Community Mental Health Journal, Vol. 36, No.

3, June 2000

The Caregiver’s Perception

of Behavioral Disturbance in
Relatives with Schizophrenia:
A Stress-Coping Approach

Helene L. Provencher, Ph.D.

Jean-Pierre Fournier, M.D., FRCPC
Michel Perreault, Ph.D.
Jean Vezina, Ph.D.

ABSTRACT: This article suggests some theoretical orientations in studying behavioral

disturbance from a stress-coping perspective. First, an overview of Lazarus and Folk-
man’s cognitive theory of stress is presented. Secondly, some linkages are proposed
between the rating scales used to measure behavioral disturbance and the concepts of
this theory. Future research directions are then suggested to further explore the af-
fective, cognitive and behavioral responses related to the management of disturbing
behaviors.

The management of disturbing behaviors is a demanding task for the

caregivers of persons with schizophrenia (Lefley, 1996). Over the last
twenty years, several instruments have been developed to measure the
concept of behavioral disturbance (Provencher, Fournier, Perreault, &
Vezina, 2000). A variety of rating scales have been applied to a set of
patient behaviors, such as those evaluating the frequency and severity

Helene L. Provencher is Associate Professor, Faculty of Nursing, and Jean-Pierre Fournier is

Clinical Associate Professor, Department of Psychiatry, both at Laval University, Centre de Recher-
che, Université Laval-Robert Giffard. Michel Perreault is Research Associate at Douglas Hospital
and Assistant Professor, Department of Psychiatry, McGill University. Jean Vezina is a Professor,
School of Psychology, Laval University.
Address correspondence to H.L. Provencher, Ph.D., Faculty of Nursing, Laval University, Québec,
Canada, G1K 7P4; e-mail: helene.provencher@fsi.ulaval.ca.

293  2000 Human Sciences Press, Inc.

294 Community Mental Health Journal

of behaviors, the degree of being disturbed or feeling distressed by the

behaviors, or the extent of the perceived ability to cope with them. The
caregiver’s subjective evaluation of patient behaviors has recently been
emphasized in the development of new self-report measures on behav-
ioral disturbance, which is germane to stress-coping approaches.
Unfortunately, the mechanisms underlying the management of dis-
turbing behaviors still remain poorly understood from a stress-coping
perspective (Lazarus & Folkman, 1984; Pearlin, Mullan, Semple, &
Skaff, 1991). Although patient behaviors have been clearly identified as
stressors for the caregivers, the appraisal and coping processes related to
them have been overlooked in the caregiving literature. Another gap
has been the lack of attention in differentiating, from a stress-coping
approach, the variety of rating scales assessing patient behaviors. Link-
ing these different scales to the specific concepts belonging to the process
of stress-coping would provide a better understanding of the cognitive,
affective and behavioral responses to patient behaviors. In addition, the
identification of the scales sharing common theoretical linkages to the
stress-coping process would make comparisons across studies easier.
The goal of this paper is to propose some theoretical orientations to
the study of behavioral disturbance from a stress-coping perspective.
First, a brief overview of Lazarus and Folkman’s (1984) theory will be
presented. Second, some linkages will be proposed between the rating
scales of behavioral disturbance instruments and the theory concepts.
Finally, some future research directions on behavioral disturbance will
be suggested within this stress-coping theory.

LAZARUS AND FOLKMAN’S THEORY OF STRESS-COPING

Based on this stress-coping theory, stress is defined as “a relationship

between the person and the environment that is appraised by the person
as taxing or exceeding his or her resources and endangering his or her
well-being” (Lazarus & Folkman, 1984, p. 21). This cognitive-relational
definition of stress is based on two processes: cognitive appraisal and
coping. The appraisal and coping processes rely upon five major con-
cepts: event, appraisal, coping, immediate effects, and long-term effects.
These concepts and their interrelationships are shown in Figure 1.
The event corresponds to the occurrence of a potential stressor in the
person’s constructed reality. The perception of this encounter represents
the starting point of the appraisal and coping processes.The perceived
 Helene L. Provencher, Ph.D., et al. 295

