Informa Healthcare USA, Inc.ISSN: 0161-2840 print / 1096-4673 onlineDOI: 10.1080/01612840701522127

CONCEPTUALIZING FAMILY MEMBERS OFVIOLENT MENTALLY ILL INDIVIDUALS ASA VULNERABLE POPULATION

Darcy A. Copeland, RN, PhDUniversity of Portland, Portland, Oregon, USA

A review of literature concerning familial violence andmental illness using the Vulnerable Populations ConceptualModel (VPCM) as an organizing framework is presented.Since family members are most likely to be targets if aperson who is mentally ill becomes violent, this reviewemphasizes the VPCM concepts of resource availability(including capital, stigma, and access to healthcare), risk,and health status of those family members. Thepopulation-based VPCM was used in an attempt to movethe examination of this phenomenon from a focus on theindividual to a conceptualization of it as family violenceoccurring within a broader, social context.

Mental health providers tend to focus on the primary psychiatric pa-tient as the only person in need of services; but doing so may inadver-tently invalidate, underestimate, or ignore the needs of family memberswho often serve as caregivers for that patient. Caregivers, specificallyfamily members, of mentally ill individuals face a multitude of chal-lenges. For some family members one of these challenges may includeexposure to their relative’s violent behavior. While it is acknowledgedthat mentally ill individuals can be victims of violence or abuse per-petrated by family members, many researchers investigating assaultive

The author would like to thank dissertation committee members Drs. MarySue Heilemann,Nancy Anderson, and Sally Maliski from the UCLA School of Nursing and Dr. Susan Sorensonfrom the University of Pennsylvania School of Social Policy and Practices for their assistance andsupport. Funding support for dissertation related research activities was being made possible throughNational Institute of Nursing Research grant 5 T32 NR 07077, Vulnerable Populations/HealthDisparities Research at UCLA School of Nursing and a Sigma Theta Tau, Gamma Tau Chapterresearch grant.

Address correspondence to Darcy A. Copeland, University of Portland, School of Nursing,5000 North Willamette Blvd., Portland, OR 97203-5798. E-mail: [email protected]

943

944 D. A. Copeland

psychiatric patients report that family members are the victims of a men-tally ill relative’s violent acts more than 50% of the time (APA, 1996;Nestor, Haycock, Doiron, Kelly, & Kelly, 1995; Steadman et al., 1998).In general, the most common family member targeted is a parent (Binder& McNeil, 1986; Straznickas, McNeil, & Binder, 1993).

There is an abundance of scientific literature addressing the relation-ship between violent behavior and mental illness, but the majority ofthese studies address the issue from an individualistic perspective. It islargely addressed with respect to the violent mentally ill individual’s de-mographic, clinical, psychosocial, or historical/criminal characteristics(Estroff et al., 1994; Estroff et al., 1998; Estroff & Zimmer, 1994; Nestoret al., 1995; Steadman et al., 1998; Straznickas, McNeil, & Binder, 1993;Stuart & Arboleda-Florez, 2001; Swanson, Holzer, Ganju, & Jono, 1990;Swanson et al., 2000; Swanson et al., 2002; Tardiff, Marzuk, Leon, &Portera, 1997). Violence in families that is perpetrated by an individualwho is mentally ill is rarely conceptualized under the broad umbrella offamily violence.

In order to make the wealth of information regarding violence andmental illness, emphasizing familial violence, more accessible, a lit-erature review of the current state of knowledge on familial vio-lence perpetrated by a mentally ill individual is presented. The Vul-nerable Populations Conceptual Model developed by Flaskerud andWinslow (1998) is a population-based model used as the organizingframework to review the literature about this unique form of fam-ily violence from a social rather than an individual perspective. Theuse of this model allows the review of literature to focus on spe-cific concepts relevant to this phenomenon and provides the opportu-nity to increase coverage of issues that have lacked attention in thepast.

THE VULNERABLE POPULATIONS CONCEPTUAL MODELAND FAMILY MEMBERS OF VIOLENT MENTALLYILL INDIVIDUALS

Vulnerable populations are those social groups who experience in-creased relative risk or susceptibility to adverse health outcomes as aresult of limited resource availability (Flaskerud & Winslow, 1998).Vulnerable populations may also be described as those groups in societywho experience health disparities, defined by the National Institutes ofHealth (NIH) as “differences in the incidence, prevalence, mortality, andburden of diseases and other adverse health conditions that exist amongspecific population groups in the United States” (NIH, n.d, ¶ 6).

Family Members as a Vulnerable Population 945

The Vulnerable Populations Conceptual Model (VPCM) emphasizescommunity health and therefore stresses opportunities and resourcesavailable in the community that help its members achieve and maintainoptimal health (Flaskerud & Winslow, 1998). The conceptual model(see Figure 1) proposes four relationships among the concepts of re-source availability, relative risk, and health status. Model concepts aredefined in Table 1. The four proposed relationships are: 1. lack of re-sources increases relative risk, 2. increased exposure to risk factors leadsto increases in morbidity and mortality, 3. at the same time, compromisesin health status may intensify ongoing exposure to risk factors, and4. patterns of morbidity and mortality in a community may deplete ex-isting resources further compromising their availability. Practice andeducation issues, research, and ethical and policy analysis may be di-rected at any of the concepts directly or the relationships among themin the VPCM (Flaskerud & Winslow, 1998). Analysis of these con-cepts may help illuminate the factors contributing to a specific socialgroup’s health disparity and give direction to primary, secondary, or ter-tiary interventions to be utilized in practice to alleviate those disparities.Because family members of mentally ill individuals have been shownto be at increased risk of victimization if their relative becomes violent

FIGURE 1. Vulnerable Populations Conceptual model applied to family mem-bers of mentally ill individuals. From “Conceptualizing vulnerable populationshealth-related research,” by J.H. Flaskerud and B.J. Winslow, 1998, NursingResearch, 47(2), p. 70. Copyright 1998 by Lippincott Williams & Wilkins.Adapted with permission.

