The impact of a substance abuse disorder on the well being of family caregivers of adults with menta by Emily Sandberg Gold

The Impact of a Substance Abuse Disorder on the Well-Being of Family Caregivers of Adults With Mental Illness •; Samue! A. MacMaster, Ph.D.

ABSTRACT. The impact that substance use has on an individual with mental illtiess has been documented; however, little is known about the impact that this may have for a family caregiver. Data was collected in a cross sectional study using mailed questionnaires to a convenience sample of family members of persons with mental illness (n — 110). Hierarchical linear regression analysis was used to determine the impact of substance use status upon four measures of well-being within a stress-coping model. The variables within the model were able to account for a significant proportion of the variance in each of the measures: perceptions of burden, depression, anxiety and physical health status (R^ ^ .419 to .202). However, substance use status was not a significant predictor in any of these equations. Symptomatology and a measure of specific social support were the most significant predictors of burden (^ — .345,, p < .001 and ß — .330. p < .001). Perceptions of caregiver burden were found to be the most significant predictor in each of the other three analyses iß = .515, p < .000; ß - .511, p < .000; ß = - . 5 7 1 , p < .000). Results

Samuel A, MacMaster is affiliated with the University of Tennessee, 193 Polk Avenue, Suite E-Rm. 261, Nashville, TN 37203 (E-mail: smacmast@ utk.edu). The author would like to thank his dissertation committee: David Biegel, Lenore Kola, Mark Singer, and Antoinette Graham of Case Western Reserve University. Journal of Family Social Work, Vol. 11(1) 2008 Available online at http://jfsw.haworthpress,com © 2008 by The Haworth Press, Inc. All rights reserved. doi: 10.1080/10522150802007311

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of this study suggest that substance use may not be as important as the other predictors included in the model in determining the well-being of family caregivers. KEYWORDS. Family caregivers., mental illness., stress-coping, substance use

Co-occurring substance abuse and mental health disorders affect a significant number of individuals (Kessler, Chiu, Demler, & Walters, 2005; Kessler, Nelson, McGonagle, Edlund, Frank, & Leaf, 1996; Reiger et al., 1990). This group of consumers has been typified by the seriousness of their problems when compared to other groups of consumers with mental illness (Caton, Wyatt, Felix, Grunberg, & Dominguez, 1993; Swofford, Kasckow, Scbeller-Gilkey, & Indrbitzin, 1996; Cuffel, 1992, 1993; Drake, McLaughlin, Pepper, & Minkoff, 1991; Drake, Rosenberg, & Mueser, 1996). The results of research on tbe caregivers of tbe mentally ill have borne out the tremendous objective and subjective burdens placed on family caregivers (Biegel, Song, & Chakravartby, 1994; Le単ey. 1996). The impact on families is usually conceptualized as a reaction to stress of caregiving. In tbis framework the ill family members' symptomatology bas an effect on the stress of caregiving, which in turn leads to the outcomes of burden and diminished subjective well being (Biegel, Sales, & Schultz, 1991; Grad & Sainsbury, 1963; Hatfield, 1978; Hoenig & Hamilton, 1966). Due to the significantly worse symptomatology that individuals with dual diagnosis present with, the impact on the family can be expected to be more significant than families with a member with only mental illness or substance abuse. Clark (1996) reports that the importance of relative caregivers to their ill family members in terms of support, both financial and emotional, cannot be ignored. Clark and Drake (1994) investigated the objective burden of expenditures of time and money by family caregivers on behalf of their family members with dual diagnoses. Dixon, McNary, and Lehman (1995) investigated the impact of substance abuse on family relationships from the consumers" perspective, comparing the survey results from dually diagnosed and singularly diagnosed psychiatric inpatients. Sciacca and Hatfield (1995) surveyed members of the Maryland

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Alliance for the Mentally III to determine family caregivers' problems and needs. Results of their exploratory survey found that family caregivers were most often concerned with the consumers' denial over the substance abuse problem and their health declines related to the substance abuse. This study focuses on the family caregivers of dually diagnosed individuals, those individuals with both substance abuse and mental health diagnoses. The purpose of this study is to explore the effects of the caregiving relationship on health and well being of family caregivers of dually diagnosed individuals, in comparison to the effects of the caregiving relationship on family caregivers of individuals diagnosed solely with a mental illness. This research will attempt to answer the following question: Is the substance abuse status (currently using, having a past history of use, or no history of use) of a family member with mental illness the most significant predictor of the physical and emotional well-being of family caregivers as compared with all other factors included in the stress-coping model? The Stress Coping