FIGURE 1

Theoretical Model of the Stress-Coping Process

(Folkman, 1997; Folkman et al., 1991; Lazarus & Folkman, 1984)

frequency and severity of the encounter are relevant empirical indicators

of the event (Lazarus & Folkman, 1984).
The appraisal process brings meaning and emotional quality to the
encounter. This process is subdivided into two interdependent compo-
nents: primary and secondary appraisals. Through primary appraisal,
the person determines the significance of a specific encounter on his or
her well-being. The central issue for the person is to clarify “What do
I have at stake in this encounter” (Folkman & Lazarus, 1988, p. 310). An
encounter can be appraised as irrelevant, benign-positive, or stressful
(Lazarus & Folkman, 1984). Resulting from the primary appraisal, a
“potential” stressor may then be perceived as a “real” stressful one.
The secondary appraisal is concerned with the person’s evaluation of
the resources and options that are required for coping with the encoun-
ter. The main concern for the person is then: “What can I do? What are
my options for coping and how will the environment respond to my
actions?” (Folkman & Lazarus, 1988, p. 310). Therefore, the notions of
perceived ability to cope and changeability of the encounter are relevant
to the evaluation of secondary appraisal (Folkman et al., 1991).
The appraisal of the encounter is influenced by antecedent person
characteristics and environmental variables (Folkman & Lazarus,
296 Community Mental Health Journal

1988). The former corresponds to an array of variables, including psycho-

logical (e.g., values, beliefs, problem-solving skills), sociological (e.g.,
cultural background, socio-economic status), health (e.g., medical his-
tory), and contextual variables (e.g., family or sociopolitical conditions)
(Folkman et al., 1991). Environmental variables refer to the nature,
imminence, ambiguity and duration of the encounter and to the avail-
ability of resources to facilitate with coping (Folkman & Lazarus, 1988).
Among them are social resources (e.g., perceived social support), mate-
rial resources (e.g., person’s income), and institutional and political
resources (e.g., health care agencies, consumer groups) (Folkman et al.,
1991, 1994). Finally, an encounter first appraised as unchangeable or
stressful may be reappraised as changeable or benign, and vice versa
(Folkman et al., 1991). This is based on the assumption that the person
“constantly evaluates changes in the person-environment relationship”
(Folkman et al., 1991, p. 245). The process of reappraisal is then likely
to be influenced by changes in the person (e.g., acquisition of new skills)
or changes in the environment (e.g., lack of accessibility to support
services).
Coping is defined as the person’s constantly changing cognitive and
behavioral efforts to manage (master, reduce, or tolerate) an encounter
appraised as stressful (Folkman & Lazarus, 1985). Coping serves two
major functions: to regulate distress (emotion-focused coping) and to do
something to change for the better the stressful encounter (problem-
focused coping). Examples of emotion-focused forms of coping are using
social comparisons and doing relaxation exercises to make oneself feel
better. Examples of problem-focused forms of coping are problem-solving
strategies and seeking information. Neither emotion-focused or prob-
lem-focused forms of coping are superior in terms of their adaptative
values. However, when an encounter is appraised as unchangeable,
emotion-focused coping strategies are likely to be predominantly used.
In contrast, when an encounter is appraised as changeable, problem-
focused coping strategies are likely to be predominantly selected over
emotion-focused ones (Folkman et al., 1991).
Immediate effects and long-term effects are generated as the processes
of appraisal and coping unfold (Lazarus & Folkman, 1984). Immediate
effects are of two types, event outcome and emotion outcome. Event
outcome corresponds to the resolution of the encounter that results from
the coping process. Resolution can be favorable, unfavorable, or absent.
Emotion outcome refers to positive and negative emotion (Lazarus &
Folkman, 1984). Long-term effects refers to three major classes of adapta-
tional outcomes: social functioning, morale, and somatic health. Respec-
 Helene L. Provencher, Ph.D., et al. 297

