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Social support and functional outcome in severe mental illness: The mediating role of proactive coping
Psychiatry Research 215 (2014) 39–45
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Social support and functional outcome in severe mental illness: The mediating role of proactive coping Lisa Davis n, John Brekke University of Southern California, School of Social Work, Montgomery Ross Fisher Building, Los Angeles, CA 90089-0411, United States
art ic l e i nf o
a b s t r a c t
Article history: Received 25 October 2012 Received in revised form 9 July 2013 Accepted 7 September 2013 Available online 7 October 2013
Individuals with Severe Mental Illness (SMI) are faced with wide-spread social and occupational impairment, yet some are able to achieve a meaningful degree of functional improvement. A structural model based on Proactive Coping Theory was developed and tested in a longitudinal context to better understand: (1) the impact of proactive processes on functioning for people with SMI, and (2) the stability of the theoretical framework over time for this population. A latent path analysis examining social support, positive reappraisal, intrinsic motivation, and role functioning was tested with 148 severely mentally ill individuals receiving psychosocial rehabilitation treatment at baseline. An observed path analysis of the model was examined at six months post-baseline with 102 people. The baseline model displayed an excellent fit to the data and accounted for 54% of the variance in role functioning. Results at time 2 also suggest the empirical promise and potential longitudinal viability of the model. In line with Proactive Coping Theory and a social resources model of coping, social support may facilitate proactive coping processes to enhance role functioning, and these processes may be stable over time for people with SMI. & 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Schizophrenia Severe mental illness Social support Functional outcome Proactive coping
1. Introduction Even with advances in psychosocial rehabilitation, up to twothirds of individuals with Severe Mental Illness (SMI) lack community participation and have difficulty maintaining basic social roles such as spouse, parent, or employee (Bellack et al., 2007). However, increasing evidence suggests some may persist in goal-striving (Corrigan and Phelan, 2004; Roe et al., 2006), developing a sense of agency and self-efficacy (Mueser et al., 2002; Onken et al., 2007; Ridgway, 2001), and making significant gains in social and occupational functioning (Kurzban et al., 2010). This evidence indicates the course of illness and outcomes associated with disorders, such as schizophrenia, are heterogeneous and can improve (e.g., Davidson, 2003; Hopper et al., 2007), and a central way in which individuals with SMI may influence such improvements is through coping processes. While previous conceptualizations of coping have narrowly focused on circumventing or reducing the negative impact of stressful events, few investigations have examined proactive coping as a means of facing the complex challenges posed by SMI. Proactive coping represents an integration of positive reappraisal processes and motivational elements that re-contextualize coping to include goal-management rather than focusing solely on risk-management
n
Corresponding author. Tel.: þ 1 213 740 2711; fax: þ 1 213 821 2088. E-mail address: [email protected] (L. Davis).
0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.psychres.2013.09.010
(Schwarzer and Taubert, 2002; Sohl and Moyer, 2009). A greater understanding of the proactive coping construct may shed light on mechanisms associated with functional improvements for a population with significant deficits in this area (Bellack et al., 2007). A primary aim of this study is to examine a theoretically based model of proactive coping, including antecedents to proactive coping and pathways from proactive coping to enhanced role functioning, for people with SMI. This investigation also explores whether the structural model under study is viable over time for this population. Theoretical developments from the behavioral sciences have broadened knowledge of coping processes that promote resilience in the face of acute and chronically stressful situations. Proactive Coping Theory (Schwarzer and Taubert, 2002) extends the scope of the coping construct to include active engagement in meaningmaking processes and a future-oriented focus on initiating change that draws from motivation theory (Parker et al., 2010). A proactive coping orientation involves positively reappraising demanding or stressful situations as having value based on their perceived potential to promote growth (Folkman, 1997), an appraisal process that gives rise to intrinsically motivated goal-striving (Schwarzer and Taubert, 2002). Intrinsic motivation has been defined as goaldirected behavior based on internally-driven rewards related to interest, meaning, and purpose (Ryan and Deci, 2000). The proactive coping construct is well illustrated by Greenglass et al. (2005) in a study in which older adults in a rehabilitation hospital viewed rehabilitation as a challenge to be mastered, a perception
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related to higher levels of motivation and improved functional outcomes, namely distance walked during rehabilitation exercises. Proactive coping has also been shown to predict functional independence among the elderly (Greenglass et al., 2006), selfcare among individuals with diabetes (Thoolen et al., 2009), and improved work performance and self-efficacy among non-clinical populations (Greenglass et al., 2006; Greenglass & Fiksenbaum, 2009; Sohl and Moyer, 2009). Proactive coping may have substantial significance for understanding improvements in the course of SMI, yet only a single study to date has investigated this construct with a psychiatric population (Yanos, 2001). Yanos (2001) found that a larger number of proactive strategies were associated with greater social functioning among people with SMI. This study also aims to investigate antecedents to proactive coping. Social-psychological frameworks, such as a social resources model of coping (Moos and Holahan, 2003), posit that coping does not occur in a vacuum; rather social processes such as receiving caring, esteem, and assistance in meeting tangible and psychological needs contribute to enhanced coping abilities (Sarason et al., 1985). A social resources model of coping also suggests that social support exerts an indirect influence on functioning via adaptive coping (Moos and Holahan, 2003). In support of this framework, Greenglass et al. (2006) found the relationship between social support and functional ability was mediated through proactive coping among the elderly. Investigations of a social resources model among people with SMI remain sparse, however, Hultman et al. (1997) found that greater levels of social integration among people with schizophrenia were related to lower re-hospitalization rates, and that this relationship was mediated through approach coping. The present study seeks to build on these investigations by: (1) broadening the coping paradigm applied to SMI by including motivational elements as suggested by Proactive Coping Theory (Schwarzer and Taubert, 2002), (2) examining the role of social support as a coping resource for people with SMI, and (3) exploring whether the relationships under study remained stable over time by investigating the model at baseline and at six months post-baseline. In order to achieve these aims a structural model was developed (see Fig. 1). As suggested by a social resources model of
coping (Moos and Holahan, 2003), the model depicts social support as an antecedent to proactive coping processes (i.e., positive reappraisal and intrinsic motivation). Central to the model is the notion that positively reappraising stressful circumstances as potential opportunities for growth gives rise to intrinsic motivation, a theoretically proposed process underlying Proactive Coping Theory (Schwarzer and Taubert, 2002). Proactive Coping Theory also posits that these processes enhance functioning, therefore pathways from positive reappraisal to role functioning and intrinsic motivation to role functioning, were hypothesized. Lastly, based on a social resources model of coping (Moos and Holahan, 2003), it was hypothesized that the relationship between social support and functioning would be mediated through proactive coping (i.e., positive reappraisal and intrinsic motivation). Fig. 1 represents the latent structural model with hypothesized associations among all paths; hypothesized associations are the same for the path model at time two. 2. Material and methods 2.1. Subjects The present analyses used data from a study examining mechanisms of functional rehabilitative change in community-based service settings for individuals diagnosed with a severe mental illness. The parent study employed a prospective follow-along design of patients who were living in the community and who were being admitted to one of four community-based psychosocial rehabilitation programs in Los Angeles County that were participating in a countywide assertive community treatment initiative (Young et al., 1998). The sample was drawn from consecutive admissions of individuals meeting the following inclusion criteria: (i) diagnosed with a serious mental illness (i.e. schizophrenia, schizoaffective, schizophreniform disorder, bi-polar disorder, major depression with psychotic features); (ii) residence in Los Angeles for at least three months; (iii) age between 18 and 55. Subjects were excluded if they met criteria for alcohol or drug dependence in the prior six months, or had an identifiable neurological disorder. Rehabilitation services included monitoring of psychotropic medications, on-site training and rehabilitative experiences to supported work, and social and living opportunities in the community. The baseline sample consisted of 148 individuals; 44% were diagnosed with schizophrenia, 16% with schizoaffective disorder, 23% with bipolar disorder with psychotic features, and 17% with major depression with psychotic features. A total
Fig. 1. Hypothesized structural model based on a social-resources proactive coping paradigm. Paths where a positive association was predicted are represented with a plus sign (þ ) and the hypothesized mediation effect is represented with a dotted line.
