Interpersonal loss in the context of family caregiving: Implications of communal relationships theory

Abstract

Much is known about the emotional costs of providing care to an ill or disabled family member. However, surprisingly little attention has been devoted to investigating how caregiver distress is related to interpersonal loss (i.e., reactions to changes in the typical day-to-day support behaviors that formerly characterized the caregiver–care recipient relationship). Drawing on the theory of communal relationships (e.g., Clark & Mills, 1979, 1993), this study proposes that the magnitude of interpersonal loss that caregivers experience, as well as its contributions to depressed affect, both directly and indirectly (through impact of interpersonal loss on perceived caregiving burden) are likely to depend on the type of relationship that existed between caregiver and care recipient prior to the onset of illness or disability. In this context, several hypotheses and directions for further research are proposed. It is hoped that future researchers will incorporate loss measures into their research and consider how aspects of preexisting relationships influence associations among interpersonal loss and variables (e.g., burden, social support) known to predict caregiver well-being.     

Relationship quality and potentially harmful behaviors by spousal caregivers: how we were then, how we are now. The Family Relationships in Late Life Project

Structured interview data from 142 caregivers (98 wives, 44 husbands) indicate that more depressed caregivers are more likely to treat their spouses in potentially harmful ways. However, consistent with hypotheses derived from communal relationships theory, when the preillness relationship between caregiver and care recipient was characterized by mutual responsiveness to each other's needs (i.e., was more communal), caregivers were less depressed and less frequently engaged in potentially harmful behaviors. These effects were not attributable to demographic factors, amount of care provided, care recipient dementia status, or length of time in the caregiving role. Rather, multivariate analyses suggest that the extent to which premorbid relationships were communal in nature determines whether caregivers perceive their current relationships as rewarding, which, in turn, predicts caregiver depression and potentially harmful behaviors.     

Caregiving in the close relationships of cardiac patients: Exchange,power, and attributional perspectives on caregiver resentment

Individuals with a cardiac condition and their spousal caregivers were recruited from cardiac rehabilitation centers and interviewed separately. Based on exchange theory, it was expected that greater caregiver resentment would be associated with feeling underbenefited in the relationship and with an orientation to relationships that did not focus on the needs of the partner (communal), but did focus on “tit-for-tat” reciprocity (exchange). It was also expected that those caregivers who were more likely to get their needs satisfied in the relationship before the cardiac incident would be more resentful at giving care. Finally, based on attributional theory, it was predicted that caregivers who thought that their spouses were not taking responsibility for improving their health would be more resentful. As predicted, more resentful caregivers were those who felt underbenefited, were more exchange oriented, and judged that their partners were not working toward improving their health. In addition, only those with a low communal orientation toward their spouse showed a relationship between feeling underbenefited and resentment. The needs centrality prediction was not supported. The findings illustrate the utility of applying theories developed in the close relationship area to the understanding of caregiving with chronically ill populations.     

Record keeping in two types of relationships

On the basis of a distinction between communal and exchange relationships (Clark & Mills, 1979; Mills & Clark, 1982), the following predictions were made: (a) Members of exchange relationships would keep track of individual inputs into joint tasks and (b) members of communal relationships would not. These hypotheses were tested in three studies. In each study, subjects worked on a task with a partner with whom they (a) desired or had a communal relationship or (b) desired or had an exchange relationship. The task involved locating and circling number sequences in a large matrix. Whether subjects used a pen of the same or of a different color from that used by their partner served as the dependent measure. If partners worked with pens of the same color individual inputs wee obscured. If they worked with different color pens, individual inputs were clear. Given this, if the proportion of subjects in a condition choosing different color pens was greater than 50% (chance), it was taken as evidence that subjects in that condition were trying to keep track of individual inputs. If this proportion was less than 50%, it was taken as evidence that subjects were trying to avoid keeping track of individual inputs. As predicted, in all three studies the proportion of subjects in the exchange conditions who chose a different color pen was significantly greater than 50% and was significantly greater than the proportion of subjects in the communal conditions who chose a different color pen. Also as expected, in no study was this percentage greater than 50% in he communal conditions.(ABSTRACT TRUNCATED AT 250 WORDS)     