tively, they correspond to effective, affective and physiological outcomes

(Lazarus & Folkman, 1984). Social functioning reflects “the effectiveness
with which the demands of a specific encounter are managed” (Laza-
rus & Folkman, 1984, p. 183). Morale corresponds to the “positive and
negative affect a person experiences during and after an encounter”
(Lazarus & Folkman, 1984, p. 183). Somatic health refers to the physio-
logical changes that are generated by the encounter.
A favorable resolution concludes the coping activity, and leads to
positive emotion (e.g., happiness) and beneficial long-term effects. In
contrast, an unfavorable resolution or no resolution, calls for additional
coping efforts and generates negative emotion (e.g., distress) and detri-
mental long-term effects (Lazarus & Folkman, 1984). Recent refine-
ments in the theory have been proposed taking into consideration the
role of positive psychological states in persons confronted with enduring
stressful situations (Folkman, 1997). Three additional pathways are
suggested for positive emotions in the stress-coping process. The first
and second pathways indicate that positive emotion is the result of a
new meaning attached to the coping situation, which is itself secondary
to unsatisfactory event outcomes (e.g., unfavorable or no resolution) or
negative emotion (e.g., distress). In the first pathway, meaning-based
coping consists in reframing the encounter into a positive perspective
(e.g., positive reappraisal), revisiting personal goals and planning coping
strategies that bring meaning through the enhancement of a sense of
personal control, and relying on spiritual beliefs and practices to find
existential meaning. The coping activity is directed to the encounter
itself and both problem-focused and emotion-focused strategies are used.
In the second pathway, meaning-based coping refers to reframing ordi-
nary events into meaningful and positive ones. The coping activity here
is directed to the relief of the distress provoked by the unfavorable
or no resolution of the encounter, and emotion-focused strategies are
predominantly selected.

LINKAGES OF BEHAVIORAL DISTURBANCE

INSTRUMENTS TO LAZARUS AND FOLKMAN’S THEORY
OF STRESS AND COPING

Based on this theory of stress-coping, behavioral disturbance is concep-

tualized here as a stress phenomenon in which the appraisal and coping
processes are central. More specifically, the concept of behavioral dis-
turbance can be re-defined as a person-situation transaction in which
298 Community Mental Health Journal

the patient behaviors are appraised by the caregiver as taxing his or

her resources and mobilizing his or her efforts to cope with them. The
specific context in which the management of the patient behaviors takes
place, is thus highlighted, which is congruent with the theory.
Guided by the theoretical definitions of the five concepts (Lazarus &
Folkman, 1984), three of them can be specifically linked to the rating
scales used to measure behavioral disturbance. The concepts of the
theory are: event, appraisal, and immediate effects. The rating scales
are those measuring the perceived frequency and severity of the patient
behaviors, the degree of being disturbed by the behaviors, the degree
of feeling distressed by the behaviors, and the extent of the perceived
ability to cope with the behaviors. The specific linkages between the
rating scales and the concepts of event, appraisal, and immediate effects
are represented in Table 1. Considering that two types of rating scales
have been frequently applied to the same set of behaviors in several
instruments, each instrument can thus be linked to more than one
theory concept.

Event

The scale of perceived severity of patient behaviors (Creer & Wing, 1975;
Platt, Weyman, & Hirsch, 1983) and the scale of perceived frequency
of patient behaviors (Barrowclough & Tarrier, 1987; Biegel, Milligan,
Putnam, & Song, 1994a; Biegel, Song, & Chakravarthy,1994b; Creer &
Wing, 1975; Gopinath & Chaturvedi, 1992; Hewitt, 1983; Hoult, Rey-
nolds, Charbonneau, Coles, & Briggs, 1981; Levene, Lancee, & Seeman,
1996; Mueser, Webb, Pfeiffer, Gladis, & Levinson, 1996; Reinhard, 1994;
Runions & Prudo, 1983; Szmukler et al., 1996; Tessler, 1989) can both
be linked to the concept of event. This is justified by the fact that
these two rating scales serve to document the “reality” of the encounter
(patient behaviors) as perceived by the caregiver. Because they do not
provide any information about the caregiver’s meaning of the patient
behaviors, they cannot be considered as an appraisal. Rather, they
are “plain” indicators of the caregiver’s personal observations of the
occurrence of patient behaviors.

