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The role of protective factors on outcomes for Latinos with schizophrenia
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Content
The Role of Protective Factors on Outcomes for Latinos with Schizophrenia
by
Mercedes Hernandez
______________________________________________________________
A Dissertation Presented to the
FACULTY OF THE USC SCHOOL OF SOCIAL WORK
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(SOCIAL WORK)
August 2014
THE ROLE OF PROTECTIVE FACTORS ii
Dedication
This dissertation is dedicated to my mom who exemplifies strength and resilience. Her
unconditional love and encouragement have sustained me through everything that I have ever
strived to achieve. Gracias por tu infinito amor y apoyo, mamá.
THE ROLE OF PROTECTIVE FACTORS iii
Acknowledgements
I am grateful to a number of people who have helped me carry out this study. First, to
my faculty mentor and dissertation chair, Dr. Concepción Barrio, whose guidance and support
has been instrumental in my work as a doctoral student. It has been a pleasure to work with her
as she has consistently demonstrated genuine care for my academic development and has been a
role model for the researcher and scholar that I aspire to become. I am grateful to my
dissertation committee members, Dr. Ann-Marie Yamada and Dr. Chih-Ping Chou for their
critical feedback and support throughout the dissertation process. I also thank Dr. John Brekke
who provided valuable feedback during the proposal-writing phase. Finally, I am deeply grateful
to the families and consumers who participated in this study for allowing me to learn from them
and share their experiences.
Support for this study was provided by a dissertation grant from the National Institute of
Mental Health 1R36MH102077-01.
THE ROLE OF PROTECTIVE FACTORS iv
TABLE OF CONTENTS
Dedication ii
Acknowledgements iii
List of Tables vi
List of Figures vii
Abstract viii
CHAPTER ONE: INTRODUCTION 1
Study Aims 3
Significance of Study 4
CHAPTER TWO: LITERATURE REVIEW 5
Disparities in Mental Health Treatment 5
Components of Family Psychoeducation 7
Family Psychoeducation and Cultural Context 8
Culturally Based Family Intervention for Mexican Americans 10
Conceptual Framework 11
Protective Factors 14
Protective Factors and Latinos 15
Summary 21
CHAPTER THREE: METHODS 22
Mixed-Methods Design 22
Phase 1-Aim 1 (Quantitative Analysis of Parent Study Data) 22
Sample 23
Measures 27
Parent Study Preliminary Findings 30
Quantitative Data Analysis 31
Phase 2-Aim 2 (Qualitative Data Collection and Analysis) 33
Sample and Data Collection 34
Qualitative Data Analysis 36
CHAPTER FOUR: RESULTS 37
Preliminary Quantitative Results 37
Main Quantitative Results 37
Qualitative Results 63
CHAPTER FIVE: DISCUSSION 75
Implications and Future Directions 81
Limitations 83
Conclusion 84
THE ROLE OF PROTECTIVE FACTORS v
References 85
Appendix A: Interview Guide Domains 108
THE ROLE OF PROTECTIVE FACTORS vi
LIST OF TABLES
Table 1: Baseline Family Member and Consumer Characteristics 25
Table 2: Baseline Family Member and Consumer Measures 26
Table 3: Baseline Key Family Member Characteristics by Treatment Condition 38
Table 4: Family Post-Study and Follow-up Measures by Treatment Condition 39
Table 5: Baseline Consumer Characteristics by Treatment Condition 40
Table 6: Consumer Post-Study and Follow-up Measures by Treatment Condition 41
Table 7: Protective Factors and Burden Total Measure Mediation Models 47
Table 8: Protective Factors and Knowledge Mediation Models 50
Table 9: Protective Factors and Quality of Life Mediation Models 55
Table 10: Criticism and Intrapsychic QLS Mediation Model 56
Table 11: Criticism and Instrumental QLS Mediation Model 56
Table 12: Protective Factors and PANSS Mediation Models 60
Table 13: Warmth and Generalized Psychopathology Mediation Model 61
Table 14: Summary of Findings Indicating Effects of Protective Factors on Outcomes 62
THE ROLE OF PROTECTIVE FACTORS vii
LIST OF FIGURES
Figure 1: Heuristic model for cultural exchange 12
Figure 2: Cross-lagged model 32
Figure 3: Mediation model 32
THE ROLE OF PROTECTIVE FACTORS viii
Abstract
Family psychoeducation interventions have demonstrated significant clinical and
functional outcomes among consumers with schizophrenia and their family members. In
particular, interventions that incorporate protective factors with low-acculturated Latinos have
been found to benefit this cultural group, suggesting that protective factors are influential in
supporting treatment effects. This study examined the positive influence of salient protective
factors (family hope, family warmth/criticism, adaptability and cohesion) on treatment outcomes
for key family members (burden, knowledge of the illness) and consumers (quality of life,
symptoms) with schizophrenia. The study was informed by a cultural exchange framework and
utilized a sequential explanatory mixed-methods design with secondary quantitative data (N =
64) from an NIMH-funded intervention development study of a culturally based family
psychoeducation model for Latinos. Phase 1 involved examining the effects of protective factors
on family and consumer outcomes over time, followed by mediation analyses of the influence of
protective factors on intervention outcomes. Findings informed the second phase of the study,
during which qualitative data from a subset of intervention participants (20 key family members
and 14 consumers) were collected and analyzed to explore protective factors further and the
influence of the intervention on outcomes. Overall, findings showed promise for the influence of
protective factors on family and consumer outcomes. In particular, we found that perceptions of
criticism decreased for family members and consumers in the intervention. Furthermore, this
decrease led to an indirect effect for improved intrapsychic and instrumental quality of life
components among consumers. In addition, consumers experienced an increase in perceptions of
family warmth and there was a trend for improvement among family members. The improved
perception of family warmth among consumers led to an indirect effect for reduced general
THE ROLE OF PROTECTIVE FACTORS ix
psychopathology symptoms. Our qualitative findings provided further depth regarding
protective factors that included hope, religion/spirituality, and family environment as salient
themes. Participants overwhelmingly believed that knowledge gained from the intervention was
a resource that influenced their perceptions of the illness, treatment, stigma, and wellbeing.
Taken together our findings elucidate how culturally based psychoeducation interventions may
enhance culturally salient protective factors and further support the use and effectiveness of this
intervention for Latino consumers with schizophrenia and their families.
THE ROLE OF PROTECTIVE FACTORS 1
CHAPTER ONE
Introduction
Families play an integral role in the recovery process for individuals with schizophrenia.
Providing treatment to consumers within their family context is considered an effective means of
supporting consumer wellbeing (Lucksted, McFarlane, Downing, & Dixon, 2012). The impact
of a serious mental illness such as schizophrenia is far reaching affecting not only individuals
who experience the illness but their family members as well. Family members caring for a loved
one with schizophrenia have reported challenges in their caregiving that can lead to negative
emotional and physical outcomes (Breitborde, López, & Kopelowicz, 2010; Grandón, Jenaro, &
Lemos, 2008; Magaña, Ramirez Garcia, Hernandez, & Cortez, 2007). In addition, these families
when compared to families not caring for a family member with schizophrenia, have been found
to be at a greater risk for mental illness including affective, anxiety, and substance abuse
disorders among others (DeVylder & Lukens, 2013). Interventions targeting the family system
may therefore provide preventative care and support for these families.
Over the years, there has been a shift in how family involvement is perceived in treatment
(Huey, Lefley, Shern, & Wainscott, 2007). While past beliefs and practices alienated family
members by falsely blaming them for causing the illness, empirical evidence has demonstrated
the important contribution that families can have on consumer wellbeing (Pitschel-Walz, Leucht,
Bauml, Kissling, & Engel, 2001). In this effort, the schizophrenia Patient Outcomes Research
Team (PORT) has consistently recommended family psychoeducation as an evidence-based
treatment because it has demonstrated favorable clinical and functional outcomes for families
and consumers (Dixon et al., 2010; Kreyenbuhl, Buchanan, Dickerson, & Dixon, 2010; Lehman
et al., 2004; Lehman & Steinwachs, 1998; Pharoah, Mari, Rathbone, & Wong, 2010)
THE ROLE OF PROTECTIVE FACTORS 2
Interventions that include family members address the sociocultural needs of underserved
ethnic groups, such as Latinos, whose strong family orientation may benefit from a treatment
modality that acknowledges family influence (Vega et al., 2007). Studies on disparities in
mental health treatment with Latinos and other underserved and underresearched groups have
highlighted the need to incorporate cultural preferences in treatment as a way to facilitate
treatment access and adherence (Lopez, 2002; U.S. Department of Health and Human Services,
2001; Vega et al., 2007).
Family psychoeducation models that have included protective components with low-
acculturated Latino families have shown positive outcomes for consumers (Kopelowicz, Zarate,
Smith, Mintz, & Liberman, 2003; Kopelowicz et al., 2012). Protective components or factors
refer to resources such as family hope that are used by consumers and families to ameliorate
difficult experiences resulting from the illness (Rutter, 1987). However, few studies have
directly examined the influential role of protective factors on family intervention outcomes.
These findings can inform an improved intervention that may enhance effectiveness for the
growing number of Latinos and their families being served in the public mental health sector. In
addition, although studies on psychoeducational interventions have focused on relapse as an
outcome measure, little is known about consumer and family conceptions of wellbeing,
particularly among racial and ethnic minorities, whose view of recovery may extend beyond
relapse as an indicator of clinical relevance (Dixon, Adams, & Lucksted, 2000). Such
knowledge is important because it will improve family psychoeducational interventions and
better address the needs of Latino consumers and the families that support them.
THE ROLE OF PROTECTIVE FACTORS 3
Study Aims
This study utilized a mixed-methods approach to examine the influence of protective
factors on outcomes for Latino family members and consumers who participated in a controlled
intervention development study of a culturally based model funded by the NIMH (Barrio &
Yamada, 2010). The study used quantitative data (N = 64) from the parent study. In addition,
qualitative data from a subset of 34 participants (20 key family members and 14 consumers) was
collected from the intervention condition of the parent study. The study was guided by a cultural
exchange framework (Palinkas et al., 2009; Palinkas, Allred, & Landsverk, 2005) that was the
basis of the culturally based family intervention (Barrio & Yamada, 2010).
Aim 1: To examine the effects of protective factors on outcomes for family members and
consumers who participated in a culturally based family intervention compared to those who
received treatment as usual. Specifically, protective factors included family level of hope, the
expressed emotion components of warmth and reduced criticism, and family
adaptability/cohesion. For family members, outcomes consisted of burden and knowledge of the
illness. Consumer outcomes included quality of life and symptomatology.
Aim 2: To explore family member and consumer perceptions of salient protective factors
and how these are utilized among the family system. Because perceptions of what constitutes a
significant outcome may vary depending on cultural beliefs regarding wellness, we explored in
more depth how participation in the intervention influenced consumer and family member
perceptions of mental illness, treatment, and service utilization. We also explored the potential
effect of the intervention on improving perceptions of the illness for consumers and families.
THE ROLE OF PROTECTIVE FACTORS 4
Significance of Study
This study has strengths that are innovative to the study of family psychoeducation
interventions for Latinos. First, by examining how a culturally based family intervention that
supported protective factors related to salient cultural domains (e.g., warmth) affected outcomes
and well-being among Latinos, we can more readily examine the benefits of personalized
approaches for this underserved group. This study aligns with the Surgeon General’s (U.S.
Department of Health and Human Services, 2001)
recommendation on “culturally responsive
therapy for Latinos”
(U.S. Department of Health and Human Services, 2001, p. 147), with the
purpose of improving treatment. Second, this study extends beyond the traditional examination
of treatment success, which may obscure clinically and culturally relevant factors for Latino
consumers and families. Specifically, this study’s iterative approach builds from quantitative
findings to inform qualitative data collection and analyses to examine how a culturally based
family intervention may influence consumer and family perceptions of mental health, treatment,
and service utilization. The cultural exchange framework serves as a theory and a method in
guiding the study’s iterative process; the knowledge gained from our mixed-methods approach
will be used to inform and enhance the intervention model’s effectiveness. Third, few studies
have examined family psychoeducation effects over time; existing studies produced mixed
results (Masanet, Montero, Lacruz, Bellver, & Hernandez, 2007; McWilliams et al., 2012;
Montero, Masanet, Bellver, & Lacruz, 2006; Tarrier, Barrowclough, Porceddu, & Fitzpatrick,
1994). The use of longitudinal data permits examination of the process of change, a critical
aspect of studying treatment effects, especially as they relate to cultural influences over time.
Lastly, this study seeks to provide a model for the cultural enhancement of treatments for other
ethnic minority groups.
THE ROLE OF PROTECTIVE FACTORS 5
CHAPTER TWO
Literature Review
Disparities in Mental Health Treatment
Psychosocial interventions have been found to impact outcomes of schizophrenia that are
not adequately managed by medication alone, such as quality of life and caregiving challenges
experienced by family members (Mueser, Deavers, Penn, & Cassisi, 2013; Pfammatter, Junghan,
& Brenner, 2006). Despite the growing evidence regarding psychosocial interventions in the
treatment of schizophrenia, there is limited availability of these best practices in mental health
settings (Davidson, 2010; Dixon et al., 2010; Drake, Bond, & Essock, 2009; Horvitz-Lennon,
Donohue, Domino, & Normand, 2009; Lehman & Steinwachs, 1998; Torrey et al., 2001). A
study examining trajectories of medication and psychotherapy service use among individuals
after their first psychotic admission found that 54.6% continuously used medication and only
17.4% received continuous psychotherapy in the 4-year follow-up period. In addition, those who
belonged to the minimal treatment usage group experienced several episodes of relapse thus
affecting their ability to achieve complete remission (Mojtabai et al., 2009). It is estimated that
in some cases less than 10% of individuals with schizophrenia receive psychosocial interventions
that are considered evidence-based (Torrey et al., 2001). In all, evidence-based treatment for
individuals with schizophrenia is lacking; as much as 95% of consumers with schizophrenia may
lack quality care (Drake et al., 2009).
Several reports have supported family-based interventions, including the 2003 President’s
New Freedom Commission on Mental Health report that called on treatment to be “consumer
and family driven” (p.8). Yet, we find that many individuals and family members dealing with
schizophrenia do not receive this evidence-based treatment (Lucksted, McFarlane, Downing, &
THE ROLE OF PROTECTIVE FACTORS 6
Dixon, 2012; Mojtabai et al., 2009; New Freedom Commission on Mental Health, 2003). A
study using data from the PORT project (Lehman & Steinwachs, 1998) with a nationally
representative sample of individuals with Medicare and a state sample of Medicaid recipients
found that only 0.7% of Medicare-eligible and 7% of Medicaid-eligible consumers received
family psychoeducation (Dixon et al., 1999). This same study found that compared to European
Americans, African Americans with Medicaid were less likely to receive family psychoeducation
(Dixon et al., 1999).
While individuals with schizophrenia are at risk for experiencing disparities in mental
health treatment, there are even greater challenges experienced by some groups. Disparities in
access and quality of mental health treatment have been extensively documented for Latinos and
other racial and ethnic minorities, (Horvitz ‐Lennon et al., 2014; López, 2002; López, Barrio,
Kopelowicz, & Vega, 2012; Smedley, Stith, & Nelson, 2003; Snowden & Yamada, 2005; U.S.
Department of Health and Human Services, 2001; Vega, Kolody, Aguilar-Gaxiola, & Catalano,
1999; Vega et al., 2007) potentially leading to more complicated mental health conditions due to
lack of adequate care (Gonzalez, Tarraf, Whitfield, & Vega, 2010). Furthermore, disparities in
mental health care for Latinos do not remain static but appear to increase over time (Cook,
McGuire, & Miranda, 2007). Latinos are the largest ethnic minority group in the United States,
comprising 16.7% of the population (U.S. Census Bureau, 2012a, 2012b), yet Latinos with
schizophrenia and other serious mental illnesses receive fewer specialty mental health services,
including lower levels of outpatient treatment, compared to European American consumers
(Barrio et al., 2003; Snowden, 2007). Underutilization of treatment has been attributed to
various factors, including a lack of fit between treatment approaches and cultural preferences
THE ROLE OF PROTECTIVE FACTORS 7
(Alegría et al., 2007; Bernal, Jimenez-Chafey, & Domenech Rodriguez, 2009; López, 2002;
Vega et al., 2007).
Components of Family Psychoeducation
Family psychoeducation, an evidence-based treatment, was developed partly as a
response to research indicating that schizophrenia is a brain disease that can leave individuals
vulnerable to overstimulation from their social environment (McFarlane, 1983). In addition,
families began to take on more responsibilities in the daily lives of consumers due to
deinstitutionalization and the subsequent move to community mental health care. Because of the
growing role of families in support of consumers, it became necessary to provide education to
families about the illness. The goal was to bring about change in the family social environment
when necessary, to help protect consumers from possible relapse (McFarlane, 1983).
Although there are differences in how family psychoeducation is implemented in
treatment settings, psychoeducation modalities share common elements (Cohen et al., 2008).
