Community Mental Health Journal, Vol. 28, No. 5, October 1992
Social Support and Quality of I Jife of Community Support Clients Frank Baker, Ph.D. David Jodrey, Ph.D. James Intagliatc~ Ph.D.
A B S T R A C T " Two aspects of social support, availability a n d adequacy, were assessed for 729 severely m e n t a l l y ill adults enrolled in seven state-supported C o m m u n i t y Support Services (CSS) programs as part of repeated q u e s t i o n n a i r e surveys n i n e m o n t h s apart. Perceived q u a l i t y of life interviews with the clients were also conducted at both times. These interviews included the B r a d b u r n Positive and Negative Affect Scales a n d the Satisfaction with Life Domains Scale (SLDS). A v a i l a b i l i t y of social support was significantly correlated with positive affect over time, b u t not with negative affect at either point. Inadequacy of social support was significantly related to negative affect at both assessments. Both a v a i l a b i l i t y a n d adequacy of social support were significantly related to the SLDS at each time. Change i n satisfaction with life domains was found to be related to both availability and, to a lesser degree, with adequacy of social support.
Social support has been recognized for some time as an important part of programs for maintaining the severely mentally ill in the community (President's Commission on Mental Health, 1978; Turner & TenHoor, 1978). A number of states, stimulated by the availability of limited funds from the community support program at the National Institute of Mental Health (NIMH), developed their own community Dr. Baker is Professor of Health Psychology and Dr. Jodrey is a Postdoctoral Fellow in Health Psychology in the Department of Environmental Health Sciences, School of Hygiene and Public Health, The Johns Hopkins University, 615 N. Wolfe Street, Baltimore, MD 21205. Dr. Intagliata is a management consultant in Oak Park, IL. The authors gratefully acknowledge the help of Robert S. Weiss, Harry Straus and David Mandel in the collection and analysis of the data reported here. The data were obtained as part of an evaluation of the New York CSS program funded by a contract between the New York State Office of Mental Health and the Psychotechnical Applied Research Organization, Inc. of Buffalo, NY. Additional funding for the analysis of the data was provided by a grant to the first author from the New York State Health Research Council (HRC 15-074). 397
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support systems. These community support programs are seen as providing a necessary supplement to the natural support systems available to the chronically mentally ill in the community. The nature of this social support and its importance for the adjustment of mental patients in the community have been the subject of a number of papers, (e.g. Baker & Weiss, 1984; Beels, 1981; Cohen & Sokolovsky, 1978; Coyne & Downey, 1991). Healthy People 2000 (1990), which contains a national strategy for improving the health of the nation over the course of this decade, states that more adults who are disabled by severe, persistent mental disorders would benefit from enhanced social support through the use of community support programs. Quality of life has gained significant recognition as an important mental health service outcome which includes both objective and subjective components (e.g., Baker & Intagliata, 1982; Bigelow, Brodsky, Stewart, & Olson, 1982; Bigelow, McFarland, & Olson, 1991; Lehman, Ward, & Winn, 1982). A number of studies have related perceived quality of life or psychological well-being to the nature of available social support systems (Andrews, Tennant, Hewson, & Vaillant, 1978; Greenblatt, Becerra, & Sarafetinides, 1982; Henderson, 1980; Henderson, Byrne, Duncan-Jones, Adcock, Scott, & Steele, 1978; Miller & Ingham, 1976). In an earlier article, Baker and Intagliata (1982) pointed out the importance of considering perceived quality of life of chronic mental patients living in the community. This paper reports the results of a larger study which builds on this earlier pilot work. The two aspects of social support examined in the present study were originally identified in research based on the conceptualization of social support spelled out by Weiss (1974) in his theory of the basic social provisions that all individuals require. In a study of mental health and social support, drawing on this theory, Henderson, Duncan-Jones, Byrne and Scott (1980) found that there were two separate dimensions of social support: the availability for an individual of various types of social relationships, and the perceived adequacy of these relationships. This paper relates these dimensions of social support to perceived quality of life.
METHOD Subjects A stratified random sample of 844 individuals who had a history of psychiatric illness and who were being served in seven programs in upstate New York constituted the subjects of the study. The CSS program sites included state hospitals, a community
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mental health center, and other nonstate agencies funded by contract with the state for community support services. The sample was comprised of 54.1 percent females and 45.9 percent males. The ages of patients ranged from 18-89 years with a mean of 52.3 years (SD = 16.9). A majority, 56.0 percent, had never been married, 9.5 percent were currently married, and 34.5 percent were married at one time but were presently divorced, separated or widowed. With regard to education, 31.7 percent had attended eight or less grades of school, while 44.4 percent were at least high school graduates. In terms of primary psychiatric diagnosis, 62.9 percent were diagnosed as schizophrenic, 10.1 percent as having affective disorders (depression, anxiety), 7,0 percent as having organic mental disorders and the remaining 20% were distributed among various other diagnostic categories. A more detailed description of this sample of CSS clients has been published previously (Baker & Intagliata, 1984).
Questionnaire Administrations The data on which this paper is based were collected as part of an external program evaluation of the New York State community support system conducted by the authors and their colleagues (Baker & Intagliata, 1983). The CSS evaluation project team trained the case manager in each of the sites in the completion of the questionnaires. Each case manager filled out the questionnaires on about 15 of their clients over a three-week period, with an on-site research assistant available to answer questions. When questionnaires were returned, they were edited, and in some cases were checked with the respondent for clarification or additional information. The questionnaires were administered again in 1982, about nine months after the first administration. Questionnaires with complete information were obtained for 729 clients (86.4%) at both the first and second administrations. All analyses reported in this paper are based on the data from these repeated questionnaires.
Measures Included in the questionnaires were measures of social support availability and social support adequacy completed by the case managers for each of their clients included in the study sample. Also included were two measures of perceived quality of life, a scale of psychological well-being and a scale of satisfaction with life domains which the clients responded to as part of an interview administered by their case managers.
Availability of Social Support Scale. The format of the items developed by Henderson et al. (1980) was used to generate items regarding the availability of key social relationships to CSS clients. The types of social linkages asked about in these questions were based on the major types of social bonds and relational processes identified by Weiss (1974). These seven items asked whether the client had: 1. 2. 3. 4. 5. 6. 7.
friends; contact with his/her immediate family; a relationship with other professional staff besides the client's case manager; a person that the client feels close to and has an ongoing relationship with; a group of people to which he belongs and among whom he has an assured place; a relationship which includes sexual activity; and any people who rely on the client's advice, support or assistance.
The coefficient alpha obtained in the initial administration of the seven-item Availability of Social Support Scale was .63.