Appraisal

Primary Appraisal. The extent of being disturbed by the patient

behaviors (Hatfield, 1978; Hewitt, 1983; Lefley, 1987; Levene et al.,
1996; Reinhard & Horwitz, 1995; Runions & Prudo, 1983; Wykes &
 TABLE 1

Linkages of the Rating Scales in Behavioral Disturbance Instruments to the Concepts of

Event, Appraisal, and Immediate Effects
Appraisal Immediate Effects
Event
Secondary
Primary Ability Positive Negative
Concepts Frequency Severity Stressfulness Changeability to Cope Emotion Emotion

Rating Scales Perceived Perceived Degree of None Ability to None Distress

Frequency Severity Cope
Disturbance
Instruments (#) #1, #3, #4, #6, #1, #5 #2, #4, #6, #7, #8 #5, #8,
#8, #10, #11, #9, #14 #11, #15
#12, #13,
#14,
#15, #16
#1. Questionnaire on Disturbing Behaviours (Creer & Wing, 1975); #10. Family Burden: Module on Behavioral Disturbance (Tessler, 1989)
#2. Survey on Disturbing Behavior Instruments (Hatfield, 1978) #11. Scale for Assesment of Family Distress (Gopinath & Chaturvedi,
#3. Questionnaire on Problematic Behaviors (Hoult et al., 1981) 1992)
#4. Schedule on Deviant Behaviour (Hewitt, 1983) #12. Client Behavioral Problems (Biegel et al., 1994a,b)
#5. Social Behavioural Assessment Schedule’s Section on Behavioural #13. Client Behavior Scale (Reinhard, 1994; Reinhard & Horwitz, 1995)
Disturbance (Platt et al., 1983) #14. The Perceived Family Burden Scale (Levene et al., 1996)
#6. Questionnaire on Problem Behaviors (Runions & Prudo, 1983) #15. Questionnaire on Burdensome Behaviors (Mueser et al., 1996)
#7. Social Behavioral Schedule (Wykes & Sturt, 1986) #16. Experience of Caregiving Inventory: Sections on Difficult behaviors
#8. Family Questionnaire (Barrowclough & Tarrier, 1987) and Negative Symptoms (Szmukler et al., 1996)
#9. Questionnaire on the Psychological Burden of Patients’ Behavior to
Families (Lefley, 1987)
300 Community Mental Health Journal

Sturt, 1986) can be linked to the evaluation of primary appraisal. Al-

though this scale does not specifically assess threat, challenge, or harm,
it does provide a cognitive evaluation of the stressfulness of the encoun-
ter through the evaluation of the disturbance that the caregiver is per-
ceiving toward his or her well-being, which is in accordance with primary
appraisal.

Secondary Appraisal. The linkage between the scale of perceived

ability to cope (with patient behaviors) (Barrowclough & Tarrier, 1987)
and the concept of secondary appraisal is rather obvious. The person’s
self-evaluation of his or her capacity to apply a particular coping strategy
or a set of coping strategies is effectively measured by this type of scale.
It does measure the caregiver’s perception of “what can be done,” which
is germane to secondary appraisal.

Immediate Effects

Negative Emotion. The extent of feeling distressed by specific pa-

tient behaviors (Barrowclough & Tarrier, 1987; Gopinath & Chaturvedi,
1992; Mueser et al., 1996; Platt et al., 1983) can be linked to the concept
of “immediate effects,” and more specifically to “emotion outcome.” This
type of scale has been used to measure the extent of perceived distress
in relation to each behavior displayed by the patient. It corresponds to
a “molecular level” of assessment of emotion, which is consistent with
Lazarus and Folkman’s (1984) view on short-term emotion outcomes.
In summary, most of the instrumentation in behavioral disturbance
has focused mainly on the subjective evaluation of the event itself (pa-
tient behaviors) in terms of its frequency or severity. Primary appraisal
has received some research attention through the evaluation of the
degree of disturbance. An important gap is the lack of valid and reliable
information on the secondary appraisal of patient behaviors. In addition,
the immediate effects have been mostly limited to the emotional distress
elicited by the patient behaviors. Thus, a narrow range of negative
emotions has been the target of behavioral disturbance instruments
while the positive emotions attached to those behaviors have been
largely ignored.

FUTURE RESEARCH DIRECTIONS

A large number of behavioral disturbance instruments are now available

to researchers (Provencher et al., 2000). The linkages of the available
 Helene L. Provencher, Ph.D., et al. 301

rating scales to concepts belonging to Lazarus and Folkman’s (1984)

theory provide a theoretical basis for distinguishing them. Depending
on the research aims, some guidelines will be offered for selecting those
instruments specifically linked to the concepts of event, appraisal, and
emotion outcome (see Table 1). Some future research directions will
also be suggested for a better understanding of behavioral disturbance
from a stress-coping perspective.