Among these are education about the illness, support, problem solving, and crisis intervention
(Cohen et al., 2008; Harvey & O’Hanlon, 2013; Sin & Norman, 2013). Despite these
commonalities, the components that contribute to positive outcomes in family psychoeducation
are unclear; therefore, more knowledge about treatment components is needed so that they may
be better incorporated in treatment (Cohen et al., 2008). Moreover, studies have found that
family interventions that are at least 6 to 9 months in length have resulted in improved outcomes
as seen in reduced relapse rates as well as increased treatment adherence among consumers while
families have experienced a reduction in burden and improved family relationships (Dixon et al.,
2010). The recent PORT recommendations also point to the benefits of shorter treatment
duration particularly for family members (Dixon et al., 2010). In addition, it is believed that a
THE ROLE OF PROTECTIVE FACTORS 8
shorter treatment course may benefit adherence and feasibility for the delivery of
psychoeducation in community mental health settings (Cohen et al., 2008). While most evidence
has been found with individuals who experience an exacerbation of symptoms, studies have also
indicated that psychoeducation can benefit consumers who are clinically stable. As noted by
Dixon et al. (2010) given the possible fluctuation in symptoms and illness severity experienced
by consumers, psychoeducation treatment can pose benefits for consumers and families who are
not experiencing active symptoms.
Among the various models of psychoeducation, multifamily group models have been
found to bring improved benefits due to the emotional support that families receive from other
group participants (McFarlane, 2002). It is believed that the combination of knowledge and
social support found in multifamily groups can bring about substantial benefits in burden for
families and decrease relapse for consumers among other benefits. It has been noted, however,
that how family psychoeducation is delivered is as important as the content of the intervention
(McFarlane, 2002). In other words, special attention needs to be paid to how information is
provided to families, thereby highlighting the importance of sociocultural context.
Family Psychoeducation and Cultural Context
A concern regarding traditional mental health treatment is that it has its own culture
inherent in Western values that can limit its effectiveness with individuals whose background is
different from mainstream society (Bernal & Scharrón-del-Río, 2001; Hall, 2001; Rogler,
Malgady, Costantino, & Blumenthal, 1987). The probability of having success with an
intervention will increase if it encompasses values that are congruent with those receiving the
treatment (Barrio, 2000; Castro, Barrera, & Holleran Steiker, 2010). It is important to recognize
that while psychosocial interventions have been developed to treat schizophrenia and other
THE ROLE OF PROTECTIVE FACTORS 9
severe mental illnesses, most have not been tested with ethnic minority participants. Given the
low adherence and early withdrawal from treatment experienced by many racial and ethnic
minority consumers, researchers in the field of minority mental health emphasize the need to
examine how the use of culturally adapted services can improve quality of treatment for these
groups (Barrio, 2000; López, 2002; Vega et al., 2007). Empirical studies show promise for
culturally adapted interventions. A meta-analysis on culturally adapted mental health
interventions revealed a moderately strong outcome (d=.45) on the 76 culturally adapted
interventions under study (Griner & Smith, 2006). The review further indicated that
interventions developed for specific ethnic groups were four times more successful than those
that included several ethnic groups. Interestingly, out of the 76 studies identified for inclusion in
the meta-analysis, only one, Kopelowicz et al. (2003), addressed individuals diagnosed with
schizophrenia.
Family interventions that incorporate cultural preferences and protective factors
(Weisman, Duarte, Koneru, & Wasserman, 2006) by including concepts such as family cohesion
and adaptability, warmth, and hope offer support for key wellness principles (Glynn, Cohen,
Dixon, & Niv, 2006). Detrimental consequences have been found in family interventions that do
not adhere to family cultural preferences. Telles and colleagues’ 1995 study of a family
intervention using a behavior model found that a lack of consideration for cultural factors
resulted in iatrogenic effects for low acculturated Latino families. Specifically, family members
experienced an increase in expressed emotion while consumers had an increase in symptoms.
Conversely, approaches that introduced family members as a cultural resource to support a skills-
building intervention led to positive outcomes for Latino consumers (Kopelowicz et al., 2003).
In a recent multifamily group intervention study comparing the effects of a culturally adapted
THE ROLE OF PROTECTIVE FACTORS 10
group, a standard group, and treatment as usual on medication adherence and rehospitalization
among Latinos with schizophrenia, the culturally adapted group performed significantly better
than the two other conditions (Kopelowicz et al., 2012). These findings suggest the need for
more research to identify the protective factors that underpin the sociocultural processes that may
support positive treatment outcomes for consumers and families (Lefley, 2009; López,
Kopelowicz, & Cañive, 2002). Further, given that few controlled studies (Kopelowicz et al.,
2003; Kopelowicz et al., 2012; Telles et al., 1995) have been conducted with low-acculturated
Latinos, more knowledge is needed on the role of culturally salient protective factors and family
interventions in addressing ethnic disparities in mental health treatment for this group.
Results from international studies of family interventions with different ethnic groups
have supported the use of this treatment modality in decreasing symptoms and improving
functional outcomes for consumers as well as decreasing caregiver burden for family members
(Chien, Thompson, & Norman, 2008; Magliano, Fiorillo, Malangone, De Rosa, & Maj, 2006).
However, there have been mixed results with some studies reporting only significant effects for
family members (Chan, Yip, Tso, Cheng, & Tam, 2009) and varying degrees of success
depending on length of treatment, with longer treatment resulting in better outcomes (Lucksted et
al., 2012). While Lucksted and colleagues (2012) recognize that differences in outcomes may be
due to issues related to fidelity, these findings also suggest the need for more research to identify
the protective factors that implicate the sociocultural processes that may support positive
treatment outcomes for consumers and families.
Culturally Based Family Intervention for Mexican Americans
Given these important findings, it is necessary to learn more about how Latino families
utilize cultural resources to cope with stressors including those that may result from caring for a
THE ROLE OF PROTECTIVE FACTORS 11
family member with schizophrenia. Moreover, knowledge of these resources can be used to
improve interventions by incorporating and highlighting their use in treatment. As such, the
Culturally Based Family Intervention for Mexican Americans (CFIMA), the intervention in the
parent study, was informed by an ethnographic study with Latino consumers, families, and
providers (Barrio & Yamada, 2010). Salient resources emerged as protective factors, including
the centrality of family, the role of religion/spirituality, and nonjudgmental cultural attributions
that convey interpersonal warmth (Barrio & Yamada, 2010). Findings revealed that although
these resources were prominent among Latino families, they were not acknowledged and
incorporated in treatment interventions. Therefore, the development of the CFIMA intervention
included extensive family involvement to assure that appraisal and inclusion of salient protective
factors was consistently present in the treatment process (Barrio & Yamada, 2010). The present
study expanded on these findings through additional quantitative analyses and a follow-up
qualitative component. Our understanding of quantitative findings was enhanced by
interviewing families and consumers to further examine intervention results.
Conceptual Framework
The CFIMA project utilized a cultural exchange framework (Barrio & Yamada, 2010;
Palinkas et al., 2009; Palinkas, Allred, & Landsverk, 2005); similarly, the present study was
guided by a cultural exchange framework to examine the impact of the intervention on families
and consumers. The framework draws from various orientations including strengths-based
perspectives to develop and guide the intervention (Barrio & Yamada, 2010). The strengths-
based perspective offers a paradigm shift from a focus on pathology and deficits to one where
individuals and families experiencing serious mental illness may tap into existing resources with
the goal of increasing these capacities for continued growth (Rapp, 1998; Weick, Rapp, Sullivan,
THE ROLE OF PROTECTIVE FACTORS 12
& Kisthardt, 1989). The inclusion of a strengths-based perspective recognizes that individuals
exist within a social system (e.g., family, community) that possesses unique qualities and
resources (Rapp, 1998). As such, it provides the opportunity to acknowledge cultural approaches
as contributors to family wellbeing (Saleebey, 1996).
The cultural exchange framework recognizes that culture, as a dynamic process, plays an
important role in the explanatory beliefs and practices of families regarding mental illness and
treatment (López et al., 2002). Cultural exchange refers to the exchange of knowledge among
families and providers comprising three stages of assessment, accommodation, and integration,
(Figure 1) with the expectation that this process of transformation will lead to an understanding
of varying perspectives and enhance the cultural fit of services. This exchange of knowledge
creates opportunities for collaboration allowing providers and family members to learn from
each other. It is critical because the provider-client relationship has traditionally been
hierarchical and families may perceive providers as the “experts” (Saleebey, 1997). However, in
order to embrace cultural exchange it is important to validate different sources of knowledge
within the therapeutic environment (Saleebey, 1997).
Figure 1. Heuristic model for cultural exchange (Barrio & Yamada, 2010).
THE ROLE OF PROTECTIVE FACTORS 13
Specifically, the goal of the assessment stage is to learn about family members’
explanatory models and cultural resources. The provider system and the family system each
have their own value orientations regarding illness causation. Due to their training, providers
come from a scientific orientation while families’ may have other beliefs regarding illness
causation. Through the intervention’s interaction process, information about the illness is shared
with families along with a cross-cultural education component that highlights cultural strengths
in a manner that respects families’ own cultural beliefs (Barrio & Yamada, 2010). The
accommodation stage continues with psychoeducation as interventionists purposely emphasize
cultural strengths in an effort to increase knowledge and self-awareness about participant coping
strengths. It is believed that this “active attention” to families’ lived experiences and strengths,
supports participants’ growth and change (Weick, 1992). Finally, the integration stage, allows
family members and providers to share lessons learned and further reinforce treatment gains
(Barrio & Yamada, 2010). Although the model is categorized in three stages, these build on
each other while also being flexible to allow for the particular needs of the group.
Given that the CFIMA highlighted and cultivated protective factors shown to be salient in
low-acculturated Latino families, it is important to examine the role of protective factors and
their influence on consumer and family outcomes. Further, in following an iterative and
recursive approach, this study explored how cultural beliefs and practices of consumers and
family members, emphasized during the intervention, influenced treatment outcomes and
perceptions of wellbeing over time. As such, the cultural exchange extends to the research
process itself in that knowledge gained from the mixed-methods findings enhanced our
understanding of the impact of the CFIMA and can be used to further tailor the intervention for
Latino families in future work.
THE ROLE OF PROTECTIVE FACTORS 14
Protective Factors
To further develop and support evidence-based treatments for Latino consumers, more
knowledge is needed regarding the role of protective factors, particularly those that are most
salient for this group. Protective factors function as resources that alter negative outcomes
(Rutter, 1985). Rutter (1987) emphasized that the study of protective factors needs to go beyond
examining individual variables that contribute to the amelioration of risk situations. Instead,
protective factors must be studied as mechanisms involved in the process of individual and group
adaptation. Thus, protective factors may be seen as mechanisms mediating outcomes (Rutter,
1987). Moreover, there is a growing understanding that protective factors and resilience, which
is the ability to emerge stronger from adversity, occur within a sociocultural context that gives
meaning to how crises and risk events are perceived (Walsh, 2003). For example, a study
examining coping among African American caregivers of individuals with schizophrenia found
that these families utilized proactive coping strategies such as reframing negative experiences
and religion/spirituality to address caregiving challenges (Guada, 2012). When viewed as a
dynamic process, we find that resilience encompasses not only the risks and vulnerabilities that
may be found among families living with a family member with schizophrenia, but also the
strengths and resources that are involved in coping with the illness (Doornbos, 1996;
Zauszniewski, Bekhet, & Suresky, 2010). It is within this sociocultural context and systems
based perspective that the role of family influence can be best examined. Family relationships
can serve to nurture protective factors and resilience (Walsh, 2012). In the same way that the
family system is affected by having a family member with schizophrenia, we find that family
processes can serve to mediate adaptation and recovery for consumers and the family unit
(Walsh, 2012). Family contact was found to be a resource for African American consumers as it
THE ROLE OF PROTECTIVE FACTORS 15
was associated with an increase in psychosocial functioning, while family dysfunction was
related to poor functioning (Guada, Hoe, Floyd, Barbour, & Brekke, 2012). In the current study,
the influence of protective factors on outcomes were examined over time and as a mediator of
consumer and family outcomes.
Protective Factors and Latinos
Extensive epidemiological data have demonstrated that low acculturated Latinos have
better mental health outcomes when compared to US born Latinos and non-Latinos despite
various risk factors such as low SES, exposure to acculturative stress, and marginal access to
health care (Karno, Hough, et al., 1987; Vega et al., 1998; Vega, Sribney, Aguilar-Gaxiola, &
Kolody, 2004). Studies have demonstrated that the longer Latino immigrants remain in the US
the more likely they are to develop a mental and/or substance abuse disorder (Alderete, Vega,
Kolody, & Aguilar-Gaxiola, 2000; Alegría et al., 2007; Canino, Vega, Sribney, Warner, &
Alegría, 2008; Vega et al., 2004). Length of stay also poses a threat for Latinos who may be at a
higher risk for psychotic like experiences in their lifetime when immigrating at a younger age
(DeVylder et al., 2013). It may be that longer stay in their country of origin protects Latinos
from onset of psychiatric disorders by helping them to acquire cultural strengths that can serve to
buffer against potential stressors that may be experienced as immigrants in the US (Alegria et al,
2007). Therefore, it is important to examine these cultural strengths and resilient resources so
that they may be supported (Gallo, Penedo, Espinosa de los Monteros, & Arguelles, 2009) in
treatment interventions.
Hope. Among Latinos, particularly those with low acculturation, mental illness is
perceived as a fluid construct that operates in a continuum, thereby allowing families to have
greater hope during recovery while engendering a more tolerant and supportive family
THE ROLE OF PROTECTIVE FACTORS 16
environment (Guarnaccia, Parra, Deschamps, Milstein, & Arguiles, 1992). Hope as a
multidimensional construct is deeply embedded in rich spiritual and religious beliefs and
practices among Latinos and helps give meaning to stressful experiences, including those related
to a diagnosis of schizophrenia. The positive outlook held by Latino family members has been
documented, (Kopelowicz et al., 2003) revealing that Latino families are more likely to believe
that their loved one will be cured compared to European American and African American
families (Guarnaccia et al., 1992). Hope has been used as a coping resource among caregivers of
individuals with schizophrenia (Bland & Darlington, 2002; Karanci, 1995; Tuck, du Mont,
Evans, & Shupe, 1997). In addition, hope was associated with a decrease in burden beyond
length of illness among low acculturated Latino family members caring for a loved one with
schizophrenia (Hernandez, Barrio, & Yamada, 2013), indicating the potential benefits that hope
can offer as a protective factor. Similarly, a study examining hope among consumers found that
hope predicted consumer subjective wellbeing (Werner, 2012). Furthermore, hope has been seen
as encompassing subjective components of recovery that include attitudes, life orientation, and
an overall improved sense of self for consumers (Lysaker, Buck, Hammoud, Taylor, & Roe,
2006). Therefore, supporting hope among family systems may lead to improved coping and
quality of life for family members and consumers.
Religion/Spirituality. Religion/spirituality has been identified as a salient protective
factor among Latinos (Cabassa, Lester, & Zayas, 2006; Guarnaccia et al., 1992; Saunders, 2013).
A national survey found that Latinos when compared to European Americans were more likely
to use prayer to address health concerns (Gillum & Griffith, 2010). In addition, level of religious
involvement has been found to have an indirect positive association with mental health among
Latinos (Franzini, Ribble, & Wingfield, 2004). A community study with low acculturated Latino
THE ROLE OF PROTECTIVE FACTORS 17
families living with a family member with schizophrenia found that religion/spirituality not only
contributed to explanatory beliefs regarding mental illness, but also served as a powerful coping
resource for family members (Guarnaccia et al., 1992). Moreover, numerous studies have shown
that consumers with schizophrenia rely on religion/spirituality as a source of support to help
them manage their illness (Fallot, 2008; Huguelet, Mohr, Borras, Gillieron, & Brandt, 2006;
Tepper, Rogers, Coleman, & Malony, 2001). This study explored religion/spirituality as a
protective factor during the qualitative phase of the study.
Latino families. Within Latino communities, families are highly valued and have an
influential role in helping to shape and support its members (Behnke et al., 2008). It is important
to consider that Latinos are a heterogeneous group as seen in an epidemiological study, which
found that Mexicans Americans were less likely to receive mental health services when
compared to Puerto Rican, Cuban, and other Latino Americans (Alegría et al., 2007). There are
substantial differences within and between Latino groups related to variables such as level of
acculturation, country of origin, migration experiences, socioeconomic, and regional differences
that may affect the level of adherence to cultural norms (Guarnaccia et al., 2007). Yet, there are
certain cultural patterns that have been observed among Latino families in general (Vega, 1995).
For instance, several studies have found that Latinos with schizophrenia generally live with
family as seen in a study in which 75% of Latinos and 60% of African Americans lived with
their families, compared to 30% of European American consumers (Guarnaccia, 1998). Similar
results have been found in other studies indicating that Latinos with schizophrenia
overwhelmingly live with family (Barrio et al., 2003; Jenkins & Schumacher, 1999; Kopelowicz
et al., 2003; Magaña et al., 2007; Ramírez García, Hernández, & Dorian, 2009).
THE ROLE OF PROTECTIVE FACTORS 18
Among Latinos, protective factors such as family adaptability and cohesion have been
found to contribute to improved health outcomes and wellbeing (Bender & Castro, 2000) and
families are highly valued and play an influential role in helping to shape and support their
members (Behnke et al., 2008). A study found that family cohesion was associated with level of
emotional distress for Latino families but not for European American families (Weisman,
Rosales, Kymalainen, & Armesto, 2005). Furthermore, while living with family is prevalent
with Latino consumers, a study found that it also mediates the use of treatment services
(Snowden, 2007). Families may be providing consumers with the support and resources that
would otherwise be obtained through formal mental health services. While offering a high level
of support may be culturally accepted, it may also impose much strain among Latino families
(Breitborde, López, & Kopelowicz, 2010; Grandón, Jenaro, & Lemos, 2008; Magaña et al.,
2007) potentially leading to burden. Burden is conceptualized as the strain brought about by
caregiving and is comprised of objective and subjective components (Awad & Voruganti, 2008;
Maurin & Boyd, 1990). Objective components of burden address concrete factors such as
financial strain, while subjective burden deals with perceptions of burden. We may find that
level of family cohesion has implications for family wellbeing. Examining the Latino family’s
social and affective climate may help us determine how families serve as resources for
consumers, and in turn, how treatment approaches can support families and improve consumer
wellbeing.
