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Intimate relationships and gender: perspectives from Latinos with schizophrenia and their family members

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Intimate relationships and gender: perspectives from Latinos with schizophrenia and their family members

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Intimate Relationships and Gender:
Perspectives from Latinos with Schizophrenia and their Family Members
by
Paula Helu-Brown

A Dissertation Presented to

University of Southern California
GRADUATE SCHOOL

In Partial Fulfillment of the
Requirements for the Degree

DOCTOR OF PHILOSPHY
(SOCIAL WORK)

May 2017

INTIMATE RELATIONSHIPS AND GENDER 2
Table of Contents
Dedication ........................................................................................................................................ 4

Acknowledgements ......................................................................................................................... 5

Abstract ............................................................................................................................................ 6

Introduction ..................................................................................................................................... 8

Significance of Study ................................................................................................................ 8

Conceptual Framework ........................................................................................................... 10

Multiperspective Research ...................................................................................................... 18

Methods ......................................................................................................................................... 19

Parent Study and Sample ......................................................................................................... 19

Sample and Data Collection .................................................................................................... 21

Interview Guide ....................................................................................................................... 22

Analysis ................................................................................................................................... 23

Results ........................................................................................................................................... 24

Sample Demographics ............................................................................................................. 24

Salient Themes ........................................................................................................................ 25

Intersectionality Analysis Results ........................................................................................... 35

Discussion ...................................................................................................................................... 38

Strengths .................................................................................................................................. 42

Limitations ............................................................................................................................... 42

Conclusion ............................................................................................................................... 43

References ..................................................................................................................................... 44

Table 1 ........................................................................................................................................... 56

INTIMATE RELATIONSHIPS AND GENDER 3
Table 2 ........................................................................................................................................... 58

Table 3 ........................................................................................................................................... 60

Figure 1 .......................................................................................................................................... 66

Figure 2 .......................................................................................................................................... 67

Figure 3 .......................................................................................................................................... 68

Figure 4 .......................................................................................................................................... 69

Figure 5 .......................................................................................................................................... 70

Figure 6 .......................................................................................................................................... 71

INTIMATE RELATIONSHIPS AND GENDER 4
Dedication
This dissertation is dedicated to my father, Dr. Juan Carlos Helu, for his constant support
and confidence in my ability to make it this far and for always setting an example of hard work,
excellence, and perseverance. To my mother, Teté, for allowing me to break gender roles, for
teaching me that a woman can be and do anything she sets her mind to, and for her warm and
loving encouragement. And to Jason, my wonderful husband, whose love, patience, and support
kept me going and without whom these last 5 years would have been unbearable.

INTIMATE RELATIONSHIPS AND GENDER 5
Acknowledgements
My thanks and appreciation to Dr. Concepcion Barrio for being the best mentor anyone
could ask for. It was her work with Latino families that inspired me to pursue this degree in the
first place and working with her has been a great honor. I am grateful for her openness to
allowing me to explore difficult and taboo topics with my research, and I will be eternally
grateful for her guidance and kindness through every step of this program and beyond.
I want to thank the members of my dissertation committee, Dr. Maria Aranda and Dr.
Michael Messner, who generously gave their time and expertise to help better my work.
My gratitude also to Dr. Mercedes Hernandez, for being a great role model and for
allowing me to join her study with some “unconventional” questions.
I must also acknowledge all the families who allowed us to come into their homes and
shared with us intimate details about their lives. It is for them that I do this work.

INTIMATE RELATIONSHIPS AND GENDER 6
Abstract
Intimate relationships are a fundamental part of the human experience and contribute to quality
of life and recovery of patients with serious mental illness (SMI). However, few psychosocial
interventions exist to address this issue with patients with SMI and none of the existing
interventions focuses on Latinos. The intersectionality of being Latino and having a SMI can
create a very unique experience regarding intimate relationships and gender. Latinos with SMI
are known to be more family oriented and more likely to live with family members than non-
Latino Whites; therefore, some parental boundaries and expectations surrounding intimate
relationships and gender may continue to affect these individuals into adulthood. Interventions
for Latinos with SMI have been shown to be more effective when they incorporate cultural
preferences and involve family members as a source of support, and even have been found to
have a negative effect when they are not specifically tailored to cultural needs. This study was
guided by intersectionality theory and used qualitative content analysis and intersectionality
template analysis to examine data from 22 semistructured interviews of 11 patient and family
member dyads. The study was part of a second follow-up study of an intervention development
study of a culturally based family psychoeducation model for Latinos funded by the National
Institute of Mental Health. Overall findings showed promise regarding the importance of
intimate relationships in the lives of Latinos with schizophrenia. In particular, participants
overwhelmingly stated that stigma and unemployment were the main obstacles impeding them
from establishing and maintaining intimate relationships. In addition, a sense of normalcy,
advantages and disadvantages of intimate relationships, gender-related life satisfaction, hopes for
the future, and messages from family members about intimate relationships were identified as
areas of opportunity to address intimate relationships with patients and their family members.
INTIMATE RELATIONSHIPS AND GENDER 7
These findings confirm that patients with schizophrenia need to be able to establish and maintain
an intimate relationship. This study also underscores the importance of providing culturally
relevant interventions that incorporate family members as a source of support and addressing
disagreements about intimate relationships and gender roles between patients and family
members in treatment to contribute to the life satisfaction of patients with SMI.

