The document discusses the definition and statistics of poverty in the United States, highlighting that the current 'absolute poverty line' is outdated and does not reflect the actual living costs families face today. It presents alarming data, including that 37 million Americans live below the federal poverty line and the severe disparities among different demographic groups, with poverty rates particularly high among children and minorities. Additionally, it emphasizes the impact of economic downturns on poverty levels, the ineffectiveness of social safety nets, and the connection between poverty and health, education, and environmental factors.

1. Since the 1960s, the United States Government has defined
poverty in absolute terms. This makes poverty more easily
measurable. The "absolute poverty line" is the threshold below
which families or individuals are considered to be lacking the
resources to meet the basic needs for healthy living; having
insufficient income to provide the food, shelter and clothing
needed to preserve health.A large percentage of the
governments poverty measurements depend on the price of food.
"Relative poverty" can be defined as having significantly less
access to income and wealth than other members of society.
Therefore, the relative poverty rate can directly be linked to
income inequality.Means relative poverty can decline if rich
people lose a lot of money.
The current poverty measure was established in the 1960s and is
now widely acknowledged to be outdated. It was based on
research indicating that families spent about one-third of their
incomes on food — the official poverty level was set by
multiplying food costs by three. Since then, the same figures
have been updated annually for inflation but have otherwise
remained unchanged.Yet food now comprises only one-seventh
of an average family’s expenses, while the costs of housing,
child care, health care, and transportation have grown
disproportionately. Most analysts agree that today’s poverty

2. thresholds are too low. And although there is no consensus
about what constitutes a minimum but decent standard of living
in the U.S., research consistently shows that, on average,
families need an income of about twice the federal poverty level
to meet their most basic needs.
Thirty-seven million Americans live below the official poverty
line.One in eight Americans now lives in poverty.A family of
four is considered poor if the family’s income is below
$21,027.One third of all Americans will experience poverty
within a 13-year period. In that period, one in 10 Americans are
poor for most of the time, and one in 20 are poor for 10 or more
years.
“One in eight Americans -- approximately 37 million people --
now live below the federal poverty line of $19,971 for a family
of four. (A woefully inadequate measure that is 42 years old and
fails to account for basic necessities.) That's 4.9 million more
people than in 2000 and the poverty rate for children is the
highest of all age groups. Nearly 60 million people live just
above the poverty line. Using the British standard of
measurement, approximately 30 percent of Americans --and 40
percent of American children -- are living in poverty.”
Eighteen percent of children are in poverty. 10.9 percent of
working-age adults (between the ages of 16 and 64) are in
poverty.9.7 percent of the elderly are in poverty. 13.8 percent of
females and 11.1 percent of males were poor
The white non-Hispanic poverty rate is 8.2%. The poverty rate
for African Americans is 24.5%. The poverty rate for Hispanics

3. is 21.5%. The poverty rate for Asian Americans is 10.2%.
Federal minimum wage is $6.55 per hour Some states and
localities have mandated a higher minimum wage Minimum
wage in Washington state is $8.55 Minimum wage in Kansas is
$2.65, for employees not covered by the Federal Fair Labor
Standards Act
Inequality has reached record highs. The richest 1 percent of
Americans in 2005 held the largest share of the nation’s income
(19 percent) since 1929. At the same time, the poorest 20
percent of Americans held only 3.4 percent of the nation’s
income.
*
Poverty in the United States is far higher than in many other
developed nations. At the turn of the 21st century, the United
States ranked 24th among 25 countries when measuring the
share of the population below 50 percent of median
income.While the United States has the second lowest long-term
unemployment rate in the developed world, it has the highest
percentage of children who are not likely to live to age 60 and
persons living on less than 50% of the national median income
and the third highest percentage of adults lacking functional
literacy skills.
Six years after the 2001 recession ended, there were 5.7 million
more poor Americans last year than in 2000.Poverty rates in
2007 were higher than in 2000 for both native-born (11.9 versus

4. 10.8 percent) and foreign-born residents (16.5 versus 15.4
percent).Average incomes for the bottom fifth of U.S.
households were lower in 2007 than in 2000 ($11,551 versus
$12,229), and average incomes for the next highest quintile
were also lower ($29,442 versus $30,353).
Even more sobering is the fact that the number of severely poor
is growing rapidly. In 1975 the severely poor were 30% of the
population in poverty. Today a dismaying 43% of persons in
poverty are severely poor by national standards. But more
embarrassing than the share of the poverty population truly poor
is the increase in the number of persons descending into severe
poverty. While the rate of new entrants moving into poverty is
somewhat stable, those who are becoming truly poor are
increasing at a rate 56% higher than the growth rate of new
entrants into poverty.”
As another sign that poverty is now climbing rapidly, food
stamp caseloads have increased dramatically in recent months,
rising by 2.6 million people or 9.6 percent between August 2007
and August 2008, the latest month for which data are available.
In 25 states, at least one in every five children is receiving food
stamps. Because monthly food stamp caseload data are
available long before the official Census poverty data for the
prior calendar year, rising food stamp caseloads are the best
early warning sign of growing poverty.
Like previous recessions, the current downturn is likely to cause
significant increases both in the number of Americans who are
poor and the number living in “deep poverty,” with incomes
below half of the poverty line. Because this recession is likely
to be deep and the government safety net for very poor families
who lack jobs has weakened significantly in recent years,

5. increases in deep poverty in this recession are likely to be
severe.
Already there are signs that the recession is hitting low-income
Americans hard. Between September 2006 and October 2008,
the unemployment rate for workers age 25 and over who lack a
high school diploma — a heavily low-income group —
increased from 6.3 percent to 10.3 percent. Yet low-income
workers who lose their jobs are less likely to qualify for
unemployment benefits than higher-income workers, due to
eligibility rules in place in many states that deny benefits to
individuals who worked part time or did not earn enough over a
"base period" that often excludes workers' most recent
employment.
The current recession already has pushed up the unemployment
rate from 4.9 percent in December 2007 to 7.6 percent in
January 2008. Alternative measures of the labor market paint a
bleaker picture. Almost one in seven workers — some 13.9
percent of all workers — are unemployed, involuntarily working
part time, or are jobless and available for work but have grown
discouraged from looking for work. Private and government
payrolls combined have shrunk for 13 straight months, and net
job losses since the start of the recession some 14 months ago
total 3.6 million. And, those who have lost jobs are having a
very difficult time finding a new one: more than one-fifth (22.4
percent) of the 11.6 million unemployed have not been able to
find a job despite looking for 27 weeks or more.
The housing market’s ongoing troubles heighten the potential
for significant increases in homelessness during this recession.
Home foreclosures have pushed many owner and renter families
into the rental market, driving up rents in some areas by

6. increasing the demand for housing — despite falling incomes
and rising unemployment. In addition, a number of state and
localities are beginning to cut back homelessness prevention
programs due to large state and local budget shortfalls, even as
the need for these programs grows.
Urban areas have a poverty rate of 17%, compared to a poverty
rate of 9% for the suburbs. White flight No new businesses = no
jobsHigher crime rates Higher rates of pollution
Poverty rate in the South is 14%. One in seven people living in
rural America lives below the poverty line. Poverty rates are
higher in rural areas for almost every demographic.
Nearly a third of Native Americans live in poverty. The
country's 2.1 million Indians, about 400,000 of whom live on
reservations, have the highest rates of poverty, unemployment
and disease of any ethnic group in America.Indians earn only a
little more than half as much money as the average American.
Lower education— Low levels of parental education are a
primary risk factor for being low income. Eighty-three percent
of children whose parents have less than a high school diploma
live in low-income families, and over half of children whose
parents have only a high school degree are low income as
well.New to the countryDon’t possess marketable skills Has a
disabilitySingle parent households
“Many welfare recipients possess significant barriers to

7. employment. In 2002, 42 percent of welfare recipients had not
finished high school, 35 percent reported being in very poor
health, and 30 percent had not worked in recent years. Other
potential barriers to employment include the presence of an
infant, language barriers, and the need to care for a child with
disabilities. About two out of five welfare recipients (44
percent) had two or more barriers to work in 2002. The share of
recipients with multiple barriers remained fairly constant
between 1997 and 2002.”
“The working poor and unemployed are working hard, but in
most respects not moving ahead, the report concludes. While
most of those surveyed report needing less than an additional
$200 per month to meet their family’s needs, this amount of
money represents a substantial increase in hours worked at low
wages. The working poor and unemployed lack access to the
critical paths of opportunity in the new economy—higher
education, ongoing job training, job growth in suburban
neighborhoods, childcare support, and information technology.”
(Working Hard But Staying Poor, 1999)
“Under the TANF structure, the federal government provides a
block grant to the states, which use these funds to operate their
own programs. States can use TANF dollars in ways designed to
meet any of the four purposes set out in federal law, which are
to: ‘(1) provide assistance to needy families so that children
may be cared for in their own homes or in the homes of
relatives; (2) end the dependence of needy parents on
government benefits by promoting job preparation, work, and
marriage; (3) prevent and reduce the incidence of out-of-
wedlock pregnancies and establish annual numerical goals for
preventingand reducing the incidence of these pregnancies; and
(4) encourage the formation and maintenance of two-parent
families.’” (An Introduction to TANF, 2005)