946 D. A. Copeland

TABLE 1. Vulnerable Populations Conceptual Model Concepts Defined

Model concept Definition

Resource availability Socio-economic and environmental resources includinghuman capital such as employment, income, education,and housing. Social disconnection, or the degree to whicha social group experiences marginalization, stigmatizationor discrimination is a characteristic of resourceavailability. Social status and access to and quality ofhealthcare, are also aspects of resource availability.

Relative risk Exposure to various risk factors including lifestyles,behaviors, and choices. Use of health promotion services,which mitigate risk factors, and exposure to and/orparticipation in stressful events such as violence, firearmuse, unintentional and intentional injury, and suicide alsofall under the umbrella of relative risk.

Health status Patterns of morbidity and mortality. In this review,alterations in physical and emotional health will be usedto describe the health status of family members andcaretakers of mentally ill individuals.

Note. From “Conceptualizing vulnerable populations health-related research,” by J.H.Flaskerud & B.J. Winslow, 1998, Nursing Research, 47(2), 69–78.

(Arboleda-Florez, 1998; Nestor, Haycock, Doiron, Kelly, & Kelly, 1995;Steadman et al., 1998) and also encounter stigmatization in our society(Phelan, Bromet, & Link, 1998; Veltman et al., 2002), they are concep-tualized in this review as a vulnerable population.

METHODS

Three electronic data bases, PsycINFO, CINAHL, and PubMed weresearched for relevant literature using the search terms mental illness,family, violence and their respective mesh terms in the abstracts, titles,or keywords. From the results of these searches, only original researcharticles that addressed resource availability, risk, and/or health status ofa family member of a mentally ill individual were used in this review.Additionally, only studies in which the relationship between a personwith a mental illness and their family member was articulated and de-scribed as a relationship other than intimate or married partners wereincluded. With the exception of risk, the direct examination of violencedirected towards family members of mentally ill individuals has beenlargely overlooked. Therefore, a wide net was cast with respect to in-clusion of relevant literature. Time was taken to comb through articles


addressing the concepts of interest (resource availability, risk, and/orhealth status) as related to family members from as early as the 1980’s,some of which are included in this review because they are among theonly works available addressing these concepts.

Resource Availability for Family Membersof Mentally Ill Individuals

As described below, family members of mentally ill individuals areaffected by the resource needs, such as employment and housing, of theirrelatives. They face stigmatization and diminished social connectionthemselves, and express concern about access to and the quality of healthcare their relatives receive.

Employment/Income/Education/Housing

In a qualitative study with 20 caregiving family members of chroni-cally mentally ill individuals, Veltman and colleagues (2002) identifieda primary theme of “Systems Issues,” including the inability to find af-fordable housing for their relative and their desire for respite from theircaretaking role. Participants also discussed financial strains associatedwith both caring for a family member who is unable to find employmentand being unable to work more themselves due to their caretaking re-sponsibilities.

Financial characteristics have been associated with both violenceand increased burden among family members of mentally ill individ-uals. Estroff and colleagues (1994) found that individuals with majorpsychiatric disorders who were financially dependent on family mem-bers were significantly more likely to threaten others or exhibit vio-lent behavior than those who were not financially dependent on theirfamilies.

Social Connection

It can be difficult for family members to provide support to a men-tally ill family member when they perceive it as ineffective or one-sided (Hogarty et al., 1997). The National Institute of Mental Health(NIMH) National Advisory Mental Health Council (1995) reported thatthe most highly distressed individuals, those in most need of support,may be the least likely to receive it because their distress drives awaypotential supporters. At the same time, research on individuals withschizophrenia and alcoholism indicates that high levels of social supportare instrumental in decreasing relapse and the need for hospitalizationas well as increasing the successful maintenance of effective treatment

948 D. A. Copeland

(NIMH, 1995). While the social environment extends beyond the familystructure, individuals with major mental illnesses often do not have ex-tensive social support networks outside of this unit and nuclear familiesprovide a majority of the instrumental and affective support they need(Estroff & Zimmer, 1994).

The size and composition of a mentally ill individual’s social net-work have been associated with violent behavior. Estroff and colleagues(1994) investigated social functioning and social networks among indi-viduals with major mental illnesses. They found that individuals withlarger social networks and those with higher numbers of family membersin their social networks had increased odds of threatening others.

Perhaps not surprisingly, perceived threat and hostility from signif-icant others have been linked to violent behavior among mentally illindividuals (Estroff & Zimmer, 1994). The Structural Analysis of So-cial Behavior scale has been used to investigate perceptions of hostilityby both mentally ill perpetrators of violence and their targets (Estroffet al., 1994; Estroff & Zimmer, 1994). This scale requires individualsto identify their most significant other and rate that person’s behavior inrelation to their own behavior. Mentally ill respondents who engaged inviolent acts rated their identified significant others as more hostile thanthose who were not violent, but perceived themselves as more friendlyand less hostile than participants who were not violent. The more threat-ened a mentally ill respondent felt by a significant other, the higher theodds of making threats and vice versa (Estroff & Zimmer, 1994).

Stigma

In addition to the challenges of providing financial and social supportfor mentally ill individuals, family members and caregivers frequentlyreport changes in their own perceptions of social connectedness andstigmatization. Phelan, Bromet, and Link (1998) investigated stigmaamong 156 individuals identified as significant others of patients admit-ted to psychiatric units for the first time. Half of the participants in thisstudy reportedly made attempts to conceal the hospitalization of theirfamily member from others. Participants also perceived that other peopleavoided them. The perception of avoidance was significantly associatedwith high psychotic symptomology in their ill family member (Phelan,Bromet, & Link, 1998).

Additional issues of familial stigmatization were described byVeltman and colleagues (2002). In their study, caretakers described ex-periencing stigma from the public as well as within their own families.For example, children did not invite friends to their house because theywere ashamed of their parents who had schizophrenia. One caretaker did


not share “details” with extended family beyond letting them know herhusband was “not well.” The wife of an individual with bipolar disorderfelt that, “It’s a secret you keep to yourself. I have no friends” (p. 110).Some of the caretakers also described how people did not understandwhy their relative needed to be cared for because “his disability is notvisible” and “you can’t see it the way you see chicken pox” (p. 111).Interviewees shared feelings of being unappreciated, blamed, and mis-understood by the general public, but also by mental health professionals(Veltman et al., 2002).