Paradigm

The specific model used in this study is based on the work of Biegel, Sales, and Schulz (1991). Within the model, the Stressor ofthe illness characteristics and symptomatology ofthe family member with dualdiagnosis will be used. The central concept of this framework is that the existence of mental illness and substance abuse in any family member serves as a source of stress to the family caregivers, which in turn has an impact on their well-being. Within this framework the independent variables, or Stressors, impact the dependent variable of perceived stress, which in turn leads to the dependent variables of the enduring outcomes. This model also provides for the inclusion of conditioning variables, which can affect the various processes.

METHODOLOGY Research Design An exploratory non-experimental cross-sectional survey utilizing a convenience sample of family caregivers of adults with either dual diagnosis (co-occurring mental health and substance abuse disorders) or mental health disorder was used in this study. A standardized

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questionnaire consisting of primarily closed-end questions was used. This instrument utilized existing scales that have been used in previous research with family caregivers of persons with a mental health disorders and/or a substance abuse disorder and have acceptable levels of reliability and validity, or are closely based on such instruments. After all of the questionnaires had been returned, brief telephone surveys were conducted with a small sub-sample of the family members with a mental health disorder as a check on the validity and reliability ofthe family caregivers' responses to some sections of the questionnaire. Sample The sample of family caregivers was made up of persons who were a member of a support group in two cites, one in the Midwest and one in the Southeast, for family members of persons with mental illness in who provided social support to their relative (biological, marital or adoptive relationship) with a relative with mental illness. Data Collection

Procedures

Each member of the two support groups was mailed a handaddressed packet containing a self-administered questionnaire. All included scales that have either been used in previous studies with similar samples and have acceptable levels of reliability and validity, or the scales contained minor revisions of scales that have been used with similar samples and are amended for application to this study. This questionnaire had a green cover page, a stamped return envelope, and a letter outlining the use of the data and the risks involved in participating in the study, and the confidentiality of the data. Also included in these packets were two cover letters. The first cover letter was from the principal investigator that thanked the family caregiver for participating in the study, outhned the importance of the study, and explained that he is a student and this study is part of a dissertation. Each packet also contained a second letter of endorsement from the President of the specific group. Data Analysis All quantitative data was analyzed using SPSS statistical software. After the reliability had been determined for each of the scales, a

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series of hierarchical multiple regression analyses was used to test the use ofthe stress-coping model. A separate set of analyses was conducted for each of the four possible outcome variables in the framework (burden, depression, anxiety, and physical health status). The predictive value ofthe status ofthe family members' substance abuse diagnosis was used to assess the importance of this variable to the model after all other factors have been included. In this type of regression, each set of predictors adds a new set of variables that builds from the previous model. This allows for an understanding of each newly added set of variables' unique contribution to explaining the variance in the outcome variable, while controlling for the previously entered variables (Singer, Miller, Guo. Flannery, Frierson, & Slovak, 1999). The first set of predictors used in the application of this model included only caregiver demographics. This was followed by a regression analysis with a set of consumer demographics added to the model. Next, the regression was run a third time with illness characteristics and symptomatology included as predictors. An analysis that included the conditioning variables as additional predictors followed. Finally, the substance abuse status ofthe family member with mental illness was added to this regression equation. Changes in the value of the R squares were noted with the significance of the partial F test being used for the decision rule in testing the hypotheses.

RESULTS Sample Description One hundred and ten surveys were completed and returned, representing 25.7% ofthe overall sample of 433 members in both support groups. Caregiver Demographics Respondents primarily identified themselves as Caucasians (98.2%), parents (76.1%), married (74.3%). female (72.5%), and living alone or with their spouse (62.3%). The average age of the sample was almost 60 years (m = 59.3, SD := 12.3). Most respondents (59.1%) had at least a college degree. The majority (57.6%) ofthe respondents reported family incomes above $40,000 and more than a third (36.4%) were above $60,000. The majority (86.9%) of respondents

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reported regular contact with their family member, seeing him or her daily or several times per week. Consumer