INTIMATE RELATIONSHIPS AND GENDER 8
Introduction
Significance of Study
Intimate relationships have been associated with good health and quality of life in the
general population (Heffner et al., 2006; Loving & Slatcher, 2013; Meyler, Stimpson, & Peek,
2007). For patients with a serious mental illness (SMI), intimate relationships have a positive
impact on their symptomatology and recovery (Corrigan & Phelan, 2004; Estroff, Zimmer,
Lachicotte, & Benoit, 1994; Padgett, Henwood, Abrams, & Drake, 2008; Schön, Denhov, &
Topor, 2009; Yanos, Rosenfield, & Horwitz, 2001) and contribute to a sense of normalcy and
belongingness (Redmond, Larkin, & Harrop, 2010). A qualitative study examining how identity
affects the process of recovery in patient narratives found that striving for normalcy was a
common goal for patients with SMI. The findings indicated that “being normal” and “leading a
normal life” were important goals for recovery for many participants and were tied to their
ability to achieve major developmental and life milestones, specifically finding a partner and
having children (Wisdom, Bruce, Saedi, Weiss, & Green, 2008).
A recent study examined the relationship between dating and quality of life for adults
with schizophrenia and schizoaffective disorder in community mental health settings. Results
indicated that an association exists between having a romantic date during the last 30 days and
higher satisfaction with the social aspect of quality of life (Helu Fernandez, Rice, Barrio, &
Brekke, 2014). Although this secondary data analysis yielded promising results, there were
limitations, such as lack of ethnic diversity of the sample and a narrow scope of the evaluation
tool, that limited understanding of the specific experiences of the participants and more
specifically those of ethnic minorities (Helu Fernandez et al., 2014).
INTIMATE RELATIONSHIPS AND GENDER 9
Another study using qualitative data explored the perceptions of social relationships and
gender roles of Latinos with SMI and their key family members (Helu-Brown, Barrio, &
Hernandez, 2016). This study employed an intersectionality framework and addressed previous
limitations by focusing on a Latino sample consisting of seven patients with schizophrenia and
five family members of a person with schizophrenia. Five primary themes regarding
relationships emerged from the transcripts: (a) experiences and perceptions of marriage and
romantic relationships, (b) experiences and perceptions of the parenting role, (c) experiences and
perceptions of gender normative roles, (d) friendship, and (e) being alone and loneliness.
These themes indicated difficulty for both the patients and family members to
successfully establish and maintain relationships due to symptoms experienced by those with the
illness, in addition to an overall concern regarding loneliness. This study also showed that
participants perceived a sense of burden for women who care for family members with an illness,
even when the caregiver also had an illness. Because that study was based on secondary data
analysis, in-depth exploration of romantic relationships, sexuality, and gender roles was not
possible. However, these results indicate that (a) Latinos with SMI and their family members are
interested in discussing intimate relationships and gender role expectations; (b) the protective
and oppressive effects of the intersections of gender, mental illness, and culture were observable
and should be further analyzed; and (c) patients with SMI and their family members could
benefit from addressing these concerns with their mental health care provider.
Despite the importance of intimate relationships for the general population and a clear
indication of similar relevance for patients with SMI, a recent review found that few studies have
explored psychosocial interventions to address intimate relationships with patients with a SMI
(Helu-Brown & Aranda, 2016). The findings from that review also indicated that only two of the
INTIMATE RELATIONSHIPS AND GENDER 10
four existing studies included racial and ethnic demographic data; however, they did not analyze
whether any differences exist between racial and ethnic groups. Three samples were all female
and one sample was all male, thus none of the studies examined gender differences. These
studies also did not explore family context (Helu-Brown & Aranda, 2016).
Although similarities in intimate relationships may exist between Latinos with SMI and
those of other ethnicities, it is important to learn about the unique experiences and intersections
of ethnicity, mental illness, and gender among Latinos and their family members. This
knowledge can inform culturally relevant research and interventions that incorporate family
perspectives. Studies on mental health treatment disparities have found that underserved
minorities, such as Latinos, can benefit from culturally tailored interventions that acknowledge
strong family influences and their sociocultural needs (López, 2002; Vega et al., 2007).
To address the knowledge gap highlighted by existing research, this study examined how
patients with SMI and their family members providing care experience the intimate relationships
and gender-related expectations of the patients. Through an intersectionality analysis, this
multiperspective study also explored how the intersectionality of SMI, culture, and gender is
reflected in participant narratives. Intersectionality as a framework for explanation and analysis
of intersecting identities is described in the following section.
Conceptual Framework
This study relied on the following definitions of key concepts. Intimate relationships are
defined as interpersonal relationships that involve feelings of liking or loving a person, romance,
physical or sexual attraction, sexual relations, and emotional and personal support (Miller, 2014).
References to culture are based on Lederach’s (1995) definition: “Culture is the shared
knowledge and schemes created by a set of people for perceiving, interpreting, expressing, and
INTIMATE RELATIONSHIPS AND GENDER 11
responding to the social realities around them” (p. 9). For this study, Latino refers to people with
any Latin American origin; the sample specifically featured people of Mexican and Salvadorian
origin. SMI is defined by the National Survey on Drug Use and Health as a mental, behavioral,
or emotional disorder currently present or diagnosed during the past year with a minimum
duration to meet diagnostic criteria of the Diagnostic and Statistical Manual of Mental
Disorders, 5th edition (American Psychiatric Association, 2013), and causing serious
impairment in functioning and interfering with one or more major life activities. Finally, gender
is based on Connell’s (2009) definition: “Gender is the structure of social relations that centers
on the reproductive arena, and the set of practices that bring reproductive distinctions between
bodies into social practices” (p. 11).
Intersectionality. Kimberlé Williams Crenshaw (1989) first coined the term
intersectionality in an effort to address the limitations of feminist theory using gender as a single
analytic category, particularly when exploring the experiences of women of color (McCall,
2005). As a theoretical framework, intersectionality primarily seeks to shed light on the
complexity of the experiences of women of color who experience oppression and has also been
helpful in explaining and understanding the experiences of other minorities, such as lesbian, gay,
bisexual, transgender, and queer individuals and people with disabilities who may not identify as
women. Intersectionality focuses on the multiple identities of an individual or group that
intersect and result in a particular experience. The identities of an individual that may intersect
include gender, class, ethnicity, age, culture, race, disability, and sexual orientation, among
others. This theory posits that these components of identity are not mutually exclusive and
should be understood as components or elements that form an axis and are inextricably linked,
therefore reciprocally influencing one another (P.H. Collins, 2015; P. H. Collins & Bilge, 2016;
INTIMATE RELATIONSHIPS AND GENDER 12
Hancock, 2016). Intersectionality describes how individuals who belong to a social group often
share similar identities, and because of the position of these identities in a broader social context,
they can experience certain advantages or disadvantages (Rogers & Kelly, 2011).
Research has shown that Latinos with SMI can experience particular protective factors
compared to other ethnic groups with regard to mental illness. For example, an empirical study
of protective factors related to suicidal behavior found that Latinos with SMI are less likely to
experience suicidal ideation and have fewer suicide attempts than non-Latinos due to coping
beliefs and attitudes toward suicide that are believed to be protective cultural factors (Oquendo et
al., 2005). However, evidence suggests that Latinos with SMI can struggle more than
nonminorities in other aspects. A study assessing disparities in depression treatment among
racial and ethnic minorities in the United States found that Latinos are less likely to access
treatment for their illness compared to non-Latino Whites (Alegría et al., 2008). A systemic
literature review of studies on adherence to psychotropic medications found that in 10 of 16
studies, Latinos had a significantly lower rate of adherence due to risk factors such as lower
socioeconomic status and less access to care (Lanouette, Folsom, Sciolla, & Jeste, 2009).
Another study found that Latinos with a high level of behavioral familismo, or sense of
family belonging and closeness, were more likely to receive informal or religious services
instead of specialty or medical services for their mental illness (Villatoro, Morales, & Mays,
2014). Furthermore, a study analyzing data from a randomized controlled trial found that Latinos
with SMI have more difficulty obtaining employment than non-Latinos with SMI, but that
culturally tailored bilingual support yielded promising results (Mueser et al., 2014). These
struggles that stem from multiple factors in the lives of Latinos with SMI can be understood
relative to what Mizock and Russinova (2015) called intersectional stigma, which they described
INTIMATE RELATIONSHIPS AND GENDER 13
as a source of oppression for members of groups with multiple overlapping disadvantaged social
categories.
Stigma has been shown to negatively affect the self-esteem of patients with SMI. A
qualitative study of 20 participants (75% Latino sample, aged 16–24) receiving psychiatric care
indicated that stigma not only affects their self-esteem but can increase their risk of contracting
HIV and other sexually transmitted infections (Elkington et al., 2013). This study suggested that
this risk can be attributed to patients wanting to manage mental illness-related stigma by
engaging in risky sexual behavior. Other studies have found that this risk is similar in adults with
SMI as well (P. Y. Collins, Elkington, et al., 2008; P. Y. Collins, von Unger, & Armbrister,
2008).
As an analytic tool, intersectionality can be used to explore the axes of multiple social
categories to better understand the experiences and behaviors of particular groups (P. H. Collins
& Bilge, 2016). In an effort to understand the complexity of experiences related to intimate
relationships and gender roles for Latinos with SMI and their family members, this study used
McCall’s (2005) intracategorical approach. This approach views intersecting identities as the
defining qualities of the group being studied, as opposed to an intercategorical methodology,
which compares different groups that may present contrasting identities (McCall, 2005); for
example, the experiences of Latinos with SMI compared to those of non-Latino Whites without
SMI.
To gain a deeper understanding of intimate relationships and gender, several intersecting
identities should be considered. The intersecting identities pertinent to this study, as discussed in
the following section, include intimate relationships and Latino families, gender and mental
illness among Latinos, and mental illness and intimate relationships among Latinos.
INTIMATE RELATIONSHIPS AND GENDER 14
Intersection of intimate relationships and Latino families. Studies have shown that in
more traditional families, girls are socialized during adolescence to participate in household
chores and receive different rules related to dating and spending time with members of the
opposite sex compared to their male peers (Villaruel, 1998). This occurs through what is called
gender regulation, which refers to the dynamic of supervising, setting boundaries, dictating
behavior, and enacting specific gender roles according to the person’s sex assigned at birth and
societal and cultural expectations of a person or institution (Bussey & Bandura, 1999; Corbett,
2011; Courtenay, 2000; Goldner, 2002). Studies examined how Latino parents and families
regulate their adolescent children’s intimate and romantic involvement, finding that the most
common method of regulation is enforcement of gender-related roles and behaviors stemming
from traditional cultural beliefs (González-López, 2005; Hovell et al., 1994; Raffaelli & Ontai,
2001). Because Latinos with SMI are more likely to remain at home as adults (Cauce &
Domenech-Rodríguez, 2002; P. N. Cohen & Casper, 2002; Fry, 2016) and incorporating family
members in their care has been proven beneficial to their recovery (López, 2002; Vega et al.,
2007), it is important to understand whether the regulation of adult children’s intimate
relationships by family members continues and how related family perspectives may compare to
those of patients.
According to an ethnographic study by González-López (2005) involving Mexican
immigrants in the United States, how relationships and sexuality are established and expressed in
Mexican society is mostly created and reinforced by the family. Families are also a source of
rules and regulations regarding gender that dictate how children experience and interpret
romantic and intimate relationships as they grow up (Connell, 2003). In Latino culture, as in
many other cultures, parents and sometimes grandparents are primarily responsible for gender
INTIMATE RELATIONSHIPS AND GENDER 15
socialization. These family members often impose boundaries aimed at protecting their children
by keeping them close to home and emphasize messages about how their sons and daughters
should interact with members of the opposite sex that vary depending on their gender (González-
López, 2004; Rafaelli & Ontai, 2004). Although this approach may be similar in other cultures,
Latinos may continue to be affected beyond childhood and adolescence, because they are more
likely to live in intergenerational households into adulthood compared to non-Latino Whites
(Cauce & Domenech-Rodríguez, 2002; P. N. Cohen & Casper, 2002; Pew Research Center
Analysis, 2009).
This study explored different points of view regarding intimate relationships and gender
performance and the cultural aspects of these perceptions to find innovative ways to address
intimate relationship and gender with patients while also incorporating family and other cultural
preferences. Because Latinos with SMI are more likely to live with family members and benefit
from including them in treatment, this study also examined whether intimate relationship and
gender regulation persist into adulthood and how this may affect the lives of patients and their
family members.
Intersection of gender and mental illness among Latinos. Aside from being related to
reproductive function as defined by Connell (2009), gender can also consists of a set of beliefs
and practices regarding labor, power differences, and character traits of men and women
(Rosenfield & Mouzon, 2013). These conceptions of gender can be similar among many races,
cultures, and socioeconomic statuses. However, studies have shown that in more traditional
cultures and those of lower socioeconomic standing, which tend to be common among many
Latinos in the United States, the rigidity of these beliefs, gender role expectations, gender
socialization, and higher economic demands can have a negative impact on mental health for
INTIMATE RELATIONSHIPS AND GENDER 16
both men and women (P. Y. Collins, von Unger, et al., 2008; Meyer, Schwartz & Frost, 2008;
Mirowsky & Ross, 2003; Wirth & Bodenhausen, 2009).
According to D. Cohen (2005), men from traditional Mexican American families are
generally expected to be strong, dominant, and the main providers for their families. Although
there may be an overlap in gender expectations across cultures, aspects of masculinity for Latino
men, such an expectation of self-sufficiency, can affect their ability to seek help when
experiencing symptoms of mental illness (Vogel, Heimerdinger-Edwards, Hammer, & Hubbard,
2011). Raffaelli and Ontai (2004) stated that Latino parents generally socialize their daughters
through more traditional gender-related messages than their sons, particularly when it comes to
setting limits on dating and granting privileges to venture outside of the household. González-
López (2005) affirmed that some of these traditional gender-related expectations endure the
process of immigration and acculturation to some degree.
Having a SMI can make it difficult for men to acquire and maintain steady employment
and provide for a family (Brohan, Slade, Clement, & Thornicroft, 2010; Link, Struening, Neese-
Todd, Asmussen, & Phelan, 2001). Studies have shown that the traditional socialization of men
to be masculine, such as in Latino families, can have negative mental health outcomes when they
are not able to perform their expected gender role (Cleary, 2012; Good, Borst, & Wallace 1994;
Fragoso & Kashubeck, 2000; Vogel et al., 2011), leading to worse mental health outcomes.
Similarly, women who cannot fulfill their gender role expectations such as being mothers or
caregivers can experience an increased level of psychological distress (Rosenfield & Mouzon,
2013).
Intersection of mental illness and intimate relationships for Latinos. As previously
mentioned, people who have a mental illness experience stigma (Brohan et al., 2010; Corrigan &
INTIMATE RELATIONSHIPS AND GENDER 17
Watson, 2002; Corrigan, Watson, & Barr, 2006; Link et al., 2001; Rüsch, Angermeyer, &
Corrigan, 2005). Studies have shown that stigma can result in sexual isolation for people with
SMI (Wright, Wright, Perry, & Foote-Ardah, 2007). Recent articles noted that among women
with SMI, sexual expression and intimacy are also sources of stigma when they are under the
care of family members or institutions where they may not have privacy or permission to engage
in relationships with members of the opposite sex (Blalock & Wood, 2015; Carr, Green, &
Ponce, 2015; Mizock & Russinova, 2015).
Establishing an intimate relationship can be further complicated for Latinos with SMI,
because engaging in intimate relationships without family approval can be considered
unacceptable behavior (P. Y. Collins, Elkington, et al., 2008; Rafaelli & Ontai, 2004). The goal
of this study was to learn more about these experiences of patients and family members
providing care to better understand both perspectives and ultimately inform culturally sound
research and interventions that address intimate relationships and gender while encouraging
family participation.
In sum, intimate relationships are a fundamental part of human experience and contribute
immensely to quality of life and recovery of patients with SMI. However, research has shown
that few psychosocial interventions exist to address this issue among patients with SMI. Latinos
with SMI are known to be more family oriented and more likely to live with family members
than non-Latino Whites; therefore, some parental boundaries and expectations regarding intimate
relationships and gender may continue to affect patients into adulthood. Interventions for Latinos
with SMI have been shown to be more effective when they incorporate cultural preferences and
involve family members as a source of support. The current study sought to add to knowledge in
this understudied area, particularly regarding the lives of Latinos with SMI and their family
INTIMATE RELATIONSHIPS AND GENDER 18
members. The intersectionality framework can help improve our understanding of how gender,
mental illness, and culture intersect and may inform culturally relevant research, treatment, and
interventions.
The aforementioned intersections illustrate the significance of the relationships among
Latinos with SMI and their family members, creating the basis for this study regarding the
perspectives of both groups with respect to intimate relationships and gender.
Multiperspective Research
Kendall et al. (2009) stated that multiperspective studies are most useful in the following
domains: (a) when trying to understand the relationships and dynamics among patients and their

