Interdependent Recovery of Adults with Schizophrenia: Asian American Consumer Perspectives of Family Involvement and Influence

Abstract

Objective

Family involvement is important in the recovery experience of culturally diverse adults with schizophrenia. However, little is known about the influence of family among consumers purported to have close family ties without regular contact. This study explored Asian American consumers ‘views about family relationships and participation in their recovery.

Methods

Secondary analysis of qualitative data from a larger project was conducted to explore family-related themes of eight Asian Americans receiving services from recovery-focused programs in urban Southern California.

Results

Most consumers described their family support as adequate while simultaneously reporting limited family involvement. Asia-born and U.S.-born Asian consumers varied in describing family support, suggesting providers consider nativity in culturally responsive service delivery.

Conclusions and Practice Implications

Families need not be present to affect the perspectives of Asian Americans receiving recovery-oriented services. The extent of family influences on recovery, beyond the initial determination of current family contact, requires further exploration.

Close examination of family involvement and influence among Asian Americans is important because this group disproportionately underutilizes mental health services (Abe-Kim et al., 2007) and family influences their help-seeking (Okazaki, 2000). Although substantial demographic variation exists among Asian Americans, mental illness stigma, psychological disorder prevalence (Takeuchi et al., 2007), and mental health service underutilization (Sue, Cheng, Saad, & Chu, 2012) are considered fairly ubiquitous, allowing for exploration of recovery experiences across Asian American consumers. Most studies recruited Asian immigrants served by ethnic-specific programs. This study examined family involvement and influence in the recovery process of Asian Americans receiving community-based psychosocial rehabilitation services.

Methods

This secondary analysis used qualitative data from a larger project exploring sociocultural issues in a purposive sample of ethnically diverse adults receiving community-based mental health services. All eight Asian American (Chinese, Filipino, Japanese, Korean, Taiwanese, and Vietnamese) participants (four women) with schizophrenia (without current substance use disorders) and recruited by caseworkers were included. Participant ages ranged from 28 to 60 years and education varied from 6th grade to college, with most reporting 12 years of education. According to medical charts, length of illness ranged from 2 to more than 30 years and participants lived in supervised or supported community housing, took antipsychotic medications, did not currently experience positive psychotic symptoms, and received public assistance. Asia-born consumers spoke English as their second language.

Semistructured in-depth interviews (approximately 1 hour) were audio recorded, transcribed, and translated (two Korean-language interviews) by bilingual master’s-level research assistants. Participants provided written informed consent and HIPAA forms under protocols of the university’s institutional review board and the county department of mental health’s research committee.

Data were analyzed using coding consensus, co-occurrence, and comparison (Willms et al., 1990). Transcripts were independently coded based on the interview guide and emergent themes. The final list of codes was constructed through a consensus of two investigators. Categories were further condensed into broad themes regarding family involvement or influence.

Results and Discussion

Family Involvement

Although all participants initially described close family connections, none lived with significant others, except for one person living with a partner, and all reported only occasional family contact. These living arrangements are inconsistent with those among Asian Americans participating in ethnic-specific mental health programs (Bae & Brekke, 2002).

Emotional support

The parents of the Asia-born participants were deceased. Descriptions of parental emotional support among the four U.S.-born Asians conveyed mixed messages, were brief, and lacked detail. One participant reported: “They are supportive. I call my parents every day. I ask them how they’re doing and they ask me how I’m doing. We talk about five, ten minutes and that’s it.” Another participant reported perceived support, but actual support appeared limited:

Sometimes I don’t see them until maybe two or three months later because they have their own lives. They’re really busy. But I know they love me and I know if I ever need their support, they be there for me, but they want me to learn how to grow up and be on my own too.

Two U.S.-born Asian participants described their sibling involvement as limited or ambivalent. “My step-sisters, I hardly ever see them because they have their own lives.” “My older sister, she’s married and I hardly ever see her.”

In contrast, Asia-born participants appeared to have more consistent contact, stronger emotional ties, and more satisfaction with siblings’ emotional support:

I have my brother and sister over there [in home country], but I do not see them in 20 or 30 years. They are always saying “come back and we will take care of you. Do not live in America alone. Do not worry; we will take care of you.

