Differences in Daily Hassle Patterns Among California’s Seriously Mentally Ill Sheltered Care Residents

Abstract

The present study investigated the daily hassles of a severely mentally ill population in sheltered care facilities in California. The results show that financial problems, loneliness, boredom, crime, accomplishments, verbal and written expression, and health were their most frequent concerns, reflecting the life-style of a low income, socially isolated, population whose disability renders an active, upwardly mobile life difficult. Age, gender, racial, and residential status differences in the most frequent and most severe hassles were found with age differences being the most pronounced. Younger individuals reported more hassles than elderly individuals, the nature of their concerns focus more on social acceptance, while physical health issues were of greater importance for elders. Racial differences were second in prominence, with discrimination issues being high in the minds of minority members of the population. Sheltered care residents were less stressed by problems with crime and declining physical abilities and more stressed by problems with exploitation and confrontation than were community dwellers.

Stressors or “hassles” have been found to be associated with poor psychological and somatic health (DeLongis, Coyne, Dakof, Folkman, & Lazarus, 1982; Gruen, Folkman, & Lazarus, 1988; Lazarus, 1984). In vulnerability/stress models of severe mental disorder, exposure to stressful situations is seen as capable of triggering psychotic episodes and hence perpetuating the disability (Anthony & Lieberman, 1986; Bowers & Wing, 1983; Nuechterlein & Dawson, 1984; Strauss & Carpenter, 1977). The seriously mentally ill (SMI) tend to be particularly vulnerable to the impact of stress for they often lack the problem-solving and social skills needed to cope effectively with stressful situations (Hertz, 1984; Rochester, 1978; Spivak, Platt, & Shure, 1976). This study addresses the nature of stressors or “hassles” of the SMI in sheltered care (i.e., board and care, halfway houses, and family care homes) as opposed to stressors faced daily by other residents in other settings.

The nature of hassles people commonly face appears to be role-related and therefore varies from one population to another (Kanner, Coyne, Schaefer, & Lazarus, 1981). Not surprisingly, problems with boredom and social isolation have been reported by the SMI (Kearns & Taylor, 1989; Lehman, Ward, & Linn, 1982). In their comparison of the hassles experienced by a community dwelling SMI sample (n = 69) and a general population sample (n = 36), Miller and Miller (1991) found that the main difference between the SMI and the mainstream population was that the SMI reported too few things to do and loneliness as problems, whereas the mainstream population reported too many things to do and too many social obligations. Items of overlap among the 10 most frequently reported hassles between the two populations included: “doing chores”, “planning meals”, “making decisions”, “losing things”, and “not getting enough rest”. Such overlap reflects shared social characteristics and roles.

Demographics also seem important in hassles reports. For example, Folkman, Lazarus, and Pimley (1987) found that compared to elderly individuals, middle-aged individuals reported more hassles regarding finances, work, home maintenance, personal life, and family and friends. Women reported more hassles having to do with environmental and social issues than men.

No information regarding the impact of sheltered care placement on their experience of hassles has been reported for an SMI population. This study therefore addresses two questions (a) what are the hassles of the mentally ill? and, (b) how do demographic and residential status differences amongst the SMI affect the nature of their reported hassles?

Method

This study is part of a 10-year follow-up study of a probability sample of 393 SMI persons residing in 214 sheltered care facilities located in 157 census tracts throughout California (Segal & Aviram, 1978). The first set of data was collected in 1973 while the follow-up data were collected from 1983–1985. Data were collected via structured personal interviews. For further details on the sampling methodology, see Segal and Aviram (1978).

From 1983 to 1985 the residents were traced through both formal and informal sources. Of the 393 residents interviewed in 1973, 360 (91.6%) were located at follow-up (hereafter designated as 1983). Of these residents, 270 (75.0%) were alive and 90 (25.0%) were confirmed dead. Of the 270 residents located alive, 253 (93.7%) consented to be re-interviewed. However, 19 of these interviews were deleted due to questionable validity as a function of the participants’ extreme psychological disability. Thus, the sample consisted of 234 subjects. For further details on follow-up methodology, see Segal and Kotler (1992), Segal and Silverman (1993), and Silverman and Segal (1994).