Demographics

The average age of consumers was 37 years of age (m = 37.1, SD = 10.8). Most consumers (91.7%) had completed high school and a significant portion (31.3%) ofthe sample had completed college. Most consumers (70%) had never been married, nor were most consumers (67.3%) currently working. Approximately two-thirds (67.3%) ofthe sample was male. The largest percentage of consumers (42.9%) lived with their family caregiver, however more than a third of the consumers (37.6%) lived in their own home or apartment. Diagnosis The existence of a mental health disorder was assumed, as all respondents had involved themselves with a support group due to their family member's mental illness. Almost all of the caregivers (97.3%) reported knowing their family member's diagnosis. Slightly more than half of the consumers (56.2%) were reported by their family caregiver to be diagnosed with either schizophrenia or schizoaffective disorder. Most of the remaining consumers were reported to have severe mood disorders (bi-polar disorder, or severe depression). Receipt of

Treatment

Almost all of the consumers (99.1%) were reported to have received mental health services, beginning at an average of age of approximately 22 years (M = 22.4, SD ^ 8.8). However there is a great deal of variability in the age at which mental health services were first received, as ages ranged from 4 to 65. However, this range is somewhat misleading as approximately two-thirds of the sample (66.1%) first received services between the ages of 16 and 25. A much smaller minority (20%) of the sample was reported to have received substance abuse services, starting at an average age of almost 22, with a range of 12 to 44. ÂĄÂĄÂĄness-Related

Problems

Almost all of the consumers (91.7%) had been hospitalized. The average number of hospitalizations was slightly more than five

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(5.4), with a range of 1 to 30. The average length of stay ofthe most recent hospitahzation was almost a month (m = 27.9 days), however most consumers (69.8%) were hospitalized for less than two weeks (three consumers who had been hospitalized for more than 90 days inflated the mean score). Slightly more than a quarter of the sample (26.8%) had been incarcerated. A slightly smaller number ofthe consumers (15.5%) had been homeless. The average number of episodes of homelessness was more than two (m = 2.1), with a range of one to seven; however, most consumers (57.1%) who had been homeless had only been homeless once. The average length of the most recent episode of homelessness was 17 days; again, this also appears to be somewhat inflated by outliers, as most consumers (72.1%) had been homeless for less than a month.

Mental Health Symptoms The Client Behavioral Scale was used to measure the existence and frequency of symptoms which are thought to be particularly burdensome. The 18-question scale is part of the Family Report Package (Macias & Solomon, 1996). Family caregivers were asked to report whether their family member had experienced any of the possible mental health symptoms over the past six months and, if a symptom had been experienced, how serious a problem it had been. The responses to these eighteen items were averaged, creating a ftve-point scale with a theoretical range of 0, or "no problems," to 4, or "mostly serious problem." This scale had a high degree of internal reliabihty in this study (Cronbach's Alpha â&#x20AC;&#x201D; .92). As a group, family members reported an average score of 1.47 (SD = .94), or an approximate score of between 1, "mostly minor," and 2, "sometimes minor," per item. However, there was a great deal of variability in scores, both in the range of overall scores (0 to 3.57), and in the variability among the eighteen symptoms. As a group "feeling guilty" was reported to be the least severe (m = 0.86) (and the only symptom that was reported below one), while "lacking energy" was reported to be the most severe (m = 2.23), followed by "depressed" (m = 2.11).

Substance Abuse Symptoms An amended version of the Family CAGE, developed by Frank, Graham, Zyzanski, and White ( 1992), was used to assess the substance abuse status of the family member with a mental health