Perceptions of wellness are strongly linked to culture (Guarnaccia et al., 1992).
International studies have generally found that consumers in less developed countries tend to
have better outcomes (Hopper & Wanderling, 2000; Jablensky, 1992; Leff, 1992; Lin &
Kleinman, 1988) in part due to the more accepting family cultural norms that allow consumers to
THE ROLE OF PROTECTIVE FACTORS 19
achieve greater community integration (Kurihara, Kato, Reverger, & Yagi, 2000). These studies
suggest that cultural factors play an important role in conceptions of mental illness including
treatment seeking and engagement (Kulhara & Chakrabarti, 2001). Cultural beliefs come into
play in the family’s explanatory model by giving meaning to the illness within a cultural value
framework (McCubbin, McCubbin, Thompson, & Thompson, 1998). It has been found that
attributing the cause of schizophrenia to an external factor and not the individual, is a
characteristic of low acculturated Latino families (Guarnaccia et al., 1992; Weisman, Gomez, &
Lopez, 2003). Externalizing the cause serves as a form of protection that decreases the negative
emotional affect and interactions that may result when individuals are believed to have sole
responsibility and control for the illness (Lefley, 1987). Studies that have examined perceptions
of illness attribution in caregivers find that negative schemas lead to more distress for the
caregiver and consumer (Barrowclough, Tarrier, & Johnston, 1996; Breitborde, Lopez, &
Nuechterlein, 2009).
Although families act as a valuable resource for consumers, it is also important to
consider how cultural beliefs and practices within family systems may impede treatment and
adherence. In particular, consumers and families may grapple with stigma as a barrier to
effective treatment. A study examining medication adherence among Latinos found that family
cultural beliefs regarding mental illness and treatment contributed to perceptions of stigma
among Latinos receiving services (Interian, Martinez, Guarnaccia, Vega, & Escobar, 2007).
Furthermore, a study comparing the influence of stigma on treatment seeking among immigrant
and European American women found that the former were more likely to cite concerns about
stigma as a reason for not seeking mental health treatment (Nadeem et al., 2007). We need a
more nuanced understanding of how cultural processes affect Latino consumer outcomes. The
THE ROLE OF PROTECTIVE FACTORS 20
present study sought to advance our understanding of these family processes by qualitatively
exploring consumer and family member perceptions of mental illness, including stigma, and how
these perceptions may have been influenced by the intervention.
Family environment. Numerous studies on expressed emotion have established a link
between family social environment and symptom relapse in individuals with schizophrenia
(Bebbington & Kuipers, 1994; Brown, Monck, Carstairs, & Wing, 1962; Butzlaff & Hooley,
1998). Expressed emotion refers to the emotional environment within a family system as
evidenced by criticism, emotional overinvolvement, hostility, and warmth (Brown, 1985).
Family environment has been associated with differences in the course of schizophrenia among
ethnic groups (Karno, Jenkins, et al., 1987; Kopelowicz et al., 2002). In particular, a study
comparing low-acculturated Mexican American families with European American families
found that family warmth contributed to a decrease in relapse for Mexican American consumers
but not European American consumers (López et al., 2004). Therefore, it appears that family
warmth has positive effects on consumer outcomes for Latinos. Studies in the area of expressed
emotion with low acculturated Mexican-Americans have revealed that these families tend to
have lower levels of expressed emotion when compared to European Americans (Karno, Jenkins,
et al., 1987; Kopelowicz et al., 2002). In addition, while criticism is a predictor of relapse for
European Americans, emotional overinvolvement tends to lead to relapse for Mexican American
consumers. Overall, these findings reveal the importance of sociocultural influences on
schizophrenia and emphasize the possible protective mechanisms operating within these family
systems.
Family environment has primarily been examined from the perspective of family
members and not consumers. However, given that expressed emotion is a transactional process,
THE ROLE OF PROTECTIVE FACTORS 21
it is important to consider how consumers and family members perceive the families level of
expressed emotion (Keefe, Lopez, Tiznado, Medina-Pradas, & Mendoza, 2012; Rosenfarb,
Bellack, Aziz, Kratz, & Sayers, 2004). A study examining perceptions of expressed emotion
among individuals with depression found that consumer perceptions were a better predictor of
relapse when compared to standard measures (Hooley & Teasdale, 1989). Therefore, our
studies’ inclusion of family member and consumer perceptions of warmth and criticism will
provide us with a more inclusive perspective of these components of expressed emotion.
Summary
The current study seeks to add to our understanding of protective factors and their
contribution to treatment outcomes among families and consumers within a culturally based
family psychoeducation model. In particular, the intervention’s cultural exchange framework
can help improve our understanding of how we can benefit from existing cultural strengths that
families bring into treatment. The new rich qualitative data and its integration with quantitative
findings, will offer a more nuanced picture and generate new perspectives on data interpretation,
and guide us as we refine the intervention for future study.
THE ROLE OF PROTECTIVE FACTORS 22
CHAPTER THREE
Methods
Mixed-Methods Design
This study utilized a sequential explanatory mixed-methods design in which secondary
quantitative data from the parent study was analyzed, followed by the collection and analysis of
qualitative data (Creswell & Plano Clark, 2007). This approach allowed for a multidimensional
examination of key protective variables and their influence on treatment outcomes (Palinkas,
Aarons, et al., 2011; Palinkas, Horwitz, Chamberlain, Hurlburt, & Landsverk, 2011). The
qualitative component facilitated a deeper exploration of the Latino family cultural context and
its effect on intervention outcomes and experience. In particular, an insider perspective on
salient intervention outcomes was obtained for family members and consumers.
Phase 1 - Aim 1 (Quantitative Analysis of Parent Study Data)
Data for this study come from a controlled intervention study (CFIMA) with Latino
families with a loved one diagnosed with schizophrenia (Barrio & Yamada, 2010). Specifically,
outcomes were based on family and consumer data collected from the parent study at baseline,
post-study, and 3-month follow-up. Hypotheses for the first aim were:
H1: Families and consumers in the intervention compared to those in usual care will
experience an increase in protective factors over time. For family members, this increase in
protective factors will contribute to a decrease in burden and an increase in knowledge of the
illness over time. For consumers, this increase in protective factors will contribute to
improvement in outcomes as evidenced by an increase in quality of life over time and a decrease
in symptoms.
THE ROLE OF PROTECTIVE FACTORS 23
H2: The relationship between treatment condition and outcomes for families in the
intervention compared to those in usual care will be mediated by protective factors so that as
protective factors increase, family members will experience a decrease in burden and an increase
in knowledge of the illness as a result of the mediation.
In addition, we will explore the role of protective factors as potential mediators for
consumer outcomes. Given that preliminary analyses have indicated that there is an association
between protective factors and consumer outcomes, thus indicating potential indirect treatment
effects, we can further explore through mediation analyses protective factors that may have a
greater influence on outcomes (quality of life and symptoms).
Mediation will allow us to explore the potential benefit of improving protective factors in
our intervention. Overall, our quantitative analyses will give us an indication of how to refine
our intervention and guide our subsequent qualitative data collection and analysis.
Sample
The CFIMA intervention featured 16 weekly multifamily group sessions held at one of
the community mental health centers (CMHCs) where participants were recruited. Study criteria
included: (1) diagnosis of a schizophrenia spectrum disorder as defined in the DSM-IV; (2) at
least 18 years old; (3) no substance use or abuse disorder; (4) currently receiving medication
support; and (5) living or maintaining contact on a weekly basis with a family member. Eligible
consumers were contacted by bilingual/bicultural research assistants and asked to participate in
the study. With consumer’s permission, a key family member was identified and asked to
participate in the study. Consumers in the treatment-as-usual (TAU) condition received
customary care consisting of medication support along with an array of psychosocial services;
however, family members did not receive any family based services. Participants were recruited
THE ROLE OF PROTECTIVE FACTORS 24
for the parent study from outpatient CMHCs directly operated by the County Department of
Mental Health. The Institutional Review Board of the university approved all study procedures.
The sample included 64 dyads (64 key family members and 64 consumers) that were
randomly assigned into either the intervention (n = 27) or TAU (n = 37) condition. Initially there
were 9 participants who were assigned to the intervention condition; however, although data
were collected for one of the dyad members the other (either their key family member or the
consumer) ultimately decided not to participate in the study and therefore these participants were
not enrolled.
Of the 64 family dyads enrolled at baseline, 92% (n = 59) remained at post-study
(treatment 96%; TAU 89%) and at follow-up 84% (n = 54) of families remained in the study
(treatment 93%; TAU 78%). There were no differences between treatment condition and
attrition at post-study χ
2
(1, N= 64) = 1.10, p = .30 or follow-up χ
2
(1, N= 64) = 2.39, p = .12.
Because data analyses were conducted using Mplus 7.11, (Muthen & Muthen, 2010) missing
data were addressed using the expectation maximization algorithm found in maximum likelihood
estimation (Kline, 2011). In addition, we employed a bias-corrected bootstrap test to examine
the 95% confidence limits for indirect effects, which have been found to be beneficial in
obtaining more accurate confidence intervals for indirect effects due to improved Type 1 error
rates and improved power (MacKinnon, 2008; MacKinnon, Lockwood, & Williams, 2004).
Family members primarily spoke Spanish and were of Mexican (81%) origin.
Consumers were also Spanish-speaking, although many were bilingual, with 54% born in the
United States. The majority (92%) of family members fell in the very Mexican-mostly Mexican
acculturation group using the Acculturation Rating Scale for Mexican Americans (Cuellar,
Harris, & Jasso, 1980), while most (53%) consumers were in the bicultural group. Tables 1 and
THE ROLE OF PROTECTIVE FACTORS 25
2 provide information on key demographic characteristics and variables of interest for family
members and consumers.
Table 1
Baseline Family Member and Consumer Characteristics
Family
(N=64)
Minimum-
Maximum
Consumer
(N=64)
Minimum-
Maximum
Age, M (SD) 53 (13.45) 20-81 37 (13.34) 19-69
Education, M (SD) 7.5 (4.19) 0-15 9.60 (4.36) 0-20
Gender, n (%)
Female 53 (83%) 19 (30%)
Male 11 (17%) 45 (70%)
Marital Status, n (%)
a
Married 41 (64%) 9 (14%)
Separated 6 (9%) 5 (8%)
Divorced 5 (8%) 1 (2%)
Widowed 5 (8%) 1 (2%)
Single, never married 5 (8%) 46 (72%)
Single, cohabitating 2 (3%) 2 (3%)
Relation to consumer, n (%)
a
Mother 35 (55%)
Spouse 8 (13%)
Sibling 8 (13%)
Son/Daughter 3 (5%)
Father 4 (6%)
Aunt 2 (3%)
Other
b
4 (6%)
Length of Illness
c
, years, M (SD) 12.78 (11.75) 0-46
a
Percentage values may not total 100% due to rounding error
b
cousin, fictive kin, grandmother, sister-in-law
c
Sample size varies due to missing values
THE ROLE OF PROTECTIVE FACTORS 26
Table 2
Baseline Family Member and Consumer Measures
a
Family
(N=64)
Consumer
(N=64)
ARSMA
b,c
1.53 (.574) 2.22 (.768)
Burden .693 (.526)
Financial .609 (.551)
Routine .742 (.639)
Leisure .723 (.656)
Interaction .813 (.736)
Effect .573 (.663)
Knowledge 5.98 (1.72)
QLS
b,d
2.78 (1.30)
Intrapsychic
3.42 (1.45)
Interpersonal
2.85 (1.45)
Instrumental
1.44 (1.97)
Commonplace
2.48 (1.31)
PANSS
b,e
2.27 (.765)
Positive
2.02 (.870)
Negative
2.65 (1.05)
Generalized
2.19 (.716)
Hope 4.12 (.979)
FACES-II
b,f
3.77 (.692)
Adaptability 3.50 (.727)
Cohesion 4.00 (.798)
Expressed Emotion
g
Warmth 9.05 (1.41) 8.42 (2.19)
Criticism
h
6.33 (2.72) 5.91 (2.70)
a
Table presents mean scores
b
Sample size varies due to missing values
c
Acculturation Rating Scale for Mexican Americans;
d
Quality of Life
e
Positive and Negative Syndrome Scale;
f
Family Adaptability and Cohesion Scale
g
Individual Perceptions of Parents’ or Key Relatives’ Views
h
Reverse coded, value represents low criticism/acceptance
THE ROLE OF PROTECTIVE FACTORS 27
Measures
All measures were translated and culturally adapted using established guidelines for
cross-cultural equivalence (Chavez, Matias-Carrelo, Barrio, & Canino, 2007; Matias-Carrelo et
al., 2003; Wild et al., 2005).
Acculturation. To examine acculturation with key family members and consumers, we
used the Acculturation Rating Scale for Mexican Americans (ARSMA) (Cuellar, Harris, &
Jasso, 1980). It consists of 20 items on a 5-point Likert scale with higher scores indicating high
acculturation. Items asked participants questions such as “in what language do you think?” The
internal consistency for this measure was excellent for family members (α=.93) and consumers
(α=.94).
Protective factor measures.
Family member hope. Hope was examined using the Hope for the Patient’s Future Scale
that was adapted from the Miller Hope Scale (Miller & Powers, 1988) in a study with Latino
family caregivers of individuals with with schizophrenia (Kopelowicz et al., 2003). Similarly, in
our study, this measure was administered to key family members and consisted of 20 items rated
on a 5-point Likert scale ranging from 1 (no hope) to 5 (a lot of hope). Participants were asked
how much hope they had that “the illness of your family member gets better” and “your family
member will be able to develop his/her own goals for the future.” The internal consistency for
this sample was excellent (α=.96).
Family level of warmth and family level of criticism. The Individual Perceptions of
Parents’ or Key Relatives’ Views (Hooley & Teasdale, 1989) was used to examine warmth and
criticism among key family members and consumers. The measure contains 2 items assessing
warmth and 2 items assessing criticism on a 10-point Likert scale, with higher values indicating
THE ROLE OF PROTECTIVE FACTORS 28
higher levels of warmth and criticism. Items examining warmth asked participants “how warm
is your parent/relative of you?” While items examining criticism asked participants “how
disapproving is your parent/relative of what you do?” To facilitate interpretation and examine
criticism as a protective factor, the items examining criticism were reverse coded so that higher
values would indicate less criticism, in other words family members would be accepting of
consumers. Findings from Keefe, López, Tiznado, Medina, and Mendoza (2012), which
consisted of additional internal consistency analysis, revealed a good consistency for family
members with a median α=.62 and a range α=.39-77 for warmth and for criticism items median
α=.57 with a range α=-.47-.85. The warmth and criticism items for consumers were also found
to have good internal consistency with a median α=.86 and range α=.70-.89 for warmth and
median α=.72 and a range α=.35-.93 for criticism (Keefe et al., 2012). Our sample had similar
results for family members with warmth (α=.48) and criticism (α=.54) while the internal
consistency among consumers for warmth (α=.60) and for criticism (α=.62).
Family adaptability and cohesion. The Family Adaptability and Cohesion Evaluation
Scales (FACES II) (Olson, Bell, & Portner, 1992) was used to examine family adaptability and
cohesion among family members and was administered to key family members. It consists of 30
items measuring adaptability and cohesion within the family system on a 5-point Likert scale
ranging from 1 (almost never) to 5 (almost always). Items include “our family tries new ways of
dealing with problems” to examine adaptability and “each family member has input regarding
major family decisions” to examine cohesion. The internal consistency has been found to be
excellent for the total measure (α=.90), cohesion subscale (α=.87), and good for the adaptability
subscale (α=.78) (Olson, Bell, & Portner, 1992). For this sample the total measure (α=.90) and
cohesion subscale (α=.90) had excellent internal consistencies and the adaptability subscale had
THE ROLE OF PROTECTIVE FACTORS 29
good consistency (α=.77). Moreover, the FACES II measure can identify family types ranging
from balanced to represent high functioning families to extreme representing low functioning
families, thus illustrating the variability of family types, which may change throughout the
family life cycle (Vega et al., 1986). In the current study, on average family members were
considered connected and flexible at baseline and had comparable scores to national averages for
adaptability with a mean score of 49 (SD=10.18) and cohesion mean score of 64 (SD=12.77)
(Olson, Bell, & Portner, 1992).
Outcome measures.
Burden. The Family Burden Interview Schedule (FBIS) was used to examine burden (Pai
& Kapur, 1981) among key family members. We used a 20-item shortened version adapted by
researchers in a previous study with a family sample of Latinos of Mexican origin (Kopelowicz
et al., 2003). The FBIS includes a total burden composite score examining objective burden and
5 subscales rated on a 3-point scale, with higher scores indicating greater objective burden. The
subscales include financial burden, routine family activities, family leisure, family interaction,
and effect on physical and mental health of others. Items include “has another family member
had to stop working due to consumer’s illness” (financial burden) and “problems caused by you
not having time to attend to other family members” (routine family activities). The burden
measure had an excellent internal consistency for this sample (α=.92).
Family member knowledge of schizophrenia. To examine knowledge of the illness
among key family members we used the Knowledge of the Illness Measure (Amenson, 1998). It
consists of 10 items related to schizophrenia, with 3 categorical response options (1) yes, (2) no,
and (3) don’t know. Correct responses were summed with greater values indicating more
THE ROLE OF PROTECTIVE FACTORS 30
knowledge of the illness. Items asked key family members if “schizophrenia is a brain disorder”
and if “doing things for persons with schizophrenia is the best way to help them recover.”