To assess the problems of our SMI population, we used a list of daily hassles derived from the Hassles Scale (Kanner, Coyne, Schaefer, & Lazarus, 1981). We used 46 of the 117 items on the scale given that some of the original items had little relevance to this population (e.g., items dealing with work and home maintenance) coupled with the fact that other descriptive studies, as well as studies investigating health outcomes, have used a reduced number of items (Gruen et al., 1988; Delongis, Folkman, & Lazarus, 1988). Given that our interest was in what tends to be a source of chronic daily hassles for this population, a trait version of the items was used (Kanner et al., 1981). That is, we investigated the hassles that were typical for the person rather than those experienced in the last month (the state version of the scale). We first determined whether the hassle was present and then coded its severity. The severity of each hassle was rated on a four-point Likert Scale with zero indicating no hassle and three indicating an extremely severe hassle.

Results

Sample demographic characteristics in 1983 (n = 234) are summarized as follows: (a) 53% were male; (b) age ranged from 28–75 ($\overline{\mathrm{X}}=53.4$, SD = 12.4); (c) 53.6% were never married, 5.6% were married, and 40.8% were divorced, widowed, or separated; (d) 80.5% were Supplemental Security Income (SSI) recipients (e) 7.7% were employed; (f) 78.9% were white, 8.2% were black, and 12.9% were of other racial origin, primarily Hispanic; and (g) 55.6% resided in sheltered care facilities, 31.2% resided in the community (i.e., lived in their own or a rented house or apartment, with family, or in a hotel), 10.3% resided in nursing homes (i.e., licensed hospitals distinct from sheltered care homes), and 2.9% resided in state mental hospitals or an inpatient psychiatric ward. None of the participants were homeless.

Frequency of Hassles

A rank ordered list of the most frequently reported hassles is provided in Table 1. (Herein ranks are given in parentheses). Financial concerns (1, 7), loneliness (2), boredom (4), crime (5), accomplishments (3, 8, 10), verbal and written expression (6, 9), and health (11) were among their most frequently reported hassles. Little difference was found between the most frequently reported hassles and those found to be most severe, with the eight most frequent stressors also being considered the most severe. Items added to the 11 most severe hassles were health-related (12, 13) and being exploited (20). These results are consistent with other research on the SMI suggesting that the areas of their lives such individuals are least satisfied with include finances, unemployment, safety, and family and social relations.

Table 1.

Hassles Scale Rank Ordered for 1983 Residents

	Hassles by rank	% Hassled
1.	Rising prices of common goods	48.3
2.	Being lonely	44.7
3.	Troubling thoughts about future	42.3
4.	Too much time on hands	42.3
5.	Crime	39.5
6.	Filling out forms	39.2
7.	Not enough money for entertainment	39.0
8.	Regrets over past decisions	35.3
9.	Inability to express myself	35.0
10.	Concerns about getting ahead	33.5
11.	Declining physical abilities	33.5
12.	Smoking too much	33.3
13.	Physical illness	31.6
14.	Fear of rejection	31.4
15.	Concerns about owing money	31.1
16.	Trouble with reading, writing, spelling	31.1
17.	Too many interruptions	30.6
18.	Not enough money for transportation	30.2
19.	Fear of confrontation	29.9
20.	Being exploited	29.9
21.	Troublesome neighbors	29.2
22.	Difficulties seeing or hearing	29.1
23.	Concerns about new events	27.3
24.	Gossip	26.8
25.	Concerns with meeting high standards	26.6
26.	Inconsiderate smokers	24.9
27.	Concerns about bodily functions	24.2
28.	Concerns about inner conflicts	24.0
29.	Prejudice and discrimination	23.8
30.	Too many responsibilities	23.3
31.	Trouble with arithmetic skills	23.2
32.	Concern over the meaning of life	22.5
33.	Social obligations	22.4
34.	The weather	21.8
35.	Concerns about medical treatment	21.2
36.	Not getting enough rest	20.5
37.	Side effects of medication	20.0
38.	Nightmares	19.2
39.	Not enough time to do necessary things	18.9
40.	Financial dealings with friends	18.5
41.	Television	15.5
42.	Too many things to do	14.6
43.	Problems with my children	12.1
44.	Sexual problems–physical	10.7
45.	Legal problems	9.3
46.	Menstrual problems	4.7