The perception of feeling judged negatively by others is not un-common among family members of mentally ill individuals. Strueninget al. (2001) studied caregivers of consumers of mental health services.Roughly 70% of their respondents believed that most people woulddevalue a mental health consumer with a serious mental illness and43% believed that most people also devalued the families of consumersof mental healthcare (Struening et al., 2001). Richardson (2001) re-ported similar findings in a study of 235 parents of children betweenthe ages of 5 and 19. In her study, 29% of parents reported that otherfamily members would not approve if they took their child for men-tal health services. Roughly 28% of these parents reported that theywould be concerned if somebody found out that their child was re-ceiving mental health services, and 12% expected to feel embarrassedwhen taking their child to a mental health professional (Richardson,2001).

Access to and Quality of Healthcare

Few studies were found that addressed access to and quality of men-tal healthcare from the perspective of a family member or caregiver. Interms of anticipated access to mental healthcare, parents in Richardson’s(2001) study anticipated difficulty getting an appointment for their mi-nor child with a mental health professional (33%), not knowing whereto go for services (24%), and being dissatisfied with what services wereavailable (21%). A number of parents (32%) also reported a lack of un-derstanding regarding the role of mental health professionals. Parentsalso had concerns about the capability of mental healthcare professionalsto provide services for their children. Forty-one percent of these parentsanticipated wondering if they could trust the mental health professional,19% were concerned that the professional would not care about theirchild, 15% expected the professional to be disrespectful and 14% ex-pected the professional to be unfriendly to their child (Richardson, 2001).

Many family members and caregivers of mentally ill individualsare dissatisfied with the treatment they receive from mental health

950 D. A. Copeland

professionals. Veltman and colleagues (2002) found that family mem-bers felt they received differential treatment by healthcare professionalscompared to families of physically ill individuals. Lack of attention paidto caregivers by the healthcare system was also described. One partici-pant stated, “as a caregiver, you’re always fighting the system” (Veltmanet al., 2002, p. 111). Other participants also felt that their caretaking ef-forts were taken for granted; specifically that mental healthcare providersoperated under the assumption that these family members were willingand able to care for their ill relative (Veltman et al., 2002). In interviewswith 22 parents of individuals with schizophrenia, Ferriter and Huband(2003) reported that many parents perceived the information receivedfrom mental health professionals regarding their child’s diagnosis orprognosis as insufficient or inaccurate.

While access to and quality of healthcare have been the topic of morecurrent research, these studies have focused primarily on the percep-tions of parents of minor children with mental disorders, thus the needsof parents of adult children remain largely unexamined. Table 2 in-cludes descriptions of studies relevant to resource availability for familymembers of mentally ill individuals. Taken together these studies re-veal family members of mentally ill individuals as having poor resourceavailability. Social connection and social status appear to be particularlyaffected.

Relative Risk of Violence and Victimization for FamilyMembers of Mentally Ill Individuals

Family members of mentally ill individuals are at increased risk ofvictimization when their relatives become violent and may, in somecases, delay seeking assistance from healthcare providers.

Risk for Violent Behavior

Several studies addressing the risk of violent behavior towards fam-ily members by mentally ill individuals have concentrated on at leastone of three factors: demographics, clinical characteristics, or social en-vironment. Straznickas and colleagues (1993) found that with respectto demographic characteristics, mentally ill individuals who violentlyattacked a parent were significantly younger than those who attackedother people. They were more likely, although not significantly, to livewith their parents and not be married. Binder and McNeil (1986) foundthat among the 46 psychiatric patients in their sample who assaultedsomebody within two weeks prior to hospitalization, patients who as-saulted a family member were significantly more likely to live with their

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953

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954


families. In contrast, Estroff and Zimmer (1994) found residence typenot to be salient in predicting who would commit a violent act amongthose with a severe and persistent mental illness. In their study, men andwomen threatened family members and others in equal proportions, butwhen participants actually engaged in violent acts, women were morelikely to direct violent acts toward family members—75% versus 56%for men (Estroff et al., 1994). Additionally, Estroff and Zimmer’s (1994)participants who were physically or sexually abused as children weresignificantly less likely to engage in threatening or violent behavior thanthose with no history of abuse.

Alternatively, Swanson et al. (2002) found that physical abuse eitherbefore or after age 16 significantly increased the risk of violent behavior.In this large, multi-state study, violent behavior among individuals with asevere mental illness in the previous year was associated with experienc-ing or witnessing community violence, substance abuse, mood disorder,post-traumatic stress disorder, poor subjective mental health status, psy-chiatric hospital admission, and lower psychiatric symptomotology. Thecombination of exposure to community violence, substance abuse, andhistory of violent victimization substantially increased the likelihood ofviolent behavior beyond that of any risk factor in isolation (Swansonet al., 2002).

In a study of clients utilizing community mental health services andtheir familial caregivers, characteristics significantly associated with fa-milial violence within the previous two years were younger patient age,patient illicit drug use, and poor relationship quality between the patientand caregiver (Vaddadi, Gilleard, & Fryer, 2002). Current heavy alcoholconsumption and current cannabis use have also been associated signif-icantly with higher levels of abuse towards caretakers (Vaddadi, Soosai,Gilleard, & Adlard, 1997).

In an early study of assaultive behavior among psychiatric inpatients,Tardiff (1984) found no significant differences in age, gender, diagnosis,or length of stay between those who had assaulted a family member andthose who assaulted any other individual prior to hospitalization. In alater study of violent behavior among discharged psychiatric patients,Tardiff et al. (1997) found that the only significant differences betweenviolent versus nonviolent patients were that those who were violent dur-ing the month prior to admission were nine times more likely to be violentafter discharge. Further, those with borderline or antisocial personalitydisorders were four times more likely to be violent after discharge whencompared to those without those disorders (Tardiff et al., 1997).