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disorder. Family caregivers were also asked a global question: does your family member have problems with alcohol or other drugs? While traditionally, an instrument used for clinical screening, the CAGE has been utilized extensively in research and has been found to be reliable, the median internal consistency rehability across 22 samples was .74, with a range of .52 to .90 (Shields & Caruso, 2004). This scale also had a high degree of internal rehability (Cronbach's Alpha = .85). Ninety-six of the caregivers completed the instrument, and 49 of them recorded the existence of a substance use problem. Ten additional caregivers did not complete these four questions, but did write in the margin that their family member did not use substance and were coded as negative screens. A further measure of the substance abuse, whether it was ongoing or in the past, was determined by one question, asking if the substance use was continued. Ofthe 49 family caregivers reporting positive screen results, 18 (16.4%) reported that their family member continued to use substances. The positive screens were strongly correlated with a number of other measures of substance abuse status. A strong correlation was found with a global question asking whether the family member with mental illness had a substance use problem (.78, p < .0001) and whether the family member with mental illness had attended substance abuse specific 12-step meetings (.55, p < .0001) or substance abuse treatment (.49, p < .0001). A correlation was also found with questions asking about the family member's substance use history, including alcohol use (.63, p < .0001), marijuana use (.55, p<.0001), hallucinogen use (.37, p < .0001), cocaine use (.32, p < .002), and prescription drug use for non-medical purposes (.25, p < .02). Other questions about substance use history (heroin, inhaled substances and water intoxication) were not significantly correlated, which appears to be a function of the small number of family caregivers reporting these types of substance use by their family member (five or fewer in each category).

Specific Informal Social Support Informal social support specific to the caregiving situation was measured by a revised selection of eight items from the Interpersonal Support Evaluation List (ISEL) (Cohen & Holberman. 1983). These items were altered to measure social support specific to the caring of a family member with mental illness. This scale had an acceptable degree of internal reliability (Cronbach's Alpha = .799). As a group.

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family caregivers scored an average of 1.88 (SD = .62) on this scale, with a range of 1 to 3.5. This indicates that family members as a group reported a positive level of social support. Family members reported the most agreement with the statements about inclusion with their social support systems, i.e. that they were included by their circle of friends (m — 1.64, SD = .90) and that they are rarely not invited to functions because of their family member (m = 1.55. SD = .81). However, family caregivers reported the least agreement with the item that asked that, if they were sick, they could easily find someone to help them with their ill family member (m = 2.42, SD — 1.1). Four additional questions developed by Biegel and used in the Pilot Managed Care Research Project were also used to ascertain the level of available social support (Johnsen, Biegel, Shafran, & MacMaster, 2000). These four questions asked the family caregiver to respond to the following question for family, friends, neighbors, and agency professionals. This second scale, the Satisfaction with Social Support Scale, had an acceptable degree of internal rehability (Cronbach's Alpha ^ .78). Family members as a groups scored a mean of 2.34 (SD — .67) on this scale, indicating that they received slightly less than enough support from the four groups. Scores on these four items were strikingly similar. Means for the four items were within two tenths of a point of each other: family (2.37. SD = .84), friends (2.45, SD = .84), neighbors (m - 2.27, SD = .96) and professionals (m == 2.30, SD = .62). This scale was statistically significantly correlated with the measure of social support specific to caring for a family member with a mental illness (.638, p < .0001), suggesting that these two scales measure two similar constructs. Interestingly, the individual items from each scale were significantly correlated with the mean of the other scale.

Service Use Use of services by family caregivers was measured by a series of questions based on the format of the Treatment Service Review (TSR) developed by McLellan, Alterman, Luborsky, and Cacciola (1992). A nine-item service checklist based on the Treatment Service Review asked family caregivers to report how many days in the past month that they attended any of nine possible mental health, substance abuse or dual diagnosis services measured service use. Due to the nature of service use, it is highly unlikely that all of these items would

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be interrelated. The score is a total of the number of days that the family caregiver reported receiving services. Family caregivers reported attending services an average of 4.1 (SD — 8.67) days in the last month, however there was again a great deal of variability, as family members reported attending as few as 0 and as many as 60 days of services within the last month. More family members had discussions with a professional at a program not attended by their family member (n = 38) or at programs attended by family members {n = 31) and/or attended an NAMl meeting {n = 31). Conversely, only one family member reported attending a substance abuse specific service for his or her own needs. Relationships with