8. Furthermore, the nation’s basic cash assistance safety net for
very poor people who are jobless is much weaker and less well
equipped to meet the challenges that a serious economic
downturn poses than it was in previous major recessions. The
biggest changes in that safety net have resulted from changes in
public assistance policies at both federal and state levels. As a
result of changes in such policies, basic cash assistance reaches
many fewer poor families with children than in the recessions of
the 1970s, 1980s, and 1990s. Today, only about 40 percent of
families eligible for cash assistance under the Temporary
Assistance for Needy Families program actually receive it.
That is about half the percentage of families eligible for
TANF’s predecessor (the Aid to Families with Dependent
Children program) that received its benefits during the
recessions of earlier decades.
In addition, those poor unemployed individuals not raising
minor children who don’t qualify for unemployment insurance
no longer are eligible for any type of cash assistance. State
general assistance programs — formerly the safety net of last
resort for this group of people — were largely eliminated across
the country in the late 1980s and early 1990s (except for
programs for people with disabilities). Many of these
individuals cannot even qualify for food stamps; in most parts
of the country, jobless people aged 18-50 not raising minor
children are restricted to three months of food stamps out of
every three-year period. As a result, there is a substantial
population of individuals for whom there is little or no safety
net at all. That population will grow much larger in the next
year or two.
BusinessDictionary.com, 2007—“social services -- Definition:

9. Benefits and facilities such as education, food subsidies, health
care, and subsidized housing provided by a government to
improve the life and living conditions of the children, disabled,
the elderly, and the poor in the national community.”
In 2002 over 5.1 million families, or 4.6% of U.S. households,
lived in subsidized housing. HUD has operated many different
kinds of housing programs, but these can be classified under
three headings: public housing owned by the government,
tenant-based programs that provide people vouchers to
subsidize rent, and project-based programs that underwrite the
costs of private owners who, in turn, pledge to house low-
income people.
Food subsidies will cost taxpayers $55 billion in fiscal 2007 and
account for 61 percent of the USDA’s budget.Food
stampsStudents receiving free and reduced lunch The women,
infants, and children (WIC) program
Loss of health insurance and rising health care costs are one of
the main reasons why people are falling into poverty. 46 million
Americans lack health insurance, or one in seven people. In the
U.S. health insurance is tied to your job, which means no job =
no health insurance.
Head Start program After school programsPublic schooling
Vouchers Charter schools

10. Many people can’t afford a reliable car, so transportation to a
job can be difficult. Free public transportation—the bus,
subway/metro
The religious angle—helping those in poverty is a central tenant
of many world religions. The ethical angle—many believe that
if you have the ability to do so, then you have an ethical
obligation to help your fellow citizens in poverty. We are all
Americans and we cannot allow one country of haves and one
country of have-nots.
Persistent childhood poverty is estimated to cost our nation
$500 billion each year, or about four percent of the nation’s
gross domestic product.Poverty = less education = less
competent workforce = lower U.S. economic competitiveness
The experience of severe or chronic economic hardship limits
children’s potential and hinders our nation’s ability to compete
in the global economy. American students, on average, rank
behind students in other industrialized nations, particularly in
their understanding of math and science. Analysts warn that
America’s ability to compete globally will be severely hindered
if many of our children are not as academically prepared as
their peers in other nations.
“…diseases very similar to those plaguing Africa, Asia, and
Latin America are also occurring frequently among the poorest
people in the United States, especially women and children.
These diseases -- the "neglected infections of poverty" -- are
caused by chronic and debilitating parasitic, bacterial, and
congenital infections. While most Americans have never heard
of neglected tropical diseases (NTDs), the analysis estimates
that these infections occur in hundreds of thousands of poor

11. Americans concentrated primarily in the Mississippi Delta
(including post-Katrina Louisiana), Appalachia, the Mexican
borderlands, and inner cities. These diseases represent a major
cause of chronic disability, impaired child development, and
adverse pregnancy outcomes, yet many of them are preventable.
The pervasive impact of poverty on health is evident regardless
of how poverty is measured. David Williams and his colleagues
at the University of Michigan thus found that people with
annual incomes of under $10,000 had more than three times the
risk of dying in a given year as those who made more than
$30,000. Dozens of other studies have produced similar
findings, regardless of whether income, education, or
occupation was used as the marker of low socioeconomic status.
Finally, and moving the unit of analysis from the individual to
the community, the now-classic Alameda County Study in
California demonstrated that residence in a poor neighborhood
itself, regardless of the individual's income, resulted in a risk of
dying 40 percent higher than would be expected on the basis of
age, gender, and even smoking history.
Environmental factors—poor people are more likely to work or
live in areas with low environmental quality. For example, you
are much more likely to find coal fired power plants, emissions
producing factories, and waste dumps near communities where
poor people live. Environmental racism—the practice of placing
power plants or other environmentally bad industries near
minority communities.
Poverty—is it the fault of the individual or society? People who
blame society tend to argue that forces like capitalism and
racism are to blame for domestic poverty. People who blame the
individual tend to focus on factors like individual will and

12. personal choices for why domestic poverty exists.
Social services—are they a right that cannot be taken away or
are they a privilege that can be taken away? Are social services
like health care and subsidized housing and food a human right?
Governments can provide negative rights and positive rights.
Negative right = something the government won’t interfere with
or take away (life, liberty, pursuit of cash). Positive right =
something the government provides or gives you.
Poverty—is it even possible to eliminate it? Even if it is
possible, are the cures worst than the disease? Is there an
acceptable level of poverty that we can be content with?
MENTAL ILLNESS
The Effects On Family
MENTAL ILLNESS DEFINEDSerious mental illness is defined
as a diagnosable mental, behavioral, or emotional disorder that
meets the criteria of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV-TR) and results in function
impairment that substantially interferes with or limits one or
more life activities (i.e. employment, self-care, social
relationships)
SERIOUS MENTAL ILLNESSApproximately 15 million adults

13. are diagnosed with a serious mental illness that result in
comparatively severe impairmentSchizophrenia (unable to tell
the difference between real and unreal experiences), bipolar
disorder (manic depression/mood swings) and major depression
are common forms of mental illnessRecovery from mental
illness is possible, however the mental health system has been
known to simple manage symptoms and label it as a long-term
disability
RECOVERYRecovery is the process of being able to work,
learn and participate fully in the communityRecovery from
mental illness was once thought to be impossible but more
documented long-term outcome studies have shown
otherwiseTreatment focuses on the impairments resulting from
the illness, such as hallucinations, with the goal of alleviating
or eliminating these symptoms
PARENTS WITH MENTAL ILLNESSWomen with mental
illness have normal fertility rates and bear an average or above
average number of childrenMost women are diagnosed with
mental illness prior to pregnancy but approximately 10 to 15%
are diagnosed postpartumMost state mental health agencies are
unaware of their adult patient’s parenting statusWhen custody is
taken from a parent with mental illness, the decisions are
typically made by child services rather than the treatment team
PARENTS WITH MENTAL ILLNESSIn many states a
diagnoses of mental illness justifies the removal of children and
termination of parental rightsThe parents are often viewed as
permanently being unable to fulfill parental roles and face great

14. barriers in trying to prove they are fit to be parentsIn reality, a
person with a serious mental illness may or may not be able to
care for a child but with treatment functional abilities to raise a
family may changeParenting sometimes regulates the life of
individuals with mental illness
IMPACT ON PARENTINGMental illness can compromise
parenting ability and affect parent-child relationshipsParenting
may be interfered by symptoms of mental illness:Psychotic-
hallucinations and delusionsNegative symptoms such as low
energy, lack of initiative, social withdraw and diminished
emotional expressivenessMood symptoms- manic depressive
episodesCognitive problems- attention, concentration and
memoryStigmatization and isolationNeglect or harmful
behaviors
RISK OF MENTAL ILLNESS FOR CHILDRENResearch has
shown that children of a parent with mental illness are at a
greater risk for developing psychosocial and mental health
problemsCommon problems these children may
experienceConfusion in response to unsettling
behaviorEmbarrassmentIsolationKeeping family
secretsNeglectStigmatizationConcern about their own
vulnerability to mental illness
OUTCOMES ON CHILDREN AS ADULTSResearch has shown
there are different feelings these children experience when
becoming adults:Feelings of grief or lossEmpathetic pain for
their parentGuilt that they somehow caused the illnessA belief
that their own needs were not met as childrenA sense of