Quality of life. The Quality of Life Scale (QLS), (Heinrichs, Hanlon, & Carpenter, 1984)
was used to examine quality of life for consumers. The QLS has been found to be effective at
determining quality of life over time and between treatment conditions (Cramer et al., 2000)
among individuals with schizophrenia. It features 4 factors scored by a trained rater that evaluate
interpersonal relations, instrumental roles, intrapsychic objectives, and common activities using a
total of 21 items rated on a 6-point Likert scale, with higher values indicating more adequate
functioning. Items include “how often have you done things for enjoyment that involve other
people” (interpersonal relations) and “what makes life worth living for you” (intrapsychic
foundations). The internal consistency for this sample was excellent (α=.93).
Severity of psychiatric symptoms. The Positive and Negative Syndrome Scale (PANSS)
(Kay, Fiszbein, & Opler, 1987) is a well established measure used to examine severity of
psychiatric symptoms among consumers. The PANSS consists of 30 items with 3 subscales
(positive, negative, general psychopathology) scored by a trained rater on a 7-point Likert scale,
with higher scores representing greater symptom severity. Items include “diminished interest in
social interaction due to passivity, apathy, energy, or avolition” (negative symptoms) and
“impaired awareness or understanding of one’s own psychiatric condition and life situation”
(general psychopathology). The internal consistency for this sample was excellent (α=.91).
Parent Study Preliminary Findings
Findings of mixed-effect analyses of key outcome variables from the CFIMA trial (Barrio
et al., 2014) showed promising results, with significantly lower family burden over time for
those in the intervention compared to usual care. For family members, there was a significant
THE ROLE OF PROTECTIVE FACTORS 31
increase of knowledge of the illness in the intervention group over time compared to families in
usual care. Although analyses of consumer outcomes (quality of life, symptoms) did not reveal
statistically significant differences over time, the direction of the effects were promising in that
symptoms were lower and quality of life was higher for those in the intervention compared to
usual care in both post-study and follow-up assessments. It is important to note that the CFIMA
employed a family group format without direct participation from consumers in weekly group
sessions. Therefore, it is not surprising that consumer outcomes did not reach statistical
significance; nevertheless, the direction of effects reflects benefits for consumers. Further,
findings from a recent study using CFIMA baseline data indicated that family hope for the future
had a strong influence on decreasing family burden beyond effects explained by consumer
symptomatology and length of illness (Hernandez, Barrio, & Yamada, 2013).
Quantitative Data Analysis
To examine Hypothesis 1, longitudinal analyses were conducted using path models—
specifically, cross-lagged models (Figure 2)—to examine the effect of protective factors on
outcomes over time. Separate analyses were conducted with each protective factor and outcome
variable for families and consumers. Longitudinal analyses using cross-lagged modeling
allowed for the simultaneous examination of our two variables (protective factors, outcomes)
over time (Kline, 2011). Given the proposed study’s iterative process, our analytical methods
helped address “the ongoing process of change and influence” (Maruyama, 1998, p. 102)
prompted by the intervention.
THE ROLE OF PROTECTIVE FACTORS 32
Figure 2. Cross-lagged model without disturbances.
Group = Treatment Condition; PF = Protective Factor; O = Outcome
Following our path analyses, mediation analyses (Hypothesis 2) were conducted with
group as the independent variable and outcome as the dependent variable. By including the
protective factors as mediators (Figure 3), we examined the positive effect of these factors on
outcomes and thereby gained a greater understanding of how the intervention, by increasing
protective factors, indirectly lead to favorable consumer outcomes (Chen, 1990). Separate
analyses were conducted with each protective factor and outcome variable for families and
consumers.
Figure 3. Mediation model.
Group = Treatment Condition; PF = Protective Factor; O = Outcome
PF
2
PF
1
PF
0
Group
O
0
O
1
O
2
Group
PF
1
O
2
THE ROLE OF PROTECTIVE FACTORS 33
To assess model fit, three established goodness-of-fit statistics—the Chi-square (χ
2
),
Comparative Fit Index (CFI), and Root Mean Square Error of Approximation (RMSEA)—were
used (Kline, 2011). In order to obtain a good model fit we need a nonsignificant p-value for the
χ
2
, CFI ≥ .95, and RMSEA<.05. It is important to note that the RMSEA has been found to be
problematic for small sample sizes and may cause one to reject a good fitting model due to a
large RMSEA value and wide confidence intervals (Byrne, 2012; Kline, 2011). Therefore,
consideration was given to a possible discrepancy in RMSEA model fit due to our small sample
size. Based on our directional hypotheses and modest sample size, main analyses were
conducted using 1-tailed probability to reduce type II error and statistical significance at level
α=.05.
Phase 2 - Aim 2 (Qualitative Data Collection and Analysis)
Following a sequential explanatory mixed-methods design, the second study phase (Aim
2) incorporated qualitative methods to expand on quantitative findings (Palinkas, Aarons, et al.,
2011; Palinkas, Horwitz, et al., 2011). We explored participant perceptions of salient protective
factors examined in Phase 1, such as hope. In addition, we explored other areas shown to be
salient among Latino families, such as religion/spirituality, (Cabassa et al., 2006; Guarnaccia et
al., 1992) and determine whether stigma, a potential obstacle for treatment and service use, was
affected by the intervention. Further, we explored how participation in a culturally based
intervention featuring family psychoeducation that acknowledged and cultivated cultural beliefs
and practices may have influenced consumer and family perceptions of mental illness and use of
treatment. Finally, we explored perceptions of wellbeing and determined how those perceptions
may have been influenced by the intervention. Whereas the first phase examined the influence
of protective factors on outcomes over time and the mediating influence of those factors, our
THE ROLE OF PROTECTIVE FACTORS 34
qualitative methods captured the emic or culturally specific perspective, providing a fuller
understanding of the effects of family interventions among Latinos (Leong, Leung, & Cheung,
2010). Because our qualitative component is exploratory, no hypotheses were developed;
however, we were guided by our cultural exchange framework and quantitative findings. In
particular, we explored the following questions:
(1) What are participants’ perception regarding protective factors and how are these used
by family members and consumers?
(2) How has participation in the intervention influenced participants’ perception and
behavior regarding the illness and treatment?
(3) What do participants consider as the most salient outcomes for consumer wellbeing
and how was this influenced by the intervention?
Sample and Data Collection
We maintained contact with the CMHCs where participants were recruited for the parent
study since the intervention ended. We aimed to reach as many of the dyads that were part of the
intervention as possible. Purposive sampling methods were used to obtain a subset of
participants from the intervention condition of the parent study. In order to maximize the
probability of reaching our target sample of 20 dyads, all intervention participants (n=27) were
initially contacted by letter explaining the purpose of the current study and informing them that
they would receive a phone call providing further study details. We attempted to contact all
participants by phone; however, there were some family members who no longer had the same
telephone number and therefore were not able to be contacted. Initially 22 family members
agreed to participate in the study; however, one later declined and the other could not be reached
after several attempts. Our final sample consisted of 34 participants (20 key family members and
THE ROLE OF PROTECTIVE FACTORS 35
14 consumers). Although we were able to connect with 20 key family members, there were 6
incomplete dyads because consumers were either living in a residential facility or the PI was not
able to connect with the consumer. To obtain adequate information about differences in
knowledge, beliefs, and experiences regarding domains of interest, it is generally recommended
that qualitative sample sizes range between 12 and 26 participants (Guest, Arwen, & Johnson,
2006; Luborsky & Rubinstein, 1995). Family members were primarily female (16, 80%) and
most consumers were male (11, 79%). In addition, most family members were mothers (12,
60%). The majority of family member interviews were conducted in Spanish (18, 90%) while
most consumer interviews were conducted in English (8, 57%).
Participants were interviewed using a semi-structured interview guide (Appendix A) with
open-ended questions that permitted participants to expand on areas they considered important.
The interview guide included questions on protective factors as well as questions pertaining to
perceptions of mental illness, treatment, stigma, and service use. The interview guide was pilot-
tested with 5 bilingual/bicultural volunteers whose feedback was used to modify the guide. The
PI is bilingual/bicultural and conducted all interviews in either Spanish or English as requested
by participants. All interviews were conducted at participants’ homes at their request except for
two families who requested to be interviewed at the University in a private office. Regardless of
setting, precautions were taken to maintain confidentiality during the interview. All interviews
were audio recorded and were approximately 60 to 90 minutes in length. Each participant
received $20 in compensation. Participants were provided with an information sheet addressing
their rights as participants in their preferred language prior to the interview. The PI read the
information sheet to participants and answered any questions that they had regarding the study.
THE ROLE OF PROTECTIVE FACTORS 36
Similar to the first phase of the study, the Institutional Review Board of the university approved
all qualitative study procedures.
Qualitative Data Analysis
Interviews were transcribed in their original language after removal of all identifying
information. The primary analysis method involved developing categories and themes that
addressed our research questions as well as themes generated from the data (Willms et al., 1990);
the process was therefore influenced by grounded theory methods (Glaser & Strauss, 1967;
Strauss & Corbin, 1990). Initially, open coding was used to break down data and facilitate
analysis, followed by axial coding, which consisted of creating categories based on the open-
coding findings (Strauss & Corbin, 1990). A list of codes was created after careful review of
each transcript. Once the coding process was complete, categories were developed that
represented themes and subthemes based on patterns observed in the data. Comparisons were
made across and within groups to examine variability in responses to the intervention. Data
gathered from different sources contributed to the understanding of protective factors and
culturally specific perceptions of wellbeing and outcomes. To facilitate the management and
analysis of data, ATLAS.ti 7 (Muhr, 2012) software was used.
THE ROLE OF PROTECTIVE FACTORS 37
CHAPTER FOUR
Quantitative Results
Following the sequential explanatory mixed methods design of this study, quantitative
results will be presented first followed by qualitative results.
Preliminary Quantitative Results
Table 3 presents key family member characteristics based on treatment condition at
baseline and Table 4 presents key family member measures at post-study and follow-up.
Analyses revealed statistically significant differences in baseline burden and knowledge of the
illness scores with family members in the treatment condition having on average more burden
and higher scores on the knowledge of the illness measure when compared to those in TAU.
Baseline consumer characteristics based on treatment condition are included in Table 5; Table 6
presents post-study and follow-up measures. Consumers whose families participated in the
intervention were significantly younger, had a shorter length of illness, were more acculturated,
and had a higher mean score on the commonplace quality of life subscale at baseline when
compared to those in TAU. Given group difference, when necessary, the aforementioned
variables were controlled in analysis.
Main Quantitative Results
Family member results are presented first with each outcome variable (burden,
knowledge) and protective factor (hope, expressed emotion, FACES) consisting of path analyses
followed by mediation analyses. The same pattern is followed with consumer outcomes (QLS,
PANSS) and protective factors. The path model tested the first hypothesis that intervention
participants will experience an increase in protective factors when compared to
THE ROLE OF PROTECTIVE FACTORS 38
Table 3
Baseline Key Family Member Characteristics by Treatment Condition
a
CFIMA
(n=27)
TAU
(n=37) Test Statistic
Age, M (SD) 52 (10.90) 54 (15.11) t= 0.695
Education, M (SD) 7.6 (4.37) 7.4 (4.13) t= -.116
Gender, n (%)
χ
2
= .185, df=1
Female 23 (85%) 30 (81%)
Male 4 (15%) 7 (19%)
Marital Status, n (%)
b
Married 19 (70%) 22 (60%) χ
2
= 3.61, df=5
Separated 2 (7%) 4 (11%)
Divorced 3 (11%) 2 (5%)
Widowed 1 (4%) 4 (11%)
Single, never married 2 (7%) 3 (8%)
Single, cohabitating
2 (5%)
Relation to consumer, n (%)
b
Mother 17 (63%) 18 (49%) χ
2
= 15.85, df=12
Spouse 3 (11%) 5 (14%)
Sibling
8 (22%)
Son/Daughter 2 (7%) 1 (3%)
Aunt 1 (4%) 1 (3%)
Father 3 (11%) 1 (3%)
Other
c
1 (4%) 3 (8%)
Measures
d
t
ARSMA
e,f
1.51 (.580) 1.56 (.576) -0.30
Burden .945 (.527) .518 (.452) -3.48**
Financial .741 (.618) .514 (.482) -1.59
Routine .982 (.676) .568 (.558) -2.68*
Leisure .972 (.633) .541 (.619) -2.73*
Interaction 1.15 (.760) .568 (.620) -3.36**
Effect .864 (.681) .360 (.569) -3.22**
Knowledge 6.65 (1.74) 5.50 (1.56) 2.74*
Hope 4.17 (1.04) 4.08 (.944) -0.33
FACES-II
f,g
3.82 (.561) 3.73 (.782) -0.58
Adaptability 3.62 (.522) 3.41 (.845) -0.12
Cohesion 4.00 (.742) 4.00 (.849) -0.003
Expressed Emotion
Warmth 9.19 (1.08) 8.95 (1.61) -.668
Criticism
h
7.02 (2.32) 5.82 (2.91) -1.76
a
Table presents mean scores;
b
Percentage values may not total 100% due to rounding
error;
c
cousin, fictive kin, grandmother, sister-in-law;
d
Mean (SD)
e
Acculturation Rating Scale for Mexican Americans
f
Sample size varies due to missing values
g
Family Adaptability and Cohesion Scale;
h
Reverse coded,
value represents low criticism/acceptance; *p<.05, **p<.01; two-tailed
THE ROLE OF PROTECTIVE FACTORS 39
Table 4
Family Post-Study and Follow-up Measures by Treatment Condition
a
CFIMA
(n=26)
TAU
(n=33) t
CFIMA
(n=26)
TAU
(n=31) t
Post-Study Follow-up
Burden
b
.756 (.486) .429 (.438) -2.70* .640 (.461) .433 (.447) -1.70
Financial .837 (.656) .538 (.638) -1.76 .640 (.564) .355 (.432) -2.14*
Routine .712 (.518) .485 (.583) -1.56 .770 (.703) .653 (.667) -.636
Leisure .942 (.626) .394 (.527) -3.65** .630 (.621) .307 (.511) -2.14*
Interaction .789 (.619) .417 (.536) -2.47* .660 (.680) .565 (.689) -.518
Effect .410 (.576) .273 (.437) -1.04 .453 (.576) .237 (.357) -1.64
Knowledge
b
8.23 (1.14) 6.33 (1.61) -5.07** 8.04 (1.64) 5.87 (1.43) -5.33**
Hope
b
4.12 (.860) 4.03 (1.09) -0.368 4.03 (.947) 3.98 (.910) -0.219
FACES-II
b,c
3.89 (.593) 3.85 (.451) -0.29 4.00 (.587) 3.90 (.514) -0.719
Adaptability 3.66 (.604) 3.56 (.532) -0.645 3.82 (.555) 3.67 (.563) -1.02
Cohesion 4.09 (.672) 4.10 (.521) -0.06 4.16 (.681) 4.09 (.595) -0.381
Expressed Emotion
Warmth
b
9.25 (1.32) 8.63 (1.68) -1.53 9.20 (1.04) 8.90 (1.30) -.966
Criticism
b,d
7.38 (2.25) 6.29 (2.79) -1.63 7.48 (2.23) 6.68 (2.44) -1.28
a
Table presents mean scores
b
Sample size varies due to missing values
c
Family Adaptability and Cohesion Scale
d
Reverse coded, value represents low criticism/acceptance
*p<.05, **p<.01; two-tailed
THE ROLE OF PROTECTIVE FACTORS 40
Table 5
Baseline Consumer Characteristics by Treatment Condition
a
CFIMA
(n=27)
TAU
(n=37)
Test statistic
Age, M (SD) 32 (13.26) 41 (12.29) t= 2.73*
Education, M (SD) 10.74 (3.49) 8.76 (4.78) t= -1.92
Gender, n (%)
χ
2
= 1.25, df=1
Male 21 (78%) 24 (65%)
Female 6 (22%) 13 (35%)
Marital Status, n (%)
b
χ
2
= 3.68, df=5
Single, never married 21 (78%) 25 (68%)
Married 3 (11%) 6 (16%)
Separated 1 (4%) 4 (11%)
Single, cohabitating 1 (4%) 1 (3%)
Divorced
1 (3%)
Widowed 1 (4%)
Length of Illness
c
yrs, M (SD) 6.70 (5.70) 17.29 (13.07) t= 4.03**
Measures
d
t
ARSMA
c,e
2.47 (.765) 2.04 (.731) -2.21*
PANSS
c,f
2.23 (.844) 2.29 (.711) 0.323
Positive 2.08 (.965) 1.97 (.802) -.477
Negative 2.49 (1.04) 2.78 (1.05) 1.06
Generalized 2.18 (.794) 2.20 (.663) 0.103
QLS
c,g
3.07 (1.39) 2.56 (1.20) -1.57
Intrapsychic 3.76 (1.70) 3.17 (1.19) -1.53
Interpersonal 3.11 (1.49) 2.65 (1.41) -1.26
Instrumental 1.59 (2.07) 1.32 (1.92) -.531
Commonplace 2.91 (.961) 2.16 (1.46) -2.43*
Expressed Emotion
Warmth 8.90 (1.58) 8.10 (2.48) -1.52
Criticism
h
5.96 (2.42) 5.88 (2.90) -0.116
a
Table presents average scores
b
Percentage values may not total 100% due to rounding error
c
Sample size varies due to missing values
d
Mean (SD)
e
Acculturation Rating Scale for Mexican Americans
f
Positive and Negative Syndrome Scale
g
Quality of Life Scale
h
Reverse coded, value represents low criticism/acceptance
*p<.05, **p<.001; two-tailed
THE ROLE OF PROTECTIVE FACTORS 41
Table 6
Consumer Post-Study and Follow-up Measures by Treatment Condition
a
CFIMA
(n=26)
TAU
(n=34) t
CFIMA
(n=25)
TAU
(n=31) t
Post-Study Follow-up
QLS
b,c
3.03 (1.16) 2.63 (1.21) -1.304 3.06 (1.10) 2.85 (1.25) -.674
Intrapsychic 3.84 (1.36) 3.33 (1.30) -1.455 4.09 (1.07) 3.56 (1.25) -1.656
Interpersonal 2.80 (1.22) 2.55 (1.43) -.723 2.92 (1.29) 2.85 (1.43) -.185
Instrumental 1.86 (2.13) 1.26 (1.91) -1.131 2.90 (1.06) 2.83 (1.23) -.223
Commonplace 2.92 (1.28) 2.58 (1.43) -.969 3.13 (1.32) 2.63 (1.47) -1.30
PANSS
b,d
2.00 (.624) 2.11 (.669) 0.654 1.78 (.469) 1.93 (.589) 1.062
Positive 1.78 (.721) 1.90 (.860) .597 1.63 (.527) 1.65 (.632) 0.163
Negative 2.31 (.756) 2.59 (1.04) 1.172 2.06 (.695) 2.35 (1.03) 1.198
Generalized 1.96 (.608) 1.98 (.561) 0.127 1.72 (.483) 1.88 (.582) 1.058
Expressed Emotion
Warmth
b
9.16 (1.15) 7.71 (3.00) -2.59* 9.11 (1.76) 8.05 (2.23) -1.89
Criticism
b,e
7.29 (2.58) 5.37 (3.32) -2.52* 7.59 (2.52) 6.43 (2.76) -1.551
a
Table presents average scores
b
Sample size varies due to missing values
c
Quality of Life
d
Positive and Negative Syndrome Scale
e
Reverse coded, value represents low criticism/acceptance
*p<.05; two-tailed
THE ROLE OF PROTECTIVE FACTORS 42
those in TAU. For family members, this increase in protective factors will contribute to a
decrease in burden and an increase in knowledge of the illness over time. For consumers, this
increase in protective factors will contribute to improvement in outcomes as evidenced by an
increase in quality of life over time and a decrease in symptoms. The purpose of mediation
analyses was to test the second hypothesis where it is believed that the relationship between
treatment condition and outcomes for families in the intervention compared to those in TAU will
be mediated by protective factors. As protective factors increase, family members will
experience a decrease in burden and an increase in knowledge of the illness. Furthermore,
mediation analyses for consumers will explore potential indirect treatment effects for consumers
in the intervention compared to those in TAU.