Event

For those whose study interest is in documenting the prevalence of

patient behaviors (event), the following instruments are appropriate:
#1, #3, #4, #6, #8, #10, #11, #12, #13, #14, #15, and #16. Although these
instruments do not measure the caregiver’s cognitive responses, they
do provide useful information about those specific behaviors that they
encounter. Additional work is needed to further explore the possible
multidimensional nature of perceived behaviors and to precise the ap-
praisal and coping processes related to behavioral categories (Proven-
cher et al., 2000).

Appraisal

Primary Appraisal. If the purpose is to target those patient behav-

iors that are significant to the caregivers (primary appraisal), then the
following instruments should be considered: #2, #4, #6, #7, #9, and
#14. Further research is necessary to verify the theoretical distinction
between the perceived frequency of behaviors (event) and their degree
of disturbance (primary appraisal). There is some empirical evidence
pointing out that the most frequent individual patient behaviors are
not necessarily the same as those that are perceived as most disturbing
(Provencher et al., 2000), thus possibly reflecting some differences in
their appraisal and coping processes. More research is also required to
compare valid and reliable categories of patient behaviors in terms of
their prevalence and level of disturbance.

Secondary Appraisal. The Family Questionnaire (Barrowclough &

Tarrier, 1987) is recommended for those investigating the perceived
ability to cope with the patient behaviors. Additional research is clearly
needed to better understand the role of secondary appraisal in the
management of disturbing behaviors. One possible avenue of research
is to explore the concept of efficacy expectations (Bandura, 1977) as
302 Community Mental Health Journal

part of the secondary appraisal (Lazarus & Folkman, 1984) and apply
it to disturbing behaviors. In particular, more knowledge is needed
about the efficacy expectations (e.g., “I am able to do the things needed
to cope with the behavior”) related to distinct categories of behaviors.
A second avenue of research is the systematic evaluation of the per-
ceived changeability of each patient behavior. While the patient’s own
perception of the changeability of his or her symptoms has been ad-
dressed in relation to coping strategies (Wiedl & Schöttner, 1991), this
dimension of secondary appraisal has been neglected from the caregiv-
er’s perspective. Its evaluation will allow for testing the assumption
that emotion-focused and problem-focused coping do vary in function
of the perceived changeability of the encounter (see Figure 1).
A third avenue of research is the study of causality, responsibility,
and blame attributed to the patient for the occurrence of disturbing
behaviors, as additional components of secondary appraisal. While
causal attribution corresponds to the “factors that produce an event,”
responsibility attribution implies a “judgment regarding an individual’s
accountability for the event,” and blame attribution refers to an “evalua-
tive judgment concerning the implicated individual’s liability for censure
(Bradbury & Fincham, 1990, p. 18). An orderly sequence, or entailment
process, has been suggested for the three types of attributions, that is,
a blame attribution presupposes a judgment of responsibility, which
rests upon the determination of causality (Bradbury & Fincham, 1990;
Shaver, 1985).
Lazarus and Folkman (1984) treated causal attributions as “cold cog-
nitions” and considered them as nonrelevant components of the ap-
praisal process. However, the caregiver’s efforts to understand the occur-
ence of the patient behaviors in identifying their related causes and in
determining the patient’s accountability and liability for sanction for
them are meaningful attempts to answer the fundamental question“why
are those behaviors happening?” The proposed entailment model for
the three types of attribution highlights, in particular, the caregiver’s
evaluative judgment about the patient behaviors, which is a major di-
mension in clinical interventions aimed at the effective management of
disturbing behaviors (Kanter, 1984).
Causal attributions have been investigated mainly in high and low
expressed emotion families. Relatives who considered the causes of prob-
lem behaviors to be personal to the patient and controllable by him
or her tended to be more critical and/or hostile toward the patient
(Barrowclough, Johnston, & Tarrier, 1994; Brewin, MacCarthy, Duda &
Vaughn,1991; Weisman, Lopez, Karno, & Jenkins, 1993). For behavioral
 Helene L. Provencher, Ph.D., et al. 303

categories, caregivers who interpreted the negative symptom behaviors

as part of the patient’s personality had the tendency to expect more
change from him or her and were more likely to use coercive strategies
(e.g., critical comments) to control these patient behaviors (Greenley,
1986; Harrison & Dadds, 1992; Hooley, 1987). Additional work is needed
to better understand the responsibility and the blameworthiness attrib-
uted to the patient for distinct categories of behaviors as well as to
verify the relevance of the entailment process within the specific context
of managing disturbing behaviors.