15. growing up too fastFeelings of hopelessness and
helplessnessRegret for their unfulfilled potential
PARENTING WITH MENTAL ILLNESSNot all parents with
mental illness are ineffective parents, nor do all of their
children suffer from such adverse consequencesMany children
of parents with mental illness are successful across social and
educational domainsThese children may also grow up to be
stronger and more compassionate towards others with a greater
appreciation for life
HAVING A CHILD WITH MENTAL ILLNESSSocieties attitude
towards mental illness has been fearful, stigmatizing, blaming
and shunning the afflicted individual as well as their familyA
physical problem may be seen, but the cause of mental suffering
can not be seen and mind functions are under control of the
individual so they are often seen as responsible for their
behaviorsTherefore, individuals and families dealing with
mental illness tend to become isolated and overcome with
shame
FAMILY LIFE CYCLEDepending on the time of diagnoses for
the child, the family life cycle may be disruptedInformation
about the disorder may not be fully discussed within the family
and communication problems begin to developIn some families,
the pain and stigma that comes with the diagnoses causes them
to go into denial and try to appear as if everything is normal. It
may be discouraged to discuss the problemThere have been
interventions designed to address this serious problem on the
individual level through family and group therapy settings

16. ILL VS. WELL SIBLING RELATIONSHIPSSibling
relationships have a profound impact on development and is a
connection in which the child learns to impact with peers,
explore different roles, manage disagreements, and learns to
share secrets, belongings and feelingsWhen a child has a sibling
with a mental illness the impacts can be profound:You may be
ashamed you are relatedGuilty that you have a better
lifeEnvious that nothing is expected of themRelieved that you
are not the sick one
ILL VS. WELL SIBLINGSThe well sibling very often is
presented as high functioning and independent whose symptoms
of dysfunction and pain are hidden or dismissedThey have
apparent adjustments and secret distressesWell sibling attempts
to disassociate themselves from the ill siblingWell sibling
becomes overly responsible caregiversWell sibling becomes
mature and independent prematurelyWell sibling feels
guiltyWell sibling feels neglected by parentsWell siblings are
neglected by the mental health and healthcare systems
FAMILY RECOMMENDATIONSThere are ways to enhance the
quality of relationships within the familyWhen possible engage
the entire family soon after someone develops a mental
illnessProvide information and education about the illness, even
is there is uncertainty about the nature of the problemFacilitate
grieving process for everyone in the familyConnect siblings to
other siblings with similar family situationsReconnect family
members to each other and establish appropriate boundaries

17. RECOMMENDATIONS CONTINUEDCreate opportunities for
genetic counselingAllow for discussions about future
planningProvide support and normalize reactionsAsk about well
siblings and their feelings about ill siblings
Overall it is very important to keep in mind the family functions
that may be affected by having an individual with mental illness
within the family
REFERENCES
Abrams, M. S. (2009). The well sibling: Challenges and
possibilities. American Journal of Psychotherapy, 63 (4), 305-
317.
Costea, G. O. (2011). Considering the children of parents with
mental illness: Impact on behavioral and social functioning. The
Brown University Child and Adolescent Behavioral Letter, 27
(4), 1, 5-6.
Marsh, D .T. (2009). Parental mental illness: Issues in custody
determinations. American Journal of Family Law, 23 (1), 28-36.
RESEARCH ARTICLE
Family identity and severe mental illness: A thematic synthesis
of
qualitative studies
Ángela R. Acero*,†,‡, Adrián Cano-Prous‡, Gabriel
Castellanos§, Raquel Martín-Lanas* &

18. Ana Canga-Armayor*
* University of Navarra, Navarra, Spain
† Universidad de La Sabana y Clínica Universidad de La
Sabana, Chía, Colombia
‡ Clínica Universidad de Navarra, Navarra, Spain
§ Fundación Universitaria de Ciencias de la Salud, Bogotá,
Colombia
Correspondence
Ana Canga-Armayor, Department of Adult
Nursing, School of Nursing, University of
Navarra, C/ Irunlarrea 1, 31008, Ed. Los
Castaños, Pamplona, Navarra, Spain.
E-mail: [email protected]
Received: 4 May 2015
Accepted: 5 August 2016
http://dx.doi.org/10.1002/ejsp.2240
Keywords: family identity, systematic
reviews, qualitative analysis, severe mental
illness, social identity approach

19. Abstract
There is a growing amount of research showing that a shared
social identity
and the sense of belonging to a family have a potential effect on
health.
However, little is known about the effects of severe mental
illness on family
identity. The authors carried out this thematic synthesis based
on a systematic
review of literature on family narratives of severe mental illness
and family
identity. The main findings indicate that in many families (i)
their identity
—as a shared social identity—undergoes a transformation
process by which
the identity aspects of being a family are reinforced; (ii) family
members often
take on a caring role as their main family role; and finally, (iii)
a cultural com-
ponent shapes this transformation process. The authors describe
implications
for research and application in the mental health field. All in
all, family
identity is transformed by the experience of severe mental
illness.
One in four adults in the world suffers from mental
illness (MI) (defined as a significant disturbance in
behaviour, emotional control, or cognition because of
dysfunction in mental processes), a condition that is asso-
ciated with significant distress (American Psychological
Association, 2013; World Health Organization, 2001).
Among them, people with a severe MI (SMI) represent
1% to 4% of the population and are affected most
permanently and seriously (Lavikainen, Lahtinen, &

20. Lehtinen, 2000; Substance Abuse and Mental Health
Services Administration, 2013). The term SMI is used
to describe a group of people with MI who require still
more health care because of the characteristics of their
condition—more severe and persistent symptoms, their
resources and/or psychosocial situation, and the fact that
their functional state is more severely impinged upon
(Charlwood, Mason, Goldacre, Cleary, & Wilkinson,
1999; Parabiaghi, Bonetto, Rugger, Lasalvia, & Leere,
2006). The diagnostic categories that pertain to SMI
usually include psychoses, major affective disorders,
somatoform disorders, disorders related to stress, behav-
iour disorders, and personality disorders (Charlwood
et al., 1999), although not everyone with these diagnoses
has an SMI. Although a wide variety exists in the course
of MI, people suffering from SMI—in contrast to those
without SMI—present increased rates of both morbidity
and mortality, are more frequently unemployed and sin-
gle, and are disabled to a higher degree (De Hert et al.,
2011). These factors mean they require constant support
and care, which, in many cases, is provided by their
families, who also live through the illness (Calderon,
2011; Lefley, 1996; Pearson, 1993; Seeman, 1988).
The connection between family and SMI has been
studied for several decades. Families were first seen as
the origin of MI and, later, as the first recipient of its ef-
fects (Cook, Pickett, & Bertram, 1997). Currently, SMI is
recognised as a condition that generates chronic stress
on the entire family, and, therefore, many studies have
assessed the effects of its burden and stigma on the fam-
ily and on family members, as well as ways families cope
and their resilience, social support and functioning, and
so forth (Saunders, 2003). During the last decades, re-
search and health interventions have focused on family

21. strengths and on recovery, the latter being understood
more as a process than as a result or goal (Gehart,
2012a). At the same time, the recovery movement in
the mental health field has shifted attention from a sin-
gle person’s intrapsychic symptoms onto psychosocial
functioning, including relational, social, cultural, and
other aspects (Gehart, 2012a). The purpose of this focus
is to make it plausible for a mentally ill person to start a
process of recovery or ‘a journey of healing and trans-
formation enabling […] her/him to live a meaningful
life in a community of his or her choice while striving
to achieve his or her full potential’ (U.S. Department
of Health and Human Services, 2004, p. 1). In this re-
gard, the main aspects of this process include identity
and, in addition, connectedness or community-centred
European Journal of Social Psychology 47 (2017) 611–627
Copyright © 2017 John Wiley & Sons, Ltd. 611
EJSP
http://dx.doi.org/10.1002/ejsp.2240
elements, such as relationships, friends, and family
(Leamy, Bird, Le Boutillier, Williams, & Slade, 2011;
Onken, Craig, Ridgway, Ralph, & Cook, 2007).
Concerning the family, recent studies evidence its
potential effect as a facilitator of both recovery and
relapse (Bradshaw, Armour, & Roseborough, 2007;
EnglandKennedy & Horton, 2011; Guarnaccia & Parra,
1996; Schon, Denhov, & Topor, 2009). Similar findings
have been reported in qualitative studies, where per-
sons with an SMI diagnosis perceive that family both
facilitates and hinders the recovery process on SMI:

22. The former does so by providing motivation and moral
and practical support; the latter through forcing inpa-
tient treatment, displaying stigma and lack of under-
standing, and acting as a source of stress (Aldersey &
Whitley, 2015).
Over the last few years, identity has been studied with
attention to diverse areas related to subjective aspects of
SMI experience, resulting in the acknowledgement of its
importance (Drake & Whitley, 2014; Levine & Ligenza,
2002; Rowe, 2012). These areas of research have also re-
vived interest in the perspective of identity in SMI
(Bergstresser, 2006; Estroff, 1989; Wisdom, Bruce,
Saedi, Weis, & Green, 2008; Yanos, Roe, & Lysaker,
2010). Likewise, during the last decade, research has
shifted from analysing social groups and their effect
on physical and mental health (Holt-Lunstad & Smith,
2012) to the introduction of a group identity perspec-
tive in order to gain a better understanding (Jetten,
Haslam, Haslam, Dingle, & Jones, 2014). This innova-
tive perspective shows that shared social identities—more
than the fact of belonging to a group or not—may have
a positive or negative impact on health (Jetten et al.,
2014). For this reason, they have been commonly
labelled as ‘social cures’ (Jetten, Haslam, & Haslam,
2012), bringing the study of social identity closer to
mental health.
When a person takes on a new challenge, a part of
their foundation and support is expected to come from
a set of aims, values, and beliefs that are steady over
time (Schwartz, 2005) and largely from people, relation-
ships, and meanings reciprocally and co-biographically
constructed within the family (Viladrich, 2005). To this
end, King and Wynne (2004) suggest that sharing
stories, topics, and rituals within a family results in the

23. integration of family and personal stories, as well as
the transmission of a family identity. Despite its rele-
vance, research on family identity when dealing with
SMI is scarce. This review attempts to increase existing
knowledge in this field.
Background
Coping and Identity
The Social Identity Model of Identity Change states that
important life events—such as an MI—affect not only
personal identities but also social identities.
Furthermore, when maintained or acquired, social iden-
tities may buffer the consequences of negative changes
by allowing for some continuity (Jetten & Pachana,
2012). This is not applicable in all cases, for instance, in
the consumption of psychoactive substances; Dingle,
Stark, Cruwys, and Best (2015) show that the process
of rehabilitation, as well as the identities of rehabilitation,
is more associated with breaking identities and member-
ships than with the creation of new ones.
In the case of MI, studies show that there is a stigma
towards both the individual and the family that lives
with an SMI. They further detail how collective experi-
ence and the identification of similar groups have both
harmful and beneficial effects on a single person. Iden-
tifying with a stigmatised group produces a negative
effect on one’s self-esteem, but at the same time, it fa-
cilitates access to different mechanisms that lead to
the rejection of those stigmas and stereotypes and to
group support (Crabtree, Haslam, Postmes, & Haslam,
2010). However, for many people, far from being just
another group, the family is of utmost importance.

24. Thus, we will look at the concept of family identity
from two points of view: family identity as something
that makes a family be a family and family identity as
a social identity. In addition, we will then flesh out
the connections between social identity and health,
and we will then present the objectives of this review
and thematic synthesis.
Family identity
Cigoli and Scabini (2006) define family identity as a set
of characteristics that make family different from other
groups of people, including three dimensions: (i) its or-
ganisation as a primary group, enabling a bonding be-
tween its members in the uniqueness of their being
and existence; (ii) its dimension as a symbol of the
bonding between them, where justice, loyalty, hope,
and trust allow for the relationship between and mu-
tual care of its members; and (iii) a dynamic
dimension where reciprocal giving, although not sym-
metric, is unconditional (Scabini & Manzi, 2011).
Family identity can also be defined from the view-
point of group identity based on social identity theory
(Tajfel & Turner, 1986) and self-categorisation theory
(Turner, Hogg, Oakes, Reicher, & Wetherell, 1987). So-
cial identity theory defines social identity as a part of a
person’s self-conception, comprising both a cognitive
component and an emotional component. The former
component derives from the feeling of being a member
of a group, whereas the latter is rooted in the value and
emotional meaning associated with that membership
(Spears, 2011). This is the result of a process of social
categorisation, as well as identification with the groups
we belong to and of a process of comparison with other
groups, allowing for the assessment of one’s own group

25. (s) and assigning significance and value to it. The theory
of self-categorisation understands identity as a concept
with different levels of abstraction (personal, group,
and human) related to the comparative groups and con-
texts in which it is analysed (Ashforth & Mael, 1989;
Turner et al., 1987). From this perspective, personal
Á. R. Acero et al.Family identity and severe mental illness
European Journal of Social Psychology 47 (2017) 611–627
Copyright © 2017 John Wiley & Sons, Ltd.612
and group identities represent different levels of self-
categorisation, and the definition of self is always rela-
tional and comparative. From this theory, other con-
cepts have emerged such as identity salience, social
influence, group formation, and collective behaviour
(Spears, 2011).
With this background taken into consideration,
family identity is understood as the particular under-
standing each family has of itself as a group, and its
members’ sense of identification with that group
(Ashforth & Mael, 1989; Ellemers, Spears, & Doosje,
2002; Scabini & Manzi, 2011; Spears, 2011; Tajfel &
Turner, 1986; Turner et al., 1987). This identity is in
permanent construction through family members’ in-
teractions around the intimate matters that constitute
their life together, including their experiences, shared
roles, emotions, and so forth. These matters permit
common beliefs, and meanings about the sense of
belonging emerge, as well as a sense of ‘we-ness’,
which is built up through social interaction and
through a relationship with the wider social context

26. (Ashforth & Mael, 1989; Ellemers et al., 2002; Lawler,
2003; Spears, 2011).
Family identity as a social cure
Social identities—such as family identity—allow us to
focus on what we share with others (e.g., a shared iden-
tity as a mother or as a sales person at a particular com-
pany). Beyond that fact, being included by others or by
oneself in a social identity bolsters the perception that
such inclusion—whether it is external or personal—is
important and significant for self-definition. In this
way, the personal perception of that inclusion as impor-
tant allows it to become a role, a relationship, or an
internalised membership to ‘understand the self and
one’s place in the world’ (Jetten et al., 2014, p. 113).
This means that an identity may be understood as a
shared identity or as a self-categorisation within a group
with which the same identity is shared. The fact of shar-
ing an identity makes a difference between being in a
group and belonging to a group (e.g., one can attend a
political meeting with other people without necessarily
supporting or belonging to that political group). When
an identity is shared, it sets guidelines that inform be-
haviour even in the absence of a leader (Reicher,
1987). Additionally, belonging to a group—the subjec-
tive feeling of belonging or self-categorisation—and
sharing the feeling of belonging with others allow for
the group’s social influence to reach a particular person
(Haslam, 2014; Turner, 1991). This potential can also
have a positive influence on health during times of
stress (by feeling supported, esteemed, and capable;
Greenaway et al., 2015) or can negatively affect physical
and mental health when social identification with a rel-
evant group is lost or altered (Cruwys, Haslam, Dingle,
Haslam, & Jetten, 2014).

27. Concerning family, which most people would con-
sider as the most significant group to which they belong,
research has shown that in the presence of a strong
identification with the family, the establishment of pos-
itive relationships with relatives becomes easier and, as
a result, health improves. In contrast, a feeling of dis-
tance and a lack of commitment to one’s family lead to
poor relationships among its members and are associ-
ated with adverse effects on health (Sani, 2012). In a
very different vein, research on national identity has
demonstrated how collective participation in several
contexts—associated with daily life, as well as events
and experiences such as an illness—is seen as an oppor-
tunity to strengthen the group through a common fate.
In addition, during these moments, questions about
‘who we are’ as a group both come up and can be an-
swered (O’Donnell et al., 2016; Páez & Rimé, 2014). In
other words, they highlight how shared social identity
can be formed, transformed, and maintained in the ex-
perience of collective contexts. As Reiss and Oliveri
(1980) point out, this means that the challenging cir-
cumstances that families face—for example, illnesses—
become opportunities to reconsider who they are as a
group, what their values and beliefs are, and what they
are capable of. As a result, those circumstances afford
families the opportunity to construct their place in the
world (Reiss & Oliveri, 1980).
Family identity, conceived from this point of view,
has an important influence on the way people with
MI, and their families, experience, give sense to, and
cope with the process of illness and recovery. In addi-
tion, such influence spreads to other family members’
health throughout the process of illness. However, de-