Communal Behaviors and Psychological Adjustment of Family Caregivers and Persons With Spinal Cord Injury

OBJECTIVE: Examined the influence of mutual communal behaviors on the adjustment reported by persons with spinal cord injury (SCI) and their family caregivers. Previous research has found that persons who have a history of mutually communal behaviors in relationships may react differently to relationship changes after an acquired physical disability than dyads with few communal behaviors. METHOD: Family caregivers and persons with SCI were administered measures of mutual communal behaviors, depression, and life satisfaction. Structural equation modeling was used to test the relations among caregivers' communal behaviors and care recipients' communal behaviors, depression, and life satisfaction. RESULTS: Caregiver and care recipient reports of communal behaviors were not significantly correlated. Significant paths indicated that care recipients' communal behavior scores were positively associated with their life satisfaction, and care recipients' depression was inversely associated with their life satisfaction. Caregivers' communal behavior scores were unrelated to their self-reported adjustment. CONCLUSIONS: Caregiver-care recipient dyads may differ in their perceptions of communal behaviors in their relationships. Although care recipient reports of communal behavior may be related to their life satisfaction, communal behaviors may not serve a similar function among caregivers of persons with SCI.     

The Caregivers' Attachment and Relationship Education Class: A New and Promising Group Therapy for Caregivers of Individuals with Parkinson's Disease

The authors examined whether a newly developed group therapy, based on principles of attachment theory and emotionally focused couples therapy, can potentially address the unique mental health and relationship difficulties in caregivers of individuals with Parkinson's disease. A comprehensive outreach effort, involving a review of 251 military veterans' medical records, yielded enrollment of seven spousal caregivers in the group therapy. At 1-month follow-up, caregivers who initially reported mild or greater levels of caregiver burden demonstrated statistically reliable declines in psychological distress, relationship distress, or both. Posttreatment surveys indicated positive perceptions in overall helpfulness of treatment goals, as well as positive changes in insight (e.g., greater understanding of the patient's attachment needs) and behaviors (e.g., greater social contact and self-care of the caregiver). Results are considered in the context of inadequate access to treatment for caregivers of spouses with Parkinson's disease or other major medical issues.     

Caregiving: The Forgotten Element in Attachment

In attachment theory, an attachment behavioral control system in the child and a complementary caregiving system in the parent act together to protect the young. The attachment account, however, fails to supply a motivation for caregiving. As a result, it cannot give a theoretical explanation for the responsive and attentive behaviors empirically observed in caregivers of secure children. In this article, we present an account of caregiving that places emotion at the center of caregiving (the connection theoretical orientation). In this account, the dyadic emotion of caring serves as an autonomous motivation to see that the needs of a specific dependent are met. Unlike the "on-off" caregiving in attachment theories, connection caring is conceptualized as enduring and variable: Caregivers experience different levels of caring over the course of a relationship. Through the emotional concepts of caring, empathy, and responsibility, the connection theoretical orientation is able to provide the coherent account of caregiving that the attachment theoretical orientation's cybernetic concepts have been unable to supply.     

Costs and satisfaction in close relationships: The role of loss–gain framing

Two studies were conducted to clarify the pattern of mixed results found in past research regarding the association between costs and satisfaction in close relationships. Insights from Prospect Theory (D. Kahneman & A. Tversky, 1979, 2000) suggested the importance of gain–loss framing in understanding costs. When costs are attached to valued outcomes, they are perceived as gains or investments; otherwise they are perceived as losses. Appreciation by one's partner for communal behaviors and family chores provided the basis for exploring costs as gains versus losses. We hypothesized that when costs were appreciated, the greater the costs, the greater the relationship satisfaction; whereas when they were not appreciated, the greater the costs, the lower the relationship satisfaction. Further, we expected appreciation to be associated with perceived motives for incurring the costs: positively with “want” perceptions and negatively with “should” perceptions. These hypotheses were supported in research with both dating couples and women in long‐term marital or cohabiting relationships and using two types of communal behaviors: Partner Favors and more tedious Family Chores. In general, the greater the number of communal behaviors and family chores, the greater the relationship satisfaction when appreciated; the greater the number, the lower the satisfaction when relatively unappreciated.     