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Adequacy of Social Support Scale. In the Adequacy of Social Support Scale seven parallel questions were asked about the client's feelings regarding the adequacy of these social attachments, including: how the client felt about the number of friends he/ she had, the client's satisfaction with the amount of contact that he/she had with immediate family members, the client's feelings about the level of his/her sexual activity, etc. The alpha obtained for the Adequacy of Social Support Scale was .69. The reliabilities for this scale and the Availability of Social Support Scale were equal to or greater than those reported by the Henderson group. For example, one of the members of that research group, Duncan-Jones (1978), reported that the best of their measures achieved an alpha-coefficient of the order of .7 while others were only .5 or lower. Bradburn Positive and Negative Affect Scales. The measures used to assess the client's sense of psychological well-being were the Positive and Negative Affect Scales developed by Bradburn (Bradburn, 1969; Bradburn & Caplovitz, 1965). Bradburn developed items which were intended as research measures of the mental health of individuals based on self-reports concerning their happiness, life satisfaction, or psychological well-being. One of the main products of this effort was a scale which consists of ten questions about the respondents' recent affective experiences, five positive and five negative. On the positive side, respondents are asked whether they have during the past two weeks felt particularly excited or interested in something, proud of having been complimented, pleased at having accomplished something, on the top of the world, or that things were going their way. The negative experiences which are probed deal with whether the respondent has felt too restless to sit still, lonely, bored, depressed, or upset because of criticism. These two five-item clusters are termed the Positive Affect Scale and the Negative Affect Scale. To the surprise of Bradburn and other researchers, the scores on these scales were found to be independent and to some extent seemed to be correlated with different variables. Bradburn (1969) saw negative affect scores as related '~primarily to variables that have been dealt with by the traditional 'mental illness' approaches" (p. 12). These particular variables showed no association with positive affect scores. Bradburn later theorized that people's feelings of psychological well-being were composed of two subjective feeling states, positive and negative affect, which could vary independently. He concluded that overall sense of psychological well-being was a function of the difference between one's levels of positive and negative affect. The items as a whole were labeled the Affect Balance Scale (ABS), with a single ABS score calculated as the difference between a person's scores on the positive affect scale and the negative affect scale. The ABS has been used widely as a measure of psychological well-being, (e.g., Campbell, 1981). Andrews and Withey (1976) confirmed the essential independence of the positive affect score and the negative affect score. In the current administration, the two subscales were scored separately. The alpha coefficient obtained for the positive affect items was .74 and for the negative items the alpha was .77. The positive and negative affect scores were not correlated. Satisfaction with Life D o m a i n s Scale The Satisfaction with Life Domains Scale (SLDS), a measure of respondent satisfaction with various life areas, was constructed by adapting the ~Taces" response format developed by Andrews and Withey (1976) to assess client's satisfaction regarding 15 life domains (Baker & Intagliata, 1982). Respondents to the SLDS are asked to indicate
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their feelings by choosing one of seven faces ranging from a t~smiley" face with a large upturned smile (scored 7) to a "frowning" face with a deeply downturned mouth (scored 1). The CSS clients were asked to pick the face that best represented their degree of satisfaction with the following life areas: 1. 2, 3. 4. 5, 6. 7. 8. 9. 10. 11. 12. 13. 14, 15,
Their house/apartment/place of residence. Their neighborhood as a place to live. The food they ate. The clothing they wore. Their health. The people they lived with. Their friends. Their relationship with their family. How they got on with other people. Their job/work/day programming. The way they spent their spare time. What they did in the community for fun. The services and facilities in their area. Their economic situation, The place they lived in compared with the state hospital.
A total score was calculated by summing the responses for the 15 items. The alpha coefficient for the SLDS was .84 and the mean item-total correlation was .47.
RESULTS Social Support: Patterns of Change Over Time Before discussing the relationships between social support and perceived quality of life, the patterns of change in the measures of social support will be examined.
Availability of Sources of Social Support: The pattern of availability of different types of social support at the time of the first survey is revealing. Of course, by being in the CSS program, all of the clients in the study had case managers assigned to them. However, the vast majority of clients apparently also had available other professionals to help them in addition to their case managers. About four-fifths of the sample had at least one friend available, and the majority had some contact with their immediate family members, and an assured place in some group. Slightly more than half of the clients had a close relationship with one other person. Somewhat less than half of the sample had other people dependent upon them for advice, support or assistance. Only about a fifth of the cohort were reported by their case managers to have had any relationship that may involve sexual activity.
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Adequacy of Sources of Social Support: Adequacy of social support was m e a s u r e d by asking for the case m a n a g e r s ' j u d g m e n t s of client satisfaction w i t h each of the same seven sources of social support considered above. The types of social support t h a t the clients initially r a t e d themselves as most satisfied w i t h included support from a professional other t h a n t h e i r case m a n a g e r s (82%), the n u m b e r of other people depending on t h e m (79%), and t h e i r extent of i n v o l v e m e n t w i t h a n o t h e r person (77%). The Adequacy of Social Support Scale, the sum of the seven items, showed significant i m p r o v e m e n t over time (t = 4.64, df = 604, p < .001). Apparently, case m a n a g e r s ' beliefs about the sufficiency of available social support improved across the i n t e r v a l b e t w e e n the two surveys.
Social Support and Client Characteristics Social support as m e a s u r e d by the methods was differentially r e l a t e d to client variables.
Social Support and Demographic Variables: The availability of social support, both at the times of the Wave I and W a v e II q u e s t i o n n a i r e surveys, was significantly r e l a t e d to gender. More m e n h a d a low availability of social support score across both surveys a n d more w o m e n h a d h i g h scores at the times of both surveys, while w o m e n w e r e more likely to improve and m e n w e r e slightly more likely to decrease in t h e i r availability of social support over the n i n e - m o n t h period b e t w e e n the surveys (x 2 (3) = 23.54, p < .001). The age of clients was significantly inversely r e l a t e d to availability of social support a v e r a g e d over the two periods of t i m e sampled in t h e CSS client questionnaires (x 2 (26) = 25.66, p < .05). The y o u n g e s t clients h a d the most social support available, and the oldest the least. Despite this difference y o u n g e r clients were significantly more likely t h a n older ones to be j u d g e d as feeling t h a t t h e i r social support was not a d e q u a t e at both times (x2 (12) = 79.5, p < .001). In t e r m s of change in social support adequacy over the n i n e - m o n t h period, t h e r e was little difference across age categories except t h a t a s o m e w h a t smaller proportion of clients over 65 years of age showed any change e i t h e r up or down. Social Support and Primary Diagnosis: Availability of social support was also significantly r e l a t e d to the client's p r i m a r y diagnosis (x 2 (15) = 38.83, p < .001). In general, schizophrenics and substance abusers w e r e
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likely to have less social support at the times of both surveys than were clients with a primary diagnosis of affective disorders. Further, clients with affective disorders were more likely to go from a low availability of social support to a higher availability than were clients with diagnoses of substance abuse or organic mental disorders. Clients with organic mental illness or substance abuse as their primary diagnosis were more likely than clients in all other diagnostic categories to go from a higher score on the availability of social support to a lower score over time.Adequacy of social support was also significantly related to psychiatric diagnosis (x2 (15) = 28.30, p < .05). When compared with clients in all other diagnostic categories, clients with affective disorders were more likely to be judged as seeing their social support as inadequate at both surveys and relatively fewer of them were likely to see their social support as highly adequate at both times. However, as compared to the other diagnostic groups, a larger proportion was also more likely to increase in their feelings of adequacy over time. The diagnostic group with the largest proportion of clients rated as satisfied with their level of social support was the group of clients with organic mental disorders as their primary diagnosis.
Perceived Quality of Life Findings The perceived quality of life measures, discussed below, were obtained directly from the clients by the case managers.