With respect to clinical characteristics, Straznickas and colleagues(1993) reported that 26% of the violent attacks against parents by a

956 D. A. Copeland

mentally ill individual involved paranoid delusions. Similarly, Nestoret al. (1995) found that the delusional beliefs of severely violent forensicpsychiatric patients, the majority of whom had murdered a parent, in-volved significantly more imposter delusions and personal targets whencompared to a less violent group of patients at the same facility. In astudy with family members living with individuals admitted to a psy-chiatric hospital, individuals diagnosed with schizophrenia, schizoaf-fective disorder, or bipolar disorder were more abusive towards theirfamilial caretakers than those with other diagnoses (Vaddadi et al.,1997).

Family Member Risk for Violent Victimization

As previously mentioned, when individuals with a mental illness dobecome violent, family members are the most likely victims (Estroff& Zimmer, 1994; Estroff et al., 1998; Estroff et al., 1994; Steadmanet al., 1998; Straznickas, McNeil, & Binder, 1993; Tardiff et al., 1997).In an early study of violence perpetrated by 300 hospitalized mentallyill individuals, Binder and McNeil (1986) found that 54% of the violentpatients had assaulted a family member (34% of those assaulted wereparents) and that 64% of the patients who assaulted a family memberplanned to return home to their family after discharge. This is particularlyconcerning in light of Tardiff and colleagues’ (1997) findings in which69% of patients who reported violent behavior within two weeks ofhospital discharge had attacked the same person before admission mostoften a family member.

Returning home after discharge may contribute to multiple hospi-talizations. In a study investigating the relationship between familyviolence and hospital recidivism, defined as two or more hospitaliza-tions in one year, Turkat and Buzzell (1983) found that 30% of allrecidivist hospitalizations were a direct result of threats of violenceagainst family members and 40% of all recidivists had threatened amember of their family at least once. In contrast, only 5% of the re-cidivist hospitalizations were a result of threats of violence to non-relatives and 11% a result of public disturbances (Turkat & Buzzell,1983).

Limit setting is one specific situational factor that may increase afamily member’s risk of violent victimization. Straznickas, McNeil andBinder (1993) found that an interaction between a caregiver and theirmentally ill family member involving limit setting immediately pre-ceded 63% of assaults against parents. These researchers speculate thatindividuals who assume a caretaking role, are in frequent contact with,and consequently attempt to set limits on the behaviors of their ill family


members, are at risk of becoming targets of violence (Straznickas et al.,1993).

Acknowledging that violent behavior involves interaction betweena perpetrator and a victim, the quality of the relationship between amentally ill individual and the person toward whom s/he directs vi-olent behavior has been investigated. Estroff et al. (1998) examinedthe relationship between mentally ill participants who were violent andthe significant others who were the specific targets of that violence.Significant others who were targets perceived themselves as exception-ally more hostile towards the respondent who was mentally ill than didsignificant others who were not targets of violence.

Use of Preventive Services

Binder and McNeil (1986) classified families in which patients as-saulted family members into four types. These included families withmore than one individual with a severe mental illness, families with morethan one violent individual, prompt help-seeking families, and delayedhelp-seeking families. Families with multiple mentally ill members com-prised 24% of the sample and families with multiple violent individuals16%. Prompt help-seeking was defined as seeking help for their men-tally ill family member within two weeks of the onset of psychoticsymptoms or after more than one episode of violent behavior. Delayedhelp-seeking families were those who did not seek professional help formore than two weeks after the onset of psychotic symptoms or morethan two episodes of violent behavior. A large proportion of families intheir study, 44%, were classified as delayed help seeking families, whileonly 16% promptly sought help. The delayed help-seeking families at-tempted to manage the patient on their own. Family loyalty and lackof knowledge were two reasons these families provided for not seekinghelp more quickly (Binder & McNeil, 1986).

Utilization of outpatient mental health services may be a protectivefactor for families with a mentally ill individual at risk of becomingviolent. In their study of the social context of violence among peoplewith serious psychiatric disorders, Estroff and colleagues (1998) foundthat family members of individuals who used outpatient mental healthservices 51 or more times in one year were significantly less likely to bethe target of violence. Similarly, baseline data from a study of the effectsof involuntary outpatient commitment indicate that violent behavior inthe past year was significantly higher among individuals who had lowsocial support, were recently homeless, were substance users, had para-noid symptoms, had threat-control override symptoms, or had two ormore hospitalizations within the previous year (Swanson et al., 2000).

958 D. A. Copeland

Involuntary outpatient commitment longer than 6 months resulted insignificantly lower odds of violent behavior during the study year whencontrolling for baseline history of violence. The risk of violent behaviorwas three times greater among participants who misused substances anddid not take prescribed medications during the follow-up period. Simi-larly, a combination of outpatient commitment longer than six monthsand three or more outpatient visits a month significantly reduced the riskof violent behavior (Swanson et al., 2000).

Family members of mentally ill individuals are at increased risk of vi-olent victimization if their ill relative becomes violent. Table 3 includesdescriptions of studies with findings related to relative risk for violentbehavior and violent victimization for family members of mentally illindividuals. While outpatient mental health services, including involun-tary outpatient commitment, might have the potential to mediate someviolent behavior, families might choose to manage the patient them-selves, in their home, and delay seeking professional assistance. Highrisk of victimization in addition to delayed help-seeking make familymembers particularly vulnerable to the negative effects of violence intheir homes.

Health Status of Family Members of Mentally Ill Individuals

Certain populations are exposed to greater numbers of risk factors,which are associated with increased morbidity and premature mortality(Flaskerud & Winslow, 1998). It is noteworthy that the death of a familymember at the hands of a mentally ill individual is a very rare event.Table 4 includes descriptions of studies with findings related to the healthstatus of family members of mentally ill individuals. Unfortunately, verylittle available research emphasizing the health status of family membersand caretakers of mentally ill individuals extends beyond burden orcoping.

Some of the research on burden among family members and care-givers of mentally ill individuals has attempted to determine whatbehaviors contribute to perceptions of burden. Jones and colleagues(1995) found objective burden among caregivers to be much moreprevalent than subjective burden. Six caregiver behaviors were per-ceived as objectively burdensome by 100% of the participants: groom-ing, housework, cooking, providing transportation, managing money,and managing time. Of the seven client behaviors, excessive demandswere ranked as most objectively burdensome by participants. Bothobjective and subjective burden were associated more with caregiv-ing behaviors than client behaviors (Jones, Roth, & Jones, 1995).