Parents of Adults with Intellectual and Developmental Disabilities (IDD) and Compound Caregiving Responsibilities

In some cases, parents caring for an adult child with an intellectual and/or developmental disability (IDD) must balance this with caregiving for another family member. This dual responsibility, referred to as “compound caregiving”, may contribute to increased feelings of distress, or change their perceived ability to care for their child. The current study examined how compound caregivers differ from other parents of adults with IDD, and whether compound caregiving is significantly associated with family distress. Data was available for 199 parents aged 38 to 91 years who were seeking adult services for their son or daughter with IDD. Parents completed a mailed questionnaire and telephone interview in which they indicated compound caregiver responsibilities. Parents identified as compound caregivers were then compared to those who were not in terms of family characteristics, as well as parental perceptions of burden and mastery, and family distress as measured by the Revised Caregiver Appraisal Scale and the Brief Family Distress Scale, respectively. Nearly half of the parents reported being compound caregivers. The demographic profile of these parents was no different from that of the other parents but their children were slightly younger. Compound caregiving was significantly associated with parental perceptions of burden and mastery and family distress. Demands outside of caring for an adult child with IDD can negatively influence family functioning and must be included as part of caregiving assessments.     

Burden,Interdependence, Ethnicity,and Mental Health in Caregivers of Patients with Schizophrenia

Caring for a patient with schizophrenia often results in high levels of perceived burden and poorer overall mental health. Using a sample of 176 caregivers of patients with schizophrenia, the present study examined how two components of burden (objective and subjective) interacted with interdependence and ethnicity to influence relatives' overall mental health. In line with study hypotheses, and with the stress‐appraisal‐coping model developed by Lazurus and Folkman (1984), we found that subjective burden mediated the relationship between objective burden and mental health. In other words, subjective appraisals of caregiving appeared to partially underlie the association between the concrete costs of caregiving and psychological outcomes in schizophrenia caregivers. Also as hypothesized, we found that interdependence, or the perceived interconnectedness of individuals within a group, moderated the relationship between objective burden and subjective burden. In other words, when levels of interdependence were high, the objective components of burden appeared to have a weaker relationship with subjective burden. When interdependence was low, on the other hand, objective burden was more likely to be associated with subjective burden. This finding suggests that helping caregivers to value harmony and connection with others over individual self‐interests may reduce the likelihood that objective stressors (which are often inevitable in schizophrenia) will result in subjective distress. On the basis of prior research, we also tested several hypotheses regarding the role of ethnicity and its association with burden, interdependence, and mental health. However, contrary to expectations, no ethnic patterns were observed.     

Relationship orientation, quality of prior relationship, and distress among caregivers of Alzheimer's patients

Communal orientation and closeness of the caregiver-patient relationship were investigated as predictors of distress among caregivers of Alzheimer's patients. Persons high in communal orientation were less depressed than those low in communal orientation. Caregivers reporting a close relationship with the patient before illness onset felt less burdened than those whose relationship had not been close. Communal orientation interacted with closeness when data were analyzed separately for men and women. Among men, being low in communal orientation and having a relatively poor prior relationship were associated with the highest levels of depression, levels that put them at risk for clinical depression. Among women low in communal orientation, higher levels of depression were related to having a close prior relationship with the patient.     