Responses to Positive and Negative Affect Scales: Table I presents the proportion of the CSS clients recalling positive and negative experiences at the two administrations of the Bradburn affect measures. Data from a 1978 national survey of the general population (Campbell, 1981) are included in this table for comparison purposes. The pattern of responses to the Bradburn scales of the whole group of 729 CSS clients is essentially similar to that of the subsample of 118 clients in an earlier paper (Baker & Intagliata, 1982). The proportions of clients in the present larger sample who agreed to each of the five Positive Affect Scale items were from 5 percent to 12 percent lower than the general population sample on four of the items. As with the earlier subsample, the whole CSS study group exceeded the national survey group in the percentage of respondents who had ~Telt on top of the world in the past few weeks." This may have reflected some confusion about the wording of this statement. By the time of the second administration of the positive items in 1982, however, the CSS
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TABLE 1 Comparison of CSS Client Cohort and National Survey Sample on Percentages of Yes Responses to Bradburn Scales of Positive and Negative Affect
1981
1982
National Survey* 1978
62
64
74
69
69
77
75 45 69
77 40 70
87 42 74
46
55
48
52 56 52
56 59 52
24 30 30
38 729
42 729
22 3,692
CSS Clients Items Positive Affect During the past few weeks have you ever felt: Particularly excited or interested in something? Proud because someone complimented you on something you had done? Pleased about having accomplished something? On top of the world? That things were going your way? Negative Affect So restless that you couldn't sit long in a chair? Very lonely or remote from other people? Bored? Depressed or very unhappy? Upset because someone criticized you? Number of cases
*These r e s u l t s of a n a d m i n i s t r a t i o n of the B r a d b u r n Affect Balance Scale to a n a t i o n a l s u r v e y sample are from Campbell (1981).
client study cohort had dropped down below the national sample in the proportion of clients who agreed with this item. Other items showed only slight variations over time. The total scale scores on the Positive Affect Scale were not significantly different over time. With regard to the Negative Affect Scale, as with the partial CSS client sample, the whole sample were much more willing than the
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national survey to indicate that they felt "lonely or remote from other people," "bored," "depressed or very unhappy," and "upset because someone criticized them." Initially, there was an indication that fewer of the CSS clients felt "so restless that they couldn't sit long in a chair" than the general population sample, but this increased by the time of the second interview to a proportion which was higher. Except for the item regarding feelings of unhappiness and depression, which remained the same, the proportions of agreement with the negative affect items increased over time. Although only the item '~feeling restless" was statistically significant when considered separately (x2 = 15.28, p < .001), the total score on the summed Negative Affect Scale showed a significant increase (F(1,615) = 4.97, p < .05).
Satisfaction with Life Domains Table 2 presents the pattern of CSS client responses to the other perceived quality of life measure used in this study, the SLDS. This may be compared to the results of an administration of similarly worded items to a national population sample (Andrews & Withey, 1976) as presented in a smaller sample pilot study. As reported in the pilot study (Baker & Intagliata, 1982), there is also in this larger sample a skewness in the distribution of SLDS responses with a clustering of responses at the positive end of the scale. Table 2 presents the means and standard deviations for the individual items that make up the SLDS. The mean item scores are significantly higher at the time of the second administration of the SLDS for the CSS clients' feelings about their neighborhood, their food, and their health. The item with the highest level of client satisfaction was the one comparing the place the clients currently lived in to the state hospital, and this remained high. This clearly represents a strong endorsement of deinstitutionalization from those who were deinstitutionalized. The most dissatisfaction was expressed regarding the clients' feelings about their economic situation and their relationships with their families, and this did not change significantly. The responses at the first interview were comparatively low regarding the clients' feelings regarding their health, but these improved to a significant degree. A comparison of the overall SLDS scale mean at time I (X = 5.38, SD = .91) and time II (X = 5.45, SD = .99) showed a small but statistically significant increase (t = 2.00, df = 600, p < .05).
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TABLE 2 M e a n s a n d S t a n d a r d D e v i a t i o n s o f C S S C l i e n t s to S a t i s f a c t i o n w i t h Life D o m a i n s S c a l e at F i r s t a n d S e c o n d I n t e r v i e w s 1
Life Domain Questions 1. Which face comes closest to expressing how you feel about your house/apartment/place of residence? **2. Which comes closest to expressing how you feel about this particular neighborhood as a place to live? *3. Which comes closest to expressing how you feel about the food you eat? 4. Which face comes closest to expressing how you feel about the clothing you wear? *5. Which comes closest to expressing how you feel about your health? 6. Which face comes closest to expressing how you feel about the people you live with? 7. Which comes closest to expressing how you feel about your friends? 8. Which comes closest to expressing how you feel about your relationship with your family? 9. Which comes closest to expressing how you feel about how you get on with other people? 10. Which comes closest to expressing how you feel about your job/work/day programming?
Interview I
Interview H
X1
SD1
X2
SD2
5.53
1.61
5.62
1.56
5.27
1.67
5.46
1.59
5.40
1.64
5.53
1.61
5.45
1.57
5.50
1.50
5.05
1.75
5.24
1.70
5.39
1.68
5.46
1.66
5.67
1.47
5.63
1.49
5.17
1.97
5.19
1.89
5.48
1.47
5.60
1.44
5.41
1.72
5.38
1.63
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TABLE 2, Continued
Interview I
Interview H
X1
SD1
i 2
SD2
11. Which face comes closest to expressing how you feel about t h e w a y you spend y o u r spare time?
5.39
1.49
5.43
1.48
12. Which comes closest to expressing how you feel about w h a t you do in t h e c o m m u n i t y for fun?
5.23
1.59
5.20
1.54
13. Which comes closest to expressing how you feel about t h e services a n d facilities in this area?
5.51
1.47
5.50
1.44
14. Which comes closest to expressing how you feel about y o u r economic situation?
4.55
2.05
4.69
1.90
15. Which comes closest to expressing how you feel about t h e place you live now, c o m p a r e d w i t h the state hospital?
6.37
1.22
6.28
1.21
Life Domain Questions
1N ranges between 500 and 620 depending upon extent of missing data for individual items. *p < .05 **p < .01
Social Support and PQOL The two indices of social support differed in t h e i r relationship to t h e B r a d b u r n affect m e a s u r e s . The availability of various social relationships was significantly r e l a t e d to t h e client's self-report on t h e positive affect d i m e n s i o n of perceived q u a l i t y of life. This was t r u e both at t h e t i m e of t h e first s u r v e y (r 1 = .21, p < .001, n -- 657) a n d a t t h e second s u r v e y @2 = .25, p < .001, n = 636). However, t h e availability of social relationships was not significantly r e l a t e d to t h e dimension of n e g a t i v e affect (r i = .02, p = .33, n = 663; r 2 = .02, p = .31, n = 641).
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A reverse p a t t e r n was found for the scale of adequacy of social support and its relationship w i t h the two B r a d b u r n subscales. A significant negative correlation was found b e t w e e n adequacy of social support and negative affect (r I = -.32, p < .001, n -- 571; r 2 = -.29, p < .001, n = 640). This indicates t h a t clients who were j u d g e d as more satisfied w i t h t h e i r social support w e r e less likely to report negative affect. However, adequacy of social support was not significantly r e l a t e d to positive affect at the first or second a d m i n i s t r a t i o n of the measures. R e g a r d i n g the Satisfaction with Life Domains Scale, availability of social support was modestly but significantly correlated w i t h the total satisfaction scores at the first q u e s t i o n n a i r e a d m i n i s t r a t i o n (r 1 = .14, p < .001, n = 661) and at the second (r2 = .11, p < .01, n = 617). Adequacy of social support was also significantly r e l a t e d to SLDS at both waves (rl = .16, p < .001, n = 551; r 2 = .18, p < .001, n = 513). Some changes in PQOL m e a s u r e s were found r e l a t e d to the availability and adequacy of social support at both survey times. A l t h o u g h changes in negative affect were not r e l a t e d to the social support measures, positive affect and SLDS scores were. M a i n t e n a n c e of h i g h levels of social support availability at both data collection points was associated w i t h i m p r o v e m e n t s in positive affect (F(3,588) = 3.05, p < .05). The availability of social support was also found to be r e l a t e d to changes in SLDS scores, w i t h the g r e a t e s t increase in SLDS score occurring for clients who were initially low in available social support and t h e n increased in their social support availability score (F(3,587) = 5.37, p < .01). Levels of satisfaction w i t h life domains also increased significantly for clients who m a i n t a i n e d a d e q u a t e social support over both points in time (F(3,486) = 2.95, p < .05). The m a g n i t u d e of change for those whose adequacy of social support h a d increased was twice as large as the increase in life satisfaction for those whose social support adequacy h a d r e m a i n e d high.