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Table 1 Baseline sample characteristics (N ¼148). Variables Demographics Mean age in years (18–57) Mean years education Race/ethnicity African–american Latino White Asian Other Marital Status Married Gender Male Observed Variables Social Support Emotional/info Tangible Affection Positive social interaction Positive reappraisal Positive reappraisal item 1 Positive reappraisal item 2 Positive reappraisal item 3 Positive reappraisal item 4 Positive reappraisal item 5 Positive reappraisal item 6 Intrinsic motivation Purpose Motivation Curiosity Role functioning Work productivity Independent living skills Family functioning Social functioning
%/mean
39 (S.D. ¼10.0) 12 (S.D. ¼5.7) 50.9% 12.6% 25.8% 4.4% 6.3% 9% 62%
30.46 (S.D.¼ 9.77) 9.63 (S.D.¼ 3.50) 10.10 (S.D.¼ 4.04) 9.94 (S.D.¼ 3.73) 2.72 2.61 2.57 2.24 2.82 2.45
(S.D. ¼ 1.09) (S.D.¼1.14) (S.D.¼1.19) (S.D.¼ 1.18) (S.D.¼ 1.05) (S.D.¼ 1.16)
3.16 (S.D. ¼1.70) 3.04 (S.D. ¼1.70) 2.82 (S.D.¼ 1.88) 1.95 (S.D. ¼1.66) 3.27 (S.D. ¼ 1.58) 3.38 (S.D.¼ 1.86) 3.29 (S.D.¼ 1.89)
of 115 individuals were retained in the study at time two. Out of the time 2 sample 13 individuals had insufficient data on the main variables under study and were dropped from the analyses (N¼ 102). Analyses examining differences between the baseline sample and individuals measured at time 2 indicate there were no significant differences in the demographic profile of the samples (e.g., age, gender and ethnic make-up). Additionally, results from t-tests indicated that there were no significant differences between diagnostic groups (those diagnosed in the schizophrenia spectrum and those diagnosed with bipolar disorder or major depression with psychotic features) at baseline or at time 2 with regard to levels of social support, positive reappraisal, intrinsic motivation, role functioning, symptom severity or insight into illness. A combination of structured clinical interviews conducted by trained mental health professionals and self-report surveys were used to collect these data. The data were gathered in a face-to-face interview format. Baseline sample characteristics are presented in Table 1. The average length of time on medication among the sample was 13 years (S.D.¼ 9.50). Overall, psychiatric symptom severity (as measured by the Brief Psychiatric Rating Scale; Ventura et al., 1993) was in the mild range (mean¼ 43.73, S.D. ¼12.34; possible range: 24–168). Forty-one percent of the sample was taking atypical antipsychotic medications (e.g., risperidone and quetiapine), 20% were taking mood stabilizers (e.g., divalproex sodium and lithium citrate), 5% were taking typical antipsychotic medications (e.g., chlorpromazine and fluphenazine), and the remaining individuals were taking anti-depressant and/or anti-anxiety medications (e.g., fluoxetine and bupropion) or did not provide information regarding medication usage.
2.2. Instruments 2.2.1. Social support Indicators representing the latent construct of social support were derived from the Medical Outcomes Study (MOS) Social Support Survey, a 19-item self-report survey measuring perceived availability of emotional support, tangible support, affection, and positive social interaction (Sherbourne and Stewart, 1991). Items for each of the four subscales were summed and each sub-scale score was used to represent an indicator of the social support latent variable. The MOS has demonstrated high internal consistency, and previous evidence supports its four-factor structure (Gjesfjeld et al., 2008). The subscale alphas for the current study range from 0.71 to 0.93; the total scale alpha is 0.95 for the present sample.
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2.2.2. Positive reappraisal Positive reappraisal was measured using a subscale derived from The Coping Response Inventory-Adult Form (CRI; Moos, 1993), a 48-item self-report survey evaluating eight types of copings. The positive reappraisal subscale measures the degree to which respondents cognitively reframe a stressful situation to see it in a positive light (CRI; Moos, 1993). Each of the sub-scale's six items were used as indicators of the positive reappraisal latent variable. The CRI has demonstrated good convergent validity and moderate internal consistency (Moos, 1993). The total scale alpha for the present sample is 0.80 and the alpha for the positive reappraisal sub-scale is 0.85. 2.2.3. Intrinsic motivation Intrinsic motivation was assessed based on ratings developed from the Quality of Life Scale (QLS; Heinrichs, 1984). The QLS is a semi-structured interview conducted by a trained assessor to evaluate internal processes such as curiosity, purpose, and motivation to seek new challenges. The interviewer uses data gathered from open-ended probes to create a single score for three separate domains of intrinsic motivation (curiosity, purpose, and motivation). Recent evidence suggests that these three items load together on a single-factor with acceptable internal consistency (Nakagami et al., 2008). The alpha for the present sample is 0.83. 2.2.4. Role functioning The Role Functioning Scale represents a measure of four functional domains for people with SMI: work, social functioning, family functioning, and independent living skills (RFS; Goodman et al., 1993). Data gathered in a face-to-face interview is used to provide anchored descriptions of the quality and quantity of community functioning in each of these four domains. A single score is determined for each domain. The RFS has been shown to have good inter-item and test-retest reliability (Goodman et al., 1993) and previous evidence suggests that all items load on a single factor (Brekke et al., 2005). 2.2.5. Covariates Participants were asked to report their age, race/ethnicity, and gender as part of a face-to-face demographic interview conducted during the baseline assessment battery. Ethnicity was dichotomized into White and Non-White. The age of respondents is a continuous variable. Awareness of mental illness was measured using a composite score based on the Scale of Unawareness of Mental Disorder (SUMD; Amador et al., 1993). Higher scores on the SUMD indicate lower levels of awareness. The scale has demonstrated good inter-item and test-retest reliability (Amador et al., 1994); the alpha for the present sample is 0.70. 2.3. Statistical analyses To examine associations between the variables of interest and evaluate the mediating role of positive reappraisal and intrinsic motivation, path analyses were conducted at baseline and at six months post-baseline using Mplus statistical software (Version 5.2; Muthén & Muthén, 1998–2007). Power to detect statistical significance of the baseline model was examined using R statistical software based on the hypothesis-testing framework for Root-Mean-Square Error of Approximation (RMSEA; MacCallum et al., 1996). With α ¼0.05, null hypothesis RMSEA of 0.00 and alternative hypothesis RMSEA of 0.05, and the degrees of freedom for the model ranging from 125 to 145 (depending on the size of the final model), the range of statistical power for a sample size of 148 is between 0.80 to 0.86. With sufficient statistical power, latent path modeling was used at baseline to facilitate simultaneous evaluation of psychometric properties of scales, relationships among the constructs in the structural model, and measures of model fit. Given the limited statistical power at time 2 (N ¼ 102), we used an observed path model at this time point to serve as a preliminary test of theory in a longitudinal context. The use of latent variables at baseline required a two-step analytic strategy (Anderson and Gerbing, 1988). First, an adequate factor structure for measurement models was confirmed. Factor loadings for each observed indicator as well as a number of statistical fit indices for measurement models were examined. Indications of acceptable model fit are considered to be a chi-square statistic that is nonsignificant (P40.05), a CFI value equal to or above 0.95, and an RMSEA value equal to or below 0.06 (Kline, 2004). After satisfactory measurement models were established individually, all latent variables were allowed to freely correlate to determine model fit for the overall measurement model at baseline. The second step of the analysis at baseline provided verification of the latent structural model. A model with all hypothesized structural paths left free to vary was specified. Next, covariates were added to the model one at a time to test their association with specific variables of interest based on a review of relevant literature. An association between ethnicity and positive reappraisal was tested based on evidence suggesting this coping mechanism is more efficacious among ethnic minorities than non-minorities (Helgeson et al., 2006) and an association between gender and social support was tested based on evidence suggesting social support has a differential impact on functioning for men and women (Hafner, 2003). Also, an association between age and role functioning and age and intrinsic