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961

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90U

.S.

Exa

min

eth

ere

latio

nshi

pbe

twee

nvi

olen

cean

dps

ychi

atri

cdi

sord

ers

amon

gad

ults

livin

gin

the

com

mun

ityus

ing

Epi

dem

iolo

gic

Cat

chm

ent

Are

ada

ta

10,0

59ho

useh

old

resi

dent

s;36

8of

who

mre

port

edvi

olen

tbeh

avio

rw

ithin

the

past

year

56%

ofth

ose

repo

rtin

gvi

olen

tbeh

avio

rm

etcr

iteri

afo

ra

psyc

hiat

ric

diso

rder

;R

ates

ofvi

olen

cein

crea

sed

with

num

ber

ofdi

agno

ses—

7%of

thos

ew

ithon

edi

agno

sis

vs22

%of

thos

ew

ithth

ree

orm

ore

diag

nose

sw

ere

viol

ent;

Subs

tanc

eab

use

was

the

mos

tpre

vale

ntdi

sord

eram

ong

thos

ew

how

ere

viol

ent

Swan

son

etal

.,20

00U

.S.

Test

whe

ther

outp

atie

ntco

mm

itmen

thel

psto

redu

ceth

ein

cide

nce

ofvi

olen

ceam

ong

peop

lew

ithse

vere

men

tali

llnes

s

262

invo

lunt

arily

hosp

italiz

edpa

tient

sor

dere

dto

outp

atie

ntco

mm

itmen

tupo

ndi

scha

rge;

114

cont

rols

rele

ased

from

outp

atie

ntco

mm

itmen

t,10

2as

sign

edou

tpat

ient

com

mitm

ent,

46“s

erio

usly

viol

ent”

coul

dno

tbe

rand

omiz

edan

dw

ere

assi

gned

outp

atie

ntco

mm

itmen

t;53

%m

ale;

79%

sing

le;6

6%A

fric

anA

mer

ican

,33%

non-

His

pani

cw

hite

,1%

othe

r;16

5gr

adua

ted

high

scho

ol;1

37an

nual

inco

me

<$

6000

Con

trol

ling

for

base

line

viol

ence

,alo

wde

gree

ofpe

rcei

ved

soci

alsu

ppor

twas

asi

gnifi

cant

risk

fact

orfo

rvi

olen

ce,

aco

mbi

natio

nof

exte

nded

outp

atie

ntco

mm

itmen

tand

rece

ivin

gfr

eque

ntse

rvic

essi

gnifi

cant

lyre

duce

dvi

olen

ce

962

Swan

son

etal

.,20

02U

.S.

Exa

min

eth

epr

eval

ence

and

corr

elat

esof

viol

ent

beha

vior

byin

divi

dual

sw

ithse

vere

men

tali

llnes

s

802

adul

tsw

ithps

ycho

ticor

moo

ddi

sord

ers

rece

ivin

gtr

eatm

ent

thro

ugh

the

publ

icm

enta

lhea

lthsy

stem

;mea

nag

e=

42;6

5%m

ale,

47%

whi

te,4

5%A

fric

anA

mer

ican

,3%

His

pani

c,5%

othe

rra

ce/e

thni

city

;33%

less

than

high

scho

oled

ucat

ion;

18%

empl

oyed

The

1-ye

arpr

eval

ence

ofvi

olen

cew

as13

%;V

aria

bles

sign

ifica

ntly

asso

ciat

edw

ithvi

olen

tbeh

avio

rin

clud

edho

mel

essn

ess,

mar

ried

/coh

abita

ting,

poor

subj

ectiv

em

enta

lhea

lthst

atus

,vi

olen

cein

the

curr

ente

nvir

onm

ent,

subs

tanc

eab

use,

psyc

hiat

ric

hosp

ital

adm

issi

onin

last

year

Tard

iff,

1984

U.S

.E

xam

ine

the

freq

uenc

yof

assa

ultiv

ebe

havi

oran

dth

ech

arac

teri

stic

sof

assa

ultiv

epa

tient

sad

mitt

edto

two

priv

ate

psyc

hiat

ric

hosp

itals

784

patie

nts

adm

itted

toa

priv

ate

psyc

hiat

ric

hosp

itala

ccep

ting

only

volu

ntar

yad

mis

sion

s—61

%fe

mal

e;81

9pa

tient

sat

adi

ffer

entp

riva

teho

spita

lacc

eptin

gvo

lunt

ary

orin

volu

ntar

ypa

tient

s—49

%fe

mal

e

Am

ong

the

assa

ultiv

epa

tient

sat

both

hosp

itals

,the

targ

ets

wer

epr

edom

inan

tlyfa

mily

mem

bers

othe

rth

anch

ildre

nor

spou

ses

(Con

tinu

edon

next

page

)

963

TA

BL

E3.

Rel

ativ

eR

isk

ofV

iole

ntB

ehav

ior

and

Vic

timiz

atio

nfo

rFa

mily

Mem

bers

ofM

enta

llyIl

lInd

ivid

uals

(Con

tinu

ed)

Aut

hor/

Yea

rlo

catio

nPu

rpos

e/A

imSa

mpl

ech

arac

teri

stic

sFi

ndin

gs:R

elat

ive

risk

Tard

iff,

Mar

zuk,

Leo

n&

Port

era,

1997

U.S

.

Ass

ess

the

freq

uenc

yan

dty

pes

ofvi

olen

ceby

psyc

hiat

ric

patie

nts

two

wee

ksaf

ter

disc

harg

ean

das

sess

the

char

acte

rist

ics

ofpa

tient

sw

how

ere

viol

ent

430

patie

nts

adm

itted

toa

priv

ate

psyc

hiat

ric

hosp

itala

ndin

terv

iew

edtw

ow

eeks

afte

rdi

scha

rge;

54%

fem

ale;

64%

whi

te,1

7%A

fric

anA

mer

ican

,15

%L

atin

o;4%

Asi

anan

dot

her;

65%

18–3

9ye

ars

ofag

e,35

%40

–59

year

sof

age

16of

the

patie

nts

repo

rted

one

orm

ore

viol

enta

ctw

ithin

two

wee

ksaf

ter

disc

harg

e;M

osto

fth

eat

tack

sw

ere

dire

cted

tow

ards

fam

ilym

embe

rsor

intim

ates

;The

rew

ere

nodi

ffer

ence

sbe

twee

nth

ose

who

wer

ean

dth

ose

who

wer

eno

tvio

lent

with

resp

ectt

oag

e,ra

ce,A

xis

Idi

agno

sis,

drug

/alc

ohol

use,

orse

lfre

port

edm

edic

atio

nco

mpl

ianc

eT

urka

t&B

uzze

ll,19

83U

.S.