Burden
The model included the baseline burden score given the significant group differences on
this variable. In addition, length of illness was included as a covariate due to its possible
influence on burden. Given that the burden measure includes five subscales, these were analyzed
separately as outcomes in addition to examining the total burden scale score.
Hope.
Path analyses. The path model had a moderate fit (χ
2
=23.414, df=8, p=.003, CFI=.926,
RMSEA = .174, C.I.=.094, .257, p=.009). There was no direct effect between treatment and
burden. However, previous longitudinal analysis using mixed effects methods (Barrio et al.,
2014), which examined the overall trajectory of burden, indicated a decrease in burden over time
for those in the intervention compared to those in TAU. Given that path and mediation analyses
examine the effects at specific time points, these did not capture the overall trajectory as is
possible in mixed effects analyses. In addition, the path from group to hope was not significant.
THE ROLE OF PROTECTIVE FACTORS 43
However, there was an effect between hope and burden at post (β=-0.405, SE=.037, p<.001), but
not at follow-up. Path analyses with all burden subscales and hope revealed similar results
regarding model fit and a significant path from hope to the subscale at post-study. For the family
interaction subscale, the path from hope to the family interaction variable was not only
significant at post-study, but also at follow-up.
Mediation analyses. Analysis with the total burden scale and hope revealed a moderately
good fit (Table 7) with a significant path between hope and burden. Mediation analyses with the
subscales revealed that the routine (β=-0.472, SE=.065, p<.001) and family interaction
(β=-0.431, SE=.074, p<.001) subscales had similar findings including model fits to the total
burden scale. The remaining subscales did not have significant paths.
Expressed emotion.
Warmth path analyses. The path model including family warmth as a protective factor
resulted in a moderately good model fit (χ
2
=15.592, df=8, p=.0486, CFI=.940, RMSEA = .122,
C.I.,.009, .211, p=.096). There were some promising results for the effect of treatment on family
warmth at post-study (β=0.17, SE=.336, p=.051) and effect of family warmth on burden at post-
study (β=-0.162, SE=.032, p=.057). As expected the subscales had similar effects on the path
from group to warmth at post-study, however, model fits were poor except for the leisure
subscale, which had a moderately good fit (χ
2
=11.099, df=8, p=.1961, CFI=.962, RMSEA =
.078, C.I.=.000, .177, p=.297) .
Warmth mediation analyses. Findings from mediation analysis with warmth as the
mediator and the total burden measure had a good model fit; however, there were no significant
paths (Table 7). The subscales had similar model fits and there were no significant paths.
THE ROLE OF PROTECTIVE FACTORS 44
Criticism path analyses. The family criticism path model had a good model fit (χ
2
=13.669, df=8, p=.0908, CFI=.955, RMSEA = .105, C.I.=.000, .198, p=.160), however, none of
the paths were significant. The model with the financial burden subscale had a good model fit,
(χ
2
=6.696, df=8, p=.5697, CFI=1.000, RMSEA = .000, C.I.=.000, .130, p=.675) and the only
significant path was from criticism to financial burden at post-study (β=-.216, SE=.032, p=.045).
The routine burden subscale had a moderately good fit (χ
2
=18.179, df=8, p=.0199, CFI=.907,
RMSEA =.141, C.I.=.053, .228, p=.046) and the path from criticism to routine burden was also
significant at post-study (β=-.254, SE=.030, p=.037). The leisure burden subscale had a good
model fit; however, there were no significant paths. Finally, the family interaction and effect on
others subscales had poor model fits and there were no significant paths.
Criticism mediation analyses. Mediation analyses with criticism revealed a good model
fit (Table 7) and a significant effect from group to criticism. Similar results were found with the
burden subscales.
FACES.
Path analyses FACES total scale. Results indicated a good model fit for the path model
including the total burden scale and FACES (χ
2
=10.365, df=8, p=.2403, CFI=.983, RMSEA =
.068, C.I.=.000, .171, p=.348). There was a significant path from burden at post to FACES at
follow-up (β=-.211, SE=.127, p=.034) so that as burden increased FACES decreased at follow-
up. There was also a significant path from FACES to burden at follow-up (β= -0.223, SE=.090,
p=.014). The financial subscale had a good model fit (χ
2
=8.106, df=8, p=.4232, CFI=.999,
RMSEA = .014, C.I.=.000, .148, p=.540) and the path from the financial subscale at post-study
and FACES at follow-up was significant (β=-.196, SE=.087, p=.031). The leisure subscale had a
good model fit (χ
2
=8.955, df=8, p=.3461, CFI=.990, RMSEA = .043, C.I.=.000, .157, p=.463)
THE ROLE OF PROTECTIVE FACTORS 45
and the path from the leisure subscale at post-study and FACES at follow-up was significant (β=-
.226, SE=.086, p=.012). The family interaction subscale also had a good model fit and the path
from FACES to the subscale was significant at post-study (β=-.439, SE=.152, p=.000). The
effect on others subscale had a poor model fit and the path from FACES to the subscale was
significant at post-study (β=-.254, SE=.111, p=.018). The other burden subscales did not have
significant paths.
Mediation analysis FACES total scale. As seen in Table 7, results with the FACES total
measure as mediator indicated a good model fit and the path from FACES to the total burden
measure just missed significance (p=.05). There were no significant effects with the financial,
routine, and leisure subscales. The family interaction (β= -0.376, SE=.173, p=.003) and effect on
others (β= -0.221, SE=.097, p=.020) subscales had significant effects from FACES to the
outcome variables with moderate model fits.
Path analyses adaptability subscale. The adaptability subscale and the total burden scale
had a moderately good fit (χ
2
=13.811, df=8, p=.0868, CFI=.950, RMSEA = .107, C.I.=.000,
.199, p=.154) and the path from burden at post-study to adaptability at follow-up was significant
(β= -0.238, SE=.150, p=.034). In addition, the path from adaptability to burden was significant
at follow-up (β= -0.159, SE=.075, p=.040). The financial and leisure burden subscales had
moderately good fits, but there were no significant effects. The family interaction subscale had a
moderately good fit and the effect from adaptability to the subscale was significant at follow-up
(β= -0.329, SE=.145, p=.006). Finally, the routine subscale had a poor model fit and there was a
significant effect from routine at post-study to adaptability at post-study. The effect on others
subscale also had a poor model fit and there was a significant effect from adaptability to the
subscale at follow-up.
THE ROLE OF PROTECTIVE FACTORS 46
Mediation analysis adaptability subscale. The total burden scale and adaptability
subscale had a good model fit and the path from adaptability to burden almost reached
significance (p=.057). The financial subscale had a good model fit (χ
2
= .001, df=1, p=.9801,
CFI=1.000, RMSEA=.000 C.I.=.000, .000, p=.982) and the path from adaptability to the
subscale was significant, however, the coefficient was positive (β= 0.253, SE=.117, p=.025)
indicating that as adaptability increased financial burden increased. The routine and leisure
burden subscales had good model fits, but no significant effects. The family interaction
(χ
2
=1.150, df=2, p=.5627, CFI=1.000, RMSEA=.000, C.I.=.000, .211, p=.612) and effect on
others (χ
2
=.325, df=2, p=.8499, CFI=1.000, RMSEA=.000, C.I.=.000, .136, p=.870) subscales
had good model fits and similar to other models, the path from adaptability to these subscales
was significant (β= -0.282, SE=.153, p=.014), (β= -0.227, SE=.079, p=.008), respectively.
Path analyses cohesion subscale. The cohesion FACES subscale had a good model fit
(χ
2
=13.601, df=8, p=.0928, CFI=.966, RMSEA = .105, C.I.=.000, .197, p=.163) and there was a
significant effect from cohesion to the burden total scale at follow-up (β= -0.245, SE=.087,
p=.017). The financial burden subscale had a good model fit, but there were no significant
effects. The routine subscale had a moderate fit and there was a significant effect from cohesion
to routine burden at follow-up (β= -0.257, SE=.124, p=.011). The leisure subscale had no
significant effects with a good model fit. The family interaction subscale had a good model fit
and similar to other models the path from cohesion to the subscale at follow-up was significant
(β= -0.445, SE=.140, p<.001). Lastly, the effect on others subscale also had a good model fit
with no significant effects.
Mediation analysis cohesion subscale. The total burden scale, cohesion, leisure, and
effect on others subscales had no significant paths and had poor model fits.
THE ROLE OF PROTECTIVE FACTORS 47
Table 7
Protective Factors and Burden Total Measure Mediation Models
Hope
a
Warmth
b
Criticism
c
FACES
d
β SE p
e
β SE p
e
β SE p
e
β SE p
e
Protective factor (post) regressed on
Group 0.048 0.255 0.354 0.197 0.374 0.051 0.210 0.635 0.042 0.043 0.145 0.380
Burden (follow-up) regressed on
Group 0.030 0.099 0.396 -0.018 0.111 0.438 -0.009 0.12 0.471 -0.019 0.106 0.435
Protective factor (post) -0.371 0.048 0.001 -0.091 0.029 0.174 -0.097 0.022 0.222 -0.178 0.095 0.050
Burden (baseline) 0.624 0.101 0.000 0.718 0.113 0.000 0.700 0.116 0.000 0.681 0.11 0.000
Length Ill
0.023 0.004 0.421 0.017 0.005 0.446 0.020 0.005 0.436 -0.003 0.005 0.491
Correlations
Group with Burden (baseline) 0.405 0.030 0.001 0.405 0.030 0.001 0.405 0.030 0.001 0.405 0.030 0.001
Length Ill with Group -0.313 0.661 0.000 -0.463 0.660 0.000 -0.463 0.661 0.000 -0.462 0.659 0.000
Length Ill with Burden (baseline) -0.462 0.765 0.006 -0.314 0.766 0.006 -.314 0.767 0.006 -0.313 0.764 0.006
Standardized Estimates; Direct and Indirect Paths Not Significant
SE=standard error
a
Model Fit: χ
2
=6.163, df=2, p=.0459, CFI=.911, RMSEA=.180, C.I.=.021, 351, p=.069
b
Model Fit: χ
2
=.460, df=2, p=.7945, CFI=1.000, RMSEA=.000, C.I=.000, .157, p=.822
c
Model Fit: χ
2
=2.788, df=2, p=.2481, CFI=.977, RMSEA=.078 C.I.=.000, .273, p=.302, represents low criticism/acceptance
d
Family Adaptability Cohesion Scale total measure model fit: χ
2
=3.520, df=2, p=.1720, CFI=.956, RMSEA=.109, C.I=.000,
.293, p=.220;
e
p-value=one-tailed
THE ROLE OF PROTECTIVE FACTORS 48
Although the routine and interaction burden subscales had a significant effect from cohesion to
the outcome, the model fit was also poor.
Knowledge
Prior longitudinal analyses using mixed effects methods (Barrio et al., 2014) included
family level of education as a covariate because it contributed to outcomes. However, given that
family level of education was not significant in path analyses, it was removed and family
acculturation was included because it was found to be correlated with education and including
both could contribute to collinearity. In addition, for path analyses, a better model fit was
obtained when including acculturation only at follow-up. Because of group differences, the
baseline knowledge score was included in all models.
Hope.
Path analysis. Path analysis revealed a moderate model fit (χ
2
=19.364, df=9, p=.0223,
CFI=.940, RMSEA = .134, C.I.=.045, .217, p=.052). There was a significant treatment effect on
knowledge at post (β= 0.398, SE=.356, p<.001) and follow-up (β= 0.301, SE=.549, p=.023).
Findings revealed no significant group effect on hope at either post or follow-up. However,
there was a significant effect of hope on knowledge at post (β= 0.236, SE=.153, p<.001), but not
at follow-up. There was a better model fit and a significant effect of hope on knowledge when
hope at follow-up was included when examining knowledge at follow-up. In other words, it
appears that hope has an effect on knowledge when examined cross-sectionally, but not over
time.
Mediation analysis. Findings revealed a moderate fit and a significant direct effect of
group on knowledge (Table 8); however, there was no effect of hope on knowledge.
THE ROLE OF PROTECTIVE FACTORS 49
Expressed emotion.
Warmth path analysis. Findings indicated a moderately good model fit for family
warmth. As indicated previously, there was a significant direct effect of treatment on
knowledge; however, there was no indirect effect. Although there was promising results with
group on warmth at post evaluation (p=.052).
Warmth mediation. Mediation analysis with warmth revealed a moderate model fit and
similar to path analysis, the path from group to warmth just missed significance as seen on
Table 8.
Criticism path analysis. Analysis with family criticism resulted in a good model fit.
However, except for the direct effect of treatment on knowledge, there were no other significant
paths.
Criticism mediation. The model with criticism as the mediator had a good model fit and
a significant effect of group on criticism (Table 8). Findings indicated that those in the
intervention were less critical; however, given that the score is reverse coded, the estimate is
positive.
FACES.
Path analysis. Findings indicated a good model fit for our knowledge and FACES
model. However, there was no significant direct or indirect effect of FACES on knowledge.
The FACES subscales had similar findings.
Mediation analysis. The FACES total scale mediation model (Table 8) and cohesion
subscale had poor model fits while the adaptability mediation subscale had a good model fit.
However, other than the direct effect of group on knowledge there were no significant effects.
THE ROLE OF PROTECTIVE FACTORS 50
Table 8
Protective Factors and Knowledge Mediation Models
Hope
a
Warmth
b
Criticism
c
FACES
d
β SE p
e
β SE p
e
β SE p
e
β SE p
e
Protective factor (post) regressed on
Group 0.048 0.255 0.354 0.197 0.374 0.051 0.210 0.635 0.042 0.040 0.145 0.389
Knowledge (follow-up) regressed on
Group 0.496 0.419 0.000 0.478 0.433 0.000 0.459 0.439 0.000 0.475 0.44 0.000
Protective factor (post) 0.137 0.177 0.077 -0.019 0.157 0.444 0.072 0.070 0.233 -0.028 0.373 0.396
Knowledge (baseline) 0.208 0.105 0.018 0.253 0.106 0.006 0.250 0.098 0.003 0.257 0.105 0.005
Acculturation 0.181 0.274 0.018 0.189 0.264 0.011 0.200 0.269 0.009 0.179 0.259 0.014
Correlations
Group with Knowledge (baseline) 0.333 0.100 0.003 0.333 0.100 0.003 0.334 0.100 0.003 0.333 0.100 0.003
Acculturation with Group 0.034 0.035 0.393 0.035 0.035 0.392 0.035 0.035 0.390 0.035 0.035 0.390
Acculturation with Knowledge (baseline) 0.261 0.134 0.029 0.260 0.134 0.029 0.260 0.134 0.029 0.261 0.134 0.029
Standardized Estimates; Direct and Indirect Paths Not Significant
SE=standard error
a
Model Fit: χ
2
=4.480, df=2, p=.1064, CFI=.926, RMSEA=.139, C.I.=.000, 316, p=.145
b
Model Fit: χ
2
=8.094, df=2, p=.0175, CFI=.839, RMSEA=.218, C.I.=.078, .384, p=.030
c
Model Fit: χ
2
=2.708, df=2, p=.2582, CFI=.979, RMSEA=.074, C.I.=.000, .271, p=.313,
represents low criticism/acceptance
d
Model Fit: χ
2
=10.694, df=2, p=.0048, CFI=.773, RMSEA=.261, C.I.=.123, .423,
p=.009; Family Adaptability and Cohesion Scale
e
p-value=one-tailed
THE ROLE OF PROTECTIVE FACTORS 51
QLS
The QLS path models included consumer education. Education was included due to its
possible influence on QLS. However, the path was only included at follow-up, because
including the path at both time points led to a poor model fit. In addition, although PANSS was
correlated with QLS, when adding the baseline PANSS score to the model it was no longer
significant and when adding the PANSS score to each outcome based on study period, there was
a poor model fit, therefore PANSS was dropped from the model. In addition, given the
significant group differences for length of illness and consumer age at baseline these were
initially included separately in the model; however, they were removed because they provided a
worse model fit and did not significantly contribute to the model. Moreover, given that length of
illness and consumer age were correlated with group it added multicollinearity to the model.
