Models of self and others and their relation to positive and negative caregiving responses

Beyond the symptoms: Exploring attachment styles and reality-testing among schizophrenia clients from a nursing perspective

WHAT IS KNOWN ON THE SUBJECT?: The insecure attachment styles are associated with mental health problems and can influence reality perception, particularly in individuals with schizophrenia. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper provides empirical evidence for the correlation between insecure attachment styles and reality-testing impairment in clients with schizophrenia. Higher reality testing impairment scores were observed in specific demographics: males who were unmarried and aged between 40 and 50 years old, as well as those with a duration of illness of less than 5 years. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The findings underscore the importance for nurses to understand insecure attachment styles, particularly anxious and avoidant styles, in clients with schizophrenia. Healthcare providers and nurses should understand the psychological dynamics of clients with insecure attachment styles to establish effective therapeutic relationships. A secure, structured and consistent environment is vital to modifying insecure attachment styles and promoting reality orientation. Secure Attachment Style Psycho-Educational Program, Mentalization, Cognitive Interpersonal Therapy, and Cognitive Analytic Therapy can help reduce reality-testing impairment. Imply early intervention through educating mothers on fostering secure bonds can potentially prevent future occurrences of schizophrenia. WHAT ARE THE IMPLICATIONS FOR FUTURE RESEARCH?: Conducting empirical studies to explore the associations between insecure attachment style, social functioning, and poor service engagement is essential. Research is needed to investigate specific techniques for managing insecure attachment styles, particularly the avoidant ones, and reality testing impairments within the therapeutic setting.

ABSTRACT

INTRODUCTION: Insecure attachment styles are associated with mental health problems and may influence reality perception.

AIM

This study investigated the link between attachment styles and reality-testing impairment in individuals with schizophrenia.

METHODS

A cross-sectional survey with 200 participants diagnosed with schizophrenia assessed their attachment styles (Psychosis Attachment Measure) and reality-testing abilities (Bell Reality Testing Inventory).

RESULTS

A significant positive correlation emerged between insecure attachment and poorer reality testing (r = .394, p < .001). Avoidant attachment was most prevalent (mean scores: 17.01, SD = 3.71), followed by anxious attachment (16.53, SD = 4.20). Reality-testing impairment manifested across all three domains: uncertainty of perception (7.16, SD = 2.45), reality distortion (3.52, SD = 1.21), and hallucinations/delusions (26.63, SD = 5.83). Interestingly, specific demographics (male, unmarried, 40-50 years old) and those with a duration of illness of less than 5 years had higher mean scores (27.35, SD = 5.61).

DISCUSSION

Insecure attachment styles, notably anxious and avoidant, are dominant among clients with schizophrenia, who also struggle with reality distortion, perceptual uncertainty, and hallucinations/delusions in all three domains.

IMPLICATION FOR PRACTICE

Healthcare providers and nurses should understand the psychological dynamics of clients with insecure attachment styles to establish effective therapeutic relationships. A secure, structured, and consistent environment is vital to modifying insecure attachment styles and promoting reality orientation. Secure Attachment Style Oriented Psycho-Educational Program, Mentalization, Cognitive Interpersonal Therapy, and Cognitive Analytic Therapy can help reduce reality-testing impairment. Fostering Maternal and Child Health (MCH) centers on empathizing secure bonds between mothers (and mothers-to-be) and their children to promote healthy attachment styles as a preventive measure.

Does Family Functioning Matter? Understanding the Relationship Between Family Interactions and Depressive Symptoms for Caregivers of Cancer Patients

BACKGROUND

Caregivers of cancer patients are at increased risk of depression and other health challenges. There is limited understanding of the role of the caregiver's own family members in promoting or discouraging mental wellbeing. Family functioning conceptualizes how family members interact to promote a positive family environment and has the potential to impact caregiver mental health. The purpose of this study is to assess the association between family interactions and depressive symptoms among family caregivers of cancer patients.

METHODS

Secondary analysis of baseline data from an NIH-funded randomized control trial of family caregivers of cancer patients recruited from academic palliative care clinics at three sites (2 Midwest, 1 East). We tested for an association between caregiver responses to the Family Quality of Life in Dementia-Family Interactions Subscale and Patient-Reported Outcomes Measurement Information System Depression Short Form 8A using a block-wise approach to linear modeling.

RESULTS

A total of 246 caregivers were included in analysis; caregivers were mostly White (82%), not Hispanic or Latina/o (96%), and female (65%), with an average age of 55 years. Overall, participants had high family interactions (mean 57.7, sd 11.7) and an average depressive symptom burden (t-score 52.4, SD 8.57). Family interactions was significantly negatively associated with depressive symptoms (b = -.163, se = .057) when accounting for relevant covariates.

CONCLUSION

Family caregivers with more positive family interactions are likely to have fewer depressive symptoms, suggesting family functioning may play a key role in bolstering family caregiver mental health and wellbeing.