Demographic Differences in the Frequency of Hassles

When looking at the most frequently reported hassles, the results in Table 2 reveal that there are differences as a function of demographic characteristics and residential status. As the participants get older, concerns with social pressures (e.g., fear of rejection) and self-expression tended to be replaced by physical health concerns. Whereas loneliness was the most frequently reported concern in the youngest and oldest groups, it was not among the top 11 concerns for the middle-aged group, which suggests that this group has greater social involvement. Another interesting difference was that the elderly reported fewer hassles than the younger groups. All of the top 11 hassles for the youngest group (range = 58.3%–42.5%) were reported with greater frequency than any of the top 11 hassles for the elderly group (range = 41.1 %–23.6%), while eight of the 11 hassles of the middle-aged group (range = 56.3%–36.5%) were more frequently reported than any of the concerns of the elderly. For females, physical health concerns tended to be more important than for males while self-expression problems tended to be less important. There were no differences between whites and the total sample which is not surprising given that nearly 80% of the sample was white. For blacks, problems with confrontation and neighbors were of greater concern than for the sample as a whole while money for entertainment and loneliness were of less concern. Other racial groups (primarily Hispanics) reported more differences in their concerns than blacks with five of the 11 hassles being different. These other minorities not only focus on troublesome neighbors but on concerns characteristic of immigrant groups (e.g., exploitation) and less educated groups (e.g., problems with arithmetic skills).

Table 2.

Differences in 11 Most Frequently Reported Hassles Relative to the Sample as a Whole

Change in top 11 hassles	Age
	30–45	46–60	61–75
Added	Fear of rejection Concerns with meeting high standards Smoking too much	Trouble with reading, writing, or spelling Physical illness Smoking too much	Physical illness Too many interruptions Difficulties seeing or hearing
Deleted	Concerns about getting ahead Filling out forms Declining physical abilities	Being lonely Inability to express myself Declining physical abilities	Filling out forms Inability to express myself Concerns about getting ahead
	Gender
	Female		Male
Added	Physical illness		Smoking too much Too many interruptions
Deleted	Inability to express myself		Concerns about getting ahead Declining physical abilities
	Race
	White	Black	Other
Added		Fear of confrontation Troublesome neighbors Trouble with arithmetic skills	Being exploited Troublesome neighbors Physical illness Smoking too much
Deleted		Not enough money for entertainment Being lonely	Crime Troubling thoughts about the future Regrets over past decisions Inability to express myself Concerns about getting ahead
	Place of residence
	Sheltered Care	Community	Nursing Homes
Added	Being exploited Fear of confrontation	Smoking too much Physical illness Fear of rejection	Concerns about owing money Physical illness Being exploited Trouble with arithmetic
Deleted	Crime Declining physical abilities	Inability to express myself Not enough money for entertainment Concerns about getting ahead	Filling out forms Regrets over past decisions Concerns about getting ahead Inability to express myself

With respect to residential status, sheltered care residents were less stressed by problems with crime and declining physical abilities, but more stressed by problems with exploitation and confrontation. For community dwelling residents, problems with physical illness, rejection, and smoking were of greater concern than for the total sample, while problems with self-expression, money for entertainment, and achievement were of less concern. Nursing home residents showed greater divergence from the total sample than either sheltered care or community residents, with four of their 11 concerns being different. As with the sheltered care group, concerns with exploitation were problematic, as well as physical illness, finances, and arithmetic skills.

In addition to looking at demographic differences in the 11 most frequently reported hassles, we also looked at age, gender, racial, and residential status differences in the reported frequency of all 46 hassles. The greatest number of differences (23 hassles) were by age (see Table 3). The general trend was for a greater percentage of the young (30–45) to report being hassled than the middle-aged (46–60), and a greater percentage of the middle-aged to report hassles than the elderly (60–75). This general trend was true for all hassles except: loneliness, side effects of medication, rising prices of common goods, and filling out forms.

Table 3.