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motivation was tested based on evidence that aging leads to declines in these areas (Fucetola et al., 2000; Kooij et al., 2008). Finally, associations between awareness of mental illness and each of the latent variables was tested based on evidence that it impacts a wide range of psychosocial functioning domains (Amador et al., 1993; Olfson et al., 2006). For the model at time 2, composite scores were used to test the same structural model configured at baseline; model specification and testing of covariates were conducted in the manner described above. Significant paths between covariates and variables of interest were retained in the final model at each time point. Fullinformation maximum likelihood (FIML) estimation of parameters was conducted using raw data as input (less than 7% of values missing). Direct and indirect effects and their standard errors were estimated, and the Sobel (1982) test was used to determine the significance of the indirect effect. Sobel's method calculates the significance of the mediated effect by dividing the mediated effect estimate by its standard error, which is derived from Sobel's formula. This method allows for formal significance testing of the indirect effect (MacKinnon et al., 2002).
3. Results 3.1. Confirmatory factor analyses Each of the latent constructs at baseline produced an excellent fit to the data (see Table 2 for overall measurement model fit indices; (Kline, 2004)). Factor loadings for each latent construct also indicated that the items loaded well onto their respective constructs (see Fig. 2; Bagozzi and Yi, 1988). 3.2. Structural model at baseline Given the excellent results in the measurement model at baseline, the structural model was tested to examine relationships among the latent constructs. The final baseline model possesses excellent model fit statistics (see Table 2), suggesting that empirical data did not significantly deviate from the theorized model. The model accounts for 19% of the variance in positive reappraisal, 20% of the variance in intrinsic motivation, and 54% of the variance in role functioning. All of the standardized path coefficients are shown in Fig. 2; paths represented by dotted lines are nonsignificant. As hypothesized, there were several significant direct effects among the variables of interest at baseline (see Fig. 2). Social support was positively associated with positive reappraisal, indicating that individuals with higher levels of perceived social support more frequently engaged in positive reappraisal. Positive reappraisal was positively associated with intrinsic motivation, suggesting that participants who more frequently engaged in positive reappraisal showed higher levels of intrinsic motivation, and higher levels of intrinsic motivation were in turn associated with higher role functioning performance. Age was negatively associated with intrinsic motivation, as was unawareness of mental illness. Higher scores on the SUMD indicate poorer awareness (Amador et al., 1993); therefore, individuals with lower levels of awareness (i.e., higher scores) demonstrated lower levels of intrinsic motivation. In addition to direct effects, there was a significant indirect effect between social support and role functioning as hypothesized. The significant indirect effect estimate indicates the relationship between social support and role functioning was mediated through positive reappraisal and intrinsic motivation (indirect effect estimate¼ 0.08, Table 2 Goodness-of-fit indices for tested models.
P¼ 0.03). Evidence showing the original relationship between social support and role functioning, with all other paths in the model constrained to zero, changed from significant (β¼0.27, P¼0.03) to non-significant in the presence of the mediators (β¼ 0.19, P¼ 0.13), further supported the robustness of the mediation findings (Baron and Kenny , 1986). These results suggest that social support exerts an indirect influence on functional performance through the mechanisms of positively reframing stressors and intrinsically motivated goal striving. To further substantiate the hypothesized sequence of variables in the model, we tested a ‘reverse’ mediation model (Baron and Kenny , 1986). A model testing positive reappraisal and intrinsic motivation as potential mediators with role functioning predicting social support indicated that positive reappraisal and intrinsic motivation were not significant mediators. The absence of a mediated effect in the alternative model was evidenced by a lack of significant paths among all direct effects in the model [i.e., role functioning to positive reappraisal (P¼0.40), positive reappraisal to intrinsic motivation (P¼0.08), and intrinsic motivation to social support (P¼0.53).] Relationships among social support and intrinsic motivation, and positive reappraisal and role functioning were not significant as originally proposed. Further investigation revealed that these non-significant paths represented additional mediated effects in the model; the relationship between social support and intrinsic motivation was mediated through positive reappraisal (indirect estimate¼ 0.10, P ¼0.03) and the relationship between positive reappraisal and role functioning was mediated through intrinsic motivation (indirect estimate¼0.18, P ¼0.02). The potential implications of these findings are discussed below. 3.3. Structural model at time 2 The structural model at six months post-baseline also demonstrated excellent model fit statistics (see Table 2), suggesting that empirical data did not significantly deviate from the theory under study over time. The model at time 2 accounts for 10% of the variance in positive reappraisal, 24% of the variance in intrinsic motivation, and 43% of the variance in role functioning. All of the standardized path coefficients at time 2 are shown in Fig. 3; paths represented by dotted lines are non-significant. As with the baseline model, the model at time 2 demonstrates a positive relationship between social support and positive reappraisal and a positive relationship between intrinsic motivation and role functioning. However, the relationship between positive reappraisal and intrinsic motivation did not reach statistical significance at time 2 and the lack of this direct path precluded a possible mediation effect between social support and role functioning. The relationship between social support and role functioning was also not significant, not due to a mediation effect as evidenced at time 1. Lastly, in contrast to the baseline model, there was a positive relationship between social support and intrinsic motivation at time two. Unawareness of mental illness was the only covariate with a significant association at time 2; congruent with the baseline model it was negatively related to motivation indicating that individuals with lower levels of awareness (i.e., higher scores on the SUMD; Amador et al., 1993) demonstrated lower levels of intrinsic motivation.
4. Discussion
Model
χ2
d.f.
P
CFI
TLI
RMSEA
Baseline measurement Baseline structural Time 2 structural
138.44 183.19 2.23
112 142 2
0.05 0.01 0.33
0.97 0.96 0.99
0.96 0.95 0.99
0.04 0.04 0.03
This study applied Proactive Coping Theory (Schwarzer and Taubert, 2002) along with a social resources model of coping (Moos and Holahan, 2003) to examine relationships among social support, proactive coping processes, and functional outcomes in a longitudinal context for people with SMI. Findings from this study
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Fig. 2. Final baseline model (N¼ 148) with standardized path coefficients based on a social-resources proactive coping paradigm. Dotted lines represent non-significant paths (P40.05). *Po 0.05, **P o0.01.