Because there were fewer variables in the mediation model, it was possible to include
PANSS as a control variable; however, adding age, length of illness, or education did not
significantly contribute to the model and were therefore not included.
Hope.
Path analyses. The fit for the hope and QLS model was moderately good (χ
2
=17.445,
df=9, p=.0422, CFI=.950, RMSEA=.121, C.I.=.022, .206, p=.088). There was no direct effect of
group on hope at either time point as previously indicated, but there was a significant effect of
QLS at post-study on hope at follow-up (β= 0.144, SE=.063, p=.040) and there was also a
significant effect of hope on the total QLS at post-study (β= 0.239, SE=.114, p=.006). Findings
also indicated that education was significant (β= 0.154, SE=.024, p=.043).
The intrapsychic subscale had a moderately good fit (χ
2
=13.627, df=9, p=.1362,
CFI=.970, RMSEA=.090, C.I.=.000, .180, p=.227). There was a significant effect of the
THE ROLE OF PROTECTIVE FACTORS 52
intrapsychic subscale at post-study to hope at follow-up (β= 0.160, SE=.057, p=.027). In
addition, the path from hope to the intrapsychic subscale was significant at post-study (β= 0.202,
SE=.146, p=.031) and just missed significance at follow-up, (p=.088). The other paths for the
intrapsychic subscale were similar to the total QLS. The interpersonal subscale had a moderately
good fit; however, there were no significant paths. The instrumental subscale had a good model
fit (χ
2
=14.959, df=9, p=.0921, CFI=.959, RMSEA=.102, C.I.=.000, .190, p=.166) and there was
a significant path from hope to the instrumental subscale at post-study (β= 0.351, SE=.211,
p<.001). The commonplace subscale had a moderately good fit; however, there were no
significant paths.
Mediation analyses. The mediation model resulted in a good fit for the total QLS, but
there were no significant paths (Table 9). Mediation analysis with the QLS subscales indicated a
good model fit and hope had a significant effect on the intrapsychic (β= 0.173, SE=.093, p=.014)
and instrumental (β= 0.331, SE=.105, p<.001) subscales only.
Expressed emotion.
Warmth path analyses. The model for consumer’s perception of warmth did not have a
good model fit (χ
2
=24.239, df=9, p=.0039, CFI=.877, RMSEA=.163, C.I.=.086, .242, p=.012).
There was a significant effect of group on warmth at post-study (β= 0.262, SE=.553, p=.010). In
addition, the path from warmth to QLS at post-study was significant (β= 0.204, SE=.043,
p=.011). A similar model fit was found with the subscales; however, the only subscale that had a
significant path from warmth to the outcome (subscale) was the interpersonal subscale (β= 0.354,
SE=.053, p<.001).
Warmth mediation analyses. The model with warmth and total QLS had a good fit
(Table 9). While the path from group to warmth was significant, similar to the path model, there
THE ROLE OF PROTECTIVE FACTORS 53
were no other significant effects. Similar results were found with the QLS subscales and
warmth.
Criticism path analyses. The model containing criticism and the total QLS had a poor fit
(χ
2
=20.965, df=9, p=.0128, CFI=.892, RMSEA=.144; C.I.=.063, .226, p=.033) and there was a
significant direct effect of treatment on perceptions of criticism at post-study (β= 0.300,
SE=.745, p=.005). The QLS subscales had moderately good model fits and only the
intrapsychic subscale had a significant path from criticism to the intrapsychic subscale at follow-
up (β= 0.160, SE=.033, p=.033).
Criticism mediation analyses. The model fit was good, when examining criticism as the
mediator for the total QLS (Table 9). There was also a significant effect from group to criticism.
As can be seen (Tables 10 and 11), the intrapsychic and instrumental subscales also had a
significant path from criticism to the subscales indicating an indirect effect of treatment on these
subscales. Although the direct effect of group to the instrumental subscale was not significant
the estimate was negative. The negative estimate is most likely the result of collinearity given
the high correlation between group and criticism. In addition, further analysis indicated that the
correlation between group and the instrumental subscale was positive (r=.037). Lastly, the
commonplace subscale also had a good model fit, but did not have a significant path from
criticism to the outcome variable.
FACES.
Path analyses total FACES scale. The model fit for the total QLS and FACES was good
(χ
2
=10.536, df=9, p=.3088, CFI=.987, RMSEA=.052, C.I.=.000, .155, p=.431) and there was a
significant path from FACES to QLS at post-study (β= 0.154, SE=.206, p=.041). The
THE ROLE OF PROTECTIVE FACTORS 54
intrapsychic subscale and FACES had similar findings. However, the remaining QLS subscales
had no significant effects.
Mediation analyses total FACES scale. Analysis with the total QLS resulted in a good
model fit; however, there were no significant paths (Table 9). The intrapsychic subscale had
similar findings. The remaining subscales also had no significant paths.
Path analyses adaptability subscale. There was a significant path from adaptability to
the total QLS at post-study (β=0.154, SE=.180, p=.033) with a good model fit and similar
findings were indicated for the intrapsychic subscale. Interestingly for the interpersonal
subscale, the path from adaptability to the subscale was significant at follow-up, but the estimate
was negative (β=-0.342, SE=.146, p=.002). The remaining two subscales had no significant
paths.
Mediation analyses adaptability subscale. The adaptability subscale had a good model
fit, but there were no significant effects with the total QLS, intrapsychic, and instrumental
subscales. The interpersonal subscale had a significant effect from adaptability to the subscale
(β=-0.212, SE=.244, p=.018) and the estimate was negative. The commonplace subscale had a
good model fit and the path from adaptability to the commonplace subscale just missed
significance (p=.06).
Path analyses cohesion subscale. The model fit for the total QLS and cohesion was
good, but there were no significant effects. The QLS subscales had similar findings.
Mediation analyses cohesion subscale. The cohesion subscale model and the total QLS
along with the subscales (intrapsychic, instrumental, and commonplace) had good model fits, but
there were no significant effects.
THE ROLE OF PROTECTIVE FACTORS 55
Table 9
Protective Factors and Quality of Life Mediation Models
Hope
a
Warmth
b
Criticism
c
FACES
d
β SE p
e
β SE p
e
β SE p
e
β SE p
e
Protective factor (post) regressed on
Group 0.047 0.255 0.357 0.292 0.537 0.004 0.304 0.758 0.006 0.037 0.145 0.397
Quality of Life (follow-up) regressed on
Group -0.013 0.228 0.449 -0.014 0.238 0.445 -0.042 0.247 0.342 -0.006 0.225 0.474
Protective factor (post) 0.124 0.103 0.078 0.012 0.043 0.447 0.112 0.036 0.124 -0.103 0.212 0.132
PANSS
f
(follow-up) -0.710 0.233 0.000 -0.718 0.248 0.000 -0.712 0.238 0.000 -0.724 0.239 0.000
Correlations
Group with PANSS
f
(follow-up) -0.142 0.034 0.134 -0.142 0.034 0.134 -0.142 0.034 0.134 -0.142 0.034 0.134
Standardized Estimates; Direct and Indirect Paths Not Significant
SE=standard error
a
Model Fit: χ
2
=1.288, df=1, p=.2565, CFI=.993, RMSEA=.067, C.I.=.000, .347, p=.294
b
Model Fit: χ
2
=1.805, df=1, p=.1791, CFI=.981, RMSEA=.112, C.I.=.000, .374, p=.213
c
Model Fit: χ
2
=.053, df=1, p=.8184, CFI=1.000, RMSEA=.000, C.I.=.000, .203, p=.832, represents low
criticism/acceptance
d
Model Fit: χ
2
=.435, df=1, p=.5094, CFI=1.000, RMSEA=.000, C.I.=.000, .286, p=.542;
Family Adaptability and Cohesion Scale
e
p-value=one-tailed
f
PANSS=Positive and Negative Syndrome Scale
THE ROLE OF PROTECTIVE FACTORS 56
Table 10
Criticism
a
and Intrapsychic QLS
b
Mediation Model
β SE p
c
C.I.
d
Lower Upper
Criticism (post) regressed on
Group 0.304 0.758 0.006
Intrapsychic (follow-up) regressed on
Group 0.055 0.214 0.269
Criticism (post) 0.207 0.033 0.008
PANSS
d
(follow-up)
-0.744 0.190 0.000
Correlations
Group with PANSS
e
(follow-up)
-0.142 0.034 0.134
Direct Effect 0.055 .089
-0.120 0.229
Indirect Effect 0.063 .039 -0.014 0.140
Standardized Estimates
SE=standard error
Model Fit: x
2
=.053, df=1, p=.8184, CFI=1.000, RMSEA=.000, C.I. =.000, .203, p=.832
a
Represents low criticism/acceptance
b
Quality of Life Scale (intrapsychic subscale)
c
p. -value=one-tailed
d
C.I
= Bias-corrected bootstrap confidence interval 2.5% bounds
e
Positive and Negative Syndrome Scale
Table 11
Criticism
a
and Instrumental QLS
b
Mediation Model
β SE p
c
C.I.
d
Lower Upper
Criticism (post) regressed on
Group 0.304 0.758 0.006
Instrumental (follow-up) regressed on
Group -0.095 0.279 0.217
Criticism (post) 0.241 0.041 0.016
PANSS
d
(follow-up)
-0.413 0.385 0.011
Correlations
Group with PANSS
e
(follow-up) -0.142 0.034 0.134
Direct Effect -0.095 .121
-0.332 0.143
Indirect Effect 0.073 .051 -0.026 0.173
Standardized Estimates
SE=standard error
Model Fit: x
2
=.053, df=1, p=.8184, CFI=1.000, RMSEA=.000, C.I.=.000, .203, p=.832
a
Represents low criticism/acceptance
b
Quality of Life Scale (instrumental subscale)
c
p. -value=one-tailed
d
C.I
= Bias-corrected bootstrap confidence interval 2.5% bounds
e
Positive and Negative Syndrome Scale
THE ROLE OF PROTECTIVE FACTORS 57
PANSS
Consumer age and length of illness were initially included separately given that there
were group differences in age and length of illness; however, these did not add to the model and
resulted in a poor model fit. However, education, which has been found to be related to level of
symptom severity, was included for both the path and mediation models.
Hope.
Path analyses. The path model with hope had a good model fit; however, there were no
significant paths. When examining the PANSS subscales, the positive symptom model had a
good fit, but there were no significant paths. The negative symptom model also had a good fit
(χ
2
=16.844, df=9, p=.0512, CFI=.953, RMSEA=.117, C.I.=.000, .202, p=.103), and there was a
significant path from negative symptoms at post-study to hope at follow-up (β=-0.175, SE=.078,
p=.013). The generalized path model also had a good fit (χ
2
=10.809, df=9, p=.2890, CFI=.985,
RMSEA=.056, C.I.=.000, .158, p=.410) and the path from hope at post-study and generalized
symptoms at post-study was significant (β=-0.231, SE=.120, p=.017).
Mediation analyses. The mediation model with the PANSS total scale had a good model
fit (Table 12); however, none of the paths were significant. The subscales had similar findings.
Expressed emotion.
Warmth path analyses. The path model with warmth had a poor fit. Similar to the QLS
analyses, which indicated that those in the intervention had an increase in perceptions of warmth
for consumers, there was a significant effect of treatment on warmth at post-study (β=0.257,
SE=.548, p=.010) and there was a significant path from warmth to the total PANSS scale at post-
study (β=-0.280, SE=.025, p=.003), but not at follow-up. Similar findings were indicated for the
PANSS subscales.
THE ROLE OF PROTECTIVE FACTORS 58
Warmth mediation analyses. Analyses revealed a good fit for the total PANSS scale
(Table 12), positive, and negative subscale models and warmth, however, only the path from
treatment to warmth was significant. The generalized subscale model not only indicated a
significant effect of treatment on warmth, but there was also a significant effect of warmth on the
subscale (Table 13), revealing an indirect effect of treatment on generalized symptoms.
Criticism path analyses. The model containing criticism and the total PANSS scale had
a good model fit (χ
2
=9.198, df=9, p=.4192, CFI=.998, RMSEA=.019, C.I. =.000, .143, p=.543).
It revealed that those in the intervention had a significant decrease in criticism at post-study;
however, given that the measure was reverse coded the estimate is positive indicating an
improvement in family acceptance (β=0.297, SE=.743, p=.006). There were no other significant
paths. The model with criticism and the positive, negative, and generalized symptoms subscales
had similar findings.
Criticism mediation analyses. The mediation models with criticism as the mediator had
good model fits, but other than the direct effect of group on decreasing criticism, there were no
other significant paths for either the PANSS total scale (Table 12) or subscales.
FACES.
Path analyses total FACES scale. The path model with FACES and PANSS total scale
had a good model fit (χ
2
=12.539, df=9, p=.1846, CFI=.974, RMSEA=.078, C.I.=.000, .172,
p=.289) in addition the path from FACES to PANSS was significant at post-study (β=-0.245,
SE=.126, p=.009). The path from FACES to PANSS at follow-up also had a significant effect;
however, the direction was in the opposite direction indicating probable collinearity. The
positive and generalized symptoms subscale had similar findings along with the negative
THE ROLE OF PROTECTIVE FACTORS 59
symptoms subscale except that for the negative symptoms subscale FACES was not significant
at follow-up, so that collinearity was not present for this model.
Mediation analyses total FACES scale. Results revealed a good fit; however, there were
no significant effects for the PANSS total scale and FACES (Table 12). The positive symptoms
subscale did not have a good fit and there were no significant effects. The negative and
generalized symptoms subscales had a good fit, but there were no significant effects.
Path analyses FACES subscales. The adaptability subscale had similar findings to the
total FACES measure path analyses expect for the generalized subscale where there were no
significant paths. The cohesion subscale also had similar findings except that the negative
subscale just missed significance for the effect of cohesion on the negative subscale at post-study
(p=.05).
Mediation analyses FACES subscales. There were no significant effects with the
FACES subscales and the PANSS measure and subscales.
Summary
Table 14 provides a summary of findings indicating which protective factors influenced
family member and consumer outcomes. As can be seen most protective factors contributed to
the improvement of outcomes.
THE ROLE OF PROTECTIVE FACTORS 60
Table 12
Protective Factors and PANSS
a
Mediation Models
Hope
b
Warmth
c
Criticism
d
FACES
e
β SE p
f
β SE p
f
β SE p
f
β SE p
f
Protective factor (post) regressed on
Group 0.048 0.255 0.356 0.292 0.537 0.004 0.304 0.758 0.006 0.039 0.144 0.391
PANSS
f
(follow-up) regressed on
Group -0.065 0.148 0.320 -0.020 0.140 0.438 -0.081 0.156 0.287 -0.063 0.146 0.322
Protective factor (post) -0.108 0.064 0.180 -0.195 0.036 0.118 0.071 0.020 0.269 -0.039 0.148 0.393
Education -0.305 0.015 0.008 -0.314 0.015 0.006 -0.326 0.015 0.004 -0.313 0.016 0.009
Correlations
Group with Education (follow-up) 0.226 0.244 0.024 0.226 0.244 0.024 0.226 0.244 0.024 0.226 0.244 0.024
Standardized Estimates; Direct and Indirect Paths Not Significant
SE=standard error
a
PANSS=Positive and Negative Syndrome Scale
b
Model Fit: χ
2
=.955, df=1, p=.3284, CFI=1.000, RMSEA=.000, C.I.=.000, .328, p=.366
c
Model Fit: χ
2
=.542, df=1, p=.4615, CFI=1.000, RMSEA=.000, C.I.=.000, .297, p=.496
d
Model Fit: χ
2
=.063, df=1, p=.8019, CFI=1.000, RMSEA=.000, C.I.=.000, .210, p=.817,
represents low criticism/acceptance
e
Model Fit: χ
2
=1.142, df=1, p=.2852, CFI=.959, RMSEA=.047, C.I.=.000, .339, p=.323;
Family Adaptability and Cohesion Scale
f
p-value=one-tailed
THE ROLE OF PROTECTIVE FACTORS 61
Table 13
Warmth and Generalized Psychopathology
a
Mediation Model
β SE p
b
C.I.
c
Lower Upper
Warmth (post) regressed on
Group 0.292 0.537 0.004
Generalized
a
(follow-up) regressed on
Group -0.017 0.145 0.449
Warmth (post)
-0.268 0.034 0.041
Education -0.256 0.015 0.018
Correlations
Group with Education 0.226 0.244 0.024
Direct Effect -0.017 .133
-0.277 0.243
Indirect Effect -0.078 .049 -0.174 0.018
Standardized Estimates
SE=standard error
Model Fit: x
2
=.542, df=1, p=.4615, CFI=1.000, RMSEA=.000, C.I.=.000, .297, p=.496
a
Positive and Negative Syndrome subscale
b
p. -value=one-tailed
c
C.I
= Bias-corrected bootstrap confidence interval 2.5% bounds
THE ROLE OF PROTECTIVE FACTORS 62
Table 14
Summary of Findings Indicating Effects of Protective Factors on Outcomes
Expressed Emotion
Hope Warmth Criticism
1
FACES
2
Total
FACES
Adaptability
Subscale
FACES
Cohesion
Subscale
Family Outcomes
Burden p, m
f f f
Financial p
p
m
Routine p, m
p
f f
Leisure p
Interaction p, f, m
p, m f, m f
Effect on others p
p, m f, m
Knowledge p
Consumer Outcomes
QLS
3
p p
p p
Intrapsychic p, m
f, i p p
Interpersonal
p
f, m
Instrumental p, m
i
Commonplace
PANSS
4
p
p p p
Positive
p
p p p
Negative
p
p p
Generalized p p, i
1
Reverse coded, value represents low criticism/acceptance
2
Family Adaptability and Cohesion Scale
3
Quality of Life Scale
4
Positive and Negative Syndrome Scale
f=path analysis follow-up
i=indirect treatment effect
m=mediation analysis
p=path analysis post-study
THE ROLE OF PROTECTIVE FACTORS 63
Qualitative Results
The qualitative phase of the study sought to explore perceptions of protective factors and
how these were utilized by intervention participants. In addition, the influence of the
intervention was further explored among participants. Analysis of family member and consumer
transcripts revealed domains addressing protective factors and the influence of the intervention
on views of the illness, treatment, and perceptions of salient outcomes. These domains are
presented below along with relevant themes.