families; (b) when exploring similarities and differences

in the perceptions of patients, their
family members, and professional caregivers; (c) when seeking to understand the individual
needs of patients, caregivers,

and family members; and (d) when seeking suggestions for
improving services

from all involved parties. Because this study sought knowledge regarding
intimate relationships and gender roles of Latino patients with schizophrenia, who according to
the literature are more likely to live with family members compared to nonminority groups
(Barrio et al., 2003; Guarnaccia, 1998; Kopelowicz, 1998), it was vital to elicit not only the
perspective of the patients but also their family members providing care.
Exploring these family members’ perceptions is crucial, particularly due to the positive
outcomes associated with family involvement in services for people with schizophrenia (Dixon
et al., 2001; Jewell, Downing, & McFarlane, 2009) and the importance of understanding
intergenerational relationships to better address issues involving couples and childrearing
(Feldhaus & Huinink, 2006; Huinink et al., 2011). The involvement of family members in the
INTIMATE RELATIONSHIPS AND GENDER 19
design and implementation of treatment has been shown to positively affect the recovery of
Latinos with schizophrenia (López, 2002; Vega & Lopez, 2001; Vega et al., 2007).
Exploring the perspectives of patients and family members is important because family
interventions that incorporate cultural preferences have been known to improve wellness
outcomes among individuals with SMI (Glynn, Cohen, Dixon, & Niv, 2006; Weisman, Duarte,
Koneru, & Wasserman, 2006). Incorporating family approaches that introduce family members
as a cultural resource to support a skills-building intervention led to positive outcomes for Latino
patients (Kopelowicz, Zarate, Smith, Mintz, & Liberman, 2003), which can be important when
developing interventions such as dating skills-building workshops or encouraging the discussion
of intimate relationships among patients, family members, and care providers. Conversely,
family interventions with low-acculturated immigrant families that fail to address family cultural
preferences have negative effects such as worsening of symptoms for patients (Telles et al.,
1995).
The specific focus of this study was to gain an understanding of the perspectives of
patients and their family members regarding intimate relationships and gender as they relate to
their quality of life and to explore similarities and differences in these perspectives to inform
culturally relevant research and interventions that address intimate relationships.
Methods
Parent Study and Sample
This study was part of the second follow-up to a parent study called Culturally Based
Family Intervention for Mexican Americans (CFIMA). CFIMA featured weekly multifamily
group sessions for 16 weeks. These sessions were held at the community mental health clinic
where participants were recruited. Study criteria were: (a) diagnosis of a schizophrenia spectrum
INTIMATE RELATIONSHIPS AND GENDER 20
disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition
(American Psychiatric Association, 2000); (b) at least 18 years old; (c) no substance use or abuse
disorder; (d) currently receiving medication support; and (e) living or maintaining contact on a
weekly basis with a family member. After identifying eligible patients, bilingual–bicultural
research assistants asked these individuals to participate in the study. After obtaining permission
from the patients, the research team identified family members providing primary support and
asked them to participate in the study. Two conditions were defined. Patients in the treatment-as-
usual condition received customary care consisting of medication support and other psychosocial
services, and family members did not receive any family-based services. In the intervention
group, patients received treatment as usual and their family members participated in multifamily
group sessions. All procedures were approved by the institutional review board of the affiliated
university. The parent study sample featured 59 dyads (59 key family members and 59
consumers) that were randomly assigned to either the intervention or treatment-as-usual
condition. The CFIMA study showed promising results, with significantly lower family burden
over time for those in the intervention compared to treatment as usual. Family members in the
intervention group experienced a significant increase in knowledge of the illness over time
compared to those who received treatment as usual.
The first follow-up study focused on 34 of the parent study’s 118 participants. This
mixed-methods study involved semistructured interviews with open-ended questions and
measures that examined the effects of protective factors on patient outcomes over time. The
interview guide included questions pertaining to protective factors and perceptions of mental
illness, treatment, stigma, and service use. Findings showed that perceptions of criticism
decreased for family members and patients in the intervention condition. This led to improved
INTIMATE RELATIONSHIPS AND GENDER 21
intrapsychic and instrumental quality of life among patients. Patients experienced an increase in
perceptions of family warmth and there was a trend toward improvement among family
members. The improved perception of family warmth among patients had an indirect effect that
reduced general psychopathology symptoms. Qualitative findings provided information
regarding the participants’ experiences of protective factors that included hope, religion or
spirituality, and family environment. Patients stated that the knowledge they obtained through
the intervention influenced their perceptions of the illness, treatment, stigma, and well-being.
Findings from this follow-up study showed how culturally based interventions can enhance
protective cultural factors.
Sample and Data Collection
After the first follow-up study, the team maintained contact with the community mental
health outpatient clinic where participants were recruited for the parent study. The recruitment
team aimed to reach as many of the dyads from the initial follow-up as possible for a second
follow-up study. To maximize the probability of reaching as many dyads as possible, all
participants in the first follow-up (N = 34) were initially contacted by phone; those who were
reached received an explanation of the purpose of the current study and scheduled either a
follow-up call or interview time. The team attempted to contact all participants by phone;
however, some family members no longer had the same telephone number and therefore were
not able to be contacted. A letter requesting a phone call from participants was sent to those who
had not responded to phone calls; however, no other participants responded to that second
attempt.
Thirteen family members and 11 patients agreed to participate in the study and were
interviewed; however, only data from complete dyads were used for this study. The final sample
INTIMATE RELATIONSHIPS AND GENDER 22
consisted of 22 participants (11 patients and 11 family members). Participants were primarily of
Mexican origin (n = 20, 90%). Most family members were female (n = 9, 81%) and most
patients were male (n = 9, 81%). In addition, most family members were mothers (n = 10, 91%).
All patients continued receiving treatment at the community mental health outpatient clinic and
along with their family members had participated in both the CFIMA study and the mixed-
methods follow-up study of the intervention outcomes. Informed consent was obtained from
each participant after all procedures had been explained.
Some participants were interviewed individually and others were interviewed together
with their family member. To accommodate to the participants’ needs, the interviews were
conducted in their preferred location and language. Eighteen interviews took place in the
participants’ homes, two in a coffee shop in the participants’ neighborhood, and two on the
campus of the affiliated university. All interviews included open-ended questions designed to
elicit the participants’ experiences of intimate and romantic relationships and gender roles of
those with an SMI diagnosis. Interviews were recorded, transcribed, and checked to ensure
accuracy.
Interview Guide
Questions for participants with SMI.
• How would you describe your relationship status?
• How has your illness affected how you connect with others romantically or
intimately?
• Is there anything about your relationships that concern you?
• What do you think needs to happen for you to feel satisfied with your life as a man or
woman?
INTIMATE RELATIONSHIPS AND GENDER 23
Questions for family members.
• What are your hopes and expectations about your family member’s personal life?
• What do you think needs to happen for your family member to feel satisfied with his
or her life as a man or woman?
• How has your family member’s illness affected his or her ability to connect with
others romantically or intimately?
Analysis
The data analysis of this study consisted of two phases: a qualitative content analysis and
an intersectionality analysis of the resulting categories. In addition, basic demographic
characteristics of participants were analyzed (Table 1).
Phase 1. Qualitative content analysis is a systematic approach used to analyze textual and
other forms of nonnumeric data. This method follows specific steps to increase trustworthiness,
rigor, and validity in the evaluation of qualitative data (Cho & Lee, 2014; Elo et al., 2014;
Forman & Damschroder, 2008; Schreier, 2014).
This study followed a method of qualitative content analysis that combined deductive and
inductive category development (Figure 1), in which questions from the in-depth interview were
used to identify sections containing information on intimate relationships and gender (Schreier,
2014). All interviews were initially reviewed and segments marked according to the answers
pertaining to each of the questions asked during the interview.
Using NVivo qualitative software, segments from the first eight interviews (four patients,
four family members) that highlighted themes related to the research questions were defined as
the initial categories, and coding rules were established to develop a coding agenda. After the
initial coding agenda was developed, four more interviews (two patients, two family members)
INTIMATE RELATIONSHIPS AND GENDER 24
were analyzed, leading to a revision of the initial tentative categories. Any emerging themes
were either added to the coding agenda as a new category or subsumed within previous
categories, resulting in the final coding agenda. This version of the coding agenda was used to
analyze all remaining interviews and was updated a final time with any new categories before
reviewing all data once again to conduct a summative check of reliability. A final coding agenda
was compiled and used to review all interviews together once more. The key themes that
emerged from the data and informed the final coding agenda are shown in Table 2. To better
illustrate the different support each key theme received, contrast graphs were developed for
overall categories for each category containing multiple themes (Figures 2–6).
Phase 2. An intersectionality analytic template (Bilge, 2009) was developed to examine
intersections of gender, culture, and mental illness that were found in the categories that resulted
from Phase 1. Murphy, Hunt, Zajicek, Norris, and Hamilton (2009) stated that it is not necessary
for the intersecting axes or categories to be explicitly discussed by participants to facilitate an
analysis of intersectionality. An intersectionality template can assist in carefully analyzing the
interplay between the theoretical framework and the data and allows for contextualization and
discussion of broader macro and mezzo contexts of social inequality (Murphy et al., 2009).
Portions of the text were extracted to provide examples of intersectionality and added to the final
template (Table 3).
Results
Sample Demographics