Informal Caregiving to Persons with AIDS in the United States: Caregiver Burden Among Central Cities Residents Eighteen to Forty-Nine Years Old

Characteristics and caregiving experiences of friends and family members caring for people with AIDS (PWAs) were examined. Based on a probability sample of informal AIDS caregivers ages 18–49 living in central cities of the United States (n = 260), analyses were conducted to (a) identify the sociodemographic characteristics of young central city caregivers; and (b) examine the effects of caregiver characteristics (relationship to PWA, gender, race/ethnicity, income, sexual orientation, HIV status, perceived susceptibility), and level of objective caregiving demands, on subjective caregiver burden. Results indicate that the largest group of caregivers in this age category are male friends of the PWA—a group not typically found among caregivers to persons with other types of illnesses. In general, gay or bisexual caregivers, caregivers who have traditional family ties to the PWA, men relative to women, and lower income caregivers, report the greatest burden. While level of caregiving demands represents the most influential predictor of caregiver burden, white and male caregivers experience greater burden, independent of level of involvement and other caregiver characteristics. Receiving instrumental support with caregiving buffers the impact of high objective demands on subjective burden.     

Overprotective Relationships: A Nonsupportive Side of Social Networks

Chronically ill adults who feel overprotected by family members tend to be more depressed. However, little is known about the source of these feelings of overly protective care. In this study, three explanations why family members may be seen by stroke patients as overprotective were tested: (a) a discrepancy between patients and caregivers in judging patient functioning; (b) caregiver protective behaviors, such as restricting the patient because of fear for the patient's safety; and (c) caregivers' negative attitudes toward the patient. Consistent with prior work, patients who felt overprotected were more depressed even when the severity of the stroke was controlled for. Caregivers with negative attitudes toward the patient were most likely to be seen as overprotective by the stroke patient. Ways in which negative, resentful attitudes of caregivers are translated into behaviors that engender feelings of overprotection are discussed.     

The role prioritization model: How communal men and agentic women can (sometimes) have it all

Men and women are persistently associated with breadwinning and caregiving roles and related stereotypes. A role prioritization model (RPM) is presented that accounts for the conditions under which penalties and benefits arise due to perceived fulfillment or neglect of communal/caregiving roles (typically associated with women) and agentic/breadwinning roles (typically associated with men). Our model makes unique contributions to understanding gender stereotyping and negative evaluations for stereotype violation (i.e., backlash). First, behaviors suggesting low prioritization of one's traditional gender role—when women appear to neglect caregiving and men neglect breadwinning—produce particularly harsh judgments. Second, behaviors indicating successful balancing of role prioritization (e.g., men who augment breadwinning with communal behavior and women who augment childrearing with agentic behavior) allow avoidance of backlash. The RPM is useful for organizing existing research on gendered perceptions and for understanding perceptions of men and women who violate gender norms to create greater gender equality.     

Declarative verbal memory impairments in middle-aged women who are caregivers of offspring with autism spectrum disorders: The role of negative affect and testosterone

Caring for offspring diagnosed with a chronic psychological disorder such as autism spectrum disorder (ASD) is used in research as a model of chronic stress. This chronic stress has been reported to have deleterious effects on caregivers' cognition, particularly in verbal declarative memory. Moreover, such cognitive decline may be mediated by testosterone (T) levels and negative affect, understood as depressive mood together with high anxiety and anger. This study aimed to compare declarative memory function in middle-aged women who were caregivers for individuals with ASD (n = 24; mean age = 45) and female controls (n = 22; mean age = 45), using a standardised memory test (Rey's Auditory Verbal Learning Test). It also sought to examine the role of care recipient characteristics, negative mood and T levels in memory impairments. ASD caregivers were highly sensitive to proactive interference and verbal forgetting. In addition, they had higher negative affect and T levels, both of which have been associated with poorer verbal memory performance. Moreover, the number of years of caregiving affected memory performance and negative affect, especially, in terms of anger feelings. On the other hand, T levels in caregivers had a curvilinear relationship with verbal memory performance; that is, increases in T were associated with improvements in verbal memory performance up to a certain point, but subsequently, memory performance decreased with increasing T. Chronic stress may produce disturbances in mood and hormonal levels, which in turn might increase the likelihood of developing declarative memory impairments although caregivers do not show a generalised decline in memory. These findings should be taken into account for understanding the impact of cognitive impairments on the ability to provide optimal caregiving.     