Immediate Effects

If the purpose of the study is to explore the negative emotional conse-

quences of patient behaviors on the caregivers (immediate effects), then
the following instruments are relevant: #5, #8, #11, and #15. More
consideration should be given to the assessment of a wider range of
stress emotions in relation to individual and categories of patient behav-
iors, such as anger, shame, sadness, disgust, anxiety, and sympathy
(Lazarus, 1993).

Middle-Range Theories on Behavioral Disturbance

The proposed conceptualization of behavioral disturbance as a person-

environment transaction puts a strong emphasis on the specific context
in which the caregiver is managing the patient behaviors. In this vein,
additional middle-range theories need to be tested taking into account
the antecedent person and environmental variables related to the ap-
praisal and coping processes. More specifically, some contextual ele-
ments of the caregiving relationships deserve more research attention,
including the type of caregiving relationship (e.g., parent, spouse, sib-
ling) (Jones, 1997), the co-resident caregiving (Seltzer, Greenberg,
Krauss, & Hong, 1997), the informal and formal social support perceived
by the caregiver and the patient (Estroff, Zimmer, Lachicotte, & Benoit,
1994; Greenberg, Sletzer, & Greenley, 1993), and the forms of care
practices (Chesla, 1991). Also relevant to both appraisal and coping
processes are the family and illness characteristics, such as family cul-
tural background (Stueve, Vine, & Struening, 1997), family life cycle
(Cook, Cohler, Pickett, & Beeler, 1997), age at the onset of the illness,
illness severity and duration of illness, and patient compliance to treat-
ment regimen (Cook et al., 1997; Lefley, 1996). The reappraisal of patient
behaviors also merits more consideration, especially light of its role in
304 Community Mental Health Journal

the development of resilience in caregivers and in the reshaping of

the coping situation into a more satisfying experience (Mannion, 1996;
Marsh et al., 1996). Finally, given that the theory of Lazarus and Folk-
man provides an intraindividual perspective of stress (Lazarus & Folk-
man, 1984), the interactional processes between family members in-
volved in the management of patient behaviors are better addressed by
theories that are more system-oriented, such as the Resiliency Family
Model (McCubbin & McCubbin, 1996).
In summary, although the concept of behavioral disturbance in schizo-
phrenia has been studied for more than two decades, its development
has been somewhat atheoretical. The theory of Lazarus and Folkman
is of heuristic value for uncovering the complex caregiver’s responses
to behavioral disturbance in relatives with schizophrenia. Additional
empirical work is required to better understand the appraisal and coping
processes related to patient behaviors from the perspective of the care-
giver.

REFERENCES

Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall.