The study sample consisted of 22 participants (see Table 1): 11 adults diagnosed with
schizophrenia (age: M = 34, range = 24–69) and their respective family members providing care
(age: M = 61, range = 30–63). Nine individuals with SMI were male and nine family members
INTIMATE RELATIONSHIPS AND GENDER 25
were female. All family members were born outside of the United States; 10 were born in
Mexico and one was born in El Salvador. Seven of 11 participants were born in the United
States, three in Mexico, and one in El Salvador. Family members consisted of eight mothers, two
fathers, and one daughter. All except one family member lived with the patient with SMI, and
two of the patients were in an intimate relationship with other individuals at the time of the
study.
Salient Themes
Obstacles to intimate relationships. Participants noted several obstacles to establishing
intimate relationships. The most salient themes were stigma, unemployment, lack of confidence,
symptoms and side effects, and a lack of opportunities to meet people.
Stigma. Stigma was the main salient theme regarding obstacles to intimate relationships.
Thirteen participants expressed that perceived stigma of their mental illness and fear of
disclosure made it difficult for them to pursue and maintain intimate relationships. A male
patient (aged 31) shared why he has struggled to pursue intimate relationships:
There is stigma because of my illness. Let me give you an example. During the time I
was being hospitalized I met a girl and she told me her story … that she had a date … and
basically this person … found out she was bipolar, he just like cut her loose like, why? …
And you know, things like that make me not to start socializing ‘cause I’m hurt as it is,
I’m going to get even more hurt.
Seven of the 13 participants specifically noted the stigma associated with illness
disclosure. Disclosing their illness is something that they often worry about when contemplating
intimate relationships. A male patient (aged 25) shared some of his struggles disclosing his
illness to his girlfriend’s family due to the stigma of mental illness:
INTIMATE RELATIONSHIPS AND GENDER 26
I guess it’s not like having a limb taken away from me so it’s a constant reminder, like if
it was diabetes or anything else. If it was more physical it’d be seen as totally different
from a mental illness, and there is a stigma I think; it’s not talked about. If I were able to
talk about it and have it be seen like it was a physical illness, it might help me. … I can
see for some people if it was physical illness they would be able to talk about it and be
more open with it, it’ll be a lot better for them, you know.
Similarly, family members shared that stigma associated with illness disclosure hindered
patients in terms of establishing or maintaining intimate relationships. A mother (aged 49)
described her son not disclosing his illness to his girlfriends: “Before, he had his girlfriends, but
when he would relapse … I don’t think he would tell them he was sick, so when they found out,
well, that was it.”
Unemployment. Eight people with mental illness and three family members stated that
not having employment was a main reason why individuals with SMI are unable to establish or
maintain an intimate relationship. Several participants mentioned that not having a job made it
difficult to support a partner or family, therefore making dating difficult or not feasible. A male
patient (aged 28) illustrated this sentiment:
Honestly, it’s difficult to find someone. For one, I don’t find it comfortable for me
myself, because I know the questions. “How much do you make? Where do you work?
What do you drive? And where do you live?” And a lot of them normally look at you and
[say] “I don’t know about that one.” Very rarely will you find someone who will accept
you.
Family members agreed with that sentiment, sharing that they believe individuals with
SMI need a job and financial security to establish and maintain an intimate relationship. A father
INTIMATE RELATIONSHIPS AND GENDER 27
(aged 56) stated that he believes his son is not able to have a girlfriend because he lacks financial
stability: “I don’t think my son can have a girlfriend; he needs to get a job, a car, independence.
He wants it now but he has to work.”
Lack of confidence. Three patients mentioned that a lack of confidence was an obstacle
for engaging with potential partners and maintaining intimate relationships. Patients shared that
this lack of confidence involved shyness or not being able to offer financial stability to a
potential partner due to lack of employment and immigration status. For example, a male patient
(aged 24) stated:
That’s when she got angry and I said some things because she made me feel insecure,
like I had nothing to offer. But I told her, “You don’t have anything either, you might be
receiving SSI or government support but you have papers. Those of us without them
could do much more and you girls have them and do nothing.”
Symptoms and side effects. Symptoms of schizophrenia and other SMIs can be
debilitating in many ways; they can affect how individuals behave and feel on a daily basis,
which can affect their ability to interact with other people. Medications prescribed to treat these
symptoms often cause side effects that further decrease their ability to establish and maintain
intimate relationships. Six participants shared their perspectives on this theme, including a
mother (aged 61), who noted: “Maybe the medication affects him more, maybe the medication
… suppresses the sexual need of a girl or I think the medication gets him down and it gets … like
headaches.”
Lack of opportunities to meet potential partners. Patients and family members shared
that a lack of opportunities to meet potential partners was an obstacle to intimate relationships.
They expressed that they rarely have contact with single people in their age group, often only
INTIMATE RELATIONSHIPS AND GENDER 28
socialize with family members, and would benefit from being able to meet other people with
whom they could potentially develop an intimate relationship. A male patient (aged 31) shared
his experience:
Just have the guts to ask someone whom I like or whomever, just for their number and
just call them and take them out on a date, ‘cause I don’t. I mean at my age group, it’s
very few that are single; most of them are married with kids so unfortunately I don’t meet
many, that’s the fact.
Family discouragement. This theme was described by both patients and family members.
Family members expressed that at times they actively discourage patients from having
relationships out of fear of worsening symptoms. A father (aged 66) described his son’s
experience: “One time my wife told him, ‘Get a girlfriend,’ and I looked at him and said, ‘No,
no, no.’ Why a girlfriend? … He can’t handle that.”
Patients shared that their family would not be supportive of them having an intimate
relationship, based on previous conversations. One male participant (aged 30) noted: “Sincerely,
I don’t think they want me to find someone. They themselves tell me, ‘Look at your brother and
the problems with the mother of his children’; looking at those cases they tell me it is better like
this.”
Previous negative experiences. For some participants, having previous negative
experiences discouraged them from seeking new intimate relationships. A mother–son dyad
shared similar views when asked about intimate relationships. The son (aged 39) said, “One time
my ex hit me and they put me in jail. That’s when I said ‘never again.’” The patient’s mother
(aged 59) shared what her son told her when she tried to encourage him to find a partner: “I told
INTIMATE RELATIONSHIPS AND GENDER 29
him, ‘Go on, go find a partner or something,’ and he said ‘What for? You remember how it was
last time.’”
Culture and religion. In one instance, culture and religion were mentioned as obstacles
to intimate relationships. A daughter (aged 30) described why she believes her mother, who has
an SMI, has not been in an intimate relationship since her husband died: “She comes from a one-
marriage culture. Her religion doesn’t allow it either. If she didn’t have culture and religious
barriers, maybe she would.”
Lack of dating skills. This theme was only shared by family members. A mother (aged
49) said she believed her son lacked the dating skills to ask someone on a date. She followed this
statement by saying that her son would benefit from addressing that issue in therapy, particularly
learning how to interact with potential partners. “He doesn’t know how to treat a woman because
he hasn’t had a relationship since he got sick. I think he would need therapy support for that.”
Inability to have children. For one of the female patients (aged 31), not being able to
have children due to a medical issue was an obstacle to establishing an intimate relationship. She
noted: “I can’t have children. So it makes it difficult in the future if you find a man and he wants
… a baby. It’ll be a difficult thing.”
The following themes illustrate the complexity of the experiences and importance of
intimate relationships in the lives of patients with SMI.
Sense of normalcy. Several participants mentioned a sense of normalcy associated with
having an intimate relationship. They shared that feeling normal would in turn have a positive
impact and lead to feeling better and overall satisfaction with life. For four patients and six
family members, having an intimate relationship in the form of dating or marriage contributed to
an overall sense of normalcy. A mother (aged 49) shared the following: “I believe he would feel
INTIMATE RELATIONSHIPS AND GENDER 30
very good if he was able to get married, have a steady job, have a family—you know, a normal
life like everyone else.”
Advantages of intimate relationships. Participants shared several perceived advantages
of having or aspiring to have an intimate relationship.
Motivation. Overall, patients and family members mentioned motivation as the main
positive aspect of intimate relationships. Participants described motivation to find a partner, get a
job to find a partner, and maintain a job to support their current partner as advantages of intimate
relationships. Many of the participants expressed that having a relationship or working toward
establishing one are great motivators for treatment adherence to “get better,” as exhibited by the
following quote from a male patient (aged 24): “Wanting life; wanting a girl motivates me,
having a female companion motivates me to get better, having family, having a place to live …
having a female companion next to me. That’s my motivation.”
Reducing boredom. Family members and patients perceived intimate relationships as a
way to help reduce boredom for patients. A male patient (aged 37) said, “I don’t tend to be bored
a lot these days, especially with my girlfriend living with me; we talk a lot, we joke around, we
watch stuff together, we do stuff together.” Family members had similar beliefs regarding
intimate relationships as a way to reduce boredom. A father (aged 63) shared, “Now that he has a
girlfriend he brings her everywhere. … They are always busy, always. … He is never bored
anymore.” This sentiment was prevalent among patients and family members, who indicated that
having a partner helps patients stay busy and reduces their opportunities to become bored.
Bonding and care. Patients and family members alike shared this theme. For family
members, having other people who could care for the patient was important; they said this
assuaged their worries about what would happen to the patient if they were to die. One patient
INTIMATE RELATIONSHIPS AND GENDER 31
said having a partner would mean he would have someone to care for him and provide
opportunities for bonding and support. This male patient (aged 31) noted, “I think I have to find
me a partner for one thing … find me someone to care for, who cares for me, and … have that
bonding between a relationship.”
Stability. Stability can be difficult to achieve when patients have ongoing symptoms of
SMI. A client who reported that he had been stable for the last several months attributed this