Relationship orientation as a moderator of the effects of social power

This research examined the hypothesis that the concept of power is mentally associated with different goals for individuals with a communal versus an exchange relationship orientation (M. S. Clark & J. Mills, 1979). It was predicted that communals associate power with social-responsibility goals, whereas exchangers link power with self-interest goals. Thus, when power is activated, distinct goals should be ignited for communals and exchangers. Power was primed unobtrusively using semantic cues in Study 1 and using naturally occurring, environmental cues in Studies 2 and 3. Across studies, power-primed communals responded in socially responsible ways, whereas power-primed exchangers acted more in line with their self-interests. These power-goal effects occurred nonconsciously. Overall, the data support taking a Person x Situation approach--one that allows for moderators such as relationship orientation--to understand power's positive and negative effects.     

Health-Related Quality of Life in a National Sample of Caregivers: Findings from the Behavioral Risk Factor Surveillance System

Purpose Recent national public health agendas, such as Healthy People 2010, call for improved public health surveillance and health promotion programs for people with disabilities and their caregivers. The goal of this study was to understand the public health impact of caregiving on health-related quality of life (HRQoL) using population-level data. Design & Methods A cross-sectional study design was used. 184,450 adults surveyed during the 2000 national Behavioral Risk Factor Surveillance System survey formed the sample. Binary logistic regression models ascertained differences between caregivers and non-caregivers in reporting reduced (“fair” or “poor”) health. Ordinary least squares regression (OLS) and multinomial logistic regression models examined the influence of caregiving status on HRQoL, measured as categories of healthy days reported in the last 30 days and the number of days reported as physical and mental health not good in the last 30 days. Results Sixteen percent (16%) of the survey respondents were caregivers. There was an interaction effect between caregiving status and age of the caregiver. In the fully adjusted models, caregivers <55 years old had a 35% increased risk of having fair or poor health (odds ratio [OR] = 1.35, 95% confidence interval [CI] 1.28, 1.43) as compared to non-caregivers in that age group, while caregivers 55 years and older had a 3% decreased risk in having fair or poor health (OR = 0.97, 95% confidence interval [CI] 0.92, 1.03) compared to non-caregivers of the same age. In the adjusted models that examined the association of caregiving and healthy days, younger caregivers similarly showed larger deficits in both mental and physical HRQoL compared to older caregivers. For example combining mental and physical days, caregivers <55 had 1.44 fewer healthy days (β = −1.44, standard error (SE) = 0.07), while caregivers 55+ had 0.55 fewer days *β = −0.55, standard error (SE) = 0.13 (compared to non-caregivers in their respective age groups). Implications With increasing population age and the projected increase in caregivers, it is important that we understand the social and public health burden of caregiving and begin to identify interventions to sustain the HRQoL of caregivers. We found that caregivers have a slight to modest decline in HRQoL compared to non-caregivers, and that caregiving affects the HRQoL of younger adults more than older adults. Further research at the population level as to the type and level of burden of caregiving is needed.     

Increasing Family Members' Appreciation of Family Caregiving Stress

Participants read a message discussing the duties of a typical family caregiver (for example, a woman taking care of her elderly mother) and the associated psychological, physical, social, and financial stresses. The message was accompanied by an appeal that was either a control or was altruistic (other-oriented: focusing on the mother/caregiver's well-being) or egoistic (self-oriented: focusing on the child of the caregiver's needs and feelings). Participants who received an altruistic appeal were more appreciative of caregiving stresses than were those given an egoistic or a control appeal. Increasing family members' awareness of the stress involved in family caregiving is a first step in encouraging them to personally intervene on behalf of the caregiver.