28. spite the key role families play on the experience of
SMI, little is known about family identity therein. We
only found one study that addresses identity and family
(Buckley-Walker, 2013), although it focuses on the rel-
atives of a person with substance use and/or a mental
disorder and the identity changes that they experience
as members of a family throughout the recovery pro-
cess; that is to say, it is more focused on the personal
identity of family members than on family identity.
Therefore, this article aims to carry out a systematic
review of the literature of family narratives related to
SMI and family identity and to perform a thematic syn-
thesis applying the perspective of family identity. In this
way, we wish to contribute to the understanding of how
family identity changes throughout the experience of
SMI and how family identity and SMI are related to
one another.
Methodology
We followed three guidelines for research and
reporting: Enhancing Transparency in Reporting the
Synthesis of Qualitative Research (ENTREQ), for the
main structure of the review (Tong, Flemming,
McInnes, Oliver, & Craig, 2012); Preferred Reporting
Items for Systematic Reviews and Meta-analyses
(PRISMA), for the systematic searching (Moher,
Liberati, Tetzlaff, & Altman, 2009); and Consolidated
Criteria for Reporting Qualitative Research (COREQ),
to assess the quality of the papers included (Tong,
Á. R. Acero et al. Family identity and severe mental illness
European Journal of Social Psychology 47 (2017) 611–627
Copyright © 2017 John Wiley & Sons, Ltd. 613

29. Sainsbury, & Craig, 2007). Finally, we performed a the-
matic synthesis according to the model suggested by
Thomas and Harden (2008), with special attention to
the following questions: who are they as a family, who
are they after illness, what is it that makes them a
family, how does identity change, and how is identity
related to illness?
Search and Selection of Articles
We designed a protocol in which we previously de-
fined the review objectives, the screening method,
the inclusion and exclusion criteria, and the way in
which papers would be assessed. Given that our topic
falls within health and human sciences, we chose to
use the following databases: PubMed, Ebsco
(PsychInfo, PsychArticles, and Psychology and Be-
havioural Sciences Collection), Web of Science (all
databases), LILACS, and Teseo.
We carried out the electronic search on 15 May 2014
using the acronym PICO (Participants, Intervention or
exposition, Comparison, Outcomes; Moher et al.,
2009), with some adaptations to guide our search. The
strategy and terms used for the search are detailed in
the supporting information (Tables S1 and S2). We
included doctoral theses, excluded books, and critiques
and did not set date limits. Finally, we removed
duplicated papers within the original database interfaces
using the software Reference Manager v.11 for
Windows.
First, we did a double reading at two different times of

30. the titles and abstracts of all the documents found, and
we included those with the following criteria: (i) derived
from primary studies; (ii) carried out with families; (iii)
clear exploration of family narratives about SMI; (iv) in-
clusion of aspects related to family identity; and (v) writ-
ten in English or Spanish. We excluded papers focused
on psychoactive substance-related disorders, dementia,
and pervasive developmental disorders. These disorders
were excluded because they are usually not included in
the diagnostic criteria. That is to say, we included studies
dealing with psychotic disorders (schizophrenia,
schizoaffective disorder, delusional disorder, etc.), affec-
tive disorders (major depressive disorder and bipolar
affective disorder), behaviour disorders, obsessive–
compulsive disorder, and eating disorders (bulimia,
anorexia nervosa, etc.). Finally, we performed a manual
search based on the reference lists of papers selected as
eligible in the initial search (snowballing).
After applying the selection criteria, we obtained 15
documents from the databases and 17 from the hand
searching (snowballing). Out of these papers, three were
rejected because the full text was not written in English
or Spanish, as well as three dissertations because we
could not find the articles related to the researches. We
reviewed a total of 26 full-text documents, 13 of which
were included for the synthesis. The whole process is
displayed on the flowchart presented in Figure 1.
The characteristics of the studies included are
gathered in Table 1. The characteristics of the studies
excluded and the quality assessment of the papers
included are gathered in the supporting information
(Table S3). Even though the initial objective was to
include a variety of MIs, the majority of the articles

31. included refer primarily to the psychotic spectrum disor-
ders, which is reflected in the final sample.
Data Extraction and Qualitative Analysis
We summarised the most relevant contextual aspects of
the papers and extracted the Results/Findings section
for each of them. We then conducted a thematic analy-
sis with the aid of the software QDA Miner for Lite ©.
Codification was undertaken following Thomas and
Harden’s (2008) recommendations: free codification,
organisation of codes into descriptive themes, and the
development of analytic themes.
Free line-by-line coding. As we did not find stud-
ies directly concerning our review questions, we put
these questions to one side until a more advanced stage
of the analysis was reached. Thus, we began to carry out
a thematic analysis starting from previous findings in
the studies we had reviewed. In this way, we extracted
and then entered into the software the text of each pa-
per labelled as ‘findings’ or ‘results’. Then, we coded
these papers’ findings line by line. New codes were se-
quentially added when necessary. We finally obtained
36 codes.
Developing descriptive themes. In the second
stage, we undertook an iterative process in which we
reviewed similarities and differences between the codes
and created new codes with a higher level of abstrac-
tion. As a result of this process, we grouped all codes
into five descriptive themes and organised a hierarchical
tree structure with several layers.
Generating analytical themes. Up to that point,

32. we had produced a synthesis of the information about
the family experience with SMI organised by thematic
groups. However, we had still not further explored our
review topic and family identity, neither had we gener-
ated other notions or understandings that had ‘gone be-
yond’ the findings of the primary studies. Then, we
introduced the review questions that we had previously
set aside. Bearing in mind family narratives of MI, the
changes they had undergone as persons and as families,
and established concepts about identity, we performed a
second review of the descriptive themes that emerged
previously, the notes, and the papers’ contexts (aims,
research setting, participants, diagnosis, and time since
onset of illness). Taking everything into account, we in-
ferred the effect of the experience of SMI on family
identity. We performed a cyclical process of analysis in
two ways: ‘vertically’, searching for higher levels of ab-
straction of conceptual abstraction, and ‘transversally’,
searching for relationships between categories. This pro-
cess was carried out until new themes were sufficiently
abstract to describe and/or to explain our initial
Á. R. Acero et al.Family identity and severe mental illness
European Journal of Social Psychology 47 (2017) 611–627
Copyright © 2017 John Wiley & Sons, Ltd.614
descriptive themes, as well as inferred effects of the ex-
perience of SMI on family identity. For this last stage
of analysis, an important aspect was the comparative
process of the studies and of the participants’ context,
looking for differences and similarities.
The hierarchical tree structure of the descriptive

33. themes, the definition of codes, and an example of this
third stage of analysis are presented in the supporting
information (text, Figure S1, and Table S4).
Trustworthiness. In addition to the use of quality
assessment guidelines, throughout the entire process,
we took notes and considered the context of each study.
The first author did the review and initial codification,
which was discussed and defined in group meetings.
We independently codified 10% of the papers and then
resolved differences together. The first author also per-
formed the final analytical process with input and re-
view from all the authors.
Fig. 1: Preferred Reporting Items for Systematic Reviews and
Meta-analyses flowchart depicting the article selection
Á. R. Acero et al. Family identity and severe mental illness
European Journal of Social Psychology 47 (2017) 611–627
Copyright © 2017 John Wiley & Sons, Ltd. 615
T
a
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41. at
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42. 3
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43. b
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44. en
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-d
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45. m
ili
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,
p
ar
en
ts
/s
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lin
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s
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er
ac
e,
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am
ill
er
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&
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yr
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,
1

46. 9
9
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ex
p
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h
o
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47. er
ie
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r
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’s
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48. b
lin
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’s
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n
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s
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ic
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al
ys
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llo
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in

49. ed
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u
b
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2
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tr
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ct
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in
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50. ie
w
s
1
4
si
b
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g
s
N
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,
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,
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,
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n
,
&
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51. h
en
,
2
0
0
9
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iw
an
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ex
p
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w
h
o

52. liv
e
w
it
h
so
m
eo
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e
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it
h
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53. Ph
en
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h
2
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3
–
2
6
ye
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s
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m
is
tr

54. u
ct
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in
te
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s
1
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m
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s
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55. in
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56. p
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ta
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57. p
an
ts
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ro
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th
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ry
2
1
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58. 1
9
si
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ar
sh
et
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.,
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9
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SA
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59. er
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fo
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re
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60. f
p
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p
le
w
it
h
M
I
Th
em
at
ic
co
d
ifi
ca
ti
o
n
N
A
b
PD
,
B
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,
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61. D
,
o
th
er
IN
A
N
at
io
n
al
Su
rv
ey
w
it
h
o
p
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-
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es

62. ti
o
n
s
ab
o
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t
fa
m
ily
st
re
n
g
th
s
1
3
1
fa
m
ily
m
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b
er
s
N