SUMMARY AND DISCUSSION Both k i n and non-kin sources of social support w e r e j u d g e d to be available for the large majority of chronically m e n t a l l y ill clients enrolled in the state-supported c o m m u n i t y support programs participating in this study. Nevertheless, about h a l f of the clients r e m a i n e d dissatisfied w i t h the a m o u n t of social contact t h e y h a d w i t h t h e i r families and most w a n t e d more. P a r k s and Pilisuk (1984) also found t h a t kinship ties were central to the chronically m e n t a l l y ill in the community. Oppor-
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tunities for intimate social relationships, especially those including sexual activity, were more limited than other types of social relationships for the clients in our study. Nevertheless, the clients were seen by their case managers to be about as satisfied with this sphere of their social life as they were with less intimate social contacts. It is also important to consider opportunities that clients have for providing social support to others. Less than half of the sample were reported to have people dependent on them for advice, support, or assistance. While opportunities for providing social support to others were not available for over 50 percent of the New York State CSS clients, this was a proportionately better situation than Parks and Pilisuk (1984) found. In their study of formerly hospitalized psychiatric patients currently living in California board-and-care facilities, threequarters of their sample lacked opportunities for providing social support to others. Gender and age differences were found for social support. Women were judged to have more social support than men and were somewhat more likely to increase in social support availability over the study period. Younger clients were seen to have more social support at both times of the survey than older clients but were also less likely to feel that their level of available support was adequate. Primary diagnosis was significantly related to both availability and adequacy of social support. This study found important differences in the various measures of perceived quality of life employed. While demonstrating some of the same positive response bias shown by normal populations, the chronically mentally ill respondents in this study showed less positive affect and more negative affect than a national population sample. Across the two points in time at which these measures were collected for the chronic mental patient sample, no overall change in positive affect was seen. However, there was a slight but significant increase in negative affect observed. At least in terms of these affect measures, no improvement was demonstrated that would indicate an enhancement in client affect as a result of sheer time spent in the CSS program. Of course, to clearly observe the specific effects of receiving needed services would require a finer examination of service variables as they relate to change in these measures of perceived well-being. With regard to the other measure of perceived quality of life, the Satisfaction with Life Domains Scale items also showed a preponderance of responses at the satisfied end of the scale, a characteristic of such measures as noted above. However, the CSS clients showed a significant improvement in their SLDS total scores, suggesting that this measure of perceived life quality which asks about satisfaction
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with specific life areas might be more sensitive to improvements in the clients' feelings about life than the Bradburn affect scales. At both times, scores on the SLDS measure were significantly related to both availability and adequacy of social support. Change in satisfaction with life domains was found to be related to both availability and, to a lesser degree, with adequacy of social support. Given that one of the primary goals of a community support system is to supplement the natural social network of chronically mentally ill individuals, the finding of this study that availability of social support is related to clients' evaluation of life domains is quite encouraging. Case manager judgments of available social support for clients can be regarded as "objective"; clients' own reports of positive affect and satisfaction with various domains of their lives were "subjective"; and these were clearly related. The more questionable judgment by the case manager of how adequate these social bonds were for the client also was found to be related to life domain satisfaction, but was not consistently correlated with positive affect. However, perceived adequacy of social support was strongly negatively correlated with negative affect. The differences between life satisfaction and affective state measures of PQOL may be due to the different dimensions that each taps. McKennell and Andrews (1983) have identified two components of PQOL. One of these they call cognition, which has to do with comparisons an individual makes of particular circumstances in his/her life compared to some standard of expectation. The other component that they identify is affect, which has to do with feeling state. The SLDS measures probably include both dimensions, while the Bradburn measures include only different aspects of affect, either positive or negative. Negative affect, in particular, has been considered more as a measure of pathology (Beiser, 1974) which one might not expect to change with the availability of social support, and which might be related to the kind of dissatisfaction with life implied in low subjective adequacy of social support judgments. The findings of this study are consistent with this hypothesis. Satisfaction with life areas may be more affected by the availability of social support, not only because specific aspects of one's life may be objectively improved by what one gets from social support, including, but not limited to, the opportunity to engage in social activities, but also because other people may provide a reference group for changed standards as to what is acceptable in different life areas. Clearly, however, both aspects of social support are important, and intervention aimed at this aspect of life has been shown to have measurable effects on the quality of life of this client population.