Fig. 3. Final model at time 2 (N ¼ 102) with standardized path coefficients based on a social-resources proactive coping paradigm. Dotted lines represent non-significant paths (P40.05). *Po 0.05, **P o0.01.
support a general theoretical model in which social support and proactive coping may contribute to enhanced role functioning for a population with significant functional impairment (Bellack et al., 2007). Unlike the majority of studies, which examine coping as a means of ameliorating the impact of stressful events, the present investigation argues the role of coping be broadened to include intrinsically motivated goal-striving arising from viewing stressors as a potential vehicle for growth among people with SMI. Preliminary results supporting the temporal dimension of the theorized model also suggest relationships among proactive coping processes and functional outcomes may be stable over time for this population. These findings support further longitudinal inquiry into proactive processes, which may ultimately help inform interventions aimed at empowering individuals to progress from reacting and adapting to stress to proactively meeting challenges associated with SMI and improving the course of their illness.
Results suggest that social support from others represents an important coping resource that may promote proactive coping, which in turn mediates enhanced functioning for people with SMI. The present study, one of the few to test a social resources model of coping with an SMI population, indicates that social support may improve role functioning by way of influencing the stress appraisal process and in turn increasing motivation. Though the model at time 2 did not replicate the main mediation effect, possibly due to sample size and related statistical power considerations, findings at time 2 corroborate the strong relationship between social support and positive reappraisal found at baseline. Emotional support, information and tangible assistance from others may enable individuals with SMI to positively reframe stressors that would otherwise be perceived as overwhelming (Thoits, 1995) and view difficulties as challenges or as an opportunity for growth. The longitudinal dimension of these findings
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provides additional support for the relevance of a social resources paradigm among this population. Interventions targeting the development of social support may facilitate positively reappraising stressors, in turn increasing motivation and functioning for this population. In line with recent extensions of coping theory, the positive association between positive reappraisal and intrinsic motivation may reflect key aspects of Proactive Coping Theory (Schwarzer, 2001). Results from the baseline model are the first the authors are aware of to demonstrate this relationship for a severely mentally ill population. The re-interpretation of stressful situations as having value may engender intrinsic motivation as the situation is experienced as meaningful, interesting, or challenging (Parker et al., 2010). Individuals with SMI who engage more frequently in positive reappraisal may also sustain motivation and goal striving because they are able to regulate emotional distress and re-engage in goal pursuits in spite of set-backs and disappointments (Deci and Ryan, 2000; Deci et al., 1994). This notion is supported by investigations demonstrating that positive reappraisal predicts reductions in psychological distress for people with schizophrenia (e.g., Henry et al., 2008) as well as studies demonstrating the efficacy of positive reappraisal training in reducing distress for various clinical populations (e.g., Beck, 1997; Butler et al., 2006). Related investigations show that coping strategy enhancement, a component of some forms of cognitive behavioral therapy for psychosis, decreases psychotic symptoms (Tarrier et al., 1998), reduces stress, and lowers the risk of relapse for people with SMI (Andres et al., 2003). Results from this study build on these investigations and point toward the potential for coping interventions targeting cognitive appraisals to enhance motivation, an area found to be low for people with SMI (Velligan et al., 2006) and a significant factor in functional impairment (Medalia & Brekke, 2010). Importantly though, the lack of a significant association between positive reappraisal and motivation at time 2 indicates longitudinal replication of this relationship with larger samples is needed to substantiate the impact of stress appraisal processes on motivation over time. Findings also suggest that age and insight into illness are important factors affecting mechanisms underlying proactive coping for this population. Baseline results indicating motivation may decline with age highlight the importance of bolstering coping skills and motivation early in the course of illness for people with SMI. Poorer awareness of mental illness was also associated with lower levels of intrinsic motivation at baseline and time 2; a finding consistent with others who have found that low levels of insight and awareness of illness are related to nonadherence with antipsychotic medication and reduced efficacy of psychological interventions (e.g., Olfson et al., 2006). It is interesting to note that Lysaker et al. (2007) found the relationship between insight and coping processes among people with SMI is a complicated one. Individuals with SMI demonstrating high levels of insight but low levels of hope were more likely to use avoidant coping methods while higher levels of both insight and hope were associated with active coping strategies. These findings suggest the meanings individuals attach to having a mental illness which may moderate the way in which awareness impacts coping (Lysaker et al., 2007). Future studies examining insight and its impact on coping may further investigate potential moderators such as hope, self-stigma, self-esteem and other self-appraisals. As previously mentioned, evidence from the baseline model suggests that the relationship between social support and intrinsic motivation was mediated through positive reappraisal, and the relationship between positive reappraisal and role functioning was mediated through intrinsic motivation. These findings may suggest that social environments providing supportive feedback increase intrinsic motivation through the mechanism of reappraisal, and that
positive reappraisal may improve functioning by way of increasing motivation. While these notions are in line with Proactive Coping Theory (Schwarzer, 2001) and motivation theories (Deci and Ryan, 2000), inferences drawn from these additional mediated effects must be viewed with caution since they were not originally hypothesized. The significant association between social support and motivation a time 2 (not evidenced at baseline) may reflect a lack of statistical power to achieve the mediated relationships described above at baseline. Future studies with multiple time points and sufficient statistical power at each time point are needed to substantiate theorized change processes proposed here. Despite the potential clinical and theoretical utility of the present model, this study has several limitations. First, since the sample used for this investigation represents individuals participating in psychosocial rehabilitation, a potential confound is the impact of social interactions and support gained through treatment. Our longitudinal findings suggest that the model holds promise over time even during the receipt of rehabilitation services. Along these lines, these data do not contain information distinguishing positive aspects of social relationships from negative ones, such as social undermining (Bertera, 2005), that may affect associations among the constructs under study. Second, given previous evidence indicating that cognitively-based deficits intersect with motivational processes in schizophrenia (Barch and Dowd, 2010), future investigations examining the way in which neurocognitive functioning may influence the model under study are needed to gain further understanding of a biopsychosocial model of coping with SMI. Third, though these analyses provide an exploratory view of whether relationships among the constructs are stable over a six-month period, further investigation of these relationships over a longer period with similar samples is needed to establish the ordering of the variables and theoretical processes described here. Lastly, a non-probability sample may limit the degree to which these findings may be generalized. Results from this study extend and build upon knowledge related to effective coping for individuals with SMI. Aspects of coping that go beyond reacting to immediate stressors include actively negotiating appraisals to be less negative and seeking new challenges, an area of coping that has largely been neglected (Roe et al., 2006). The coping model outlined here suggests that social support may assist in cognitively framing the positive significance of events, in turn increasing intrinsically motivated goal striving and the fulfillment of important social roles for a highly marginalized population.