stability to having a girlfriend and being able to interact with others at the center. This male
patient (aged 37) said, “I think having a girl and friends from the center, from the wellness center
I go to, has helped me be stable. I have two close friends and I have a girlfriend.”
Happiness. According to one mother, having an intimate relationship made her son
happy. She said that after finding his girlfriend, he became more sociable and she could tell that
he was enjoying the experience. This mother (aged 53) stated, “I noticed that when he is with her
he’s very happy, he talks a lot. … He’s able to socialize more.”
Disadvantages to intimate relationships. Several disadvantages to having an intimate
relationship were identified. Three themes illustrated the perceived negative consequences of
intimate relationships, as shared by family members and patients.
Breakups can affect treatment. A disadvantage of having an intimate relationships
shared by participants is that breakups can negatively influence treatment, especially when both
individuals receive services at the same mental health clinic. This sentiment was shared by both
patients and family members. A male patient (aged 24) stated: “I do have a program now. And
it’s not like I don’t want to go, but I used to have a girlfriend there. … It’s not that I still love her
but … it’s hard to see a person from the past.”
INTIMATE RELATIONSHIPS AND GENDER 32
Being taken advantage of. Two parents shared that one of the negative consequences of
intimate relationships is that the patient might be vulnerable to being taken advantage of. This
theme did not appear to be an obstacle for the patient establishing relationships, but more of a
fear expressed by parents. One mother (aged 53) expressed concern that her son could be taken
advantage of by a potential partner: “I do think that a woman could come along who uses drugs,
and she would ask for his money and convince him to live with her so he can give her money for
drugs, and them living like that.”
Having a partner with SMI. Finally, the symptoms of a partner who also has SMI were
mentioned as a disadvantage of being in an intimate relationship. Both family members and
patients shared that having a partner with SMI can be stressful for patients because their
partner’s symptoms might trigger or exacerbate their own symptoms. A male patient (aged 25)
shared his experiences dating a woman without SMI compared to dating his current girlfriend,
who has an SMI:
[My current girlfriend] has like an anger issue, so I think that clouds like her connection
with me versus my other one, [who] didn’t have an anger issue; she didn’t have no
chemical imbalance, so she was like more calm. Affects me more.
Gender-related life satisfaction. Ten participants shared their perceptions and thoughts
regarding what it would take for individuals with SMI to feel satisfied with their lives as men or
women. Seven of those respondents described gender-related life satisfaction as dependent on
some form of intimate relationship, perhaps leading to parenthood. One participant shared that
having a good relationship with his father, as a way of shaping his own ideas of fatherhood,
would bring him satisfaction. Three other participants mentioned employment and money,
INTIMATE RELATIONSHIPS AND GENDER 33
particularly as a means of establishing an intimate relationship and forming a family. A male
patient (aged 37) described his thoughts regarding gender-related life satisfaction:
To be satisfied as a man, I think I’m doing part of it now … that I’m thinking of having a
kid with my girlfriend. I see my relationship with me and my father; I think to be a man,
for me, I have to have a good relationship with … my dad, providing for my girlfriend
and child, being there for me.
A mother (aged 61) described her son’s gender-related life satisfaction:
I’ll say for him to be satisfied, he would learn how to make good decisions and then start
meeting other people but go on the right path, because nowadays he’s staying up late,
alcohol, drugs; and that’s not good for him. … But if he makes a good decision like
staying with somebody that would go, let’s say, to the mountains, to something healthy
… to the parks and there would be no alcohol involved, drugs involved, nothing like that.
If he would go that route, I think that he can make it for sure.
Hopes for the future. Twelve participants shared their perspectives about the future of
individuals with SMI. Seven of them were family members and all but one described hopes
about the future related to an intimate relationship; the other family member shared a hope for
independence and self-sufficiency. A mother (aged 49) stated the following regarding her son’s
future:
I hope for him to be a man. To form a home and find a girl who understands him. I hope
God is willing. I have that wish that one day a medication will make him better, and he
will find a woman who will love him and he can form a life.
INTIMATE RELATIONSHIPS AND GENDER 34
For patients, their main hopes for the future involved having an intimate relationship,
ending their current relationship and finding a new partner, and getting an education. A male
patient (aged 24) shared the following hope for his future:
I hope to find a girlfriend, hopefully down the road once I get back into the dating scene
maybe I can have someone, ‘cause once I find somebody, of course I’m going to care
about that person and she’s going to care about me.
Messages from family members about intimate relationships and gender. Learning
about messages that patients receive from their family members regarding intimate relationships
and gender was very valuable. This theme elucidated attitudes toward and perceptions of
intimate relationships and gender from the point of view of family members, and was shared by
both patients and family members. Family members described delivering messages regarding
employment as a means of establishing an intimate relationship. A father (aged 56) described
what he discusses with his son regarding intimate relationships:
In order for him to have a relationship, I tell him he has to work. I tell him, “A family
needs money, a woman needs to eat and dress and have shoes and an apartment.” … Sit
down and do the math. … He needs to be stable and get a job because I say, “You are not
going to be bringing a woman to this house, you need to work and be on your own.”
One mother (aged 53) said she would want her son to have an intimate experience
without necessarily having to commit to a relationship. She described having offered to pay for a
sex worker so he could connect and spend time with a woman:
I have told him, “Look, if you are stressed out and don’t have money, I can give you
some and you can pay for a woman,” that I would pay for one of those women who sell
INTIMATE RELATIONSHIPS AND GENDER 35
themselves. I say, “Go spend some time with one of those women, but don’t do drugs.”
Maybe he will get more courage and find himself a girlfriend.
All of these themes emerged across all participants, because the initial coding was done
regardless of dyad membership. A second analysis compared themes within dyads.
Intersectionality Analysis Results
Upon examining the perspectives shared in the participants’ narratives, several themes
emerged that highlighted the interplay of different identities: gender, immigration status,
reproductive ability, and culture. All of these identities involved both oppressive and protective
factors in the lives of patients with SMI. The complete intersectionality template is outlined in
Table 3.
Three illustrations of intersectionality were observed in the category of obstacles for
intimate relationships. These instances shared by participants highlight the interactions of
gender, culture, and SMI; in one of the accounts, immigration status was also observed as an
intersecting identity. These accounts indicate that unemployment and lack of confidence can
result from some of the constraints brought forth by cultural beliefs of gender roles and mental
illness. For example, this intersectionality became evident when a male patient (aged 28)
discussed what he considers to be an obstacle for establishing an intimate relationship:
Honestly, it’s difficult to find someone. For one, I don’t find it comfortable for me
myself, because I know the questions. “How much do you make? Where do you work?
What do you drive? And where do you live?” And a lot of them normally look at you and
[say] “I don’t know about that one.” Very rarely will you find someone who will accept
you.
INTIMATE RELATIONSHIPS AND GENDER 36
In this patient’s account, gender appears to be intersecting with a belief that men must be
able to provide for a woman to be considered able or worthy to have an intimate relationship.
Although this belief may not be exclusive of the Latino culture, cultures that adhere to more
traditional gender roles can have more rigidity in these expectations (Pinto & Coltrane, 2013).
This interaction seems to be particularly oppressive for men with an SMI because their
symptomatology can make them unable to obtain or maintain gainful employment, thereby
negatively affecting their confidence and ability to find a romantic partner.
For a female patient (aged 31), this interaction of gender, culture, and SMI was not
related to employment but to her reproductive ability. She shared: “I can’t have children. So it
makes it difficult in the future if you find a man and he wants … a baby. It’ll be a difficult
thing.” Being female and not being able to have children can be a disadvantage for Latino
women, especially those with SMI. Family members expressed an overall hope and desire that
patients would find a partner and have a family, which can be a protective factor. However, this
may be difficult for women with reproductive difficulties who also have the stigma of SMI. It
may affect their ability to find or maintain a partner if the partner wishes to have children.
Having an SMI and being female could also be a concern if the woman wants to seek
reproductive services and fertility assistance.
In the category of gender-related life satisfaction, an interaction of gender, culture, and
SMI emerged. All family members who discussed gender-related life satisfaction stated that an
intimate relationship would help the patient feel satisfied with life as a man or woman. However,
family members of male patients said that for this to happen, the individual would need a job
first. This coincides with previously stated beliefs that men must have a job to be able to have an
intimate relationship. This may make it more difficult for Latino men with SMI to establish and
INTIMATE RELATIONSHIPS AND GENDER 37
maintain an intimate relationship. This is reflected in the following quote by a mother: “Well, as
a man he has an aspiration to get married one day, but he needs to have a steady job, his goal is
to see life as normal, like everyone else.”
Regarding hopes for the future, culture seemed to offer protection when it comes to
Latinos with SMI. Family members expressed a common desire for them to find a partner and
start a family. This can serve as a motivator for the patient to interact with other people and
engage in friendship and socialization. This is not true for many cultures, in which fear exists of
the patient interacting with people outside of the family or establishing romantic relationships.
Most family members in this study seemed supportive of this desire, as reflected in the following
quote shared by a mother:
I hope for him to be a man. To form a home and find a girl who understands him. I hope
God is willing, I have that wish that one day a medication will make him better and he
will find a woman who will love him and he can form a life.
Finally, an example of two participant accounts regarding family messages about intimate
relationships illustrated intersectionality. One of these accounts by a father (aged 56) illustrated
the oppressive pressure that the expectation of employment can exert on Latino men with SMI.
In order for him to have a relationship I tell him he has to work. I tell him, “A family