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REFERENCES Andrews, F.M. & Withey, S.B. (1976). Social indicators of well-being: Americans'perceptions of life quality. New York: Plenum. Andrews, G., Tennant, C., Hewson, D.M., & Vaillant, G.E. (1978). Life event stress, social support, coping style and risk of psychological impairment. The Journal of Nervous and Mental Disease, 166, 307-316. Baker, F., & Intagliata, J. (1982). Quality of life in the evaluation of community support systems. Evaluation and Program Planning, 5, 69-79. Baker, F., & Intagliata, J. (1984). The New York State community support system: A profile of clients. Hospital and Community Psychiatry, 35, 39-44. Baker, F., & Intagliata, J. (1983). CSS evaluation: Final report. Buffalo, NY: Psychotechnical Applied Research Organization. Baker, F., & Weiss, R.S. (1984). The nature of case manager support. Hospital and Community Psychiatry, 35, 925-928. Beels, C.C. (1981). Social support and schizophrenia. Schizophrenia Bulletin, 7, 58-72. Beiser, M. (1974). Components and correlates of mental well-being. Journal of Health and Social Behavior, 15, 320-327. Bigelow, D.A., Brodsky, G., Stewart, L., & Olson, M. (1982). The concept and measurement of quality of life as a dependent variable in evaluation of mental health services. In W. Tash & G. Stahler (Eds.), Innovative approaches to mental health evaluation. New York: Academic Press. Bigelow, D.A., McFarland, B.H., & Olson, M.M. (1991). Quality of life of community mental health program clients: Validating a measure. Community Mental Health Journal, 27, 43-55. Bradburn, N.M. (1969). The structure of psychological well-being. Chicago: Aldine. Bradburn, N., & Caplovitz, D. (1965). Reports on happiness. Chicago: Aldine. Campbell, A. (1981). The sense of well-being in Americ~ New York: McGraw-Hill. Cohen, C.I., & Sokolovsky, J. (1978). Schizophrenia and social networks: Ex-patients in the inner city. Schizophrenia Bulletin, 4, 546-560. Coyne, J.C., & Downey, G. (1991). Social factors and psychopathology: Stress, social support, and coping processes. Annual Review of Psychology, 42, 401-425. Duncan-Jones, P. (1978). The interview measurement of social interaction. Paper presented to Research Committee on Sociology of Mental Health, International Sociological Association World Congress, Uppsala. Greenblatt, M., Becerra, R.M., & Serafetinides, E.A. (1982). Social networks and mental health: An overview. The American Journal of Psychiatry, 139, 977-984. Henderson, S. (1980). A development in social psychiatry: The systematic study of social bonds. Journal of Nervous and Mental Disease, 168, 63-69. Henderson, S., Duncan-Jones, P., Byrne, D.G., & Scott, R. (1980). Measuring social relations: The interview schedule for social interaction. Psychological Medicine, 10, 723-734. Henderson, S., Byrne, D.G., Duncan-Jones, P., Adcock, S., Scott, R., & Steele, G.P. (1978). Social bonds in the epidemiology of neurosis: A preliminary communication. British Journal of Psychiatry, 132, 463-466. Lehman, A.F., Ward, N.C., & Linn, L.S. (1982). Chronic mental patients: The quality of life issue. The American Journal of Psychiatry, 139, 1271-1276. McKennell, A.C., & Andrews, F.M. (1983). Components of perceived life quality. Journal of Community Psychology, 11, 98-110. Miller, P.M.C., & Ingham, J.G. (1976). Friends, confidants and symptoms. Social Psychiatry, 11, 51-58. Parks, S.H., & Pilisuk, M. (1984). Personal support systems of former mental patients residing in board-and-care facilities. Journal of Community Psychology, 12, 230-244. President's Commission on Mental Health. (1978). Task panel report on community support systems, Vol. 2. Washington, D.C.: U.S. Government Printing Office. Public Health Service. (1990). Healthy people 2000: National health promotion and disease prevention objectives. Washington, D.C.: U.S. Department of Health and Human Services. Turner, J.C., & TenHoor, W.J. (1978). The NIMH community support program: Pilot approach to a needed social reform. Schizophrenia Bulletin, 4, 319-349. Weiss, R.S. (1974). The provisions of social relationships. In Z. Rubin (Ed.), Doing unto others (pp. 17-26). Englewood Cliffs, NJ: Prentice-Hall.
Social Support and Quality of I Jife of Community Support Clients Frank Baker, Ph.D. David Jodrey, Ph.D. James Intagliatc~ Ph.D.
A B S T R A C T " Two aspects of social support, availability a n d adequacy, were assessed for 729 severely m e n t a l l y ill adults enrolled in seven state-supported C o m m u n i t y Support Services (CSS) programs as part of repeated q u e s t i o n n a i r e surveys n i n e m o n t h s apart. Perceived q u a l i t y of life interviews with the clients were also conducted at both times. These interviews included the B r a d b u r n Positive and Negative Affect Scales a n d the Satisfaction with Life Domains Scale (SLDS). A v a i l a b i l i t y of social support was significantly correlated with positive affect over time, b u t not with negative affect at either point. Inadequacy of social support was significantly related to negative affect at both assessments. Both a v a i l a b i l i t y a n d adequacy of social support were significantly related to the SLDS at each time. Change i n satisfaction with life domains was found to be related to both availability and, to a lesser degree, with adequacy of social support.
Social support has been recognized for some time as an important part of programs for maintaining the severely mentally ill in the community (President's Commission on Mental Health, 1978; Turner & TenHoor, 1978). A number of states, stimulated by the availability of limited funds from the community support program at the National Institute of Mental Health (NIMH), developed their own community Dr. Baker is Professor of Health Psychology and Dr. Jodrey is a Postdoctoral Fellow in Health Psychology in the Department of Environmental Health Sciences, School of Hygiene and Public Health, The Johns Hopkins University, 615 N. Wolfe Street, Baltimore, MD 21205. Dr. Intagliata is a management consultant in Oak Park, IL. The authors gratefully acknowledge the help of Robert S. Weiss, Harry Straus and David Mandel in the collection and analysis of the data reported here. The data were obtained as part of an evaluation of the New York CSS program funded by a contract between the New York State Office of Mental Health and the Psychotechnical Applied Research Organization, Inc. of Buffalo, NY. Additional funding for the analysis of the data was provided by a grant to the first author from the New York State Health Research Council (HRC 15-074). 397
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support systems. These community support programs are seen as providing a necessary supplement to the natural support systems available to the chronically mentally ill in the community. The nature of this social support and its importance for the adjustment of mental patients in the community have been the subject of a number of papers, (e.g. Baker & Weiss, 1984; Beels, 1981; Cohen & Sokolovsky, 1978; Coyne & Downey, 1991). Healthy People 2000 (1990), which contains a national strategy for improving the health of the nation over the course of this decade, states that more adults who are disabled by severe, persistent mental disorders would benefit from enhanced social support through the use of community support programs. Quality of life has gained significant recognition as an important mental health service outcome which includes both objective and subjective components (e.g., Baker & Intagliata, 1982; Bigelow, Brodsky, Stewart, & Olson, 1982; Bigelow, McFarland, & Olson, 1991; Lehman, Ward, & Winn, 1982). A number of studies have related perceived quality of life or psychological well-being to the nature of available social support systems (Andrews, Tennant, Hewson, & Vaillant, 1978; Greenblatt, Becerra, & Sarafetinides, 1982; Henderson, 1980; Henderson, Byrne, Duncan-Jones, Adcock, Scott, & Steele, 1978; Miller & Ingham, 1976). In an earlier article, Baker and Intagliata (1982) pointed out the importance of considering perceived quality of life of chronic mental patients living in the community. This paper reports the results of a larger study which builds on this earlier pilot work. The two aspects of social support examined in the present study were originally identified in research based on the conceptualization of social support spelled out by Weiss (1974) in his theory of the basic social provisions that all individuals require. In a study of mental health and social support, drawing on this theory, Henderson, Duncan-Jones, Byrne and Scott (1980) found that there were two separate dimensions of social support: the availability for an individual of various types of social relationships, and the perceived adequacy of these relationships. This paper relates these dimensions of social support to perceived quality of life.
METHOD Subjects A stratified random sample of 844 individuals who had a history of psychiatric illness and who were being served in seven programs in upstate New York constituted the subjects of the study. The CSS program sites included state hospitals, a community
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mental health center, and other nonstate agencies funded by contract with the state for community support services. The sample was comprised of 54.1 percent females and 45.9 percent males. The ages of patients ranged from 18-89 years with a mean of 52.3 years (SD = 16.9). A majority, 56.0 percent, had never been married, 9.5 percent were currently married, and 34.5 percent were married at one time but were presently divorced, separated or widowed. With regard to education, 31.7 percent had attended eight or less grades of school, while 44.4 percent were at least high school graduates. In terms of primary psychiatric diagnosis, 62.9 percent were diagnosed as schizophrenic, 10.1 percent as having affective disorders (depression, anxiety), 7,0 percent as having organic mental disorders and the remaining 20% were distributed among various other diagnostic categories. A more detailed description of this sample of CSS clients has been published previously (Baker & Intagliata, 1984).
Questionnaire Administrations The data on which this paper is based were collected as part of an external program evaluation of the New York State community support system conducted by the authors and their colleagues (Baker & Intagliata, 1983). The CSS evaluation project team trained the case manager in each of the sites in the completion of the questionnaires. Each case manager filled out the questionnaires on about 15 of their clients over a three-week period, with an on-site research assistant available to answer questions. When questionnaires were returned, they were edited, and in some cases were checked with the respondent for clarification or additional information. The questionnaires were administered again in 1982, about nine months after the first administration. Questionnaires with complete information were obtained for 729 clients (86.4%) at both the first and second administrations. All analyses reported in this paper are based on the data from these repeated questionnaires.