Protective Factors
Hope. Family members described hope in terms of a wish or a desire for improvement of
their loved one’s illness. As one mother noted “My hope was for him to fulfill himself as a
human being, as a man.” Consumers referred to hope as something that helped them cope with
the challenges they experienced with their illness. A consumer said, “One may give in because
of the physical, but while one has hope that things can change, or as they say, it is like a light at
the end of the tunnel.” This consumer seemed to view hope as an expectation for change and
improvement in her life.
Family members overwhelmingly connected hope to their religion/spirituality. Hope was
the first protective factor that was discussed during the interview and so families had not been
prompted to talk about their religion/spirituality, yet they quickly found a connection between
these two resources. A husband said, “For me hope is God…hope comes through faith…when
you have faith, you have hope.” Family members also expressed their hope for God’s help in
bringing about an improvement or miracle in their loved one’s illness. A mother said “hope to
me is like, it’s waiting for a miracle…I have the hope that one day God will give me a miracle
and my son will change.” In addition, family members conveyed how their hope was renewed
THE ROLE OF PROTECTIVE FACTORS 64
and strengthened through their religion/spirituality. A husband noted “I believe that believing in
God, because it is the only way that one can strengthen one’s life…strengthening one’s hope,
because if you do not believe in anything or if you do not believe that something is possible…you
will not do anything.” A grandmother shared this sentiment and said, “Yes, pessimism assails
me, but I do not allow it. No. I place myself in God’s hands.”
Similar to family members, consumers readily associated their hope to their
religious/spiritual beliefs. As described by one consumer,
Hope to me is like, it has a spiritual thing connected to it. Like, it’s where mind, body,
spirit, so then if your mind, your spirit, if your mind is being tormented or whatever, or
your brain, that’s a physical thing, but your spirit is still there. It’s like it’s still, there’s
still life there.
Another consumer talked about how he finds hope for a better future through his
spirituality.
I like to play guitar and I have a song that I say that…that it feels good, ‘everything is
fine now but you know, you’re just waiting for the day that everything is going to crash
and that I rest my head on the soft of a new day.’ So, I rest on that there’s going to be a
tomorrow and no matter what I’m going through right now, there’s going to be a
tomorrow, like “primero Dios”, things can get resolved, there’s always a tomorrow, God
willing. You know, it’s like hope, well, that’s there’s going to be a tomorrow.
As a whole, it appeared that consumers’ hope was closely tied to their spiritual beliefs,
which helped them cope with the challenges that they experienced in their daily lives.
Moreover, when consumers were asked what helped them increase their hope, they
expressed how having support from their family contributed to their level of hope. As noted by a
consumer “…I think if they’re [family] more connected, it’ll help elevate my hope more.”
Consumers also expressed the appreciation they had for their family and how the hopes that their
family members had for them helped them to be more hopeful for their own future. A consumer
said,
THE ROLE OF PROTECTIVE FACTORS 65
Once she caught me doing something that wasn’t very favorable and she said, ‘don’t you
want to make me proud,’ and I saw how she had hopes for me and I kinda let her down.
Yeah, I see that she has hopes for me and that kinda motivates me to be a better person
and strive to succeed.
Religion/Spirituality. Given the salience of religion/spirituality as seen in participants’
responses on hope, family members and consumers expressed the important role this protective
factor had in their life. Moreover, they expressed how their religion/spirituality helped to nurture
their faith so that they could deal with the illness. A family member said, “Faith is what
motivates me to continue, it is something that we do not see but it is there.” Family members
also described how their faith provided them with hope and motivated them to continue
supporting their loved one with the illness. As reported by a mother, “The love for my family, the
hope that there will be something better each day. Every day, because every day is different, and
faith is there. It is something very important to me.” Overall, faith, hope, and love were
important resources used by families to deal with the illness. As expressed by one mother,
“…there is God and science and between them are love, hope, and faith.”
Similarly, consumers’ faith was an important resource in their lives, particularly during
times of distress as explained by one consumer,
…it was about being able to talk to God internally. It was my interior that sustained me
while they were giving me medication, while all of this was occurring, because none of
this ceased to occur although my mind could not endure. But then there is faith, it is
something internal.
Religion/spirituality also provided consumers with a sense of purpose and perspective
regarding their everyday lives and their illness. As said by one consumer, “It helps me. I can…
enjoy the weather and keep him in my thoughts every day. I’m kind of a happy person just
knowing there’s a God that exists.”
THE ROLE OF PROTECTIVE FACTORS 66
Family environment. Questions related to family environment elicited themes
addressing family interpersonal relationships. Family members discussed the difficulties they
encountered with consumers’ behavior and how this affected them and other family members
resulting in family burden. It was particularly the case when consumers were not clinically
stable and was further complicated among consumers who abused substances. One family
member said, “…he was rude and almost throwing things and wanting to fight with his dad, he
argues with his dad all the time.” She went on to say”…it hurts me much for him to do those
things here. Primarily drugs.”
Another family member reiterated the challenges that her son’s behavior have created for
her physical and emotional health. She said,
It tires my body out. And it’s not just physical, it’s emotional exhaustion. Just thinking
about him and he calls me, when he calls me a lot, oh God, I hate to say it, but when I see
his name on the phone, that number, it’s like oh my God why are you calling. I don’t
want to talk to you. He’s my son. I should be happy to hear from him…
Family environment also appeared to impact consumers’ wellbeing. Some consumers
expressed how lack of support from some family members was difficult for them. As one
consumer said, “when we get along…well, yeah, I feel different. More happier, more talkative,
more like that you know.” Another consumer talked about enjoying opportunities for socializing
with his extended family.
Yes, I visit my family. I have an aunt who lives close by. Sometimes they have a party or
they cook something, and they invite us, and we go. My other aunt lives further, but she
also attends and we socialize. They have some music and sometimes we watch
television…
It appears that these family gatherings provided opportunities for this consumer to engage
and receive social support from his extended family.
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Family members also conveyed the importance of family unity and how having a
supportive family environment helped the consumer. Treatment was seen as important, but just
as important was the support that consumers received from their family. One mother described it
as,
…there have to be two medicines; the doctor’s medicine and the family’s medicine. And
you know what is the family’s medicine? For there to be more family unity. More
engagement to help [the consumer] and not tell him that because he is sick you will throw
him out. On the contrary, bring them [consumers] closer to us.
Another mother remarked on the family’s unity and their support of their loved one. In
particular, she noted how her youngest daughter was involved in helping her remind consumer to
take his medication, “Being united. My youngest daughter is 14 and she is always after him,
keeps an eye on him…she comes and gives it [medication] to him and he takes it without a
problem.” It seems that the whole family comes together to support their loved one’s treatment
adherence. Similarly, a mother believed it was important for her to have daily contact with her
son to remind him of her support although he was working full-time and lived on his own. She
also expressed how she accommodated her behavior to best support her son by being patient and
not arguing with him.
…I send him a message and encourage him, ‘son, may God bless you’, because I know
that although he takes his medication and work distracts him a little, I know that even so
he must feel some discomfort…That is why I think that at all times love towards my son
and patience. Patience because I do not like to argue with him…I try to be patient, to
look for words that will not make him feel less than. It is at all times.
Influence of Intervention
Knowledge as a protective factor. Overall, family members expressed how
participating in the intervention benefitted them through increased knowledge of the illness.
From this knowledge came a better understanding regarding the illness and treatment. A mother
said, “… [after the intervention] we didn’t reprimand him as much. We were more aware of
THE ROLE OF PROTECTIVE FACTORS 68
what he had.” Families talked about their lack of information as being “blind” to their family
member’s illness. As described by a husband, “…I went to those groups and I removed the
blindfold from my eyes…they took away the blindfold and I could see what was happening
because of the information that they gave me.” Family members found that the intervention
helped them to address their previous explanatory beliefs regarding the illness. Some family
members thought the illness was a result of substance abuse by consumers and this belief had led
them to be critical of consumers. As described by a mother,
But after we started going to the meetings…and everyone gave their testimony, it was
when I was convinced that it was not drugs. That he had something else…we [mother
and father] also had to change because we would reprimand him much.
Family members appreciated learning about the symptoms associated with the illness and
about how medication can help manage some of the symptoms. As noted by a mother, “We
learned much from the classes. They helped me much because I learned more about my son’s
problem. I learned about the changes that he would have.” Learning about medication and
other treatment helped a mother see that over time there have been advancements that have
improved the quality of life for individuals, which gave her “hope in the illness.”
Families appeared to have been empowered by gaining knowledge about the illness, as it
not only helped them manage their caregiving responsibilities, but it also lead to improved
interpersonal relationship with their loved ones. One mother explained, “From there I gained
the tools and I have them to be able to endure my son’s illness. I obtained everything from there
[intervention].” A father also commented on how his son’s illness at first made him feel
“uneasy” because he did not know what was happening, “I was really scared cause I didn’t
know what it was, but once I found out what it was about, it was a different story. Different
story. I understand now and I know how to protect him.” Families often mentioned that not
THE ROLE OF PROTECTIVE FACTORS 69
knowing about the illness and what was happening to their loved ones’ had been the most
difficult aspect of their caregiving experience. A daughter also explained that the information
she gained from the intervention helped her to have more understanding towards her mother and
see her as an individual with an illness. She said,
I think that the information that they gave us, helped us much…not only to understand the
illness…to understand how my mom was feeling, what she was going through, what she
needed for her medical care, medication, and symptoms that she experienced. It helped
me very much. In other words, it completely changed the way I saw my mom…
understand how she was feeling so that we could see that regardless of her illness, there
is a human being there and that is my mom, an angel.
Consumers also commented on how the intervention benefitted their relationship with
their family members, which was largely attributed to their family members increase knowledge
of the illness and treatment such as medication. It created a more cohesive family environment
and led to improved family interpersonal relationships, which had previously been challenged by
criticism. One consumer said,
…before, [it was] always like, ‘What's wrong with you?’ …they were always
constantly, constantly and they didn't know the, the effects or the situation that I was
going through. But after a while, they went to the group sessions and they see it in a
different approach…and then we got along differently.
Consumers expressed feeling understood and accepted by their family members because
of their participation in the intervention and their knowledge of the illness. A consumer said,
“…since I know she took the meeting she knows more about it. I’m more comfortable about it.
I’m more comfortable with her knowing stuff.” Another consumer also said, “It’s not as heavy a
burden…knowing that my mom is ok with knowing how I am.” Other consumers talked about the
appreciation they felt for their family members who took time to participate in the intervention.
A consumer noted, “…the thought was appreciated that they went for me and participated in the
classes. It made me feel good that my family cares. They went on my behalf and participated.”
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Consumers saw these experiences as contributing to a more satisfying family environment that
encouraged improved family relationships.
Stigma. Family members and consumers described how perceptions of stigma had
affected their lives. When asked about possible experiences with stigma towards consumers,
some family members denied problems in this area saying immediate and extended family
members were aware of their loved one’s illness and therefore there were no differences in how
consumers were treated. However, these experiences tended to come from families who
described their loved ones’ illness as stable. It seems that most encounters with stigma came
when consumers were experiencing symptoms or during the initial stages of the illness when
families did not know what was happening to their loved ones. It was during these times when
family members most noticed negative interactions or comments from others including their own
family. As noted by a mother,
For me it is difficult. Others rejection towards him hurts me. It hurts me much because I
think family, I hear family members making comments. ‘My uncles have a crazy person
living in the house’… and that all affects me…
Another family member discussed how he noticed others staring at his son when out in
public due to his son’s behavior which may be due to medication side effects. He said, “Well,
they’re looking at him a certain way like… cause he like twitches…” However, this family
member and others expressed how as family they made an effort to see and treat consumer “as if
he did not have an illness.” Families believed that this made a difference in how consumers saw
themselves, as noted by a father, “I’m pretty sure he feels since we understand there’s no
difference and that makes a big difference for him.”
Overall, family members did not perceive any challenges to treatment because of
experiences with stigma. They believed that negative perceptions or comments by others would
THE ROLE OF PROTECTIVE FACTORS 71
not prevent them from seeking care for their loved ones. Moreover, family members talked
about how participating in the intervention helped them be more open about their loved one’s
illness and have the “courage” to disclose it others. A family member said, “it is as if it gave us
more courage to say this is what is happening…” Learning about the illness and listening to
other family members’ experiences seemed to have normalized the illness and made family
members feel comfortable disclosing to others about their loved one’s illness. A mother noted,
…I began to know how to manage the situation better and in the beginning it was family.
After it was other people, we have met. I am not embarrassed to talk about it because it
is like; it is like other people have diabetes, it is normal. It is natural. And while there is
help and the patient feels recuperated. Imagine how we would feel if there was no help?
But the classes helped me feel more comfortable to talk about it because as I said, it is
like any other problem that has a cure or if there is none, there is hope that [one] can feel
better each day.
Moreover, family members expressed how learning about the illness and the possibility
for recovery helped them to see that there was hope and that this in turn made it easier for them
to talk to others about their loved one’s illness. As noted by a mother, “it [intervention] gave me
much hope because before I did not think that they [consumers] could achieve a goal.”
Illness disclosure. When asked about experiences with stigma, consumers’ discussions
tended to focus on issues with disclosure. Consumers expressed apprehension with informing
others about their mental illness because of how they would be perceived. One consumer said,
I would think people [would] say ‘oh, this guy is crazy,’ you know. He’s not all there.”
… they would see it as weird, you know? In my opinion, it’s not something you go out
and tell people, I think. So I keep it to myself, I think. I don’t see why I would tell
someone straight out, ‘oh, I have schizophrenia, oh I’m depressive.’
Consumers were careful with who they disclosed to, usually it was only to close friends
and after knowing them well. A consumer said,
… there’s not very many people I tell straight I have this. It’s usually close friends,
people that I already knew from the past and knew I was going with it. But I mean, I’ve
only told like three people in the past year that I have this sickness. And they tell me,
THE ROLE OF PROTECTIVE FACTORS 72
‘you don’t have that.’ They see me; they see that I’m for the most part fine. I tell them, I
hear voices. I know what’s it’s like to be ok, so I just act that way.
This consumer seems to be aware of how he needs to “act” around others so that they do
not perceive him as having a mental illness which points to the lack of acceptance he may feel
because of his illness.
Most consumers commented on how others’ opinions did not dissuade them from seeking
needed treatment. However, this insight may have been more difficult at the beginning of the
illness. As one consumer noted, “The first time I was hospitalized and was discharged, I was
embarrassed to even say I had been hospitalized.” This consumer went on to describe the
concern that he had with others thinking that his illness was caused by substance abuse, which as
described earlier was also an explanatory belief held by some family members prior to the
intervention. Another consumer said,
I feel that the first time that you get the illness one begins with stigma…and with time and
treatment and information, one begins to adapt to the reality, to the illness… and the
stigma starts to go away. Yes, in the beginning, you have much embarrassment or fear
about the illness, little by little, you come to realize that it is something that you have but
it is not the end of the world and I have to continue living. And I have to continue living
with this…address it to live better and live as healthy as possible.
Although consumers had been living with their illness for several years and were mostly
clinically stable, they nevertheless may continue to experience obstacles that may affect their
quality of life particularly as it related to social and interpersonal experiences. However, as
previously mentioned, consumers appeared to benefit indirectly from their family members
participation in the intervention as it decreased criticism and led consumers to feel accepted.
These feelings of acceptance may contribute to improved self-esteem, which may alter self-
stigma perceptions.
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Salient outcomes and wellbeing.
Family interactions. When asked about salient outcomes, family members regarded
family interaction as an important outcome for consumers. Family members believed that their
loved one’s engagement with family members was indicative of improvement. A father said,
“now he greets and talks to people. And when he is like that [ill], no, he hardly talks to us.”