The nature of the relationships reflected ongoing, yet unequal, dependent ties between siblings and participants. An Asia-born participant illustrated the caregiving sibling role. “My brother wants to watch me close to him, so that I don’t fall into something else. If he doesn’t watch me, he doesn’t know how I am doing, so he prefers working with me.”

Financial support

All participants mentioned receiving financial support from family members: “My mom helps me with that; she says, ‘I’ll pay you.’” “They come and visit me at [the hospital], and they brought me money and goodies to relax me.”

Asian American cultural norms generally promote instrumental rather than emotional social support. Providing financial assistance (Kung, 2003), often reflecting feelings of obligation is common among Asian Americans.

Family Influence on the Recovery Process

Participants reported that psychiatric care, but not the experience of mental illness, was openly discussed with select family members. One participant said: “We don’t discuss the personal problem. … [My family asks] ‘How are you feeling? Are you sure you took all your medication? We worry about you.’” Families’ view of medication reportedly varied. One participant said, “They [sisters] have me take the medication. Ahh, they are telling me to take the medication.” In contrast, another participant noted: “My parents didn’t want me to take medication. … They thought there was nothing wrong with me. They told me to stop taking the medication.”

Participants described family involvement regarding hospitalization. One participant said: “They gave me the best doctors, the best hospitals and they’re very supportive.” In most regards, families reportedly deferred care responsibilities to professionals, especially psychiatrists. One consumer noted, “They [brothers] come and visit me at the hospital, but they let the doctor take care of me. They did not interfere.” Respect for authority figures combined with limited health literacy may contribute to dependence on professionals for most healthcare decisions.

Conclusions and Implications for Practice

Participants’ explanations for the relative lack of family involvement in their daily lives could be an effort to preserve family honor. Importantly, participants did not verbalize desire for more family involvement. Participants seemed more concerned about potential negative relational consequences of seeking more support (Kim, Sherman, & Taylor, 2008) and becoming a burden to their families. Further, findings revealed patterns of low-intensity and unequal dependent relationships between participants and some family members. Family involvement was largely related to care, rather than improving quality of life from involvement in education, employment, religious activities, or community engagement.

English-speaking Asian American consumers may not appear to need cultural modifications to treatment. Thus, subtle sociocultural issues and potential cultural strengths may be overlooked. Despite inclusion of consumers varying in acculturation and ethnicity, the sample size was small and may not be representative of all Asian American consumers in community-based care. Nonetheless, these descriptive findings informed suggestions for providers.

• Assess past and current family involvement and influence of consumers with limited family contact; families provide lifelong perspectives on consumers’ recovery preferences (Simich, Maiter, Moorlag, & Ochocka, 2009).

• Go beyond consumers’ initial comments and explore the nature and extent of family support. Conforming to cultural values, consumers may not initially report limited family support; exploration reveals perceptions of family involvement and influence.

• Use windows of opportunity (e.g., hospitalizations) to reengage families in the recovery process. For Asian Americans family is a safety net and likely to provide care during crises.

• Assess positive and negative family influence on recovery. Family can be supportive yet impede recovery by focusing on symptoms rather than meaningful quality of life.

Families need not be present to affect perspectives of Asian Americans receiving recovery-oriented services. Research should explore how families affect recovery processes and outcomes, considering practical issues such as duration, intensity, and circumstances of family involvement.

Table 1.

Self-Reported Family Contact among Asian American Adults with Schizophrenia

Sex	Age	Nativity	Frequency of in-person family contact	Involved family members
F	47	U.S.-born	A couple of times a year	Parents
M	32	U.S.-born	Every 2–3 months	Parents
M	44	U.S.-born	About once a year	Unspecified
F	28	U.S.-born	Every holiday	Mother
F	60	Asia-born	Once in a while	Siblings, niece
M	40	Asia-born	Rarely/none	Siblings
M	40	Asia-born	Once a month	Sibling (older brother)
F	50	Asia-born	1–2 times a month	Siblings (older sisters)

Note. For Sex, F = female, M = male.