needs money, a woman needs to eat and dress and have shoes and an apartment. … Sit
down and do the math. … He needs to be stable and get a job because I say, “You are not
going to be bringing a woman to this house. You need to work and be on your own.”
In this perspective offered by a family member, the interaction of culture, gender, and
SMI reflects the disadvantage for Latino men with SMI relative to establishing and maintaining
INTIMATE RELATIONSHIPS AND GENDER 38
intimate relationships, given their worth seems to be tied to having a job and money to support a
partner.
The final intersectional observation is illustrated in the narrative of a mother who
expressed a strong hope for her son to find companionship. She shared the following:
I have told him, “Look if you are stressed out and don’t have money, I can give you some
and you can pay for a woman,” that I would pay for one of those women who sell
themselves. I say, Go spend some time with one of those women, but don’t do drugs.”
Maybe he will get more courage and find himself a girlfriend.
The intersecting identities seen in this mother’s quote are gender and culture. In many
cultures, it may be more acceptable for men to engage in sexual relations outside of marriage,
including sexual relations with a sex worker. Although this study featured a small sample of
female participants, both participants and their families mentioned marriage as the desired or
accustomed way of having an intimate relationships.
Through this intersectional analysis, it became clear that these patients do not experience
mental illness in isolation of their other identities, but in a constant interaction that often makes it
difficult for them to enjoy their lives and aspire to establishing romantic relationships.
Discussion
The most frequent theme in the narratives of participants was stigma. Patients and family
member overwhelmingly shared that stigma was the main obstacle to their ability to establish
and maintain intimate relationships. Participants also shared that stigma associated with SMI
made them fearful about disclosing their illness to potential or existing partners. The existing
literature indicates that different forms of stigma negatively affect life satisfaction and quality of
life among people with SMI (Corrigan, Sokol, & Rüsch, 2013; Schmitt, Branscombe, Postmes,
INTIMATE RELATIONSHIPS AND GENDER 39
& Garcia, 2014), as reflected to some degree in the current sample. Future research should focus
on determining whether intimate relationships have a mediating effect on the relationship
between stigma and quality of life or life satisfaction; this could assist in identifying alternative
ways to address stigma that may have not been considered in previous interventions.
Findings also show that for many of the male patients and their families, employment
was a consistent obstacle to establishing intimate relationships. The experiences of most
participants show that employment directly affects their perceptions of their ability to establish
and maintain an intimate relationship. Not having a job impedes access to money and
opportunities to meet new people, which contribute to self-esteem. As confirmed by participants,
this can affect confidence and self-esteem, which in turn may negatively affect overall quality of
life. As research has shown, Latinos with SMI need culturally specific interventions to improve
their odds of finding and maintaining a job (Mueser et al., 2014); therefore, addressing
employment as a contributing factor to intimate relationships could be helpful in culturally
relevant employment and quality of life interventions for this population. As the intersectionality
analysis indicated, this can be of particular concern for men with an SMI who are undocumented
and therefore unable to seek employment assistance from government agencies.
These findings suggest that intimate relationships may contribute to different aspects of
quality of life and satisfaction for those with SMI. Several hopes and expectations are tied to
being able to establish and maintain intimate relationships, which may indicate that treatment
and interventions not addressing these concerns will not be comprehensive. Although
experiences varied between participants with SMI and family members, their eagerness to
discuss intimate relationships and the richness of their responses may be an indication that this is
a topic of concern and interest for this particular group.
INTIMATE RELATIONSHIPS AND GENDER 40
Another salient theme was the sense of normalcy that came from having an intimate
relationship; several participants, whether they currently had a relationship or not, tied the idea of
feeling normal to overall positive feelings and a sense of improvement. Understanding intimate
relationships as an element of life that makes people feel normal and how normalcy contributes
to the effectiveness of treatment can be very valuable in developing interventions.
Both similarities and discrepancies emerged among some of the dyads in terms of hopes
and personal expectations for patients. The study revealed that Latino families seemed
overwhelmingly supportive of their family member with SMI establishing an intimate
relationship. This brings to light the importance of including family members in treatment
because family members may help encourage clients to pursue pathways to achieve their goals in
this regard. These findings also underscore the need to develop interventions and treatment that
allow for open discussions of pressures and concerns from family members. Incorporating family
members in the conversation regarding intimate relationships can be a valuable element in
moving toward recovery and improving quality of life of Latinos with SMI.
With regard to findings from the intersectionality analysis, the intersection of gender,
culture, and SMI in terms of employment was observed through the data. The theme of obstacles
for relationships showed that for men with an SMI, having a job was seen as a requirement to
establish an intimate relationship. This may be a cultural aspect; the literature has shown that
more traditional Latino cultures see men as responsible for providing economically for a family.
However, research has shown that employment can be very difficult for those with SMI due to
their symptoms and medication side effects that can prevent them from carrying out the demands
of a full-time job. This puts men with SMI at a disadvantage when seeking a partner with whom
to establish an intimate relationship compared with women, who may have other disadvantages
INTIMATE RELATIONSHIPS AND GENDER 41
but who seem to not be expected to work as a precondition to finding a partner, and especially
compared to other men who don’t have an SMI. This intersection seemed to be further
compounded when considering immigration status.
Another intersection, being female and the ability to have children, was viewed as an
obstacle to establishing a relationship. Historically, female reproductive abilities have been one
of the main assets for women when seeking a partner. This confirms what literature has
indicated—that for women with an SMI, not being able to have children could represent a greater
disadvantage when compared to the rest of the population, given a bigger risk of the loss of
reproductive rights.
A positive intersection between culture and ideas regarding intimate relationships. The
family’s desire for companionship for the person with SMI could bring forth undue pressure on
some individuals to find a partner; however, it was refreshing to see that this differs from other
cultures that have historically prevented people with SMI from finding partners and starting a
family out of fear of continuing to pass the illness to future generations. Although one of the
dyads in this study shared that concern, it did not prevent these participants from supporting each
other and wanting to move toward having children.
Findings from this study expanded knowledge of the importance of intimate relationships
in the lives of patients with SMI. This study shed light on why Latinos with SMI might struggle
with establishing and maintaining intimate relationships, and the role that family members play
in this context. Addressing this gap in the literature can aid future research and assist in the
development of culturally relevant interventions focusing on intimate relationships that address
gender and family participation.
INTIMATE RELATIONSHIPS AND GENDER 42
Strengths
Multiperspective approach. The importance of family members in different aspects of
the lives of Latinos with schizophrenia is fundamental to the effectiveness of treatment and their
recovery. Including the perspectives of family members and patients from the same dyad
provided a glimpse into their shared hopes, perceived advantages and disadvantages, messages
from family members that could be unhelpful, and other important aspects of intimate
relationships and gender. These perspectives can serve as a guide for further study and as
elements to be included in culturally relevant interventions with similar groups.
Intersectionality. Several factors emerged from the data that indicate that gender,
culture, and SMI are constantly interacting and creating unique experiences for participants.
Intersectionality analysis revealed that several issues bring about an added layer of disadvantages
that could be attributed to the multiple intersections of the categories observed. Some protective
factors were also observed in participants’ narratives, such as a strong desire from family
members to have an intimate relationship, which often translated as support and encouragement
of patients in their search for an intimate relationship. Being able to observe the interactions of
different identities and how these may be protective or oppressive in the lives of patients with
SMI can help inform future interventions addressing intimate relationships that incorporate
family members.
Limitations
Generalizability. This study sought to provide descriptions of the experiences of
intimate relationships and gender of the participants and describe how intersectionality was
reflected in those experiences. However, it is not possible to state that these experiences are the
same for all Latinos with mental illness and their family members. Therefore, it is imperative for
INTIMATE RELATIONSHIPS AND GENDER 43
other researchers and practitioners to use these data only as an example of the diverse nature of
experiences individuals with SMI may have regarding intimate relationships and gender roles.
Using a feminist theory with few female participants with SMI. Intersectionality is
considered a feminist theory. The author is aware of the implications of using such a theory
when only two of the participants with SMI were female. There is a risk of continuing to nullify
the experience of women with disabilities by not expanding the sample to seek female
participants. The reasons for including more female participants are associated with time,
resources, and sample characteristics. In the initial recruitment stage for this study, there were
several female participants; however, some of them were no longer reachable at the address or
phone number provided or they did not schedule a time for the interview to take place.
Despite the limitations of the gender composition of the sample, it is important to note
that intersectionality has been used to explore what Bilge (2009) called “invisible masculinities.”
Not all masculinities represent the dominant group, and being able to focus on masculinities of
Latino men with disabilities is a way of bringing light to other types of processes that can
stigmatize and pathologize men as well.
Conclusion
This study’s findings can provide future direction in research on intimate relationships of
Latinos with SMI. By addressing this gap in knowledge, we can move toward the development
of culturally relevant interventions and treatment for Latinos with schizophrenia and ultimately
contribute to improvement in mental health outcomes for Latinos with schizophrenia and other
serious mental disorders.