Inve

stig

ate

the

rela

tions

hip

betw

een

hosp

italr

ecid

ivis

man

dfa

mily

netw

ork

inte

ract

ions

,spe

cific

ally

tow

hate

xten

tare

thre

ats

offa

mily

viol

ence

afa

ctor

inre

hosp

italiz

atio

n

49in

divi

dual

sho

spita

lized

two

orm

ore

times

duri

ngon

eca

lend

arye

ar;1

2w

ere

hosp

italiz

ed4

orm

ore

times

,17

thre

etim

es,a

nd20

twic

e;52

%w

ere

whi

tem

ales

,42%

whi

tefe

mal

es,6

%bl

ack

mal

es;a

vera

geag

e=

33;

aver

age

year

sof

educ

atio

n=

10.3

;73%

wer

esi

ngle

ordi

vorc

ed

83%

ofth

ein

divi

dual

sho

spita

lized

4or

mor

etim

esha

dth

reat

ened

thei

rfa

mili

esw

ithvi

olen

ceat

leas

tonc

e

964

Vad

dadi

,Gill

eard

&Fr

yer,

2002

Aus

tral

ia

Exa

min

eth

efr

eque

ncy

with

whi

chfa

mily

care

rsex

peri

ence

dve

rbal

and

phys

ical

abus

efr

omre

lativ

esan

dto

iden

tify

corr

elat

esan

dco

nseq

uenc

esof

that

abus

e

101

patie

nts

and

fam

ilym

embe

rca

rers

from

aco

mm

unity

men

tal

heal

thse

rvic

ew

how

ere

eith

erliv

ing

with

orha

dat

leas

ttw

ice

aw

eek

cont

actw

ithth

atpr

imar

yfa

mily

care

r;Pa

tient

s—65

men

,64

rece

ived

disa

bilit

y,12

empl

oyed

;Car

ers—

44m

othe

rs,

28m

othe

rsan

dfa

ther

s,3

fath

ers,

aver

age

age

=57

year

s

40%

ofca

rers

had

been

thre

aten

edby

viol

ence

atso

me

poin

tin

thei

rre

lativ

e’s

illne

ss—

22%

inth

ela

stye

ar;4

0%ha

dbe

enhi

tor

stru

ckat

som

epo

int–

24%

inth

ela

stye

ar;1

7%su

stai

ned

aph

ysic

alin

jury

—4%

inth

ela

stye

ar

Vad

dadi

,Soo

sai,

Gill

eard

&A

llard

,199

7A

ustr

alia

Exa

min

eth

epr

eval

ence

ofva

riou

sty

pes

ofab

use

expe

rien

ced

byca

rers

ofpa

tient

sad

mitt

edfo

rac

ute

psyc

hiat

ric

hosp

italiz

atio

nan

dex

plor

eth

eco

rrel

ates

and

cons

eque

nces

ofth

atab

use

101

acut

ely

adm

itted

psyc

hiat

ric

patie

nts

and

thei

rpr

imar

yca

rers

;Pat

ient

s—60

%m

ale,

age

rang

e18

–54,

43%

unem

ploy

ed,

47%

had

nosc

hool

ing

afte

rag

e15

;Car

ers—

age

rang

e18

->75

,54

%pa

rent

s(4

7%of

tota

lwer

em

othe

rs)

33%

ofca

rers

wer

eph

ysic

ally

thre

aten

ed“s

ever

al/m

any

times

,”17

%w

ere

hito

rst

ruck

“sev

eral

/man

ytim

es,”

20%

repo

rted

som

eph

ysic

alin

jury

965

TA

BL

E4.

Hea

lthSt

atus

ofFa

mily

Mem

bers

ofM

enta

llyIl

lInd

ivid

uals

Aut

hor/

Yea

rlo

catio

nPu

rpos

e/A

imSa

mpl

ech

arac

teri

stic

sFi

ndin

gs:H

ealth

stat

us

Bib

ou-N

akou

,Dik

aiou

&B

aira

ctar

is,1

997

Eng

land

Exa

min

eth

ere

latio

nshi

pbe

twee

nfa

mily

burd

enan

dps

ycho

logi

cal

dist

ress

amon

gfa

mily

mem

bers

ofps

ychi

atri

cpa

tient

s

“Car

ers”

ofin

divi

dual

sw

ithsc

hizo

phre

nia

incl

uded

pare

nts,

sibl

ings

,spo

uses

/par

tner

s;73

%w

omen

;52%

pare

nts;

40%

over

age

55

Sign

ifica

ntpo

sitiv

eas

soci

atio

nsbe

twee

n“c

arer

”m

enta

lhea

lthan

dsu

bjec

tive

burd

en;P

erce

ived

mas

tery

and

psyc

holo

gica

ldis

tres

ssi

gnifi

cant

lypo

sitiv

ely

asso

ciat

edC

itron

,Sol

omon

o&

Dra

ine,

1999

U.S

.E

xam

ine

perc

eive

dhe

lpfu

lnes

sof

self

-hel

pgr

oups

for

fam

ilies

ofpe

ople

with

am

enta

lilln

ess

202

mem

bers

ofA

llian

cefo

rth

eM

enta

llyIl

lin

Penn

sylv

ania

—81

%pa

rent

s,9%

sibl

ings

,5%

spou

ses,

3%ad

ult

child

ren;

Mea

nag

e=

60;

“pre

dom

inan

tlyw

hite

mid

dle-

clas

sm

othe

rs”