Acknowledgments Support for this study has been provided by NIMH grant R01 MH 53282 awarded to Dr. John Brekke. The NIMH had no further role in study design, analysis and interpretation of the data, the writing of the report, or the decision to submit the manuscript for publication. The authors would like to thank Mr. Mark Morales and Mr. Bob Aisley who kindly assisted in the collection of these data. References Amador, X., Flaum, M., Andreasen, N., and Strauss, D., Awareness of illness in schizophrenia and schizoaffective and mood disorders, Archives of General Psychiatry 51(10), 1994, 826–836. Amador, X., Strauss, D.,Yale, S., Flaum, M., Endicott, J. Gorman, J., Assessment of insight in psychosis, American Journal of Psychiatry 150, 1993, 873. Anderson, J., Gerbing, W., 1988. Structural equation modeling in practice: a review and recommended two-step program. Psychological Bulletin 103, 411–423. Andres, K., Pfammatter, M., Fries, A., Brenner, H., 2003. The significance of coping as a therapeutic variable for the outcome of psychological therapy in schizophrenia. European Psychiatry 18, 149–154.
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Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Social support and functional outcome in severe mental illness: The mediating role of proactive coping Lisa Davis n, John Brekke University of Southern California, School of Social Work, Montgomery Ross Fisher Building, Los Angeles, CA 90089-0411, United States
art ic l e i nf o
a b s t r a c t
Article history: Received 25 October 2012 Received in revised form 9 July 2013 Accepted 7 September 2013 Available online 7 October 2013
Individuals with Severe Mental Illness (SMI) are faced with wide-spread social and occupational impairment, yet some are able to achieve a meaningful degree of functional improvement. A structural model based on Proactive Coping Theory was developed and tested in a longitudinal context to better understand: (1) the impact of proactive processes on functioning for people with SMI, and (2) the stability of the theoretical framework over time for this population. A latent path analysis examining social support, positive reappraisal, intrinsic motivation, and role functioning was tested with 148 severely mentally ill individuals receiving psychosocial rehabilitation treatment at baseline. An observed path analysis of the model was examined at six months post-baseline with 102 people. The baseline model displayed an excellent fit to the data and accounted for 54% of the variance in role functioning. Results at time 2 also suggest the empirical promise and potential longitudinal viability of the model. In line with Proactive Coping Theory and a social resources model of coping, social support may facilitate proactive coping processes to enhance role functioning, and these processes may be stable over time for people with SMI. & 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Schizophrenia Severe mental illness Social support Functional outcome Proactive coping
1. Introduction Even with advances in psychosocial rehabilitation, up to twothirds of individuals with Severe Mental Illness (SMI) lack community participation and have difficulty maintaining basic social roles such as spouse, parent, or employee (Bellack et al., 2007). However, increasing evidence suggests some may persist in goal-striving (Corrigan and Phelan, 2004; Roe et al., 2006), developing a sense of agency and self-efficacy (Mueser et al., 2002; Onken et al., 2007; Ridgway, 2001), and making significant gains in social and occupational functioning (Kurzban et al., 2010). This evidence indicates the course of illness and outcomes associated with disorders, such as schizophrenia, are heterogeneous and can improve (e.g., Davidson, 2003; Hopper et al., 2007), and a central way in which individuals with SMI may influence such improvements is through coping processes. While previous conceptualizations of coping have narrowly focused on circumventing or reducing the negative impact of stressful events, few investigations have examined proactive coping as a means of facing the complex challenges posed by SMI. Proactive coping represents an integration of positive reappraisal processes and motivational elements that re-contextualize coping to include goal-management rather than focusing solely on risk-management
n
Corresponding author. Tel.: þ 1 213 740 2711; fax: þ 1 213 821 2088. E-mail address: [email protected] (L. Davis).
0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.psychres.2013.09.010
(Schwarzer and Taubert, 2002; Sohl and Moyer, 2009). A greater understanding of the proactive coping construct may shed light on mechanisms associated with functional improvements for a population with significant deficits in this area (Bellack et al., 2007). A primary aim of this study is to examine a theoretically based model of proactive coping, including antecedents to proactive coping and pathways from proactive coping to enhanced role functioning, for people with SMI. This investigation also explores whether the structural model under study is viable over time for this population. Theoretical developments from the behavioral sciences have broadened knowledge of coping processes that promote resilience in the face of acute and chronically stressful situations. Proactive Coping Theory (Schwarzer and Taubert, 2002) extends the scope of the coping construct to include active engagement in meaningmaking processes and a future-oriented focus on initiating change that draws from motivation theory (Parker et al., 2010). A proactive coping orientation involves positively reappraising demanding or stressful situations as having value based on their perceived potential to promote growth (Folkman, 1997), an appraisal process that gives rise to intrinsically motivated goal-striving (Schwarzer and Taubert, 2002). Intrinsic motivation has been defined as goaldirected behavior based on internally-driven rewards related to interest, meaning, and purpose (Ryan and Deci, 2000). The proactive coping construct is well illustrated by Greenglass et al. (2005) in a study in which older adults in a rehabilitation hospital viewed rehabilitation as a challenge to be mastered, a perception
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related to higher levels of motivation and improved functional outcomes, namely distance walked during rehabilitation exercises. Proactive coping has also been shown to predict functional independence among the elderly (Greenglass et al., 2006), selfcare among individuals with diabetes (Thoolen et al., 2009), and improved work performance and self-efficacy among non-clinical populations (Greenglass et al., 2006; Greenglass & Fiksenbaum, 2009; Sohl and Moyer, 2009). Proactive coping may have substantial significance for understanding improvements in the course of SMI, yet only a single study to date has investigated this construct with a psychiatric population (Yanos, 2001). Yanos (2001) found that a larger number of proactive strategies were associated with greater social functioning among people with SMI. This study also aims to investigate antecedents to proactive coping. Social-psychological frameworks, such as a social resources model of coping (Moos and Holahan, 2003), posit that coping does not occur in a vacuum; rather social processes such as receiving caring, esteem, and assistance in meeting tangible and psychological needs contribute to enhanced coping abilities (Sarason et al., 1985). A social resources model of coping also suggests that social support exerts an indirect influence on functioning via adaptive coping (Moos and Holahan, 2003). In support of this framework, Greenglass et al. (2006) found the relationship between social support and functional ability was mediated through proactive coping among the elderly. Investigations of a social resources model among people with SMI remain sparse, however, Hultman et al. (1997) found that greater levels of social integration among people with schizophrenia were related to lower re-hospitalization rates, and that this relationship was mediated through approach coping. The present study seeks to build on these investigations by: (1) broadening the coping paradigm applied to SMI by including motivational elements as suggested by Proactive Coping Theory (Schwarzer and Taubert, 2002), (2) examining the role of social support as a coping resource for people with SMI, and (3) exploring whether the relationships under study remained stable over time by investigating the model at baseline and at six months post-baseline. In order to achieve these aims a structural model was developed (see Fig. 1). As suggested by a social resources model of
coping (Moos and Holahan, 2003), the model depicts social support as an antecedent to proactive coping processes (i.e., positive reappraisal and intrinsic motivation). Central to the model is the notion that positively reappraising stressful circumstances as potential opportunities for growth gives rise to intrinsic motivation, a theoretically proposed process underlying Proactive Coping Theory (Schwarzer and Taubert, 2002). Proactive Coping Theory also posits that these processes enhance functioning, therefore pathways from positive reappraisal to role functioning and intrinsic motivation to role functioning, were hypothesized. Lastly, based on a social resources model of coping (Moos and Holahan, 2003), it was hypothesized that the relationship between social support and functioning would be mediated through proactive coping (i.e., positive reappraisal and intrinsic motivation). Fig. 1 represents the latent structural model with hypothesized associations among all paths; hypothesized associations are the same for the path model at time two. 2. Material and methods 2.1. Subjects The present analyses used data from a study examining mechanisms of functional rehabilitative change in community-based service settings for individuals diagnosed with a severe mental illness. The parent study employed a prospective follow-along design of patients who were living in the community and who were being admitted to one of four community-based psychosocial rehabilitation programs in Los Angeles County that were participating in a countywide assertive community treatment initiative (Young et al., 1998). The sample was drawn from consecutive admissions of individuals meeting the following inclusion criteria: (i) diagnosed with a serious mental illness (i.e. schizophrenia, schizoaffective, schizophreniform disorder, bi-polar disorder, major depression with psychotic features); (ii) residence in Los Angeles for at least three months; (iii) age between 18 and 55. Subjects were excluded if they met criteria for alcohol or drug dependence in the prior six months, or had an identifiable neurological disorder. Rehabilitation services included monitoring of psychotropic medications, on-site training and rehabilitative experiences to supported work, and social and living opportunities in the community. The baseline sample consisted of 148 individuals; 44% were diagnosed with schizophrenia, 16% with schizoaffective disorder, 23% with bipolar disorder with psychotic features, and 17% with major depression with psychotic features. A total
Fig. 1. Hypothesized structural model based on a social-resources proactive coping paradigm. Paths where a positive association was predicted are represented with a plus sign (þ ) and the hypothesized mediation effect is represented with a dotted line.