Measures Included in the questionnaires were measures of social support availability and social support adequacy completed by the case managers for each of their clients included in the study sample. Also included were two measures of perceived quality of life, a scale of psychological well-being and a scale of satisfaction with life domains which the clients responded to as part of an interview administered by their case managers.
Availability of Social Support Scale. The format of the items developed by Henderson et al. (1980) was used to generate items regarding the availability of key social relationships to CSS clients. The types of social linkages asked about in these questions were based on the major types of social bonds and relational processes identified by Weiss (1974). These seven items asked whether the client had: 1. 2. 3. 4. 5. 6. 7.
friends; contact with his/her immediate family; a relationship with other professional staff besides the client's case manager; a person that the client feels close to and has an ongoing relationship with; a group of people to which he belongs and among whom he has an assured place; a relationship which includes sexual activity; and any people who rely on the client's advice, support or assistance.
The coefficient alpha obtained in the initial administration of the seven-item Availability of Social Support Scale was .63.
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Adequacy of Social Support Scale. In the Adequacy of Social Support Scale seven parallel questions were asked about the client's feelings regarding the adequacy of these social attachments, including: how the client felt about the number of friends he/ she had, the client's satisfaction with the amount of contact that he/she had with immediate family members, the client's feelings about the level of his/her sexual activity, etc. The alpha obtained for the Adequacy of Social Support Scale was .69. The reliabilities for this scale and the Availability of Social Support Scale were equal to or greater than those reported by the Henderson group. For example, one of the members of that research group, Duncan-Jones (1978), reported that the best of their measures achieved an alpha-coefficient of the order of .7 while others were only .5 or lower. Bradburn Positive and Negative Affect Scales. The measures used to assess the client's sense of psychological well-being were the Positive and Negative Affect Scales developed by Bradburn (Bradburn, 1969; Bradburn & Caplovitz, 1965). Bradburn developed items which were intended as research measures of the mental health of individuals based on self-reports concerning their happiness, life satisfaction, or psychological well-being. One of the main products of this effort was a scale which consists of ten questions about the respondents' recent affective experiences, five positive and five negative. On the positive side, respondents are asked whether they have during the past two weeks felt particularly excited or interested in something, proud of having been complimented, pleased at having accomplished something, on the top of the world, or that things were going their way. The negative experiences which are probed deal with whether the respondent has felt too restless to sit still, lonely, bored, depressed, or upset because of criticism. These two five-item clusters are termed the Positive Affect Scale and the Negative Affect Scale. To the surprise of Bradburn and other researchers, the scores on these scales were found to be independent and to some extent seemed to be correlated with different variables. Bradburn (1969) saw negative affect scores as related '~primarily to variables that have been dealt with by the traditional 'mental illness' approaches" (p. 12). These particular variables showed no association with positive affect scores. Bradburn later theorized that people's feelings of psychological well-being were composed of two subjective feeling states, positive and negative affect, which could vary independently. He concluded that overall sense of psychological well-being was a function of the difference between one's levels of positive and negative affect. The items as a whole were labeled the Affect Balance Scale (ABS), with a single ABS score calculated as the difference between a person's scores on the positive affect scale and the negative affect scale. The ABS has been used widely as a measure of psychological well-being, (e.g., Campbell, 1981). Andrews and Withey (1976) confirmed the essential independence of the positive affect score and the negative affect score. In the current administration, the two subscales were scored separately. The alpha coefficient obtained for the positive affect items was .74 and for the negative items the alpha was .77. The positive and negative affect scores were not correlated. Satisfaction with Life D o m a i n s Scale The Satisfaction with Life Domains Scale (SLDS), a measure of respondent satisfaction with various life areas, was constructed by adapting the ~Taces" response format developed by Andrews and Withey (1976) to assess client's satisfaction regarding 15 life domains (Baker & Intagliata, 1982). Respondents to the SLDS are asked to indicate
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their feelings by choosing one of seven faces ranging from a t~smiley" face with a large upturned smile (scored 7) to a "frowning" face with a deeply downturned mouth (scored 1). The CSS clients were asked to pick the face that best represented their degree of satisfaction with the following life areas: 1. 2, 3. 4. 5, 6. 7. 8. 9. 10. 11. 12. 13. 14, 15,
Their house/apartment/place of residence. Their neighborhood as a place to live. The food they ate. The clothing they wore. Their health. The people they lived with. Their friends. Their relationship with their family. How they got on with other people. Their job/work/day programming. The way they spent their spare time. What they did in the community for fun. The services and facilities in their area. Their economic situation, The place they lived in compared with the state hospital.
A total score was calculated by summing the responses for the 15 items. The alpha coefficient for the SLDS was .84 and the mean item-total correlation was .47.
RESULTS Social Support: Patterns of Change Over Time Before discussing the relationships between social support and perceived quality of life, the patterns of change in the measures of social support will be examined.
Availability of Sources of Social Support: The pattern of availability of different types of social support at the time of the first survey is revealing. Of course, by being in the CSS program, all of the clients in the study had case managers assigned to them. However, the vast majority of clients apparently also had available other professionals to help them in addition to their case managers. About four-fifths of the sample had at least one friend available, and the majority had some contact with their immediate family members, and an assured place in some group. Slightly more than half of the clients had a close relationship with one other person. Somewhat less than half of the sample had other people dependent upon them for advice, support or assistance. Only about a fifth of the cohort were reported by their case managers to have had any relationship that may involve sexual activity.
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Adequacy of Sources of Social Support: Adequacy of social support was m e a s u r e d by asking for the case m a n a g e r s ' j u d g m e n t s of client satisfaction w i t h each of the same seven sources of social support considered above. The types of social support t h a t the clients initially r a t e d themselves as most satisfied w i t h included support from a professional other t h a n t h e i r case m a n a g e r s (82%), the n u m b e r of other people depending on t h e m (79%), and t h e i r extent of i n v o l v e m e n t w i t h a n o t h e r person (77%). The Adequacy of Social Support Scale, the sum of the seven items, showed significant i m p r o v e m e n t over time (t = 4.64, df = 604, p < .001). Apparently, case m a n a g e r s ' beliefs about the sufficiency of available social support improved across the i n t e r v a l b e t w e e n the two surveys.
Social Support and Client Characteristics Social support as m e a s u r e d by the methods was differentially r e l a t e d to client variables.