Filial Maturity and Caregiving to Aging Parents

The aging of parents results in changes in the filial relationship. The increasing vulnerability of parents leads adult children to realize that they have individual needs and cannot fully function as sources of security and protection, as they did before. Simultaneously, the evidence of losses and disability imposes the need for care, which tends to be assumed by adult children. Therefore, there is a progressive change in the volume of support exchanges between parents and children, with more support from adult children to parents. The way adult children adapt to these transitions is influenced by several internal and relational factors. Filial maturity has been associated with filial caregiving towards aging parents. The concept of filial maturity describes a developmental stage in which the adult child overcomes the filial crisis, realizing and accepting that the parent also needs support and comfort and starting to relate to him/her beyond the strictly parental role. Thus, this study aims to explore the role of attachment and mental representation of caregiving in filial maturity. A total of 304 children aged between 35 and 64 years old participated in this study, with at least one of the living parents aged 65 years or older, not institutionalized. Attachment was assessed with the Adult Attachment Scale, mental representation of caregiving with the Mental Representations of Caregiving Scale and filial maturity with the Filial Maturity Measure. The results suggest that attachment, mental representation of caregiving and the interaction between the two explain 24.5% (p < 0.01) of variability in Comprehending and 11.1% (p < 0.05) of variability in Distance, two dimensions of filial maturity. These findings suggest that it is important to consider mental representation of caregiving and attachment when adult children must adapt to changes in the filial relationship and to the need to care for parents.

Education Differentially Buffers Cognitive Performance in Black and White Older Adults

OBJECTIVES

Given that black American older adults are more likely to have lower educational attainment and perform worse on cognitive tests than white Americans, we examined whether increased education would confer greater cognitive advantage to black Americans on measures of global and specific domains of cognitive function.

METHODS

The sample included 522 community-dwelling older adults from a larger study. An analysis of covariance was conducted with race and education as between-participant factors and global cognition as the dependent variable. A multivariate analysis of covariance was conducted with five cognitive domains (immediate memory, visuospatial/constructional ability, language, attention, and delayed memory) as the dependent variables.

RESULTS

Significant main effects indicated that black Americans, F(1,516) = 29.18, p < .001, and individuals with less education, F(1,516) = 44.93, p < .001, evidenced lower cognitive functioning, controlling for age and overall health status, and the interaction term reached statistical significance, F(1,516) = 7.95, p = .005. The impact of education on global cognitive function for black participants was more than twice as large (Cohen's d = 1.30) than for white participants (Cohen's d = .52). There was a significant race × education interaction for the cognitive domain of attention (p < .001) and a composite measure of non-memory domains (i.e., language, visuospatial/constructional, and attention; p < .001).

DISCUSSION

Our findings suggest that educational attainment is particularly important for black Americans with respect to global cognitive function, attention, and non-memory domains.

Caregiver Burden, Care Recipient Depressive Symptomology, and Social Exchange: Does Race Matter?

Informal caregivers play a vital role in supporting seriously ill patients. However, informal caregiving is burdensome and can lead to negative health outcomes for the caregiver and the care recipient. The study's aim was to evaluate relationships among caregiver burden, care recipient depressive symptomology, and race. Guided by the social exchange perspective, we examined cross-sectional dyadic data from the National Long-Term Care Survey (N = 1279). Using ordinal logistic regression, we found that higher caregiver-reported objective burden was associated with higher care recipient depressive symptoms ( P < .05), an association that was stronger for blacks. Interestingly, despite significant levels of objective burden, there was an association between lower depressive symptoms in black care recipients when there was an exchange of the social good "helpful company" with a caregiver. These findings illustrate the importance of supporting reciprocal exchange as a promising component of maintaining balanced caregiver-care recipient relationships among black older adults and their informal caregivers.

Experiencing an Intimate Partner's Breast Cancer: Attachment, Caregiving, and Burden in Men

OBJECTIVE

This study examined interrelationships among adult attachment orientations, caregiving, and caregiver burden in men of female partners with breast cancer, and tested whether caregiving patterns mediated associations between men's attachment orientations and their self-reported caregiver burden.

METHOD

The participants were 124 male partners of women with breast cancer. These participants completed assessments related to attachment, caregiving, and caregiver burden. Path models examined the associations between constructs and tested mediational effects.

RESULTS

Findings demonstrated significant associations between men's adult attachment orientations and their experience of caregiver burden. In addition, the maintenance of proximity in caregiving completely mediated the respective associations of attachment security and attachment avoidance to caregiver health problems, on one hand, and to the caregiver's self-esteem (e.g., another indicator for caregiver burden), on the other. Moreover, we found a direct effect of attachment avoidance on health problems.

CONCLUSIONS

This study highlighted the importance of addressing adult attachment dispositions and caregiving to understanding the relational processes implicated in caregiver burden. The results support the conclusion that men's adult attachment orientations and caregiving patterns toward their female partners with breast cancer are relevant contributors to men's perceptions of caregiver burden.