Rep

orte

dsu

ppor

tres

ourc

esou

tsid

eof

grou

p:24

%ot

her

fam

ilym

embe

rs,

22%

prof

essi

onal

s,17

%fr

iend

s;19

%fe

ltm

ore

over

whe

lmed

byth

eir

rela

tive

afte

rgr

oup

invo

lvem

ent

Ferr

iter

&H

uban

d,20

03U

nite

dK

ingd

om

Exa

min

epa

rtic

ipan

tvie

ws

onca

uses

ofsc

hizo

phre

nia,

thei

rem

otio

nalb

urde

n,an

dth

ehe

lpfu

lnes

sof

othe

rsw

hen

seek

ing

supp

ort

Pare

nts

of22

patie

nts

diag

nose

dw

ithsc

hizo

phre

nia

rece

ivin

gca

rein

ase

cure

fore

nsic

faci

lity;

all

whi

te;m

ean

age

=60

Des

pite

clea

rsi

gns

ofda

nger

,som

epa

rent

sre

mai

ned

prot

ectiv

eof

thei

rch

ild;E

vide

nce

ofde

sens

itiza

tion

tovi

olen

cean

das

soci

ated

fear

,and

faili

ngto

appr

ecia

teth

ele

velo

fda

nger

966

Gro

ffet

al.,

2004

U.S

.E

xam

ine

fact

ors

cont

ribu

ting

tosu

bjec

tive

stra

inex

peri

ence

dby

care

give

rsof

peop

lew

ithse

vere

men

tali

llnes

s

Invo

lunt

arily

hosp

italiz

edpa

tient

saw

aitin

gpe

riod

ofco

urt-

orde

red

outp

atie

ntco

mm

itmen

tand

thei

rca

regi

vers

—27

0pa

tient

san

dca

regi

vers

atba

selin

e,17

7pa

tient

san

dca

regi

vers

at12

mon

thfo

llow

-up;

Car

egiv

ers

wer

e59

%fe

mal

e,43

%pa

rent

s,63

%ha

da

high

scho

oled

ucat

ion,

mea

nag

e=

52ye

ars,

63%

blac

k

Atb

asel

ine,

care

give

rsu

bjec

tive

stra

insi

gnifi

cant

lypo

sitiv

ely

asso

ciat

edw

ithpa

tient

age,

psyc

hotic

diag

nosi

s,pr

oble

mbe

havi

ors,

prob

lem

sw

ithda

ilyliv

ing,

care

give

red

ucat

ion

and

age,

coha

bita

tion;

At

12m

onth

follo

w-u

p,ca

regi

ver

subj

ectiv

est

rain

sign

ifica

ntly

posi

tivel

yas

soci

ated

with

base

line

stra

in,a

ndhi

ghse

rvic

ein

tens

ity(>

3vi

sits

/mon

th),

and

sign

ifica

ntly

nega

tivel

yas

soci

ated

with

num

ber

ofda

yspa

tient

assi

gned

outp

atie

ntco

mm

itmen

t,an

dtr

eatm

ent

adhe

renc

eJo

nes,

Rot

h&

Jone

s,19

95U

.S.

Pred

icto

bjec

tive

and

subj

ectiv

ebu

rden

amon

gca

regi

vers

ofch

roni

cally

men

tally

illin

divi

dual

s

189

care

give

r-cl

ient

dyad

s;C

areg

iver

s:m

ean

age

=52

,78%

fem

ale,

78%

whi

te;C

lient

s:m

ean

age

=43

,60%

fem

ale,

76%

whi

te,3

6%liv

edw

ithca

regi

ver

Whe

ncl

ient

lived

with

care

give

r,si

gnifi

cant

pred

icto

rsof

obje

ctiv

ebu

rden

wer

egr

oom

ing,

hous

ewor

k,co

okin

g,an

dbe

ing

kept

upat

nigh

t;Si

gnifi

cant

pred

icto

rsof

subj

ectiv

ebu

rden

wer

egr

oom

ing,

med

icat

ion,

hous

ewor

k,sh

oppi

ng,c

ooki

ng,a

ndm

anag

ing

mon

ey

(Con

tinu

edon

next

page

)

967

TA

BL

E4.

Hea

lthSt

atus

ofFa

mily

Mem

bers

ofM

enta

llyIl

lInd

ivid

uals

(Con

tinu

ed)

Aut

hor/

Yea

rL

ocat

ion

Purp

ose/

Aim

Sam

ple

Cha

ract

eris

tics

Find

ings

:Hea

lthSt

atus

Perl

ick

etal

.,19

99U

.S.

Ass

ess

impa

ctof

prob

lem

beha

vior

s,ro

ledy

sfun

ctio

n,an

dad

vers

eef

fect

son

burd

enam

ong

fam

ilyca

regi

vers

ofin

divi

dual

sw

ithbi

pola

rdi

sord

er

266

inor

outp

atie

nts

diag

nose

dw

ithB

ipol

arI,

II,o

rsc

hizo

affe

ctiv

edi

sord

erm

anic

type

and

thei

rpr

imar

yfa

mily

care

give

rsPa

tient

s:58

%fe

mal

e,m

ean

age

=39

;54%

lived

with

care

give

rC

areg

iver

s:66

%fe

mal

e,44

%pa

rent

sof

patie

nt,m

ean

age

=50

,85

%C

auca

sian

,8%

His

pani

c,6%

Bla

ck

54%

repo

rted

seve

rebu

rden

;Abe

lief

that

the

patie

ntca

nco

ntro

lhis

/her

sym

ptom

sw

aspo

sitiv

ely

asso

ciat

edw

ithbo

thob

ject

ive

and

subj

ectiv

ebu

rden

;Car

egiv

erun

awar

enes

sof

the

illne

ss,a

ndbe

lievi

ngth

atth

eca

regi

ver

can

cont

rolt

hepa

tient

’sbe

havi

orw

ere

inve

rsel

yas

soci

ated

with

both

obje

ctiv

ean

dsu

bjec

tive

burd

enSo

lom

on&

Dra

ine,

1995

U.S

.D

escr

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970 D. A. Copeland

Other researchers have associated perceptions of burden among care-givers with an inability to cope with troublesome behavior, feel-ing trapped, and lack of knowledge regarding how to respond totheir child’s symptoms (Ferriter & Huband, 2003). Perlick and col-leagues (1999) found that 93% of caregivers, primarily parents, intheir sample reported at least moderate levels of objective or subjectiveburden.