Professionals

Relationships with Mental Health Professionals was assessed using the Attitudes Towards Professionals sub-scale of seven questions that were developed as part of the Evaluating Family Experiences with Severe Mental Illness questionnaire (Tessler & Gamanche, 1992). The scale had a high degree of internal reliability (Cronbach's Alpha — .89). Family members scored a mean of 2.20 on this fourpoint scale, which is indicative of some satisfaction for this group of caregivers. However as with the other scales, there is considerable variability between family caregivers, as some family caregivers reported strong agreement with all ofthe items (n — 8), while others reported disagreement with all items (n = 2). Family members were most likely to respond positively with the item that suggested that mental health professionals had suggested that they had caused their family member's illness (m — 1.29, SD = .59) (this item was negatively scored). However, they were least likely to respond positively to the item suggesting that mental health professionals were always available when they needed them. Burden Caregiver Burden was measured using the Caregiver Burden Scale (Biegel, Milligan, Putnam, & Song, 1992). The scale consists of 29 items describing feelings related to their life and the care of their family members. The responses to these 29 items were averaged, creating a five-point scale with a theoretical range of 1, or "never." to 5, or "almost always." Higher scores indicated higher levels of perceived burden. This scale had a high degree of internal reliability

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(Cronbach's Alpha = .89). Family caregivers as a group scored a mean of 2.48 on this scaie, which translates to experiencing the items almost directly between "sometimes" and "rarely" on the five-point scale. As with all other scales there was considerable variation in scores among individuals, as scores ranged between 1 and 4.46. Depression The Center for Epidemiological Studies Depression Scale was used to assess the level of depression in family caregivers. This is a 20 item scale designed by Radloff (1977) to identify individuals at risk for depression. The responses to these 20 items were averaged, creating a four-point scale of 0, or "rarely or none of the time," to 3, or "mostly or almost all of the time." Higher scores indicate higher levels of depression. This scale had a high degree of internal reliability (Cronbach's Alpha = .886). Results of this scale are scored within a theoretical range of 0 to 60, and scores higher than 16 are indicative of risk for depression. Family caregivers as a group recorded a mean score of 14.1 (SD â&#x20AC;&#x201D; 9.5) on this scale, which is less than two points under the cutoff score. Importantly, more than a third (34.3%) of the respondents scored 16 or above on this scale and are considered to be at risk for developing clinical depression. As a group, family respondents scored a per item mean of .72, which translates to experiencing the items between less than one and one or two days in the past week. As with all other scales there was considerable variation in scores among individuals, as scores ranged between 3 and 42, or .15 and 2.1 on a per-item mean. Anxiety

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Anxiety was measured with a twenty-item sub-scale of the StateTrait Anxiety Inventory (Spielberger, Gorsuch, & Lushene, 1970). The State Anxiety portion of this Scale is designed to measure "apprehension, tension, nervousness, and worry, which increase in response to physical danger and psychological stress." The responses to these twenty items were averaged, creating a four-point scale with a theoretical range of 1, or "not at all," to 4, or "very much so." This scale had a high degree of internal reliability (Cronbach's Alpha ^ .94). Family caregivers as a group scored a per item mean of 1.91, which translates experiencing the individual items close to "somewhat."

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As with all other scales, there was considerable variation in scores among individuals, as scores ranged between 1 and 3.84.

Physical Health Status A single question developed by the National Center for Health Services Research was used to measure physical health status (Brook et al-, 1979). Family members scored a mean of 3.35, or slightly better than "good" on the five point scale of 5, or "excellent," to 1, or "poor." Scores on this scale were fairly well distributed, within a positively skewed normal curve, the mode and the median were both equal to three and the majority (83.5%) of the scores were within the three middle scores. The Stress-Coping Model and Variables Caregiver Outeomes

Predicting

The Stress-Coping Model was used as the framework for the identification of variables thought to predict the caregiver outcomes related to the research question (see Table 1). These 20 variables were divided into four categories; demographics variables, illness related variables, conditioning variables, and a measure of burden that is used only in the last three analyses. The demographic variables included: caregiver's age, caregiver's gender, caregiver's marital status (dichotomous variable of currently married vs. other), caregiver's income, caregiver's relationship to family member (dichotomous variable of parent vs. other caregiver), consumer's age, consumer's gender, consumer's housing situation (dichotomous variable of lives with caregiver vs. does not live with caregiver), consumer's employment status (dichotomous variable of working vs. not working), history of incarcerations (dichotomous variable of positive history vs. negative history), and history of homelessness (dichotomous variable of positive history vs. negative history). The illness-related variables included in the model were diagnosis (dichotomous variable of schizophrenia related diagnosis vs. other), number of hospitalizations, age of onset, and symptomatology. The three conditioning variables used were: specific social support, relationships with professionals, and service use. Finally, there was a single measure of burden and substance abuse status. Technically, an ordinal level variable such as substance abuse status is not always appropriate for inclusion in a regression model.