Barrowclough, C. Johnston, M., & Tarrier, N. (1994). Attributions, expressed emotion, and patient
relapse: An attributional model of relatives’ response to schizophrenic illness. Behavior Ther-
apy, 25, 67–88.
Barrowclough, C., & Tarrier, N. (1987). A behavioral family intervention with schizophrenia
patient: A case study. Behavioural Psychotherapy, 15, 252–71.
Biegel, D.E., Milligan, S.E., Putnam, P.L., & Song, L.Y (1994a). Predictors of burden among lower
socioeconomic status caregivers of persons with chronic mental illness. Community Mental
Health Journal, 30, 473–494.
Biegel, D.E., Song, L.Y., & Chakravarthy, V. (1994b). Predictors of caregiver burden among support
group members of persons with chronic mental illness. In E. Kahana, D.E. Biegel, & M.L.
Wykle (Eds.), Family Caregiving Across the Lifespan (pp.178–215). Thousand Oaks, CA: Sage.
Bradbury, T.N., & Fincham, F.D. (1990). Attributions in marriage: Review and critique. Psychologi-
cal Bulletin, 107, 3–33.
Brewin,C.R. MacCarthy, B. Duda, K., & Vaughn, C.E. (1991). Attribution and expressed emotion
in the relatives of patients with schizophrenia. Journal of Abnormal Psychology, 100, 546–554.
Chesla, C.A. (1991). Parents’ caring practices with schizophrenic offspring. Qualitative Health
Research, 1, 446–468.
Cook, J.A., Cohler, B.J., Pickett, S.A., & Beeler, J.A. (1997). Life-course and severe mental illness:
Implications for caregiving within the family of later life. Family Relations, 46, 427–436.
Creer, C., & Wing, J.K. (1975). Living with a schizophrenic patient. British Journal of Hospital
Medicine, 7, 73–82.
Estroff, S.E., Zimmer, C., Lachicotte, W.S., & Benoit, J. (1994). The influence of social networks
and social support on violence by persons with serious mental illness. Hospital and Community
Psychiatry, 45, 669–679.
Folkman, S. (1997). Positive psychological states and coping with severe stress. Social Science
Medicine, 45, 1207–1221.
Folkman, S., Chesney, M.A., Cooke, M., Boccelari, A., & Colette, L. (1994). Caregiver burden in
HIV-positive and HIV-negative partners of men with aids. Journal of Consulting and Clinical
Psychology, 62, 746–756.
 Helene L. Provencher, Ph.D., et al. 305

Folkman, S., Chesney, M., McKusick, L., Ironson, G., Johnson, D.S., & Coates, T.J. (1991). Translat-
ing coping theory into an intervention. In J. Eckenrode, The social context of coping (pp.
239–260). New York: Plenum.
Folkman, S., & Lazarus, R.S. (1985). If it changes it must be a process: study of emotion and coping
during three stages of a college examination. Journal of Personality and Social Psychology, 48,
150–170.
Folkman, S., & Lazarus, R.S. (1988). The relationship between coping and emotion: Implications
for theory and research. Social Science and Medicine, 26, 309–317.
Gopinath, P.S., & Chaturvedi, S.K. (1992). Distressing behaviour of schizophrenics at home. Acta
Psychiatrica Scandinavica, 86, 185–188.
Greenberg, J.S., Seltzer, M.M., & Greenley, J. (1993). Aging parents of adults with disabilities:
The gratifications and frustrations of later-life caregiving. The Gerontologist, 33, 542–550.
Greenley, J. (1986). Social control and expressed emotion. Journal of Nervous and Mental Diseases,
174, 24–30.
Harrison, C.A., & Dadds, M.R. (1992). Attributions of symptomatology: An exploration of family
factors associated with expressed emotion. Australian and New Zealand Journal of Psychiatry,
26, 408–416.
Hatfield, A.B. (1978). Psychological costs of schizophrenia to the family. Social Work, 23, 355–359.
Hewitt, K.E. (1983). The behaviour of schizophrenic day-patients at home: An assessment by
relatives. Psychological Medicine, 13, 885–889.
Hooley, J. M. (1987). The nature and origins of expressed emotion. In Hahwlweg, K. & M.J.
Goldstein (Eds.), Understanding major mental disorder: The contribution of family interaction
research (pp.176–194). New York: Family Process Press.
Hoult, J., Reynolds, I., Charbonneau-Powis, M., Coles, P., & Briggs, J. (1981). A controlled study
of psychiatric hospital versus community treatment—The effect on relatives. Australian and
New Zealand Journal of Psychiatry, 15, 323–328.
Jones, S.L. (1997). Caregiver burden: the experience of parents, children, siblings, and spouses of
people with mental illness. Psychiatric Rehabilitation Journal, 20, 84–87.
Kanter, J.S. (1984). Consulting with families of the chronic mentally ill. In J.S. Kanter (Ed.),
Clinical issues in treating the mentally ill (pp. 21–32) New directions for mental health research
(no. 27). San Francisco: Jossey-Bass.
Lazarus, R.S. (1993). Coping theory and research: Past, present, and future. Psychomatic Medicine,
55, 234–247.
Lazarus, R.S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.
Lefley, H.P. (1987). Impact of mental illness in families of mental health professionals. Journal
of Nervous and Mental Disease, 175, 613–619.
Lefley, H.P. (1996). Family caregiving in mental illness. Thousand Oaks, CA: Sage.
Levene, J.E., Lancee, W.J., & Seeman, M.V. (1996). The perceived family burden scale: Measure-
ment and validation. Schizophrenia Research, 22, 151–157.
Mannion, E. (1996). Resilience and burden in spouses of people with mental illness. Psychiatric
Rehabilitation Journal, 20, 13–23.
Marsh, D., Lefley, H.P., Evans-Rhodes, D., Ansell, V., Doerzbacher, B., LaBarbera, L., & Paluzzi,
J. (1996). The family experience of mental illness: Evidence for resilience. Psychiatric Rehabili-
tation Journal, 20, 3–12.
McCubbin, M.A., & McCubbin, H.I. (1996). Resiliency in families: A conceptual model of family
adjustment and adaptation in response to stress and crises. In H.I. McCubbin, A.I. Thompson &
M.A. McCubbin, (Eds.), Family Assessment: Resiliency, coping and adaptation: Inventories for
research and practice (pp. 1–64). Madison: University of Wisconsin System.
Mueser, K.T., Webb, C., Pfeiffer, M., Gladis, M., & Levinson, D.L. (1996). Family burden of
schizophrenia and bipolar disorder: Perceptions of relatives and professionals. Psychiatric
Services, 47, 507–511.
Pearlin, L.I., Mullan, J.T., Semple, S.J., & Skaff, M.M. (1991). Caregiving and the stress process:
An overview of conpets and their measures. The Gerontologist, 30, 583–594.
Platt, S.D., Weyman, A., & Hirsch, S. (1983). Social Behaviour Assessment Schedule (SBAS): The
schedule (3rd ed.). NFER-Nelson: Windsor, Berks.
Provencher, H.L., Perreault, M., Fournier, J.P., & Vezina, J. (2000). Instruments measuring behav-
ioral disturbance in relatives with schizophrenia. Community Mental Health Journal.
Reinhard, S.C. (1994). Living with mental illness: Effects of professional support and personal
control on caregiver burden. Research in Nursing and Health, 17, 79–88.
306 Community Mental Health Journal