Moving beyond predictors of burden, researchers from Londonlooked at the effects of burden among caregivers. In this study, bothobjective and subjective burden were associated with psychologicaldistress among caregivers (Bibou-Nakou, Dikaiou, & Bairactaris, 1997).Objective burden and perceived mastery were also significantly corre-lated. Surprisingly caregivers who reported the most burden experiencedgreater perceived mastery.

Few studies have investigated violent behavior and burden specifi-cally. In an Australian study with 101 community mental health patientsand their family member caregivers, the severity of the abuse experi-enced by caregivers was significantly associated with both emotionaldistress and overall burden (Vaddadi, Gilleard, & Fryer, 2002). Estroffand Zimmer (1994) found that family members of mentally ill indi-viduals, particularly parents, described living with intimidation, threats,and fear of violence by making accommodations, placating their familymember, explaining away, or denying violent behavior that occurred.Some family members described being afraid to sleep at night and tak-ing turns sleeping so that somebody was always awake with their illrelative. One woman minimized her husband’s violence describing howhe, “probably just pushed me, and I just got off balance and fell down”(Estroff & Zimmer, 1994, p. 274).

In addition to burden, family members have reported other emotionalresponses including “loss of what might have been,” fear, grief, shock,guilt, confusion, and negative self esteem (Ferriter & Huband, 2003) andfeelings of isolation and loneliness (Veltman et al., 2002). Among onesample of caregiving family members, all of whom reported threats of oractual physical harm, 79% reported significant emotional symptomologyof their own (Vaddadi et al., 1997). In one qualitative study a mother ofa son with schizophrenia is quoted, “I don’t know what other people livelike. I think of myself as a loner even though I’m a caretaker” (Veltmanet al., 2002, p. 111). In a Swedish study with family members of mentallyill individuals, 47% of the parents reported feeling as though their child’smental illness led to mental health problems of their own, 33% reportedthat the child’s mental illness affected their ability to have company, and


21% endorsed that at times they believed their mentally ill child wouldbe better off dead (Ostman & Kjellin, 2002). A smaller percentage ofthese parents (16%) felt that their burden was so heavy that they hadsuicidal thoughts; and, at times, 14% wished that the patient had neverbeen born (Ostman & Kjellin, 2002).

Research addressing attributes with the potential to mediate someof the burden associated with providing care to mentally ill familymembers have also been conducted. Solomon and Draine (1995) con-ducted a study of adaptive coping among 225 family members, 76% ofwhom were parents, of mentally ill individuals. They looked at fam-ily characteristics, illness related stressors, family member response tostressors, and social support as predictors of adaptive coping. Noneof the illness related stressors or responses to stress were significant.Only three social support variables were significant predictors of adap-tive coping. These were support group membership, larger social net-work, and affirming support from social network members. One of theonly other significant predictors of adaptive coping was high senseof self-efficacy in responding to the relatives’ illness (Solomon &Draine, 1995).

The benefits of participation in a support group for family members ofmentally ill individuals were evaluated by Citron, Solomon, and Draine(1999). Among 195 family members (81% parents) who were membersof a support group, greater than 50% reported benefiting a great dealfrom the support group. The benefits of participation came from havingmore knowledge about mental illness, having more information aboutservices, feeling less alone in their concerns, feeling better able to copeemotionally, and feeling better able to cope with stigma. Length of timein the support group, information provision, and gaining support wereall significant predictors of group benefit for these participants (Citron,Solomon, & Draine, 1999).

There are obvious benefits to caregivers when outpatient follow-upoccurs; however, if scheduling and attendance at these appointmentsis their responsibility, it may also have unanticipated negative conse-quences for the caregiver. While Swanson et al. (1990) found that out-patient commitment and treatment decreased the risk of violent behavior,the intensity of treatment may affect caregivers in other ways as well.Groff and colleagues (2004) assessed the impact of outpatient commit-ment on caregivers of mentally ill individuals. These researchers foundthat baseline caregiver strain and high service intensity defined as morethan three visits per month were significant predictors of caregiver strainafter one-year. However, reductions in caregiver strain were significantly

972 D. A. Copeland

associated with increased number of days on outpatient commitment andtreatment adherence (Groff et al., 2004).

CONCLUSION

Use of the Vulnerable Populations Conceptual Model provided anorganizing framework for the review of literature that clearly identifiesfamily caregivers of individuals with a mental illness as a vulnerablepopulation. Family members are at increased risk of being victims iftheir mentally ill relative becomes violent. A great deal of research hasbeen conducted emphasizing risk factors for violent behavior and vi-olent victimization among mentally ill individuals and their families.Specific diagnoses and symptomology have been associated with in-creased risk of violent behavior as have younger age, cohabitation,substance abuse, and exposure to community violence. Additionally,family members who have a poor relationship with or set limits ontheir mentally ill relative’s behavior may be at increased risk of be-coming victims of violence. Increased risk of victimization in com-bination with a lack of social connection and available resources in-creases the family’s vulnerability to further violence and its negativeconsequences.

The effects of having a mentally ill family member are largely un-known beyond conceptual understanding of burden, coping, and strain.The added component of violent behavior by that family member islikely to further complicate the responses of and effects on other familymembers. How family members attempt to mitigate their risk and whatthey consider helpful amidst the social isolation and stigmatization theyexperience has not been addressed. Additionally, very little qualitativedata are available that articulates the experiences of family members ofmentally ill individuals who have been violent. Gaining a deeper under-standing of what family members experience and understand about theirmentally ill relative’s behavior is important; healthcare providers needto anticipate and provide assistance that families perceive as useful inalleviating the burden and other sequelae they experience. Understand-ing how familial caregivers decide when, where, and how to seek helpis an area in need of investigation. Additionally, research emphasizingcommunity assets as well as limitations in community settings that affectthese families and their ability to procure or provide care for their men-tally ill member could illuminate important strengths or gaps in serviceprovision in specific communities.


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conceptualizing family members of violent mentally ill individuals as a vulnerable population

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