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Table 1 Baseline sample characteristics (N ¼148). Variables Demographics Mean age in years (18–57) Mean years education Race/ethnicity African–american Latino White Asian Other Marital Status Married Gender Male Observed Variables Social Support Emotional/info Tangible Affection Positive social interaction Positive reappraisal Positive reappraisal item 1 Positive reappraisal item 2 Positive reappraisal item 3 Positive reappraisal item 4 Positive reappraisal item 5 Positive reappraisal item 6 Intrinsic motivation Purpose Motivation Curiosity Role functioning Work productivity Independent living skills Family functioning Social functioning
%/mean
39 (S.D. ¼10.0) 12 (S.D. ¼5.7) 50.9% 12.6% 25.8% 4.4% 6.3% 9% 62%
30.46 (S.D.¼ 9.77) 9.63 (S.D.¼ 3.50) 10.10 (S.D.¼ 4.04) 9.94 (S.D.¼ 3.73) 2.72 2.61 2.57 2.24 2.82 2.45
(S.D. ¼ 1.09) (S.D.¼1.14) (S.D.¼1.19) (S.D.¼ 1.18) (S.D.¼ 1.05) (S.D.¼ 1.16)
3.16 (S.D. ¼1.70) 3.04 (S.D. ¼1.70) 2.82 (S.D.¼ 1.88) 1.95 (S.D. ¼1.66) 3.27 (S.D. ¼ 1.58) 3.38 (S.D.¼ 1.86) 3.29 (S.D.¼ 1.89)
of 115 individuals were retained in the study at time two. Out of the time 2 sample 13 individuals had insufficient data on the main variables under study and were dropped from the analyses (N¼ 102). Analyses examining differences between the baseline sample and individuals measured at time 2 indicate there were no significant differences in the demographic profile of the samples (e.g., age, gender and ethnic make-up). Additionally, results from t-tests indicated that there were no significant differences between diagnostic groups (those diagnosed in the schizophrenia spectrum and those diagnosed with bipolar disorder or major depression with psychotic features) at baseline or at time 2 with regard to levels of social support, positive reappraisal, intrinsic motivation, role functioning, symptom severity or insight into illness. A combination of structured clinical interviews conducted by trained mental health professionals and self-report surveys were used to collect these data. The data were gathered in a face-to-face interview format. Baseline sample characteristics are presented in Table 1. The average length of time on medication among the sample was 13 years (S.D.¼ 9.50). Overall, psychiatric symptom severity (as measured by the Brief Psychiatric Rating Scale; Ventura et al., 1993) was in the mild range (mean¼ 43.73, S.D. ¼12.34; possible range: 24–168). Forty-one percent of the sample was taking atypical antipsychotic medications (e.g., risperidone and quetiapine), 20% were taking mood stabilizers (e.g., divalproex sodium and lithium citrate), 5% were taking typical antipsychotic medications (e.g., chlorpromazine and fluphenazine), and the remaining individuals were taking anti-depressant and/or anti-anxiety medications (e.g., fluoxetine and bupropion) or did not provide information regarding medication usage.
2.2. Instruments 2.2.1. Social support Indicators representing the latent construct of social support were derived from the Medical Outcomes Study (MOS) Social Support Survey, a 19-item self-report survey measuring perceived availability of emotional support, tangible support, affection, and positive social interaction (Sherbourne and Stewart, 1991). Items for each of the four subscales were summed and each sub-scale score was used to represent an indicator of the social support latent variable. The MOS has demonstrated high internal consistency, and previous evidence supports its four-factor structure (Gjesfjeld et al., 2008). The subscale alphas for the current study range from 0.71 to 0.93; the total scale alpha is 0.95 for the present sample.
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2.2.2. Positive reappraisal Positive reappraisal was measured using a subscale derived from The Coping Response Inventory-Adult Form (CRI; Moos, 1993), a 48-item self-report survey evaluating eight types of copings. The positive reappraisal subscale measures the degree to which respondents cognitively reframe a stressful situation to see it in a positive light (CRI; Moos, 1993). Each of the sub-scale's six items were used as indicators of the positive reappraisal latent variable. The CRI has demonstrated good convergent validity and moderate internal consistency (Moos, 1993). The total scale alpha for the present sample is 0.80 and the alpha for the positive reappraisal sub-scale is 0.85. 2.2.3. Intrinsic motivation Intrinsic motivation was assessed based on ratings developed from the Quality of Life Scale (QLS; Heinrichs, 1984). The QLS is a semi-structured interview conducted by a trained assessor to evaluate internal processes such as curiosity, purpose, and motivation to seek new challenges. The interviewer uses data gathered from open-ended probes to create a single score for three separate domains of intrinsic motivation (curiosity, purpose, and motivation). Recent evidence suggests that these three items load together on a single-factor with acceptable internal consistency (Nakagami et al., 2008). The alpha for the present sample is 0.83. 2.2.4. Role functioning The Role Functioning Scale represents a measure of four functional domains for people with SMI: work, social functioning, family functioning, and independent living skills (RFS; Goodman et al., 1993). Data gathered in a face-to-face interview is used to provide anchored descriptions of the quality and quantity of community functioning in each of these four domains. A single score is determined for each domain. The RFS has been shown to have good inter-item and test-retest reliability (Goodman et al., 1993) and previous evidence suggests that all items load on a single factor (Brekke et al., 2005). 2.2.5. Covariates Participants were asked to report their age, race/ethnicity, and gender as part of a face-to-face demographic interview conducted during the baseline assessment battery. Ethnicity was dichotomized into White and Non-White. The age of respondents is a continuous variable. Awareness of mental illness was measured using a composite score based on the Scale of Unawareness of Mental Disorder (SUMD; Amador et al., 1993). Higher scores on the SUMD indicate lower levels of awareness. The scale has demonstrated good inter-item and test-retest reliability (Amador et al., 1994); the alpha for the present sample is 0.70. 2.3. Statistical analyses To examine associations between the variables of interest and evaluate the mediating role of positive reappraisal and intrinsic motivation, path analyses were conducted at baseline and at six months post-baseline using Mplus statistical software (Version 5.2; Muthén & Muthén, 1998–2007). Power to detect statistical significance of the baseline model was examined using R statistical software based on the hypothesis-testing framework for Root-Mean-Square Error of Approximation (RMSEA; MacCallum et al., 1996). With α ¼0.05, null hypothesis RMSEA of 0.00 and alternative hypothesis RMSEA of 0.05, and the degrees of freedom for the model ranging from 125 to 145 (depending on the size of the final model), the range of statistical power for a sample size of 148 is between 0.80 to 0.86. With sufficient statistical power, latent path modeling was used at baseline to facilitate simultaneous evaluation of psychometric properties of scales, relationships among the constructs in the structural model, and measures of model fit. Given the limited statistical power at time 2 (N ¼ 102), we used an observed path model at this time point to serve as a preliminary test of theory in a longitudinal context. The use of latent variables at baseline required a two-step analytic strategy (Anderson and Gerbing, 1988). First, an adequate factor structure for measurement models was confirmed. Factor loadings for each observed indicator as well as a number of statistical fit indices for measurement models were examined. Indications of acceptable model fit are considered to be a chi-square statistic that is nonsignificant (P40.05), a CFI value equal to or above 0.95, and an RMSEA value equal to or below 0.06 (Kline, 2004). After satisfactory measurement models were established individually, all latent variables were allowed to freely correlate to determine model fit for the overall measurement model at baseline. The second step of the analysis at baseline provided verification of the latent structural model. A model with all hypothesized structural paths left free to vary was specified. Next, covariates were added to the model one at a time to test their association with specific variables of interest based on a review of relevant literature. An association between ethnicity and positive reappraisal was tested based on evidence suggesting this coping mechanism is more efficacious among ethnic minorities than non-minorities (Helgeson et al., 2006) and an association between gender and social support was tested based on evidence suggesting social support has a differential impact on functioning for men and women (Hafner, 2003). Also, an association between age and role functioning and age and intrinsic