Differences in Hassles by Age

		Young Middle-
	Hassle	(Y) (30–45) %	aged (M) (46–60) %	Elderly (E) (61–75) %	χ2 frequency	F severity
(1)	Troubling thoughts about the future	56.9	45.3	25.2	15.39*	4.59**	(Y > E)
(2)	Concerns about owing money	41.7	28.1	23.3	6.10*
(3)	Smoking too much	42.5	35.5	22.2	6.87*
(4)	Concern over the mean ing of life	34.7	18.8	13.7	9.93*	3.05*	(Y > E)
(5)	Loneliness	58.3	33.3	41.1	9.09*	4.80*	(Y > E)
(6)	Fear of confrontation	40.8	32.8	16.7	10.32*	5.07*	(Y > E)
(7)	Inability to express oneself	48.6	33.3	23.3	10.15*
(8)	Side effects of medication	24.3	27.4	9.6	7.88*
(9)	Fear of rejection	52.8	27.0	13.9	26.10***	12.83***	(Y > M > E)
(10)	Sexual problems – (Y > M > E) physical	22.5	6.3	2.8	16.41***	10.21***
(11)	Filling out forms	40.3	56.3	23.3	15.59***	4.82**	(M > E)
(12)	Being exploited	38.6	32.3	19.4	6.43*	5.38**	(Y > E)
(13)	Rising prices of common goods	54.9	54.7	36.1	6.58*	3.61*	(M > E)
(14)	Not getting enough rest	29.0	22.2	11.0	7.24*	3.73*	(Y > E)
(15)	Too many things to do	24.3	17.2	2.8	13.71**	6.65**	(Y & M > E)
(16)	Concerns with meeting high standards	42.9	25.4	11.4	17.77***	7.56***	(Y & M > E)
(17)	Trouble with reading/ writing/spelling	27.1	44.4	23.3	7.83*	7.56***	(M > Y & E)
(18)	Legal problems	15.7	9.5	2.8	7.07*	3.59*	(Y > E)
(19)	Not enough time to do necessary things	32.9	18.8	5.6	17.24***	5.84	(Y > E)
(20)	Concerns about inner conflicts	40.6	20.6	11.1	17.34***	7.00***	(Y > E)
(21)	Regrets over past decisions	46.4	36.5	23.6	8.05*
(22)	Concerns about getting ahead	41.4	44.4	16.4	14.90***	7.12***	(Y & M > E)
(23)	Prejudice and discrimination	31.4	28.6	12.3	8.34*	4.06*	(Y > E)
(24)	Not enough money for transportation					4.44*	(M > E)
(25)	Crime					3.27*	(M > E)

^*p < .05;

^**p < .01;

^***p < .001.

Racial differences were the next most common, as can be seen from Table 4, with seven of the 46 hassles being significantly different. In all cases, blacks reported being hassled with a greater frequency than whites or “other races” (e.g., Asian, Chicano, American Indian, or other).

Table 4.

Differences in Hassles by Race

	Hassle	White %	Black %	Other %	χ2 frequency	F severity
(1)	Troublesome neighbors	25.4	53.3	43.5	7.60*
(2)	Fear of confrontation	27.2	64.3	27.1	8.50*	3.51*	(B > W)
(3)	Financial dealings with friends	18.0	42.9	9.1	6.76*	8.72***	(B > W & O)
(4)	Gossip	25.9	53.3	18.2	6.23*	3.30*	(B > W)
(5)	Legal problems	8.4	26.7	4.5	6.06*
(6)	Concerns about inner conflicts	23.0	53.3	9.1	9.90**	3.86*	(B > W & O)
(7)	Concerns about getting ahead	32.3	60.0	18.2	7.18*	g 49***	(B > W & O)
(8)	Too many responsibilities					4.45*	(B > W)
(9)	Being lonely					5.36**	(B > W)
(10)	Inability to express self					4.008*	(B > W & O)
(11)	Concern with meeting high standards					4.96**	(B > W & O)
(12)	Regrets over past decisions					3.85*	(B > W & O)
(13)	Not enough money for transportation					5.21**	(B > W)
(14)	Prejudice and discrimination					3.34*	(B > W)
(15)	Concern over news events					6.84***	(B > W & O)

^*p < .05;

^**p < .01.

There were few significant differences when looking at gender or residential status other than previously noted.

Demographic Differences in the Severity of Hassles

In addition to examining demographic and residential status differences with respect to the frequency of reported hassles, we also looked at differences in the severity of hassles. Table 3 reflects age differences in severity of hassles. Differences in the frequency of reported hassles by age group outnumber differences in severity of the hassles.

Unlike age differences, however, in frequency and severity of hassles, Table 4 shows that racial differences in severity of hassles far outnumbered racial differences in frequency of hassles. Whereas there were seven hassles that were significantly different when looking at frequency, there were 13 that were different when looking at severity. As in the case of the frequency of hassles, blacks reported greater severity of hassles than whites or other races.

Finally, as with frequency of hassles, there were few significant differences when looking at the severity of hassles with respect to gender or residential status.