Similarly, a daughter commented on how she is now able to have a closer relationship with her
mother, which she was not able to have in the past as a child,
I see that she is more alert. We talk, when we talk she is coherent and her speech makes
sense…these are things that I had always longed for as a child. I had always longed for
a hug from my mother, for her to say she loved me, and to have my mother as my
mother…and I have her now. My wish came true...
Treatment compliance. Family members also noted consumer’s acceptance of their
illness, which they understood as treatment compliance, to be an important outcome for
wellbeing. One mother said, “I think he has achieved the objective, he has come to accept his
illness and continue with his treatment. That is the objective.” Families regardless of their loved
one’s level of recovery or stability, shared this sentiment. Through treatment compliance,
families were able to see consumers develop in other areas such as employment and social
relationships. As noted by a mother, “he has activities with his friends, with his girlfriend, his
work, he keeps himself busy.” Families noted how the intervention helped them to understand
the importance of compliance with treatment.
Employment. For consumers salient outcomes centered on their ability to fulfill
important social roles and responsibilities that come along with employment. Those consumers
who were employed or were involved in a meaningful activity sought continued stability so that
they could remain employed and active. A consumer noted, “I’ve been good. Yeah, I’ve been
able to hold down a job for about three and a half years now.” Although most consumers, were
THE ROLE OF PROTECTIVE FACTORS 74
not employed they nevertheless saw employment as something they strived to achieve and as a
sign that they were living a “normal life.” As one consumer noted, well, yeah, like a normal life?
Yeah, getting a job, a wife, a car, somewhere to stay. I think that’s the normal life you know…”
Wellbeing. Family members and consumers had a comprehensive view of wellbeing and
what was needed to achieve it. Family members perceived wellbeing as incorporating physical
and spiritual components and believed that these were important for their loved ones ongoing
recovery. A family member said, “We have to pay attention to her [consumer] needs, in every
aspect; physical, emotional, and spiritual, because sometimes if we only focus on the physical
there will be a lack of balance.” Consumers had similar beliefs regarding wellbeing. A
consumer said, “mental health is having a full mind, body, spiritual experience where you’re
healthy…it’s all balanced.” This sentiment was particularly found among those individuals who
were clinically stable and were following through on their recommended treatment. A consumer
noted, “what I would like is to be stable, healthy, even if I continue taking medication, to be at a
level of health, healthy, if it is possible, to be able to be cured.” This consumer seemed to
believe that taking medication and being involved in treatment did not mean that he was not
stable, but rather that treatment can lead to stability or even full recovery.
THE ROLE OF PROTECTIVE FACTORS 75
CHAPTER FIVE
Discussion
Using a mixed methods approach, this study examined the influence of protective factors
on outcomes for family members and consumers who participated in a culturally based family
psychoeducation intervention. The first phase of the study consisted of analysis of existing
quantitative data where protective factors were examined as intervening variables on outcomes
over time to provide an overall understanding of the process of change (Hypothesis 1) followed
by specific mediation analyses (Hypothesis 2). The second phase explored protective factors
further through in-depth interviews with intervention participants using qualitative methods. The
use of multiple research methods allowed us to gain a comprehensive understanding of
protective factors and the impact of the intervention on these factors and other salient outcomes.
Overall, findings illustrated promising results for protective factors on outcomes for
family members and consumers. Although, quantitative findings revealed no direct effect of
treatment on hope or family adaptability and cohesion, possibly due to a ceiling effect, so that the
possibility of improvement was limited, there was promise for the influence of these protective
factors on family burden. However, there was a statistically significant decrease in criticism
while an increase in warmth indicated a trend for family members in the intervention. It may be
that warmth and criticism are modifiable factors because they are dealing with concrete
behaviors whereas hope and adaptability/cohesion may be addressing cultural values that were
already strong within these family systems. While knowledge of the illness increased for those
in the intervention, the protective factors were not found to contribute to knowledge of the
illness. Path analysis indicated that hope contributed to an increase in knowledge, but only at
THE ROLE OF PROTECTIVE FACTORS 76
post-study. It appears that the benefits of hope on knowledge may be more challenging to
maintain over time or there may be other factors influencing this relationship.
Our study examined both clinical functioning and quality of life as outcomes, adding a
greater dimension to the understanding of consumer well-being. There was a reduction of
perceptions of criticism for consumers in the intervention leading to indirect effects for the
intrapsychic and instrumental components of quality of life. Warmth also improved and lead to a
decrease in the PANSS general psychopathology subscale. It is important to note that the
intrapsychic items on the QLS address critical areas of functioning (cognition, conations,
affectivity) that are the foundation for other quality of life components and that a deficit in this
area can seriously affect other areas of functioning (Heinrichs et al., 1984). The instrumental
quality of life subscale includes items related to social roles and consumers’ evaluation of how
they are functioning in these roles. Therefore, our findings regarding criticism and its impact on
the intrapsychic and instrumental quality of life subscales deal with critical quality of life
components that were found to be important for consumers during the qualitative phase of the
study. Similarly, findings related to warmth and general psychopathology are important because
general psychopathology is concerned with symptoms that may exacerbate prominent
schizophrenia symptoms (Kay et al., 1987).
Promising results were found for hope and the family adaptability and cohesion
protective factors for consumer outcomes. There were interesting findings related to the
interpersonal quality of life subscale and the adaptability subscale. The FACES adaptability
subscale was found to contribute to a decrease in interpersonal quality of life. It may be that
adaptability, which was considered to be within the normal range at baseline, could lead to
THE ROLE OF PROTECTIVE FACTORS 77
complicated interpersonal relationships when it increases. These are important areas to examine
for further study.
It is important to note that findings from path analyses indicated that protective factors
can be influenced by the outcome variables. For instance, the total burden measure and the
financial and leisure subscales contributed to a decrease in the total adaptability and cohesion
measure. The total burden measure and the routine subscale were also found to contribute to a
decrease in adaptability. Consequently, burden appears to affect families’ social context and
functioning. In addition, path analyses showed that quality of life and in particular, the
intrapsychic component, had a positive effect on hope. There may be a bidirectional association
between quality of life and hope. Findings also revealed that negative symptoms had a negative
effect on family members’ hope for their loved ones future. Negative symptoms are often
considered to be the most difficult to manage due to the severe consequences these can have on
individuals’ functioning (Rabinowitz et al., 2012), therefore families may experience challenges
in their level of hope when these symptoms increase.
Findings from the second phase of the study revealed salient themes that further
enhanced our quantitative results by providing insight into family member and consumer
perceptions of protective factors. For instance, hope was viewed as a wish or expectation for
favorable outcomes regarding the illness. In addition, consumers expressed how hope was
supported through their interpersonal family relationships. Hope has been conceptualized as a
multidimensional construct that includes positive perceptions for the future and is seen as an
internal resource that is developed and fostered through interpersonal relationships (Miller &
Powers, 1988; Russinova, 1999). Findings from interviews with consumers illustrated the
importance of family hope as it gave consumers the motivation to have hope in their own future.
THE ROLE OF PROTECTIVE FACTORS 78
It is also important to note that the promising findings for hope as a protective factor for
consumers in our quantitative results refer to family level of hope, suggesting that family
members’ hope has potential for influencing consumer outcomes. Furthermore, similar to other
studies, hope had a strong connection to participants’ spirituality (Bland & Darlington, 2002;
Kirkpatrick, Landeen, Woodside, & Byrne, 2001). Hope seemed to originate and was sustained
by religious/spiritual beliefs and practices particularly when participants felt that their hope was
diminishing.
Similar to other studies (Zauszniewski et al., 2010), that have examined Latinos as
caregivers (Koerner, Shirai, & Pedroza, 2013) our study found that religion/spirituality was a
dominant protective factor for family members and consumers (Guarnaccia et al., 1992). The
salience of religion/spirituality was evident in how participants expressed themselves, as it was
common for them to mention God when describing their coping and wellbeing. Participants’
religious/spiritual beliefs helped them nurture their faith and contributed to hope that was critical
to their experience as family caregivers and consumers. In addition, our findings concur with
other studies, which have found that spirituality helped frame consumers’ illness experience and
gave meaning to their lives (Kirkpatrick et al., 2001). The meaning making component of
spirituality is what sustained participants’ in the everyday challenges they may experience with
the illness.
Family environment, especially as it related to family involvement and support, was
another critical theme that emerged. Family members came together to support consumers with
tangible needs such as medication compliance as well as emotional support. However, some
families continued to experience difficulties in their caregiving as a result of consumers’ illness.
It was especially challenging for families whose loved ones had substance abuse issues. Studies
THE ROLE OF PROTECTIVE FACTORS 79
have found a high prevalence of substance abuse among individuals with schizophrenia (Swartz
et al., 2006), with a recent study indicating that those with serious mental illness experience a 4-5
times greater likelihood of substance abuse when compared to the general population (Hartz et
al., 2014). Furthermore, a study examining substance abuse among Latinos with schizophrenia
found that 23% of the sample experienced substance abuse (Jiménez-Castro et al., 2010). These
findings highlight the importance of further study to examine this issue among Latino families
and consumers.
One of our most salient findings had to do with the impact knowledge of the illness had
on family members and consumers. Overwhelmingly family members expressed that knowledge
gained from the intervention helped them to understand their loved ones experience and
ultimately benefited their interpersonal family relationships. Knowledge was viewed as a
resource and protective factor that helped families understand the illness and led to less criticism
and improved family warmth. Our quantitative findings supported the positive outcomes
regarding criticism and warmth. Furthermore, families reported family interpersonal
relationships as the most important outcome of treatment for consumers; therefore, it appears that
the intervention addressed the most salient issue for families.
Knowledge of the illness helped families to deal with the negative perceptions regarding
illness causation that may have previously led to stigma. A recent study comparing family
members who had participated in a family based group to those who had not received this
intervention, found that those in the family based group were less likely to endorse stigma as a
barrier to treatment (Marquez & Ramírez García, 2013) suggesting that psychoeducation can
pose benefits for stigma reduction. Families in our study also found that knowledge of the
illness made it easier to disclose about their loved ones illness. Although family members and
THE ROLE OF PROTECTIVE FACTORS 80
consumers did not view stigma as a deterrent for treatment, consumers had misgivings about
disclosure to others outside of their family due to potential negative reactions. Issues with
disclosure revealed the challenges that stigma may impose on consumer’s sense of self and
quality of life. A study found a relationship between self-stigma, self-esteem, hope, and quality
of life, with self-esteem mediating the relationship between self-stigma and quality of life while
hope partially mediated this relationship (Mashiach-Eizenberg, Hasson-Ohayon, Yanos, Lysaker,
& Roe, 2013). Given the promising role of hope in quality of life for consumers in our study,
future research should consider how hope could be augmented in treatment as a way of
decreasing self-stigma.
Overall, families were seen as a resource among consumers who valued the support that
was provided to them and particularly how the intervention was able to strengthen family
relationships through increased knowledge. Family psychoeducation studies have found that
knowledge of the illness can be a form of problem focus coping that may lead to improved
functioning for families and consumers (Dixon et al., 2011). It appears that knowledge led to
greater insight and feelings of self-efficacy and empowerment, which resulted in concrete
changes that improved coping among families in our study. In addition, family members
believed that treatment compliance was another important outcome for consumers, and through
their knowledge of the illness, they were better able to facilitate this process for consumers.
While family relationships were also important outcome for consumers, the majority saw
employment as an indication of their ongoing recovery. Employment has been recognized as a
desired component of rehabilitation among individuals with schizophrenia (Bond, Drake, &
Becker, 2008; Provencher, Gregg, Mead, & Mueser, 2002; Schennach, Musil, Möller, & Riedel,
THE ROLE OF PROTECTIVE FACTORS 81
2012). Consumers in our study strived to reach this objective while also maintaining a holistic
view of wellbeing that incorporated internal and external sources of support.
Implications and Future Directions
Findings from our study have several important implications for research and practice
with Latino families and consumers. First, as seen in our study, protective factors, show promise
for influencing outcomes for family members and consumers. Hope and family environment
indicated promising results in our quantitative and qualitative findings while warmth and low
criticism/acceptance contributed to indirect treatment effects for consumers. Furthermore, our
qualitative findings revealed that knowledge of the illness could serve as a protective factor for
family and consumer outcomes. While there are some studies that have included protective
factors among family members (Bland & Darlington, 2002; Zauszniewski et al., 2010) and
consumers (Kirkpatrick et al., 2001), most are conceptual and few have included low
acculturated Latino samples. Further research could enhance our conceptual understanding and
provide empirical evidence of these protective processes within a sociocultural framework.
Given that low acculturated families tend to have stronger cultural protective resources,
additional research could help us learn how these resources are sustained within family systems,
with the goal of incorporating these findings into treatment with Latinos and other
underrepresented groups. In addition, given the importance of hope, religion/spirituality, and
family involvement in the lives of these families, it is essential for treatment providers to
incorporate these protective factors in their work with Latino families and consumers (Barrio,
2000).
Second, it is important to examine how consumers’ substance abuse issues can further
contribute to burden for family members. Because dual diagnosis can be a challenge for many
THE ROLE OF PROTECTIVE FACTORS 82
consumers, it is necessary that future studies incorporate this issue when examining families,
particularly due to the stigma that may be associated with substance abuse as seen in our
qualitative findings. Third, future studies incorporating the FACES-II measure may consider
examining family types categorically as it may provide further insight regarding quality of life
components like interpersonal relationships for consumers. As seen in our study, there may be a
negative relationship between adaptability and consumer interpersonal relationships that may be
best examined with a larger sample that may allow for more variability in family types. Fourth,
our sample was comprised of individuals who had been living with the illness for several years
and were generally clinically stable. Therefore, it gave us the opportunity to learn about what
was important to these families and consumers as well as the challenges they continued to
experience. Future studies should consider examining differences in protective factors and
coping during other stages of the illness.
Fifth, our findings further illustrate the critical function that family psychoeducation has
as a treatment component for individuals with schizophrenia and the family members who
support them. Despite evidence indicating the benefits of psychoeducation, there is little
information on the critical elements or processes that lead to positive outcomes (Cohen et al.,
2008). Such information is necessary because it could facilitate changes to intervention models
and may lead to better implementation in community mental health settings (Cohen et al., 2008).
Our study findings contribute to the growing knowledge regarding cultural adaptation and
implementation of evidence-based treatment among underserved groups (Cabassa & Baumann,
2013). It is important to note that the CFIMA was implemented in an urban public mental health
setting with participants who had limited years of formal education. Nevertheless, family
members were able to come away from the intervention with an increase in knowledge of the
THE ROLE OF PROTECTIVE FACTORS 83
illness. It speaks to the value of cultural adaptation and to the interventions’ cultural exchange
framework that incorporated assessment to gain an understanding of participants’ needs and
accommodated to these needs by seeking continual feedback.
Furthermore, the intervention successfully engaged participants as seen in the high
retention rate (93%) at post-study indicating promise for the feasibility of the CFIMA. It is
important to note that the CFIMA is an intervention development study and as such, our findings
will provide additional data that will help to specify the ingredients and techniques that are most
relevant to families (Barrio & Yamada, 2010; Carroll & Nuro, 2002). A study examining
perspectives on family psychoeducation implementation found that Latino family members and
consumers believed that it was important for families to be part of an environment where they
could trust providers and feel welcomed as this would lead to family engagement in treatment
(Hackethal et al., 2013). Although, one of the goals of family psychoeducation is to increase
knowledge of the illness, so that families can better provide care and support to consumers
(McFarlane, 2002), providing information is not always enough because a failure to provide the
information in a culturally congruent manner may be counterproductive (Telles et al., 1995).
Taken together, our findings suggest that the CFIMA supported cultural beliefs and practices that
overwhelmingly benefitted participants’ relationships and showed promise for other critical
outcomes including burden, quality of life, and general psychopathology.
Limitations
There were limitations to our study that should be considered when examining our
results. In particular, the modest sample size and probable ceiling effects for some of the
protective factors may have affected our ability to detect statistically significant effects for the
quantitative findings. In addition, the expressed emotion measure examining warmth and
THE ROLE OF PROTECTIVE FACTORS 84
criticism had a limited number of items that may have contributed to the low internal consistency
for this measure. However, our use of mixed methods augmented our study findings and
provided insight to better understand family member and consumer perspectives on the
intervention, protective factors, and outcomes. Furthermore, obtaining family member and
consumer perspectives can be seen as a strength in our study because it allowed us to gain a more
comprehensive view of the family system and particularly the dyadic family relationship.
Moreover, our qualitative findings gave us the opportunity to learn about the long-term effects of
the intervention, which few studies have examined, and provided insight into what participants
consider as the most salient components. Finally, because our sample is primarily composed of
Spanish-speaking families of Mexican origin, findings may not be generalizable to other Latino
groups. However, the data come from a public mental health setting, thereby providing real-
world relevance that may be transferable to other racial and ethnic groups.
Conclusion
We expect that this study’s findings will provide future direction for our work and
enhancement of the CFIMA. Findings can contribute to our knowledge of the influence of
culturally based psychoeducation interventions on salient protective factors for Latino consumers
with schizophrenia and their families. By addressing this gap in knowledge, we can optimize the
benefits of culturally based family psychoeducation interventions and further develop evidence-
based treatments for Latino consumers with schizophrenia and their family members, an
underserved and underresearched group.
THE ROLE OF PROTECTIVE FACTORS 85
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APPENDIX B: Interview Guide Domains*
Current Functioning
Intervention
Protective Factors (Hope, Family, Religion/Spirituality)
Mental Illness
Treatment
Stigma
Service Utilization
*Questions are available upon request from author
Abstract (if available)
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Hernandez, Mercedes
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The role of protective factors on outcomes for Latinos with schizophrenia
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serious mental illness