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motivation was tested based on evidence that aging leads to declines in these areas (Fucetola et al., 2000; Kooij et al., 2008). Finally, associations between awareness of mental illness and each of the latent variables was tested based on evidence that it impacts a wide range of psychosocial functioning domains (Amador et al., 1993; Olfson et al., 2006). For the model at time 2, composite scores were used to test the same structural model configured at baseline; model specification and testing of covariates were conducted in the manner described above. Significant paths between covariates and variables of interest were retained in the final model at each time point. Fullinformation maximum likelihood (FIML) estimation of parameters was conducted using raw data as input (less than 7% of values missing). Direct and indirect effects and their standard errors were estimated, and the Sobel (1982) test was used to determine the significance of the indirect effect. Sobel's method calculates the significance of the mediated effect by dividing the mediated effect estimate by its standard error, which is derived from Sobel's formula. This method allows for formal significance testing of the indirect effect (MacKinnon et al., 2002).
3. Results 3.1. Confirmatory factor analyses Each of the latent constructs at baseline produced an excellent fit to the data (see Table 2 for overall measurement model fit indices; (Kline, 2004)). Factor loadings for each latent construct also indicated that the items loaded well onto their respective constructs (see Fig. 2; Bagozzi and Yi, 1988). 3.2. Structural model at baseline Given the excellent results in the measurement model at baseline, the structural model was tested to examine relationships among the latent constructs. The final baseline model possesses excellent model fit statistics (see Table 2), suggesting that empirical data did not significantly deviate from the theorized model. The model accounts for 19% of the variance in positive reappraisal, 20% of the variance in intrinsic motivation, and 54% of the variance in role functioning. All of the standardized path coefficients are shown in Fig. 2; paths represented by dotted lines are nonsignificant. As hypothesized, there were several significant direct effects among the variables of interest at baseline (see Fig. 2). Social support was positively associated with positive reappraisal, indicating that individuals with higher levels of perceived social support more frequently engaged in positive reappraisal. Positive reappraisal was positively associated with intrinsic motivation, suggesting that participants who more frequently engaged in positive reappraisal showed higher levels of intrinsic motivation, and higher levels of intrinsic motivation were in turn associated with higher role functioning performance. Age was negatively associated with intrinsic motivation, as was unawareness of mental illness. Higher scores on the SUMD indicate poorer awareness (Amador et al., 1993); therefore, individuals with lower levels of awareness (i.e., higher scores) demonstrated lower levels of intrinsic motivation. In addition to direct effects, there was a significant indirect effect between social support and role functioning as hypothesized. The significant indirect effect estimate indicates the relationship between social support and role functioning was mediated through positive reappraisal and intrinsic motivation (indirect effect estimate¼ 0.08, Table 2 Goodness-of-fit indices for tested models.
P¼ 0.03). Evidence showing the original relationship between social support and role functioning, with all other paths in the model constrained to zero, changed from significant (β¼0.27, P¼0.03) to non-significant in the presence of the mediators (β¼ 0.19, P¼ 0.13), further supported the robustness of the mediation findings (Baron and Kenny , 1986). These results suggest that social support exerts an indirect influence on functional performance through the mechanisms of positively reframing stressors and intrinsically motivated goal striving. To further substantiate the hypothesized sequence of variables in the model, we tested a ‘reverse’ mediation model (Baron and Kenny , 1986). A model testing positive reappraisal and intrinsic motivation as potential mediators with role functioning predicting social support indicated that positive reappraisal and intrinsic motivation were not significant mediators. The absence of a mediated effect in the alternative model was evidenced by a lack of significant paths among all direct effects in the model [i.e., role functioning to positive reappraisal (P¼0.40), positive reappraisal to intrinsic motivation (P¼0.08), and intrinsic motivation to social support (P¼0.53).] Relationships among social support and intrinsic motivation, and positive reappraisal and role functioning were not significant as originally proposed. Further investigation revealed that these non-significant paths represented additional mediated effects in the model; the relationship between social support and intrinsic motivation was mediated through positive reappraisal (indirect estimate¼ 0.10, P ¼0.03) and the relationship between positive reappraisal and role functioning was mediated through intrinsic motivation (indirect estimate¼0.18, P ¼0.02). The potential implications of these findings are discussed below. 3.3. Structural model at time 2 The structural model at six months post-baseline also demonstrated excellent model fit statistics (see Table 2), suggesting that empirical data did not significantly deviate from the theory under study over time. The model at time 2 accounts for 10% of the variance in positive reappraisal, 24% of the variance in intrinsic motivation, and 43% of the variance in role functioning. All of the standardized path coefficients at time 2 are shown in Fig. 3; paths represented by dotted lines are non-significant. As with the baseline model, the model at time 2 demonstrates a positive relationship between social support and positive reappraisal and a positive relationship between intrinsic motivation and role functioning. However, the relationship between positive reappraisal and intrinsic motivation did not reach statistical significance at time 2 and the lack of this direct path precluded a possible mediation effect between social support and role functioning. The relationship between social support and role functioning was also not significant, not due to a mediation effect as evidenced at time 1. Lastly, in contrast to the baseline model, there was a positive relationship between social support and intrinsic motivation at time two. Unawareness of mental illness was the only covariate with a significant association at time 2; congruent with the baseline model it was negatively related to motivation indicating that individuals with lower levels of awareness (i.e., higher scores on the SUMD; Amador et al., 1993) demonstrated lower levels of intrinsic motivation.
4. Discussion
Model
χ2
d.f.