63. o
N
ew
m
an
,
Si
m
o
n
d
s,
&
B
ill
in
g
s,
2
0
1
1
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K
To
ex
p
lo
re

64. th
e
im
p
ac
t
o
f
Fe
P
o
n
yo
u
n
g
ad
u
lt
si
b
lin
g
s’
se
n
se
o
f
se
lf
an

65. d
th
e
ro
le
s
th
ey
ad
o
p
t
N
ar
ra
ti
ve
an
al
ys
is
1
7
Fe
P
1
–
3
ye

66. ar
s
Se
m
is
tr
u
ct
u
re
d
in
te
rv
ie
w
s
4
si
b
lin
g
s
Y
es
Pe
n
n
y,
N
ew

67. to
n
,
&
La
rk
in
,
2
0
0
9
U
K
To
ex
p
lo
re
Pa
ki
st
an
if
am
ili
es
’
ex
p

68. er
ie
n
ce
o
f
su
p
p
o
rt
fr
o
m
an
EI
S
Ex
p
lo
ra
to
ry
st
u
d
y,
IP
A
1
5

69. Fe
P
1
9
m
o
n
th
s–
4
ye
ar
s
In
-d
ep
th
in
te
rv
ie
w
s
6
fa
m
ili
es
,
1
1

70. fa
m
ily
m
em
b
er
s
N
o
Sa
u
n
d
er
s
&
B
yr
n
e,
2
0
0
2
U
SA
To
ex

71. p
lo
re
th
e
is
su
es
im
p
o
rt
an
t
to
fa
m
ili
es
o
f
in
d
iv
id
u
al
s
w
it
h

72. sc
h
iz
o
p
h
re
n
ia
Th
em
at
ic
an
al
ys
is
N
A
b
PD
IN
A
Q
u
al
it
at
iv
e

73. w
ri
tt
en
co
m
m
en
ts
p
ro
vi
d
ed
b
y
fa
m
ili
es
w
h
o
p
ar
ti
ci
p
at
ed

74. in
a
p
re
vi
o
u
s
st
u
d
y
2
6
fa
m
ily
m
em
b
er
s
N
o
Si
n
,
M
o
o

75. n
e,
&
H
ar
ri
s,
2
0
0
8
U
K
To
ex
p
lo
re
th
e
ex
p
er
ie
n
ce
s
an
d
n

76. ee
d
s
o
f
si
b
lin
g
s
o
f
a
p
er
so
n
w
it
h
a
Fe
P
w
it
h
in
an
EI
S
Ph
en

77. o
m
en
o
lo
g
y
ap
p
ro
ac
h
1
5
Fe
P
1
–
3
ye
ar
s
Se
m
is
tr
u
ct
u
re

78. d
in
te
rv
ie
w
s
1
0
si
b
lin
g
s
N
o
St
ål
b
er
g
,
Ek
er
w
al
d
,
&
H
u
lt

79. m
an
,
2
0
0
4
Sw
ed
en
To
ex
p
lo
re
h
o
w
sc
h
iz
o
p
h
re
n
ia
p
at
ie

80. n
ts
’
si
b
lin
g
s
p
er
ce
iv
e
th
e
ill
si
b
lin
g
re
la
ti
o
n
sh
ip
an
d
th
ei
r
ro
le

81. V
ar
ia
n
t
o
f
g
ro
u
n
d
ed
th
eo
ry
1
6
PD
1
5
–
3
1
ye
ar
s
Se
m
is
tr

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ct
u
re
d
in
te
rv
ie
w
s
1
4
fa
m
ili
es
,
1
6
si
b
lin
g
s
N
o
St
ei
n
&
W
em

83. m
er
u
s,
2
0
0
1
U
SA
To
p
ro
vi
d
e
an
in
-d
ep
th
ex
am
in
at
io
n
o
f
th

84. e
p
er
so
n
al
ac
co
u
n
ts
o
f
ad
u
lt
s
w
it
h
sc
h
iz
o
p
h
re
n
ia
,
th
ei
r

85. p
ar
en
ts
,
an
d
w
el
ls
ib
lin
g
s
A
n
al
ys
is
fo
llo
w
in
g
p
ro
ce
d
u
re
s

86. o
u
tl
in
ed
b
y
M
ile
s/
H
u
b
er
m
an
an
d
Ta
yl
o
r/
B
o
d
g
an
1
4
PD
1
–

87. 1
1
ye
ar
s
In
d
iv
id
u
al
In
-d
ep
th
in
te
rv
ie
w
s
6
fa
m
ili
es
:
6
p
at
ie
n
ts

88. ,
1
2
p
ar
en
ts
,
4
si
b
lin
g
s
N
o
W
is
d
o
m
et
al
.,
2
0
0
8
N
A

89. To
id
en
ti
fy
an
d
ex
am
in
e
id
en
ti
ty
-r
el
at
ed
th
em
es
in
p
u
b
lis
h

90. ed
se
lf
-n
ar
ra
tiv
es
o
f
fa
m
ily
m
em
b
er
s
an
d
in
d
iv
id
u
al
s
w
it
h

91. SM
I
Th
em
at
ic
an
al
ys
is
N
A
b
PD
,
B
D
,
M
D
,
o
th
er
IN
A
Fi

92. rs
t-
p
er
so
n
ac
co
u
n
ts
an
d
p
er
so
n
al
ac
co
u
n
ts
fr
o
m
tw
o
jo
u
rn
al

93. s
o
f
p
sy
ch
ia
tr
y
4
5
fa
m
ily
m
em
b
er
s
an
d
p
at
ie
n
ts
Y
es
N
o

94. te
:
B
D
=
b
ip
o
la
r
d
is
o
rd
er
;
C
O
R
EQ
=
C
o
n
so
lid
at
ed
C
ri
te
ri
a
fo

95. r
R
ep
o
rt
in
g
Q
u
al
it
at
iv
e
R
es
ea
rc
h
;
EB
T
=
ea
ti
n
g
b
eh
av
io
u
r

96. d
is
o
rd
er
s
(a
n
o
re
xi
a
n
er
vo
sa
an
d
b
u
lim
ia
);
EI
S
=
ea
rl
y
in
te
rv
en

97. ti
o
n
se
rv
ic
es
;
Fe
P
=
fi
rs
t
ep
is
o
d
e
o
f
p
sy
ch
o
si
s;
IN
A
=
in
-
fo
rm

98. at
io
n
n
o
t
av
ai
la
b
le
;
IP
A
=
in
te
rp
re
ta
ti
ve
p
h
en
o
m
en
o
lo
g
ic

99. al
an
al
ys
is
;
M
D
=
m
aj
o
r
d
ep
re
ss
io
n
;
M
I=
m
en
ta
li
lln
es
s;
N
A
=

100. n
o
t
ap
p
lic
ab
le
;
O
th
er
=
p
er
so
n
al
it
y
d
is
o
rd
er
,
d
is
so
ci
at
iv
e

101. d
is
o
rd
er
,
o
b
se
ss
iv
e–
co
m
p
u
ls
iv
e
d
is
o
rd
er
;
PD
=
p
sy
ch
o
ti
c
d

102. is
o
rd
er
s
(s
ch
iz
o
p
h
re
n
ia
an
d
sc
h
iz
o
af
fe
ct
iv
e
d
is
o
rd
er
);
SM
I=
se

103. ve
re
m
en
ta
li
lln
es
s
a
To
ta
lp
re
se
n
t/
p
o
si
ti
ve
it
em
s
o
f
th
e

104. C
O
R
EQ
ch
ec
kl
is
t
(u
p
to
3
2
).
b
C
O
R
EQ
ch
ec
kl
is
t
it
em
s
d
o
n

105. o
t
ap
p
ly
in
th
es
e
st
u
d
ie
s
b
ec
au
se
th
is
to
o
lw
as
d
es
ig
n
ed
fo
r

106. p
u
b
lic
at
io
n
s
d
es
cr
ib
in
g
th
e
u
se
o
f
in
te
rv
ie
w
s
an
d
fo
cu
s
g
ro
u

107. p
s.
Á. R. Acero et al.Family identity and severe mental illness
European Journal of Social Psychology 47 (2017) 611–627
Copyright © 2017 John Wiley & Sons, Ltd.616
Results
The 13 papers included were published between 1993
and 2013. Out of them, four were carried out in the
United Kingdom—although one of them analysed a
sample with a Pakistani background, five in the United
States, and three were from different countries
(Taiwan, Colombia, and Sweden). A wide range of
methodologies was used (thematic analysis, phenome-
nology, interpretative phenomenological analysis,
grounded theory, narrative analysis, Miles and
Huberman’s model, and mixed). Twelve papers dealt
with psychotic disorders—three of them were focused
on a first episode of psychosis, four included bipolar dis-
orders, three papers included major depression, and two
included other diagnoses. Participants included siblings
(five studies), patients and family members (three
studies), parents and siblings (one study), and different
family members, including parents, children, siblings,
and grandparents (four studies).
The six main themes generated from the papers
analysed are described below.
Breakup of the Normality of Family Life