INTIMATE RELATIONSHIPS AND GENDER 44
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INTIMATE RELATIONSHIPS AND GENDER 56
Table 1
Family Member and Patient Characteristics
Family Patient
(n = 11) (n = 11)
M or n (%) M or n (%)
Age
a
61 34
Gender
Female 9 (81) 2 (19)
Male 2 (19) 9 (81)
Marital status
Married 8 (73) 0 (0)
Separated 1 (9) 1 (9)
Divorced 0 (0) 1 (9)
Widowed 1 (9) 1 (9)
Single, never married 1 (9) 7 (64)
Single, cohabitating 0 (0) 1 (9)
Relation to patient
Mother 8 (73)
Father 2 (19)
Son or daughter 1 (9)
Place of birth
Mexico 10 (91) 3 (27)
El Salvador 1 (10) 1 (10)
INTIMATE RELATIONSHIPS AND GENDER 57
United States 0 (0) 7 (63)
Note. Percentage values may not total 100% due to rounding
error.
a
Range was 30–63 for family and 24–69 for patient.

INTIMATE RELATIONSHIPS AND GENDER 58
Table 2
Salient Themes of Intimate Relationships and Gender for Latino Patients with Schizophrenia and
Their Family Members
Category Family Patient
n n
Obstacles to intimate relationships
Stigma 5 8
Unemployment 4 5
Lack of confidence 1 2
Symptoms and side effects 2 4
Lack of opportunity 1 3
Family discouragement 2 1
Previous negative experience 1 2
Culture and religion 1 0
Lack of dating skills 2 0
Inability to have children 0 1
Sense of normalcy 6 4
Advantages of intimate relationships
Motivation 2 3
Reducing boredom 2 2
Bonding and care 2 2
Stability 1 1
Happiness 1 0
INTIMATE RELATIONSHIPS AND GENDER 59
Disadvantages of intimate relationships
Breakups can affect treatment 1 1
Patient could be taken advantage of 2 0
Symptoms of a partner with serious mental illness 1 2
Gender life satisfaction 6 4
Hope for the future 6 6
Messages about intimate relationships and gender from family
Employment 4 2
Sex work 1 0