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This concern relates to the discreteness of the categories in ordinallevel data points. However, regression models are based on distributional assumptions for dependent and not independent variables. Substance abuse status in this model is used only as an independent variable. For the purposes of these analyses, the three possible categories of substance use, (no use, past history of use, and current use), were understood as a three-point scale. This allowed for the appropriate inclusion of the variable within the model. Intercorrelation among the predictor variables was examined prior to multivariate analyses. The correlations between two pairs of variables did warrant some consideration, as they are above .5. These two pairs of variables are caregiver's age and the relationship between the caregiver and the consumer (.528), and the age of onset of mental health problems and the consumer's age (.516). Although these correlations are high, i.e. above .5, these correlation values do not indicate a need to remove these variables, as they remain below .6, the standard cut-off for intercorrelation. Although none of the predictor variables needs to be removed based on intercorrelation, it is important to note the number of correlations that are statistically significant. Correlations with substance abuse status were statistically significant for four variables: caregiver's marital status, caregiver's income, consumer's gender and symptomatology. Several additional diagnostic tests were run to determine the possible existence of multicollinearity. This phenomenon was not found in the data by these analyses for the variables used in any of the four regression equations. Multicollinearity was first investigated with a visual inspection of the scatter plot of the standard residual and standard predicted values. Further diagnostic evaluations of multicollinearity were completed using VIF scores for all four equations. In all four analyses, all VIF scores were well below ten, the usual cut-off score for the determination of multicollinearity. VIF scores were consistent in all four analyses as they are based on the relationships among the variables. The highest VIF score (3.99) was found for the respondent's relationship with the consumer in all four analyses. Three other VIF scores were also above two, respondent's age, consumer's age, and burden; all other VIF scores were below two. Prior to the multivariate analyses, comparisons were also made using one-way analyses of variance (with dichotomous variables coded as dummy variables) to determine any potential differences

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based on substance abuse status. There were statistically significant differences on five of the variables: caregiver gender, consumer gender, number of hospitalizations, symptomatology and burden (see Table 2). Two of these variables, symptomatology and consumer gender, were also significantly correlated with substance abuse status. In each of the analyses, missing values were substituted with mean values. While dropping cases or variables are two other alternatives to the problem of missing data, neither of these methods was chosen for several reasons. Most importantly, mean substitution allowed for the inclusion of all cases in each ofthe analyses. This was particularly important in these analyses as the 110 cases represent a relatively modest sample. Mean substitution is also justified statistically, as it provides a more unbiased sample than the elimination of cases or variables. Cohen and Cohen (1983) report that a mean substituting procedure provides a more unbiased missing data solution, as missing values do not usually occur in random patterns and mean substituted data will not artificially inflate R"^ scores. Additionally, they further suggest that mean substitution is the most efficient process for dealing with missing data in hierarchical linear procedures, such as the ones used in this study. Impact of Substance Abuse Status on Burden The variables found in the stress-coping model were a significant set of predictors of caregiver burden (F = 5.133, p < .000). As a group, these 19 variables accounted for approximately 41.9% of the variance in the perception of burden scores for this sample of family caregivers (R" â&#x20AC;&#x201D; .419). Despite the overall good fit of the model, substance abuse status, (which was predicted to be the most significant predictor of burden), was a very poor predictor when all other variables were taken into account. The change in the F score contributed by substance abuse status was minimal (1.029) and the significance of the change was not significant (p < .313). In fact, the change in the F value brought on by the addition of substance abuse status was found to be the least significant of any of the four sets of predictors. Although the F score did increase, because it added another set of predictors to the equation there was no recordable change in the amount of variance that the equation could account for with substance abuse status as an additional variable (Change in Adjusted R^ - .000).

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Standardized regression coefficients or beta weights {ß) were used to compare the relative importance of variables in the model. Within the final model three individual predictors were found to be significant. The measure of symptomatology (/Î = .345, p < . 0 0 1 ) , the measure of specific social support {ß ^ .330, p < .001), and whether the consumer was employed (/i = -.208, p < .027) were significant predictors within the final model.