Social Support and Demographic Variables: The availability of social support, both at the times of the Wave I and W a v e II q u e s t i o n n a i r e surveys, was significantly r e l a t e d to gender. More m e n h a d a low availability of social support score across both surveys a n d more w o m e n h a d h i g h scores at the times of both surveys, while w o m e n w e r e more likely to improve and m e n w e r e slightly more likely to decrease in t h e i r availability of social support over the n i n e - m o n t h period b e t w e e n the surveys (x 2 (3) = 23.54, p < .001). The age of clients was significantly inversely r e l a t e d to availability of social support a v e r a g e d over the two periods of t i m e sampled in t h e CSS client questionnaires (x 2 (26) = 25.66, p < .05). The y o u n g e s t clients h a d the most social support available, and the oldest the least. Despite this difference y o u n g e r clients were significantly more likely t h a n older ones to be j u d g e d as feeling t h a t t h e i r social support was not a d e q u a t e at both times (x2 (12) = 79.5, p < .001). In t e r m s of change in social support adequacy over the n i n e - m o n t h period, t h e r e was little difference across age categories except t h a t a s o m e w h a t smaller proportion of clients over 65 years of age showed any change e i t h e r up or down. Social Support and Primary Diagnosis: Availability of social support was also significantly r e l a t e d to the client's p r i m a r y diagnosis (x 2 (15) = 38.83, p < .001). In general, schizophrenics and substance abusers w e r e
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likely to have less social support at the times of both surveys than were clients with a primary diagnosis of affective disorders. Further, clients with affective disorders were more likely to go from a low availability of social support to a higher availability than were clients with diagnoses of substance abuse or organic mental disorders. Clients with organic mental illness or substance abuse as their primary diagnosis were more likely than clients in all other diagnostic categories to go from a higher score on the availability of social support to a lower score over time.Adequacy of social support was also significantly related to psychiatric diagnosis (x2 (15) = 28.30, p < .05). When compared with clients in all other diagnostic categories, clients with affective disorders were more likely to be judged as seeing their social support as inadequate at both surveys and relatively fewer of them were likely to see their social support as highly adequate at both times. However, as compared to the other diagnostic groups, a larger proportion was also more likely to increase in their feelings of adequacy over time. The diagnostic group with the largest proportion of clients rated as satisfied with their level of social support was the group of clients with organic mental disorders as their primary diagnosis.
Perceived Quality of Life Findings The perceived quality of life measures, discussed below, were obtained directly from the clients by the case managers.
Responses to Positive and Negative Affect Scales: Table I presents the proportion of the CSS clients recalling positive and negative experiences at the two administrations of the Bradburn affect measures. Data from a 1978 national survey of the general population (Campbell, 1981) are included in this table for comparison purposes. The pattern of responses to the Bradburn scales of the whole group of 729 CSS clients is essentially similar to that of the subsample of 118 clients in an earlier paper (Baker & Intagliata, 1982). The proportions of clients in the present larger sample who agreed to each of the five Positive Affect Scale items were from 5 percent to 12 percent lower than the general population sample on four of the items. As with the earlier subsample, the whole CSS study group exceeded the national survey group in the percentage of respondents who had ~Telt on top of the world in the past few weeks." This may have reflected some confusion about the wording of this statement. By the time of the second administration of the positive items in 1982, however, the CSS
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TABLE 1 Comparison of CSS Client Cohort and National Survey Sample on Percentages of Yes Responses to Bradburn Scales of Positive and Negative Affect
1981
1982
National Survey* 1978
62
64
74
69
69
77
75 45 69
77 40 70
87 42 74
46
55
48
52 56 52
56 59 52
24 30 30
38 729
42 729
22 3,692
CSS Clients Items Positive Affect During the past few weeks have you ever felt: Particularly excited or interested in something? Proud because someone complimented you on something you had done? Pleased about having accomplished something? On top of the world? That things were going your way? Negative Affect So restless that you couldn't sit long in a chair? Very lonely or remote from other people? Bored? Depressed or very unhappy? Upset because someone criticized you? Number of cases
*These r e s u l t s of a n a d m i n i s t r a t i o n of the B r a d b u r n Affect Balance Scale to a n a t i o n a l s u r v e y sample are from Campbell (1981).
client study cohort had dropped down below the national sample in the proportion of clients who agreed with this item. Other items showed only slight variations over time. The total scale scores on the Positive Affect Scale were not significantly different over time. With regard to the Negative Affect Scale, as with the partial CSS client sample, the whole sample were much more willing than the
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national survey to indicate that they felt "lonely or remote from other people," "bored," "depressed or very unhappy," and "upset because someone criticized them." Initially, there was an indication that fewer of the CSS clients felt "so restless that they couldn't sit long in a chair" than the general population sample, but this increased by the time of the second interview to a proportion which was higher. Except for the item regarding feelings of unhappiness and depression, which remained the same, the proportions of agreement with the negative affect items increased over time. Although only the item '~feeling restless" was statistically significant when considered separately (x2 = 15.28, p < .001), the total score on the summed Negative Affect Scale showed a significant increase (F(1,615) = 4.97, p < .05).
Satisfaction with Life Domains Table 2 presents the pattern of CSS client responses to the other perceived quality of life measure used in this study, the SLDS. This may be compared to the results of an administration of similarly worded items to a national population sample (Andrews & Withey, 1976) as presented in a smaller sample pilot study. As reported in the pilot study (Baker & Intagliata, 1982), there is also in this larger sample a skewness in the distribution of SLDS responses with a clustering of responses at the positive end of the scale. Table 2 presents the means and standard deviations for the individual items that make up the SLDS. The mean item scores are significantly higher at the time of the second administration of the SLDS for the CSS clients' feelings about their neighborhood, their food, and their health. The item with the highest level of client satisfaction was the one comparing the place the clients currently lived in to the state hospital, and this remained high. This clearly represents a strong endorsement of deinstitutionalization from those who were deinstitutionalized. The most dissatisfaction was expressed regarding the clients' feelings about their economic situation and their relationships with their families, and this did not change significantly. The responses at the first interview were comparatively low regarding the clients' feelings regarding their health, but these improved to a significant degree. A comparison of the overall SLDS scale mean at time I (X = 5.38, SD = .91) and time II (X = 5.45, SD = .99) showed a small but statistically significant increase (t = 2.00, df = 600, p < .05).
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TABLE 2 M e a n s a n d S t a n d a r d D e v i a t i o n s o f C S S C l i e n t s to S a t i s f a c t i o n w i t h Life D o m a i n s S c a l e at F i r s t a n d S e c o n d I n t e r v i e w s 1
Life Domain Questions 1. Which face comes closest to expressing how you feel about your house/apartment/place of residence? **2. Which comes closest to expressing how you feel about this particular neighborhood as a place to live? *3. Which comes closest to expressing how you feel about the food you eat? 4. Which face comes closest to expressing how you feel about the clothing you wear? *5. Which comes closest to expressing how you feel about your health? 6. Which face comes closest to expressing how you feel about the people you live with? 7. Which comes closest to expressing how you feel about your friends? 8. Which comes closest to expressing how you feel about your relationship with your family? 9. Which comes closest to expressing how you feel about how you get on with other people? 10. Which comes closest to expressing how you feel about your job/work/day programming?
Interview I
Interview H
X1
SD1
X2
SD2
5.53
1.61
5.62
1.56
5.27
1.67
5.46
1.59
5.40
1.64
5.53
1.61
5.45
1.57
5.50
1.50
5.05
1.75
5.24
1.70
5.39
1.68
5.46
1.66
5.67
1.47
5.63
1.49
5.17
1.97
5.19
1.89
5.48
1.47
5.60
1.44
5.41
1.72
5.38
1.63
F r a n k B a k e r , Ph.D., et al.
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TABLE 2, Continued
Interview I
Interview H
X1
SD1
i 2
SD2
11. Which face comes closest to expressing how you feel about t h e w a y you spend y o u r spare time?
5.39
1.49
5.43
1.48
12. Which comes closest to expressing how you feel about w h a t you do in t h e c o m m u n i t y for fun?
5.23
1.59
5.20
1.54
13. Which comes closest to expressing how you feel about t h e services a n d facilities in this area?
5.51
1.47
5.50
1.44
14. Which comes closest to expressing how you feel about y o u r economic situation?
4.55
2.05
4.69
1.90
15. Which comes closest to expressing how you feel about t h e place you live now, c o m p a r e d w i t h the state hospital?