Reinhard, S.C., & Horwitz, A.V. (1995). Caregiver burden: differentiating the content and conse-
quences of family caregiving. Journal of Marriage and the Family, 57, 741–750.
Runions, J., & Prudo, R. (1983). Problem behaviors encountered by families living with a schizo-
phrenic member. Canadian Journal of Psychiatry, 28, 382–386.
Shaver, K.G. (1985). The attribution of blame: Causality, responsibility, and blameworthiness.
New York: Springer-Verlag.
Seltzer, M.M., Greenberg, J.S., Krauss, M.W., & Hong, J. (1997). Predictors and outcomes of the
end of co-resident caregiving in aging families of adults with mental retardation or mental
illness. Family Relations, 46, 13–22.
Stueve, A., Vine., P., & Struening, E.L. (1997). Perceived burden among caregivers of adults with
serious mental illness: Comparison of Black, Hispanic and White families. American Journal
of Orthopsychiatry, 67, 199–209.
Szmukler, G.I., Burgess, P., Herrman, H., Benson, A., Colusa, S., & Bloch, s. (1996). Caring
for relatives with serious mental illness: The development of the Experience of Caregiving
Experience. Social Psychiatry and Psychiatric Epidemiology, 31,137–148.
Tessler, R.C. (1989). Continuity of Care Residence and Family Burden. NIMH Grant No. MH
44683. Amherst: University of Massachusetts.
Weisman, A., Lopez, S.R., Karno, M., & Jenkins, J. (1993). An attributional analysis of expressed
emotion in Mexican-American families with schizophrenia. Journal of Abnormal Psychology,
102, 601–606.
Wiedl , K.H., & Schöttner, B. (1991). Coping with symptoms related to schizophrenia. Schizophrenia
Bulletin, 17, 525–538
Wykes, T., & Sturt, E. (1986). The measurement of social behaviour in psychiatric patients: An
assessment of the reliability and validity of the SBS schedule. British Journal of Psychiatry,
148, 1–11.