Impact of Substance Abuse Status on Depression The variables found in the final stress-coping model were a significant set of predictors of caregiver depression (F — 3.287, p < .000). As a group, these 20 variables accounted for approximately 29.6% of the variance in the depression scores for this sample of family caregivers (R~ = .296). Despite the overall good fit of the model, substance abuse status (which again was predicted to be the most significant predictor of depression), was a very poor predictor when all other variables were taken into account. The change in the F score contributed by substance abuse status was minimal (.294) and the significance of the change was not significant (p < .589). As with the previous hypothesis, substance abuse status was found to be the least significant of any of the other four sets of predictors in the final model. Although the F score did increase, because it added another set of predictors to the equation there was no actually a negative change in the amount of variance that the equation could account for with substance abuse status as an additional variable (Change in Adjusted R - - - . 0 0 4 ) . Standardized regression coefficients or beta weights (J?) were used to compare the relative importance of variables in the model Within the final model, three individual predictors were found to be significant. Within this model several individual predictors found within sets of predictors were extremely infiuential. Burden (^ = .515, p < .000), respondents' gender (female) {ß = -.215, p < .026), and relationship to family member (being a parent) (^ = - . 3 3 1 , p < .042), were all significant predictors within the final model.

Impact of Substance Abuse Status on Anxiety The variables found in the stress-coping model were a significant set of predictors of caregiver anxiety (F = 2.495, p < .002). As a group, these 20 variables accounted for approximately 21.5% of

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the variance in the anxiety scores for this sample of family caregivers (R^ - .217). Despite the overall good fit of the model, substance abuse status (which was predicted to be the most significant predictor of anxiety), was a very poor predictor when all other variables were taken into account. The change in the F score contributed by substance abuse status was minimal (.084) and the significance of the change was not significant (p < .773). Again, as with the previous two hypotheses, substance abuse status was the least significant of any of the sets of predictors. Although the F score increased, the addition of substance abuse status as a predictor actually decreased the amount of explained variance (Change in R^ = -.OO8) due to the inclusion of an additional predictor. Standardized regression coefficients or beta weights {ß) were used to compare the relative importance of variables in the model. Within the final model, three individual predictors were found to be significant. Within this model several individual predictors found within sets of predictors were extremely infiuential. Only burden {ß — .511, p < .000) was a significant predictor within the final model. Satisfaction with professionals also merits consideration, as it was also an important predictor within the final model (^ = -.214, p < .055), although only at the .10 level.

Impact of Substanee Abuse Status on Physieal Health Status The variables found in the stress-coping model were a significant set of predictors of caregiver physical health status (F = 2.376, p < .003). As a group, these 20 variables accounted for approximately 20.2% of the variance in the perception of physical health status scores for this sample of family caregivers (R" - .202). Despite the overall good fit of the model, substance abuse status (which was predicted to be the most significant predictor of physical health status), was a very poor predictor when all other variables were taken into account. The change in the F score contributed by substance abuse status was minimal (.653) and the significance of the change was not significant (p < .421). Although the F score increased because substance status increased the number of predictors in the equation, the overall amount of explained variance again decreased (Change in R ' = - . O O 3 ) . Standardized regression coefficients or beta weights {ß) were used to compare the relative importance of variables in the model. Within

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the final model, three individual predictors were found to be significant. Within this model several individual predictors found within sets of predictors were extremely influential. Burden (jS = -.571, p < .000), living situation (living with caregiver) (ß = —2.20, p < .028), and total family income (^ ^ 2.10, p < .046) were found to be significant predictors within the final model. A history of incarcerations {ß = -1.97, p < .060) and symptomatology {ß — 1.97, p < .085) were significant at the .10 level in the final model.

CONCLUSIONS

*•

This study provides a better understanding of the experiences of family caregivers of persons with mental illness than what is currently available in the professional literature. Despite the differences found in symptomatology and perceptions of caregiver burden, the presence of substance abuse had a limited impact on the physical and emotional well-being of family caregivers. Importantly, despite the limited impact of substance abuse status within the stress-coping model, the model itself did provide a considerable amount of explanative power for each of the caregiver outcomes. Within these models, the perception of burden was consistently the most significant predictor in the multivariate analyses of well-being, i.e., measures of depression, anxiety and physical health status. Gender and being a parent were also significant predictors of depression. Housing situation and income were also significant within the model for anxiety. The model for burden was accounted for significantly by measures of specific social support, symptomatology and employment status. There were differences on symptomatology in this study based on the status of the substance abuse problem; however these differences were found between the two groups reporting the past or current presence of a substance abuse problem. Consistent with the literature, this study found that symptomatology affected burden. Burden, in turn, had an effect on the enduring outcomes of depression, anxiety and physical health status. As with the results of other studies, diagnostic differences had a limited direct impact on the enduring outcomes. The results of this study are important. Despite a lack of support for most of the hypotheses of the study, there are important implications from the data that provide for a better understanding