The Role of Anticipated Gains and Losses on Preferences About Future Caregiving

OBJECTIVES

A growing amount of research has suggested that caregiving is not only associated with burden but entails also the potential for positive outcomes. By contrast, less is known about the roles of gain-loss-anticipations on future caregiving.

METHOD

We conducted a web-based study in which we compared three groups with differing preferences on future caregiving: being willing to provide care (potential caregivers; n = 189), remaining indecisive about whether to provide care (undecided; n = 121), and rejecting the idea to provide care (unwilling; n = 62). In addition, actual caregivers (n = 113) served as a reality check for these expectations. We assessed gain-loss anticipations with a newly developed instrument (k = 12) and offer information on its reliability and validity.

RESULTS

Groups reveal different patterns of gain-loss-anticipations. Potential caregivers resembled actual caregivers and highlighted the potential benefits of caregiving, whereas those who were undecided or unwilling to provide care perceived fewer gains and more losses.

CONCLUSION

Preferences about future caregiving are not described solely by socio-demographic aspects but are also colored by anticipations of both gains and losses. Findings point to the need to focus on motivational factors to enhance our understanding in the context of caregiving decisions.

Recalled attributes of parents with Alzheimer's disease: relevance for caregiving

Health psychology has long been involved in studies of factors that lead to more effective caregiving. Drawing on the theory of distributive justice, the underlying hypothesis of this paper was that perceptions of what a demented parent was like, prior to becoming ill, influence an adult child caregiver's provision of care, as well as the caregiver's own well-being. A secondary question dealt with the nature of retrospective ratings by caregiver informants. The sample consisted of triads of two adult children (N = 385) and a parent (N = 201) diagnosed with Alzheimer's disease, although in a few instances only one adult child was interviewed. Both retrospective and current ratings of the parent were made by caregivers, who were administered a semantic differential instrument twice over a 10-month period. Comparison of ratings from first and second interview waves suggested that perceptions of what a parent was like, prior to the onset of dementia, were more stable over time than perceptions of what the parent was currently like, at each interview. Ratings of premorbid attributes were more strongly related to ratings of the present for those parents who displayed the least evidence of cognitive decline. Regression analyses supported the hypothesized relationship between adult children's perceptions and both provision of care and well-being variables. Results have implications for projections of caregiver burden and for placement into long-term care.

Attachment in people with dementia and their caregivers: A systematic review

Attachment bonds are important for personality development, emotion regulation and mental health throughout the lifespan. This systematic review explores the relevance of attachment for people with dementia, and how attachment influences the experience of caregivers of people with dementia. Eighteen studies were included. Three focused on attachment in terms of parent fixation in dementia, three examined attachment behaviour in dementia, five addressed attachment and dementia-related behavioural problems, and seven concentrated on attachment in caregivers. Attachment behaviours were evident at various stages of dementia and the presence of parent fixation was observed when attachment needs were not being met. Insecure attachment was related to neuropsychiatric symptoms. Attachment security had important consequences for caregiver psychological health. Implications of methodological issues such as the choice of respondent, measurement issues, and the lack of a longitudinal perspective are discussed. The implications of attachment for the support of people with dementia and caregivers are considered.

Cross-national differences in the prevalence and correlates of burden among older family caregivers in the World Health Organization World Mental Health (WMH) Surveys

BACKGROUND

Current trends in population aging affect both recipients and providers of informal family caregiving, as the pool of family caregivers is shrinking while demand is increasing. Epidemiological research has not yet examined the implications of these trends for burdens experienced by aging family caregivers. Method Cross-sectional community surveys in 20 countries asked 13 892 respondents aged 50+ years about the objective (time, financial) and subjective (distress, embarrassment) burdens they experience in providing care to first-degree relatives with 12 broadly defined serious physical and mental conditions. Differential burden was examined by country income category, kinship status and type of condition.

RESULTS

Among the 26.9-42.5% respondents in high-, upper-middle-, and low-/lower-middle-income countries reporting serious relative health conditions, 35.7-42.5% reported burden. Of those, 25.2-29.0% spent time and 13.5-19.4% money, while 24.4-30.6% felt distress and 6.4-21.7% embarrassment. Mean caregiving hours per week in those giving any time were 16.6-23.6 (169.9-205.8 h/week per 100 people aged 50+ years). Burden in low-/lower-middle-income countries was 2- to 3-fold higher than in higher-income countries, with any financial burden averaging 14.3% of median family income in high-, 17.7% in upper-middle-, and 39.8% in low-/lower-middle-income countries. Higher burden was reported by women than men and for conditions of spouses and children than parents or siblings.

CONCLUSIONS

Uncompensated family caregiving is an important societal asset that offsets rising formal healthcare costs. However, the substantial burdens experienced by aging caregivers across multiple family health conditions and geographic regions threaten the continued integrity of their caregiving capacity. Initiatives supporting older family caregivers are consequently needed, especially in low-/lower-middle-income countries.