P
CFI
TLI
RMSEA
Baseline measurement Baseline structural Time 2 structural
138.44 183.19 2.23
112 142 2
0.05 0.01 0.33
0.97 0.96 0.99
0.96 0.95 0.99
0.04 0.04 0.03
This study applied Proactive Coping Theory (Schwarzer and Taubert, 2002) along with a social resources model of coping (Moos and Holahan, 2003) to examine relationships among social support, proactive coping processes, and functional outcomes in a longitudinal context for people with SMI. Findings from this study
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Fig. 2. Final baseline model (N¼ 148) with standardized path coefficients based on a social-resources proactive coping paradigm. Dotted lines represent non-significant paths (P40.05). *Po 0.05, **P o0.01.
Fig. 3. Final model at time 2 (N ¼ 102) with standardized path coefficients based on a social-resources proactive coping paradigm. Dotted lines represent non-significant paths (P40.05). *Po 0.05, **P o0.01.
support a general theoretical model in which social support and proactive coping may contribute to enhanced role functioning for a population with significant functional impairment (Bellack et al., 2007). Unlike the majority of studies, which examine coping as a means of ameliorating the impact of stressful events, the present investigation argues the role of coping be broadened to include intrinsically motivated goal-striving arising from viewing stressors as a potential vehicle for growth among people with SMI. Preliminary results supporting the temporal dimension of the theorized model also suggest relationships among proactive coping processes and functional outcomes may be stable over time for this population. These findings support further longitudinal inquiry into proactive processes, which may ultimately help inform interventions aimed at empowering individuals to progress from reacting and adapting to stress to proactively meeting challenges associated with SMI and improving the course of their illness.
Results suggest that social support from others represents an important coping resource that may promote proactive coping, which in turn mediates enhanced functioning for people with SMI. The present study, one of the few to test a social resources model of coping with an SMI population, indicates that social support may improve role functioning by way of influencing the stress appraisal process and in turn increasing motivation. Though the model at time 2 did not replicate the main mediation effect, possibly due to sample size and related statistical power considerations, findings at time 2 corroborate the strong relationship between social support and positive reappraisal found at baseline. Emotional support, information and tangible assistance from others may enable individuals with SMI to positively reframe stressors that would otherwise be perceived as overwhelming (Thoits, 1995) and view difficulties as challenges or as an opportunity for growth. The longitudinal dimension of these findings
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provides additional support for the relevance of a social resources paradigm among this population. Interventions targeting the development of social support may facilitate positively reappraising stressors, in turn increasing motivation and functioning for this population. In line with recent extensions of coping theory, the positive association between positive reappraisal and intrinsic motivation may reflect key aspects of Proactive Coping Theory (Schwarzer, 2001). Results from the baseline model are the first the authors are aware of to demonstrate this relationship for a severely mentally ill population. The re-interpretation of stressful situations as having value may engender intrinsic motivation as the situation is experienced as meaningful, interesting, or challenging (Parker et al., 2010). Individuals with SMI who engage more frequently in positive reappraisal may also sustain motivation and goal striving because they are able to regulate emotional distress and re-engage in goal pursuits in spite of set-backs and disappointments (Deci and Ryan, 2000; Deci et al., 1994). This notion is supported by investigations demonstrating that positive reappraisal predicts reductions in psychological distress for people with schizophrenia (e.g., Henry et al., 2008) as well as studies demonstrating the efficacy of positive reappraisal training in reducing distress for various clinical populations (e.g., Beck, 1997; Butler et al., 2006). Related investigations show that coping strategy enhancement, a component of some forms of cognitive behavioral therapy for psychosis, decreases psychotic symptoms (Tarrier et al., 1998), reduces stress, and lowers the risk of relapse for people with SMI (Andres et al., 2003). Results from this study build on these investigations and point toward the potential for coping interventions targeting cognitive appraisals to enhance motivation, an area found to be low for people with SMI (Velligan et al., 2006) and a significant factor in functional impairment (Medalia & Brekke, 2010). Importantly though, the lack of a significant association between positive reappraisal and motivation at time 2 indicates longitudinal replication of this relationship with larger samples is needed to substantiate the impact of stress appraisal processes on motivation over time. Findings also suggest that age and insight into illness are important factors affecting mechanisms underlying proactive coping for this population. Baseline results indicating motivation may decline with age highlight the importance of bolstering coping skills and motivation early in the course of illness for people with SMI. Poorer awareness of mental illness was also associated with lower levels of intrinsic motivation at baseline and time 2; a finding consistent with others who have found that low levels of insight and awareness of illness are related to nonadherence with antipsychotic medication and reduced efficacy of psychological interventions (e.g., Olfson et al., 2006). It is interesting to note that Lysaker et al. (2007) found the relationship between insight and coping processes among people with SMI is a complicated one. Individuals with SMI demonstrating high levels of insight but low levels of hope were more likely to use avoidant coping methods while higher levels of both insight and hope were associated with active coping strategies. These findings suggest the meanings individuals attach to having a mental illness which may moderate the way in which awareness impacts coping (Lysaker et al., 2007). Future studies examining insight and its impact on coping may further investigate potential moderators such as hope, self-stigma, self-esteem and other self-appraisals. As previously mentioned, evidence from the baseline model suggests that the relationship between social support and intrinsic motivation was mediated through positive reappraisal, and the relationship between positive reappraisal and role functioning was mediated through intrinsic motivation. These findings may suggest that social environments providing supportive feedback increase intrinsic motivation through the mechanism of reappraisal, and that
positive reappraisal may improve functioning by way of increasing motivation. While these notions are in line with Proactive Coping Theory (Schwarzer, 2001) and motivation theories (Deci and Ryan, 2000), inferences drawn from these additional mediated effects must be viewed with caution since they were not originally hypothesized. The significant association between social support and motivation a time 2 (not evidenced at baseline) may reflect a lack of statistical power to achieve the mediated relationships described above at baseline. Future studies with multiple time points and sufficient statistical power at each time point are needed to substantiate theorized change processes proposed here. Despite the potential clinical and theoretical utility of the present model, this study has several limitations. First, since the sample used for this investigation represents individuals participating in psychosocial rehabilitation, a potential confound is the impact of social interactions and support gained through treatment. Our longitudinal findings suggest that the model holds promise over time even during the receipt of rehabilitation services. Along these lines, these data do not contain information distinguishing positive aspects of social relationships from negative ones, such as social undermining (Bertera, 2005), that may affect associations among the constructs under study. Second, given previous evidence indicating that cognitively-based deficits intersect with motivational processes in schizophrenia (Barch and Dowd, 2010), future investigations examining the way in which neurocognitive functioning may influence the model under study are needed to gain further understanding of a biopsychosocial model of coping with SMI. Third, though these analyses provide an exploratory view of whether relationships among the constructs are stable over a six-month period, further investigation of these relationships over a longer period with similar samples is needed to establish the ordering of the variables and theoretical processes described here. Lastly, a non-probability sample may limit the degree to which these findings may be generalized. Results from this study extend and build upon knowledge related to effective coping for individuals with SMI. Aspects of coping that go beyond reacting to immediate stressors include actively negotiating appraisals to be less negative and seeking new challenges, an area of coping that has largely been neglected (Roe et al., 2006). The coping model outlined here suggests that social support may assist in cognitively framing the positive significance of events, in turn increasing intrinsically motivated goal striving and the fulfillment of important social roles for a highly marginalized population.
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