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of the experiences of family caregivers of persons with mental illness. The frequency of a lifetime substance abuse problem, as reported by family caregivers, approached 50% among individuals with mental health problems. There are differences between family caregivers of adults with mental illness, based on the substance abuse status of their family member, specifically in measures of symptomatology and burden. The addition of a substance abuse problem was not found to have a profound effect on the well-being of family caregivers of persons with mental illness when the other variables in the stresscoping model are included. Finally, the use ofthe stress-coping model has been supported for conceptualizing the well-being of family caregivers of persons with mental illness, with and without a co-occurring substance use problem. The findings of this study have implications for decisions by social work clinicians working with families with a family member with mental illness. The results of this study underscore the importance of including the possibility of co-occurring substance abuse problems when making decisions in the area of mental health services, and when discussing service needs. Almost half of the sample (46.2%) was screened positive for substance abuse by information provided by their family caregiver. Given what is known about the impact that substance abuse has on the well-being of individuals with mental illness, the importance of including this information cannot be overstated. Although a causal relationship was not found between the well-being of family caregivers and substance abuse status, it would also be important for practitioners to also broach this subject in order to have a complete picture of the experiences of the person with whom they are working, as significant differences were found between the groups of family caregivers based on the substance abuse status of their family member. The theoretical implications ofthe results of this study, (i.e. the use of the stress-coping model), make an important contribution to the design and delivery of services. The results of this study suggest that the stress-coping model could be appropriately used to conceptualize the impact that the combination of both a mental health problem and a substance abuse problem have on family caregivers. From this perspective, family members are seen as possible allies in continuing the recovery of their family members. Deficits in well-being among family caregivers are then correctly conceptualized as being a product ofthe impact of their relative's illness and not as preexisting personality

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problems that have caused and/or exacerbated their relative's mental health and/or substance abuse problem(s). Over time it is possible that other personality deficit models, such as the concept of codependency, may come to be viewed as inappropriate as the schizophrenigenic family model for developing services to families of persons with co-occurring problems. As with any research the results of this study should be viewed cautiously. Primary to this study's limitations is the fact that the study is based on a cross-sectional design and casual inferences cannot be made from this data. In terms of internal validity many concepts rely on self-report data by proxy, i.e., the family caregivers are reporting on the various statuses of their relatives with mental illness. This is especially relevant for data related to the status of the relative's substance abuse problem, as this information is not always readily available to family caregivers. For the purposes of this study it could be suggested that the family caregivers' perceptions are almost as important as the true status of their family member on many of these measures. This also suggests that a more in-depth qualitative approach may be necessary in further investigations into these perceptions. The most significant limitation of this study is the relatively narrow scope with which these results can be generalized. Although data was collected in two metropolitan areas, the sample is not representative all family caregivers of persons with mental illness. All respondents were affiliated with a support group where the members tend to be more involved with their relatives with mental illness and have higher levels of socio-economic status than other groups of family caregivers. Within this particular sample, not only were respondents of relatively high SES, but they were also almost exclusively all Caucasian. Even within these confines, the results of this study may be additionally biased by the relatively low response rate, only slightly more than a fifth of all of the surveys were returned. One of the most important outcomes of this study is the implication for new related projects. Three types of research are suggested by the results of this study: continued cross-sectional surveys of family members of persons with mental illness as a primary diagnosis; continued cross-sectional surveys of family members of persons with substance abuse as a primary diagnosis; and more scientific longitudinal studies. Specifically, these new research projects would either use differing samples to provide a better understanding ofthe impact of a substance abuse disorder on family caregivers or they would provide

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the ability to make casual inferences about the existence or lack of a substance use problem. Either type of study would further the knowledge that has been created from the results of this study.

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