108. Changes in general. The irruption of SMI marks a
moment of change. This change occurs in a quick and
unexpected way for almost everyone (Penny et al.,
2009). Initial warning signs reach a point at which it is
impossible not to worry about it (Stein & Wemmerus,
2001). In spite of attempts to understand some of these
behaviours as ‘normal’ responses or actions (Barker
et al., 2001), they finally become an alarm bell that re-
quires attention and are associated with deep suffering
(Barker et al., 2001; Gerace, Camilleri, & Ayres, 1993;
Newman et al., 2011; Penny et al., 2009).
From that moment on, normality in both family and
personal life begins to crumble (Barker et al., 2001;
Stein & Wemmerus, 2001). The family gets involved
in a continuous struggle to endure the symptoms, to
learn how to manage them, and to be able to carry
on with life (Barker et al., 2001). Priorities are
redefined, and other things are postponed in order to
take care of the ill relative (Newman et al., 2011).
Taking continuous care of someone leaves little time
for other activities (Huang, Hung et al., 2009; Marsh
et al., 1996).
Many things change for the family, starting with the
most quotidian aspects of life (routines, habits, etc.)
and including other more transcendent aspects (rela-
tionships, expectations, etc.; Gerace et al., 1993; Huang
et al., 2009; Lukens et al., 2004; Marsh et al., 1996;
Penny et al., 2009; Stein & Wemmerus, 2001; Wisdom
et al., 2008).
Changes in family relationships. The presence of
illness affects family relationships (Penny et al., 2009;
Saunders & Byrne, 2002). At the onset of illness, most
families experience an approach to the ill relative and

109. try to protect him or her (Barker et al., 2001).
The relationships between healthy siblings and the
ill sibling can vary. Sometimes, difficulties emerge at
the beginning of the illness, but the relationship
becomes closer and stronger later on (Huang et al.,
2009; Sin et al., 2008). Siblings may go through pro-
cesses in which they need to feel closer, although at
other times they may need to separate themselves
more or even to reassume the care, especially when
parents are not able to care for the ill brother or sister
(Sin et al., 2008).
Concerning the parent–child relationships, depend-
ing on the moment in the family life cycle and on the
age of all the persons involved, protection may prevail,
previous patterns may be reinforced, or relationships
may become more balanced (Stålberg et al., 2004). For
example, initially, parents are usually more centred on
the ill child. Most of them protect their healthy children
while they grow up, expecting them to become inde-
pendent and, at a given time, to help more with the
mentally ill child (Newman et al., 2011; Stein &
Wemmerus, 2001). In some families, after the onset of
illness, previous and unclear roles are reinforced be-
tween parents and children, giving place to confusion
and to higher emotional charge (Gerace et al., 1993;
Lukens et al., 2004). In other families, better communi-
cation and a healthier family relationship exist, making
it easier for its members to talk openly about the illness
and to contribute on an equal basis (Gerace et al.,
1993). However, in other instances, disagreements
prevail about how to behave or how to treat the ill rel-
ative. This provokes distancing between the nuclear
and extended family (Newman et al., 2011; Saunders
& Byrne, 2002).

110. As far as relationships outside the family are con-
cerned, families recognise the importance of friends
and social networks during the experience of MI
(Barker et al., 2001; Lukens et al., 2004; Saunders &
Byrne, 2002). However, many families experience a
separation from society as a consequence of stigma,
the shame they experience, the effects of the situation
and of the symptoms, a poor understanding of the ill-
ness, and so forth. Relationships with friends and social
relationships in general deteriorate.
Family Experience of Mental Illness Changes
Over Time
In the short term: grief. At the beginning of the ill-
ness, most families describe a process of grieving with a
feeling of confusion, loss, and bewilderment. There are
moments of optimism and hope mixed with others of
suffering. In general, family members continuously
worry about the ill relative and the situation (Penny
et al., 2009).
In the beginning, families respond in different ways.
Some of them deny the evidence for years or justify
their relative’s behaviours (Gerace et al., 1993); others
are immobilised after diagnosis (Gerace et al., 1993;
Lukens et al., 2004; Newman et al., 2011).
Á. R. Acero et al. Family identity and severe mental illness
European Journal of Social Psychology 47 (2017) 611–627
Copyright © 2017 John Wiley & Sons, Ltd. 617

111. There are numerous emotions that overwhelm many
families (Gerace et al., 1993; Sin et al., 2008)—fear be-
cause they do not know what is happening, what will
come, or when an episode might repeat itself and fear
because of the risk inherent to the illness’s symptoms.
In addition, family members commonly react with de-
spondency about the meaning of the illness, with self-
blame for what they did or did not do (Barker et al.,
2001) or by blaming the ill person for being ill and not
being able to fulfil their expectations (Penny et al.,
2009). Anger, rage, frustration, and sadness are other
common emotions (Gerace et al., 1993; Saunders &
Byrne, 2002).
One way in which families may respond is keeping
the ‘secret’, not talking to anyone about the illness, not
even to their own family (Gerace et al., 1993; Sin
et al., 2008; Stålberg et al., 2004). They avoid speaking
about feelings, about what to do, about what is happen-
ing, and about the future; the illness remains unnamed
(Lukens et al., 2004).
In the long term: acceptance and sense making
of illness. Families try to make sense of illness within
their own lives, allowing them to carry on (Newman
et al., 2011). Regardless of the family, a constant chal-
lenge remains (Barker et al., 2001; Marsh et al., 1996).
The shifting nature of symptoms involves continuous
adjustments that require a lot of time every day, as well
as mental and emotional energy (Barker et al., 2001;
Lukens et al., 2004). Trying to understand and to assim-
ilate the illness is difficult (Lukens et al., 2004), generat-
ing frustration because of other people’s lack of
understanding (Newman et al., 2011).
Throughout this process, many families are willing to

112. explore a variety of options on the path to recovery
(Penny et al., 2009). They develop and use skills in order
to better cope, such as recognising deficits and adjusting
their expectations, learning to recognise small advances,
and being able to identify strengths (Stein &
Wemmerus, 2001). Others find it useful to employ pos-
itive thinking, spirituality (Huang et al., 2009), and an-
ticipation (Newman et al., 2011); to question the social
constructs of normality (Stein & Wemmerus, 2001);
and to learn about the illness (Huang et al., 2009;
Stålberg et al., 2004).
Many families also find it useful to be able to talk
about what is happening in their families, including
with the ill relative (Gerace et al., 1993; Marsh et al.,
1996) and with others (Saunders & Byrne, 2002;
Stålberg et al., 2004). Some employ family rituals to
maintain a sense of normality and to encourage the in-
clusion of their ill relative (Stein & Wemmerus, 2001).
Over time, some families resign themselves to the un-
certainty of the future (Wisdom et al., 2008), whereas
others change their expectations to meet reality,
expecting to see only small changes in their relative or,
at least, that their relative will maintain gains achieved
(Penny et al., 2009). They enter a progressive process
of accepting the situation (Gerace et al., 1993; Marsh
et al., 1996).
For many families, the experience of illness fuels
change and becomes a process in which people and
families take a fresh look at their lives, giving it a new
sense of meaning (Lukens et al., 2004; Marsh et al.,
1996; Newman et al., 2011). Although some family
members distance themselves emotionally and physi-
cally over time (Gerace et al., 1993), for others, their

113. motto is to persist in the care of their relative, to always
try something else, and to try to maintain hope (Marsh
et al., 1996).
Strengthening and Transformation of Family
Identity
The sense of permanence, the meaning given to belong-
ing to their family, and the specific characteristics of
their family are highly relevant to many families after
experiencing SMI. They describe how, in dealing with
MI, they feel more united and give each other more
support, becoming in the process stronger families that
are better able to face adversity together (Marsh et al.,
1996; Sin et al., 2008). However, it is also clear that
when some families face SMI, they begin to disintegrate
(Marsh et al., 1996).
Being a family. The experience of MI increases the
amount of pride and respect that many family members
feel towards one another in forming part of their family
unit (Marsh et al., 1996). Many families state they have
a growing feeling of being one as a group, as a family, in
the process of supporting and achieving their relative’s
current needs (Marsh et al., 1996; Stein & Wemmerus,
2001). There is also a consolidation of strengths, values,
and beliefs as a family and of their sense of commitment
to each other (Marsh et al., 1996).
Many families describe developing a stronger bond
throughout the whole family and within the specific
dyads (parent/children, couple, and siblings), which al-
lows for more togetherness (Lukens et al., 2004; Sin
et al., 2008) and for the family to exercise the function
of sustenance and comfort (Marsh et al., 1996). The
component of trust and hope of the bond (Scabini &