INTIMATE RELATIONSHIPS AND GENDER 60
Table 3
Intersectionality Template
Category and
Theme
Social
Category
Discrete Consideration Intersectional Consideration
Obstacles for IR:
Unemployment
Lack of confidence
Gender
Culture
SMI
Honestly, it’s difficult to
find someone. For one, I
don’t find it comfortable
for me myself, because I
know the questions. “How
much do you make? Where
do you work? What do you
drive? And where do you
live?” And a lot of them
normally look at you and
[say] “I don’t know about
that one.” Very rarely will
you find someone who will
accept you.
Gender is intersecting with a
cultural belief that men must
be able to provide for a
woman to be considered able
or worthy to have an intimate
relationship. This seems to be
particularly oppressive for
men with an SMI because
their symptomatology can
make them unable to obtain
or maintain gainful
employment.
INTIMATE RELATIONSHIPS AND GENDER 61
Obstacles for IR:
Unemployment
Lack of
confidence
Gender
Culture
SMI
Immigration
status
That’s when she got angry
and I said some things
because she made me feel
insecure, like I had nothing
to offer. But I told her,
“You don’t have anything
either, you might be
receiving SSI or
government support but
you have papers. Those of
us without them could do
much more and you girls
have them and do nothing.”
For Latino men with an SMI,
being undocumented can
further the strain on them to
find employment, and this is
amplified by their inability to
receive government
assistance. By not having any
means to obtain money, they
are less able to establish and
maintain an intimate
relationship.
INTIMATE RELATIONSHIPS AND GENDER 62
Obstacles for IR:

Reproductive
ability
Gender
Culture
SMI
I can’t have children. So it
makes it difficult in the
future if you find a man
and he wants … a baby.
It’ll be a difficult thing.
Being female and not being
able to have children can be a
disadvantage for Latino
women with SMI. There was
an overall hope and desire
from family members to have
patients find a partner and
have a family, but this may
be difficult for women with
reproductive difficulties. It
may impact their ability to
find or maintain a partner if
the partner wishes to have
children. SMI and being
female could also be a
concern if the woman wants
to seek reproductive services.
INTIMATE RELATIONSHIPS AND GENDER 63
Gender related life
satisfaction
Culture
Gender
SMI
Well, as a man he has an
aspiration to get married
one day, but he needs to
have a steady job, his goal
is to see life as normal, like
everyone else.
All family members who
shared about gender-related
life satisfaction stated that an
IR would help the patient feel
satisfied with life as a man or
woman. However, for male
patients, their family
members said that for this to
happen, they would need a
job first. This coincides with
previously stated beliefs that
men must have a job to be
able to have an intimate
relationship. This may make
it more difficult for Latino
men with SMI to establish
and maintain an IR.
INTIMATE RELATIONSHIPS AND GENDER 64
Hopes for the
future
Culture
SMI
I hope for him to be a man.
To form a home and find a
girl who understands him. I
hope God is willing, I have
that wish that one day a
medication will make him
better and he will find a
woman who will love him
and he can form a life.
Culture seemed to offer
protections when it comes to
Latinos with SMI. There was
a common desire from their
family members for them to
find a partner and start a
family. Most family
members seemed supportive
of this desire.
Messages about IR
from family
members:
Employment
Culture
Gender
SMI
In order for him to have a
relationship I tell him he
has to work. I tell him, “A
family needs money, a
woman needs to eat and
dress and have shoes and
an apartment. … Sit down
and do the math. … He
needs to be stable and get a
job because I say, “You are
not going to be bringing a
woman to this house, you
need to work and be on
your own.”
This intersectional
consideration reflects the
disadvantage for Latino men
with SMI to be able to
establish and maintain IR,
when their worth seems to be
tied to having a job and
money to support a partner.
INTIMATE RELATIONSHIPS AND GENDER 65
Messages about IR
from family
members:
Sex work
Culture
Gender
I have told him,
“Look if you are
stressed out and don’t
have money, I can
give you some and
you can pay for a
woman,” that I would
pay for one of those
women who sell
themselves. I say, “Go
spend some time with
one of those women,
but don’t do drugs.”
Maybe he will get
more courage and find
himself a girlfriend.
The intersecting identities seen in
this mother’s quote are gender and
culture. In many cultures, it may
be more acceptable for men to
engage in sexual relations outside
of marriage, including sexual
relations with a sex worker.
Although this study featured a
small sample of female
participants, both participants and
their families mentioned marriage
as the desired or accustomed way
of having an IR.
Note. IR, intimate relationship; SMI, serious mental illness.

INTIMATE RELATIONSHIPS AND GENDER 66
Figure 1
Note. Adapted from Mayring (2000).

INTIMATE RELATIONSHIPS AND GENDER 67
Figure 2
Note. IR, Intimate relationships.

INTIMATE RELATIONSHIPS AND GENDER 68
Figure 3
Note. Sx, Symptoms.

INTIMATE RELATIONSHIPS AND GENDER 69
Figure 4

INTIMATE RELATIONSHIPS AND GENDER 70
Figure 5

INTIMATE RELATIONSHIPS AND GENDER 71
Figure 6
Note. IR, Intimate relationships.

Abstract (if available)

Abstract Intimate relationships are a fundamental part of the human experience and contribute to quality of life and recovery of patients with serious mental illness (SMI). However, few psychosocial interventions exist to address this issue with patients with SMI and none of the existing interventions focuses on Latinos. The intersectionality of being Latino and having a SMI can create a very unique experience regarding intimate relationships and gender. Latinos with SMI are known to be more family oriented and more likely to live with family members than non-Latino Whites

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Asset Metadata

Creator Helu-Brown, Paula (author)

Core Title Intimate relationships and gender: perspectives from Latinos with schizophrenia and their family members

School School of Social Work

Degree Doctor of Philosophy

Degree Program Social Work

Publication Date 05/09/2017

Defense Date 03/03/2017

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Family,gender,intersectionality,intimacy,intimate relationships,Latino,Mental Health,OAI-PMH Harvest,qualitative study,Relationships,schizophrenia,serious mental illness

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Barrio, Concepcion (committee chair), Aranda, Maria (committee member), Messner, Michael (committee member)

Creator Email helufern@usc.edu,paula_helu@yahoo.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-372178

Unique identifier UC11257977

Identifier etd-HeluBrownP-5327.pdf (filename),usctheses-c40-372178 (legacy record id)

Legacy Identifier etd-HeluBrownP-5327.pdf

Dmrecord 372178

Document Type Dissertation

Rights Helu-Brown, Paula

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA