Iris Manor Binyamini*
Department of Special Education, Faculty of Education, University of Haifa, Haifa, Israel
Received date: November 11, 2015; Accepted date: January 11, 2016; Published date: January 20, 2016
Citation: Binyamini IM. The Relationship between Bedouin Mothers' Appraisal of their Child's Schizophrenia, their Expressed Emotions and their Coping Strategies. Acta Psychopathol. 2016, 2:2. doi: 10.4172/2469-6676.100028
Background: The way mothers in the Bedouin communities cope with the stress of caring for a child with schizophrenia merits investigation.
Aim: This study examined the relationships between Bedouin mothers' appraisal of their child's schizophrenia, their expressed emotions and their strategies for coping with the illness.
Method: Sixty Bedouin mothers of children with schizophrenia completed questionnaires regarding demographic variables, incident appraisal, measure of expressed emotion, and their coping strategies.
Results: Illness appraised as a loss correlated positively and significantly with high levels of expressed emotions, but illness appraised as a challenge did not. Expressed emotions correlated negatively and significantly with use of problemfocused coping strategies, but not with emotion-focused coping strategies, and illness appraised as a challenge correlated significantly and positively with emotion-focused coping strategies.
Conclusion: The study provides preliminary evidence regarding the relationship between Bedouin mothers' appraisal of their child's schizophrenia, their expressed emotions and their choice of coping strategies.
Bedouin; Mothers; Appraisal of their child's schizophrenia; Expressed emotions; Coping strategies
A Severe mental disorder such as the schizophrenia of a child in the family is a state of chronic stress on all family members. This is a situation of continual crises, which harms not only the child suffering from schizophrenia, but the entire family system as well . The child's caregiver, in particular, may feel a great deal of distress due to the many roles involved in caring for the child, since schizophrenia is characterized by many ups and downs, times of deterioration and then remissions, which are not always predictable . To date, limited research has been conducted regarding the coping strategies of family members of people suffering from mental illness  and even less research has been conducted among populations of a non-Western culture, such as the Bedouin community in Israel.
The Bedouin community in Israel has unique characteristics. This is a traditional tribal, patriarchal society, with norms such as having a large number of children, marriages between blood relatives, living among clans of the extended family, and polygamous marriages. Additionally, this community is characterized by a low socioeconomic background, since half of the population is living in recognized settlements, while the other half lives in scattered dwellings without even basic living conditions . According to Lazarus and Folkman , choosing a strategy for coping with stressful situations is influenced by the person's appraisal of the event. This, in turn, is influenced by the appraiser’s and other family members’ personality characteristics, and in a community with traditional characteristics, the appraisal of the event is probably influenced also by the community.
In addition to the appraisal of the event, this study examined the mothers’ measure of expressed emotions (EE), which is a global measure that include five components: emotional over involvement, critical comments, hostility, positive remarks and warmth. Studies that examined the relationship between the EE ratings and the coping strategies of family members found that the EE ratings were influenced by the family members' appraisal of the situation as stressful, disturbing, uncontrollable or as resulting from the illness . A continuous illness like schizophrenia, which is the focus of the current study, creates a state of chronic stress, which requires coping processes for the purposes of adjustment  both for the person with the illness and for the surrounding family. This study is the first to examine the relationship between Bedouin mothers’ appraisal of an adult child’s schizophrenia, their EE, and their coping strategies.
The sample included 60 mothers of adult children with schizophrenia who were receiving treatment at a mental health centre that caters to the Bedouin community. The average age of mothers was 52.5 (range 35-70) years; about half of the mothers had never had any formal education (49%) and the rest had received either a primary school education (41%), or a high school education (10%). More than half (66%) did not work, most were married (92%), and others (8%) were widows. Some of the married women (35%) were in a polygamous marriage and more than half (of the married women of the study population) (60%) reported that they were married to relatives. The average number of children they had was 7. Most of the mothers lived in recognized settlements (towns) (69%) and the rest of the mothers reported living in unrecognized, scattered Bedouin villages (31%). Regarding the gender of the child with the illness, boys were the majority (72%) and the rest were girls (28%). The onset of the child's illness had occurred between6 months and3 years before the mothers completed the questionnaires (M=2.6, S.D=0.88), and the number of the child's hospitalizations in the past year ranged from 1 to 4.
The criteria for choosing the mothers for participation were: mothers who can read and write, so that they could fill out the questionnaires, mothers who agreed to participate in the study and sign the informed consent form, mothers whose husbands or heads of the family or tribe expressed his consent for their participation in the study.
With regard to the sample size, an appeal was made to every Bedouin mother whose child received treatment in the mental health care center in the Bedouin community in the course of 2014; the sample included all mothers who a) met the participation criteria for the study b) filled out the questionnaires and returned them. 73 questionnaires were handed out, 60 were filled out and returned, and those 60 were included in the sample.
This study used four research questionnaires; all the questionnaires were translated into Arabic by two Arabic-speaking interpreters for the purposes of this study. The translations were then submitted for appraisal to an external judge – a doctoral candidate studying the Arabic language, who selected the more accurate of the two versions.
The questionnaire gathered information regarding the mother’s age, education, and employment, and marital status, number of children and place of residence. Information collected about the adolescent’s child with schizophrenia included gender, the number of years of illness and the number of hospitalizations in the past year.
The questionnaire is abbreviated of Folkman and Lazarus . The original questionnaire consists of three dimensions of the initial appraisal: appraisal of loss, threat appraisal and appraisal of the challenge of the situation. Each of three dimensions has 12 items, with an internal reliability between α=0.79 and 0.89 . For the purposes of this study, the threat appraisal dimension was entirely removed, and the remaining two dimensions, appraising the illness as a loss and as a challenge, respectively, were shortened to 8 items each. Appraisal of the illness as a loss required participants to assess the degree of impact the child's illness had on different areas of their lives. Appraisal of the illness as a challenge required participants to assess the degree to which they could envision positive change occurring in various areas of their lives in the wake of the child's illness. Items are presented on a 5-point Likert scale, where choosing 1 –‘not at all’, represents a low rating for the listed item, whereas choosing 5 –‘to a great extent’, represents a high rating for the listed item. In the present study, the reliability was α=0.81 for the loss items, and α=0.87 for the challenge items.
The questionnaire is an abbreviated version of the Carver, Scheier and Weintraub's coping strategies questionnaire . The abbreviated version used in this study includes 28 items that measure 15 coping strategies: active coping, positive view and personal growth, planning, emotional support, instrumental support, suppression of competing activities, acceptance of the situation, behavioural dissociation, emotional release, mental dissociation, denial, restraint, turning to religion, alcohol and drug abuse and humour. The mothers were asked to rate their levels of use of each of the coping strategies in the period since the onset of the illness and throughout the time that the child spent living at home. Responses were indicated on a scale of 0-3, where 0 indicates ‘not at all’, and 3 ‘to a great extent’. The score for each strategy was based on the sum of its two items.
This questionnaire was developed by Kreisman and Joy  to examine levels of negative emotional expression . It was developed as an abbreviated measure and includes 11 short, simple statements, rated on a scale from 1 – ‘never’ to 3 – ‘many times’. After reversing the scores on items with positive statements, an average score of the ratings was calculated, with a high score representing a negative emotion related to the child with the illness. An earlier study, which examined the families of patients with schizophrenia in New York 4 and 8 months after hospitalization, the reliability of the EE scale was α=0.75, -0.84 . In the present study the reliability was α=0.87. Mean, standard deviation, reliability and domain scores of the research tools are presented in Table 1.
|Item||M||SD||α||Range of scores|
|Appraisal of the illness as a loss||2.6||0.79||0.81||1-4|
|Appraisal of the illness as a challenge||1.8||0.61||0.82||1-3.64|
|Expressed emotions rating||1.84||0.55||0.84||1-3.29|
Table 1: Mean, standard deviation, reliability and domain scores of the research tool.
Contact with the mothers was made through the mental health centre that caters to the Bedouin population. The questionnaires were completed by the mothers in the presence -- and if necessary with the assistance of -- a female graduate student of special education who is a member of the Bedouin community. The graduate student explained that participation was voluntary and that participants were free to withdraw at any time, and emphasised the anonymous nature of the study: the participants were guaranteed confidentiality and anonymity. The research questionnaires were filled over a period of approximately one year.
This study examined the relationships between Bedouin mothers' appraisal of their adult child's schizophrenia, their ratings on the EE scale and their coping strategies. The relationship between each of the dependent and independent variables was tested using the Spearman and Pearson correlation coefficients.
As shown in Table 2, a positive and significant correlation was found between the appraisal of the child's illness as a loss and the EE rating. Additionally, there was a positive relationship between the appraisal of child's illness as a challenge and emotion-focused and problem-focused coping strategies. The rating of the EE toward the child with the illness was negatively correlated with a problem-focused coping strategy.
|Appraisal of the illness as a loss||Appraisal of the illness as a loss||Emotion-focused coping||Problem-focused coping|
|Appraisal of the illness as a loss||0.10-||**0.60||0.10||0.03-|
|Appraisal of the illness as a challenge||0.05-||0.52**||0.25|
Table 2: Correlations between the research variable.
In addition, Spearman and Pearson tests were conducted to examine the relationships between the demographic variables and the research variables.
The current study sought to examine whether there is a relationship between Bedouin mothers' appraisal of their child's schizophrenia, their EE and their coping strategies.
The relationship between appraising a child's illness (as a loss or as a challenge) and EE – According to the findings of the current study, the mother's appraisal of her child's illness as a loss was positively and significantly correlated with high selfrated levels of expressed negative emotions toward the child with schizophrenia. The literature shows that parents who perceived a child's schizophrenia as a loss of the personal, familial and employment aspirations they had for the child also articulated higher levels of EE . Furthermore, the parents’ appraisal is influenced by several factors: personality characteristics – their own, other family members’ and those of the child with schizophrenia, as well as by the circumstances that characterize their particular situation. Thus, the appraisal is influenced by the personality characteristics of the family members as well as the patient himself, and by the characteristics of the situation. Therefore, when the mother associates the behavior of the sick child, such as, for example, his lack of motivation, his low responsiveness to the medication, his seclusion and solitude, behavior that she had not seen before, to the child's personality characteristics, and not to the nature of his illness, she will show a higher level of expressed emotions, because her sense of loss in this case pertains to the child she thought she knew, but no longer recognizes a mother who attributes behaviours of the child’s personality rather than to the nature of the illness, is likely to articulate higher levels of EE, because her sense of loss is for the boy she thought she knew, but no longer recognizes . In addition, studies have shown that family members who appraised the ill child’s symptoms as more disturbing, expressed more doubt regarding their own ability to cope with those symptoms and consequently tended to be more critical and hostile also had higher EE ratings .
In contrast to the results of the current study, the literature also shows evidence that the appraisal of the family member's illness as a challenge is negatively correlated with one's EE rating [6,12]. Interestingly, this finding was absent from the current study, which found no significant correlation between the appraisal of the child's illness as a challenge and the expressed negative emotions rating. For a family, raising a child with schizophrenia usually causes a crisis and creates many long-lasting pressures, as well as changes in the family's daily activities, difficulties in managing a routine, and the need to perform new and previously unknown roles and tasks . All of these make it difficult for family members to see the onset of the illness as a possibility for positive change or as a challenge. Another explanation can be found in the particular culture of the participant group in this study: At the onset of the illness, the child with schizophrenia and his family are exposed to experiences of fear and loneliness, they are vulnerable in their experience of "Me" and "Us", in their experience of rejection, sometimes shock and shame and guilt. There is a violation of both the maternal and the familial self-image. In the Bedouin community there is a negative social stigma attached to children with disabilities ; this kind of stigma exacerbates the damage. The mother, who is the primary caretaker of the child, her concern for the child's well-being along with the shame do not allow her to see the child's illness as a challenge, or an opportunity for change however, in addition to the stigmatising of the child with the illness, the child’s family is also stigmatised by association, and the family is perceived as responsible (guilty) for the nature of the ill child's symptoms, which are attributed to the family’s inability to restrain those behaviours . These cultural characteristics/ circumstances also suggest that it would be difficult for mothers who are the primary caregivers of the child with the illness to see their child's schizophrenia as an opportunity to face life’s challenges.
The relationship between EE and coping strategies – According to the findings of the current study, the mothers' EE ratings were found to be negatively and significantly correlated with the use of problem-focused coping strategies, but were not significantly correlated with the use of emotion-focused coping strategies. Evidence presented in the literature indicates that there is a relationship between the measures of expressed EE and choosing a specific coping strategy . It was found that families that reported low levels of EE were coping more effectively, and reported less psychological distress . Furthermore, in contrast to the results of the current study, the literature also shows that families that reported high levels of EE were more likely to use an emotion-focused coping strategy, and less likely to use a problem-focused coping strategy. This discrepancy between the results of the current study and those found in the literature could possibly be explained by suggesting that in his study, the EE ratings in fact reflected the mothers' attempts to cope with their child's uncontrollable behaviour. Expressions of negative emotions could serve to lessen the levels of stress created by the onset of the child's schizophrenia, a means of coping with the loss of the child they had known before the onset of the illness . In that case, emotional criticism or over-involvement could be interpreted as a maladaptive attempt to cope with a stressful situation involving the child with schizophrenia, who displays problematic behaviours or some form of dysfunction. Additionally, one study didn’t find any relationship between the EE rating and choosing a specific coping strategy  and yet another study found only a weak relationship between the two variables , due to the inclusion of an additional variable that functioned as a confounding variable, namely, the behaviour of the child with the illness. The more violent the behaviour of this child, the more likely the caregiver parents was to choose an avoidant coping strategy, regardless of the EE rating .
The relationship between appraisal and coping strategies – According to the findings of the current study, and in contrast to the models found in the literature, such as the Lazarus and Folkman model of stress and coping , the appraisal the event did not affect the mothers' choice of strategy for coping with their child's illness. This means that no significant correlation was found either between the mothers' appraisal of the incident as a challenge and their use of a problem-focused coping strategy, or between their appraisal of the incident as a loss and their use of a problem or an emotion-focused coping strategy. At the same time, there was another finding that contradicts Lazarus and Folkman's model: the current study showed that a significant and positive correlation was found between the mothers' appraisal of the illness as a challenge and the use of an emotion-focused coping strategy. A possible explanation for these differences may be provided by another variable examined in this study - the EE rating, which has shown is influenced by the mothers' appraisal of their child's schizophrenia, and consequently can be expected to affect their choice of a specific coping strategy. Studies that examined the field of mental illness found that the EE of hostility, criticism and over-involvement by family members in general and by the mother, as the primary caregiver for the ill child, in particular, constitute a significant factor that affects many variables in the family's life as well as directly affecting the child with the illness . Findings have shown that people with a mental illness who lived with families that measured high on the EE rating had 3–4 times more psychotic episodes, and were hospitalized more often than people with a mental illness who lived with families that measured low on the EE rating ; in addition, the family members experienced higher levels of burden and distress . We can therefore conclude that, unlike models such as that of Lazarus and Foklman , which address stress and coping in general, when addressing patterns of stress and coping with schizophrenia, there is another important variable, namely, the EE rating, which cannot be ignored when considering the coping strategies of families of children with schizophrenia.
When considering the coping of families of children suffering from schizophrenia, the variable of EE rating is an important/ necessary variable which cannot be ignored in the process of appraising how the family/mother is coping with the child's illness. Therefore, accordingly, the process of training specialists working with children with schizophrenia and their families in the Bedouin community should include a cultural awareness of the significant function of appraisal of the child's illness, expressed emotions and coping strategies.
The research findings suggest that schizophrenia constitutes a state of chronic stress that the mother has to cope with and adapt to. The degree of hostility and negative feelings in the family affect mother's choice of the strategy that she uses to cope with her child's illness. In addition, her way of evaluating the illness and the sick child's behavior affects the rating of her expressed emotions. Mothers who succeed in not seeing their child's illness as a disaster, and has a lower expressed emotions rating will cope in a more adaptive way, that is to say, she will choose a problem focused coping strategy, and would be able to help the child's rehabilitation, and to help the child become more independent faster, and to get better.
Today, most of the therapeutic attention is directed towards the child himself, and less towards the mothers, and yet there is an understanding that the family in general and the mothers in particular, are a very important factor in the recovery process of the child's with schizophrenia. Therefore, it is important to construct a treatment program, both on an individual level and a group level for the mothers in every therapeutic framework that treats children with schizophrenia in general and for mothers in the Bedouin community in particular. It is important that the program includes: providing information (medical, an explanation regarding the illness and the functioning of the child, as well as different methods of recovery), allowing a space for the release of emotions and providing professional support for the mothers.
In addition, it is important to provide professional training for teams working in hospitals and children's clinics treating this population, in order to raise awareness of the importance of the mother's role in treatment and recovery, and to give them tools for including and helping the mother.
Contrary to the existing literature, the current study found no relationship between a high rating of expressed emotions and emotion-focused coping. Additional studies are necessary to examine the effects of other positive factors: gratitude, a sense of coherence, personal growth, and social support , some of which have been studied among mothers of adult children with developmental disabilities. Such studies should consider whether such positive factors might serve as mediators between the expressed emotions rating and choosing a specific coping style, for mothers of children with schizophrenia in the Bedouin community.
The research process included asking both the mothers and the fathers to fill out the questionnaires, only ten fathers cooperated, so the study focused exclusively on the mothers. It is important to continue to try to examine the fathers' perceptions, especially in the Bedouin community, which is a patriarchal culture. Lastly, this study examined the perception of mothers with the onset of the child's illness, or immediately thereafter (up to 3 years). It is worth examining these concepts and relationships among mothers in the Bedouin community who have been raising a child with schizophrenia over a greater number of years.