6.37
1.22
6.28
1.21
Life Domain Questions
1N ranges between 500 and 620 depending upon extent of missing data for individual items. *p < .05 **p < .01
Social Support and PQOL The two indices of social support differed in t h e i r relationship to t h e B r a d b u r n affect m e a s u r e s . The availability of various social relationships was significantly r e l a t e d to t h e client's self-report on t h e positive affect d i m e n s i o n of perceived q u a l i t y of life. This was t r u e both at t h e t i m e of t h e first s u r v e y (r 1 = .21, p < .001, n -- 657) a n d a t t h e second s u r v e y @2 = .25, p < .001, n = 636). However, t h e availability of social relationships was not significantly r e l a t e d to t h e dimension of n e g a t i v e affect (r i = .02, p = .33, n = 663; r 2 = .02, p = .31, n = 641).
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A reverse p a t t e r n was found for the scale of adequacy of social support and its relationship w i t h the two B r a d b u r n subscales. A significant negative correlation was found b e t w e e n adequacy of social support and negative affect (r I = -.32, p < .001, n -- 571; r 2 = -.29, p < .001, n = 640). This indicates t h a t clients who were j u d g e d as more satisfied w i t h t h e i r social support w e r e less likely to report negative affect. However, adequacy of social support was not significantly r e l a t e d to positive affect at the first or second a d m i n i s t r a t i o n of the measures. R e g a r d i n g the Satisfaction with Life Domains Scale, availability of social support was modestly but significantly correlated w i t h the total satisfaction scores at the first q u e s t i o n n a i r e a d m i n i s t r a t i o n (r 1 = .14, p < .001, n = 661) and at the second (r2 = .11, p < .01, n = 617). Adequacy of social support was also significantly r e l a t e d to SLDS at both waves (rl = .16, p < .001, n = 551; r 2 = .18, p < .001, n = 513). Some changes in PQOL m e a s u r e s were found r e l a t e d to the availability and adequacy of social support at both survey times. A l t h o u g h changes in negative affect were not r e l a t e d to the social support measures, positive affect and SLDS scores were. M a i n t e n a n c e of h i g h levels of social support availability at both data collection points was associated w i t h i m p r o v e m e n t s in positive affect (F(3,588) = 3.05, p < .05). The availability of social support was also found to be r e l a t e d to changes in SLDS scores, w i t h the g r e a t e s t increase in SLDS score occurring for clients who were initially low in available social support and t h e n increased in their social support availability score (F(3,587) = 5.37, p < .01). Levels of satisfaction w i t h life domains also increased significantly for clients who m a i n t a i n e d a d e q u a t e social support over both points in time (F(3,486) = 2.95, p < .05). The m a g n i t u d e of change for those whose adequacy of social support h a d increased was twice as large as the increase in life satisfaction for those whose social support adequacy h a d r e m a i n e d high.
SUMMARY AND DISCUSSION Both k i n and non-kin sources of social support w e r e j u d g e d to be available for the large majority of chronically m e n t a l l y ill clients enrolled in the state-supported c o m m u n i t y support programs participating in this study. Nevertheless, about h a l f of the clients r e m a i n e d dissatisfied w i t h the a m o u n t of social contact t h e y h a d w i t h t h e i r families and most w a n t e d more. P a r k s and Pilisuk (1984) also found t h a t kinship ties were central to the chronically m e n t a l l y ill in the community. Oppor-
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tunities for intimate social relationships, especially those including sexual activity, were more limited than other types of social relationships for the clients in our study. Nevertheless, the clients were seen by their case managers to be about as satisfied with this sphere of their social life as they were with less intimate social contacts. It is also important to consider opportunities that clients have for providing social support to others. Less than half of the sample were reported to have people dependent on them for advice, support, or assistance. While opportunities for providing social support to others were not available for over 50 percent of the New York State CSS clients, this was a proportionately better situation than Parks and Pilisuk (1984) found. In their study of formerly hospitalized psychiatric patients currently living in California board-and-care facilities, threequarters of their sample lacked opportunities for providing social support to others. Gender and age differences were found for social support. Women were judged to have more social support than men and were somewhat more likely to increase in social support availability over the study period. Younger clients were seen to have more social support at both times of the survey than older clients but were also less likely to feel that their level of available support was adequate. Primary diagnosis was significantly related to both availability and adequacy of social support. This study found important differences in the various measures of perceived quality of life employed. While demonstrating some of the same positive response bias shown by normal populations, the chronically mentally ill respondents in this study showed less positive affect and more negative affect than a national population sample. Across the two points in time at which these measures were collected for the chronic mental patient sample, no overall change in positive affect was seen. However, there was a slight but significant increase in negative affect observed. At least in terms of these affect measures, no improvement was demonstrated that would indicate an enhancement in client affect as a result of sheer time spent in the CSS program. Of course, to clearly observe the specific effects of receiving needed services would require a finer examination of service variables as they relate to change in these measures of perceived well-being. With regard to the other measure of perceived quality of life, the Satisfaction with Life Domains Scale items also showed a preponderance of responses at the satisfied end of the scale, a characteristic of such measures as noted above. However, the CSS clients showed a significant improvement in their SLDS total scores, suggesting that this measure of perceived life quality which asks about satisfaction
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with specific life areas might be more sensitive to improvements in the clients' feelings about life than the Bradburn affect scales. At both times, scores on the SLDS measure were significantly related to both availability and adequacy of social support. Change in satisfaction with life domains was found to be related to both availability and, to a lesser degree, with adequacy of social support. Given that one of the primary goals of a community support system is to supplement the natural social network of chronically mentally ill individuals, the finding of this study that availability of social support is related to clients' evaluation of life domains is quite encouraging. Case manager judgments of available social support for clients can be regarded as "objective"; clients' own reports of positive affect and satisfaction with various domains of their lives were "subjective"; and these were clearly related. The more questionable judgment by the case manager of how adequate these social bonds were for the client also was found to be related to life domain satisfaction, but was not consistently correlated with positive affect. However, perceived adequacy of social support was strongly negatively correlated with negative affect. The differences between life satisfaction and affective state measures of PQOL may be due to the different dimensions that each taps. McKennell and Andrews (1983) have identified two components of PQOL. One of these they call cognition, which has to do with comparisons an individual makes of particular circumstances in his/her life compared to some standard of expectation. The other component that they identify is affect, which has to do with feeling state. The SLDS measures probably include both dimensions, while the Bradburn measures include only different aspects of affect, either positive or negative. Negative affect, in particular, has been considered more as a measure of pathology (Beiser, 1974) which one might not expect to change with the availability of social support, and which might be related to the kind of dissatisfaction with life implied in low subjective adequacy of social support judgments. The findings of this study are consistent with this hypothesis. Satisfaction with life areas may be more affected by the availability of social support, not only because specific aspects of one's life may be objectively improved by what one gets from social support, including, but not limited to, the opportunity to engage in social activities, but also because other people may provide a reference group for changed standards as to what is acceptable in different life areas. Clearly, however, both aspects of social support are important, and intervention aimed at this aspect of life has been shown to have measurable effects on the quality of life of this client population.
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