Discussion

In sum, the hassles reported by the SMI reflect the life-style of a low income, socially isolated, population whose disability renders an active, upwardly mobile life difficult. Demographic, residential status, and population differences were found. In addition to a tendency for younger individuals to experience more daily hassles than elderly individuals, the nature of their concerns focus more on social acceptance while physical health issues were more prominent in the minds of the elderly. Physical health problems were also of greater concern to female than male participants while discrimination issues were problematic for minority group members. Being exploited was high in the minds of the sheltered care and nursing home residents whereas fears of rejection were more troublesome for community dwelling participants. Physical health problems were also of greater concern to community and nursing home residents than sheltered care residents.

While this study found convergence between frequency and severity on the top eight hassles, none of the 10 most frequent hassles were identical to the 10 most severe hassles in the study by Miller and Miller (1991). Hence, our results support the general view that frequency and intensity are both good indicators of sources of daily stress and run counter to their conclusion that the severity rather than the frequency of hassles is a better predictor of what is critical to the SMI.

Although the findings on demographic and residential status differences suggest that the type of hassles experienced is to a large extent role-related and environmentally determined, the finding that the elderly SMI report fewer hassles than the younger groups is consistent with research on mainstream populations and indicates that developmental factors also play a role in the experience of hassles (Folkman et al., 1987). As these individuals age, they are less likely to perceive their environment as stressful and/or are better able to cope with the stressors they face. This suggests that involvement in intervention programs designed to improve the coping skills of the SMI may be particularly crucial for younger individuals and that these programs should take into account age-related differences in environmental perception. It is also possible that elderly SMI residents are less vocal about their hassles and may need more support before they express them.

The concerns reported by the SMI in this study yield targets for mental health professional intervention. The current emphasis on psychosocial rehabilitation for the SMI will aid in the alleviation of social isolation as well as improve communication skills. A focus in these programs on writing skills will help alleviate another source of stress for this population (e.g., filling out forms) as well as ensure that government benefits are not lost due to a failure to submit the appropriate paperwork. Enabling individuals to improve their verbal and written skills will also give them greater access to community resources. Involvement of former patients in the self-help movement is another means by which their social support network may be enhanced in addition to giving them a greater sense of accomplishment and control over their lives by having more input into their own care. The focus in these programs on greater social involvement and the acquisition of independent living skills will facilitate participation in activities within sheltered care facilities as well as the community, thus aiding in the reduction of problems with boredom.

Although nothing may be able to be done about the concerns regarding declining physical abilities, more emphasis on the delivery of preventive medical services and adequate interface between primary care and mental health care services may help address their concerns with physical illness. Such interface of services is particularly important for aging as well as community dwelling SMI persons given evidence indicating that the latter experience more health problems than residential individuals in sheltered care (Segal, VanderVoort, & Liese, 1993). Given their concern, coupled with substantial evidence that psychiatric populations are at increased risk for morbidity and mortality (Eastwood, 1975; Koranyi, 1977; Marticle, Hoffman, Bloom, Faulkner, & Keepers, 1987), better physical health care appears to be an important need for this population.

Additional emphasis also needs to be placed on insuring quality of care within residential treatment facilities so that concerns regarding exploitation among sheltered care and nursing home SMI residents may be eliminated or drastically reduced. Future research might explore this issue in greater depth so that specific policies can be developed.

Concerns regarding troublesome neighbors and confrontation with others are clearly high in the minds of minority members of this population. These concerns could be better addressed by furthering efforts to develop more appropriate matches between individuals and their environmental context. Previous research suggests that the placement of minority clients in largely segregated neighborhoods has many negative psychosocial effects (Segal, Silverman, & Baumohl, 1989). Hence, some environments may be better than others in enabling minority residents to develop socially supportive relations within their community context. Whenever possible, giving individuals a choice regarding where they want to live may help achieve a better person-environment fit. The ability of the prospective community dwelling resident to make an informed choice of an environment that will enable him/her to develop satisfying support networks could be enhanced with placement procedures that provide information on community residents and services. Similarly, for those in need of residential placement, information on the residential context would be beneficial for those who have some placement options.

During the past two decades we have seen major expansion in the self-help movement and greater emphasis on psychosocial programs aimed at enabling individuals to better cope with their daily life stressors, which appears to be of great support to this population (Goering, Wasylenki, Lancee, & Freeman, 1983). This chronicle of the daily hassles of the SMI provides documentation of the unique character of some of these concerns, especially as related to sheltered care placement. It helps validate current directions in the provision of care and lends support to the view that the client’s perspective is important to take into account in determining what kind of services will best meet their needs.