114. Manzi, 2011) among family members is reinforced.
Family members claim that they are confident they
can rely on mutual support because they feel sure that
they are not alone, whatever the circumstances may
be (Marsh et al., 1996).
Permanence and indissolubility of the bond (Scabini
& Manzi, 2011) are undeniable in many accounts; in-
deed, some family members are constantly present, re-
gardless of how much time they may have to care for
their ill relative. These family members believe they
have a responsibility and permanent obligation just for
the fact that they are family (Stein & Wemmerus, 2001).
In the same way, the dynamic component of being a
family, of giving and receiving (Scabini & Manzi,
2011), is present in family members’ expressions of care
and concern, and in their constant search for their rela-
tive and family’s well-being. This component of what a
family is, giving, is even more present in those families,
Á. R. Acero et al.Family identity and severe mental illness
European Journal of Social Psychology 47 (2017) 611–627
Copyright © 2017 John Wiley & Sons, Ltd.618
specifically in their characteristic of not being symmetri-
cal, that is to say, there is a difference in the amount
given out and the amount received back.
Although finding value in their ill relatives is difficult
for some families (Huang et al., 2009), for others, it is
noticeable how they accept them after their illness and
value and love them for being who they are (Marsh

115. et al., 1996), beyond their illness and what they can or
cannot do.
Process of transformation of identity. Within the
family, there is a meeting of multiple identities that are
co constructed and transformed in different ways. MI
involves changes in the way people see themselves as
parents, siblings, or children and in how they take on
and accept changes in the reorganisation of their lives
around the needs of a mentally ill relative.
Siblings are often faced with an important moment of
change in that they are forced to grow up faster; they
commonly assume the role that is required within the
family, making it necessary for them to assume more re-
sponsibility, to grow up, and to mature. At the same
time, this also reinforces their previous role as a brother
or sister within which they offer help, companionship,
and support (Newman et al., 2011). Brothers and sisters
go through the loss of the previous relationships and the
construction of a new one (Stålberg et al., 2004); they
see themselves as an important part of the recovery of
their brother or sister (Newman et al., 2011). However,
in many cases, family reorganisation leads to the whole
family focusing on just one person, which results in
some family members, especially healthy siblings, be-
coming ‘invisible’ (Lukens et al., 2004; Sin et al., 2008).
Some parents internalise a change in their view of the
care they give to their child and in the needs their child
may have. They assume that they will always be parents
and involve their healthy children in the care of their ill
sibling. Many parents, in addition to redirecting their
expectations regarding their children, question them-
selves and are questioned by others about their role as
parents, about their possible contribution to illness

116. (Stein & Wemmerus, 2001), and about how they react
to the behaviour of their child with SMI (Huang et al.,
2009).
Salient Identity: Expert Families in Mental Illness
and Care
Caregivers as the main salience in family
identity. With SMI, the salient and social aspects of
family identity experience the highest degree of change.
One of the principal identities that the family assumes is
that of family carer in both practical and emotional areas
(Stålberg et al., 2004). Family members are more willing
to assume the role of caregiver when there is a previ-
ously established relationship defined by closeness and
affection (Bedoya & Builes, 2013; Lukens et al., 2004;
Stålberg et al., 2004). Despite the effort required and
the strain it entails, looking after and devoting oneself
to a relative is a necessity in many families (Marsh
et al., 1996; Penny et al., 2009).
When the ill relative is a child, mothers usually as-
sume the role of the main carer. A great deal of them
put the rest of their life to one side in some way (Sin
et al., 2008). The new role demands a lot of time from
any family member’s typical activities (Huang et al.,
2009; Newman et al., 2011). The carer abandons or puts
off essential family aspects such as work, school, or their
spouse to make room for the ill relative’s needs (Huang
et al., 2009).
Families, parents, and especially mothers consider the
role of caregiver as a responsibility, an obligation that
becomes more evident when illness surfaces (Bedoya
& Builes, 2013; Penny et al., 2009). Besides, care is not

117. based on the family bond alone but also involves a great
deal of love (Bedoya & Builes, 2013; Stålberg et al.,
2004).
When mentally ill people receive care from their fam-
ilies, they report a feeling of protection and support;
they also get first-hand experience with the fact that
their needs are not the only ones in play and that all
family members’ needs should be recognised (Bedoya
& Builes, 2013; Sin et al., 2008).
The main carer develops skills to identify the early
signs of crisis (Bedoya & Builes, 2013) and, in general,
of the illness (Gerace et al., 1993). Caring families be-
come experts in MI in some ways.
Other salient family identities: a different
family. A variety of families mention that they must
get used to the fact that others consider them as a ‘differ-
ent’ family (Stålberg et al., 2004) or to seeing them-
selves as a family that other people would not want to
belong to because of the fact that one of their members
is mentally ill (Lukens et al., 2004). Many are subtly
rejected (Saunders & Byrne, 2002), which adds to the
demands of taking care of their relative and often results
in families becoming solitary, isolated, and deprived of
their social relationships and leisure time (Huang et al.,
2009). Families describe an intensification of relation-
ships, but not a broadening of them. That is to say, rela-
tionships between family members and some members
of their extended family or friends become more signif-
icant, although, in general, the total number of relation-
ships is reduced.
Some relatives also develop roles that, although re-
lated to caregiving, do not necessarily require daily in-

118. volvement. In general, these roles are focused on
giving support to the family in their attempt to cope
with the situation. For instance, some siblings mediate
with health professionals, making healthcare informa-
tion more understandable for their parents (Gerace
et al., 1993; Newman et al., 2011). Others take charge
of formalities with medication or look for information
about the illness (Newman et al., 2011). In many cases,
this involves abilities that the family member has previ-
ously developed, thus putting their skills at the service of
the family (Lukens et al., 2004; Newman et al., 2011).
Á. R. Acero et al. Family identity and severe mental illness
European Journal of Social Psychology 47 (2017) 611–627
Copyright © 2017 John Wiley & Sons, Ltd. 619
This new role can be difficult for siblings. They may
sometimes assume the role of a parent; on other occa-
sions, they may have to mediate or balance emotions,
while, at times, their role is to avoid adding more prob-
lems or suffering to the family (Lukens et al., 2004).
Family members, including the mentally ill relative,
sometimes develop another role in serving as a refer-
ence and a source of support to other families with MI,
spreading their experience and knowledge to other peo-
ple (Marsh et al., 1996).
Who Are You? Who Are We?
The family’s identity is redefined in reference to the
identity of a mentally ill relative. The family embraces
a ‘new’ member and reshapes existing bonds, roles,

119. and expectations. The ill relative adopts a new way of
seeing himself or herself and of being seen by his or
her relatives. The family is forced to recognise that the
person who was once one of its members is no longer
there (Gerace et al., 1993). He or she has changed and
will no longer be the one he or she was before (Gerace
et al., 1993; Penny et al., 2009).
For ill relatives, the onset of illness can be accompa-
nied by the perception that their self has been taken
away. In a certain way, they lose their identity and be-
come an unknown individual (Wisdom et al., 2008).
Some of them recognise themselves as vulnerable and
ill (Bedoya & Builes, 2013) persons, where the symp-
toms of MI force their identity into a dichotomy be-
tween who they are when they are healthy and when
they are ill (Wisdom et al., 2008).
For some, this means that the symptoms and illness
become the most salient and permanent aspect of their
identity (Wisdom et al., 2008) or of their relative’s iden-
tity (Barker et al., 2001). However, on other occasions,
some ill people and their relatives reach a point where
they are able to see the illness as just another part of
who they are (Wisdom et al., 2008).
Some may see their illness as a way of differentiating
themselves from their family or of defining themselves.
Others, after experiencing MI and the physical proxim-
ity that it forces upon people, undergo a process of
recovery and regained independence (Barker et al.,
2001).
Finally, when families have a mentally ill member,
they often consider the topic of future generations and
the possibility of developing an identity as a parent,

120. grandparent, or aunt/uncle, sometimes having to accept
the possibility of never filling those roles (Sin et al.,
2008; Wisdom et al., 2008).
Unique Families, Unique Identities
Although multiple aspects are common to families
experiencing MI, the fact that there are differences in
their experiences and in the sense each of them gives
to illness cannot be ignored. The changes they go
through are closely related to the culture they reside in
and to each family’s particular context.
In the study carried out by Bedoya and Builes (2013)
with Colombian families, in the research conducted by
Huang et al. (2009) with families from Taiwan, and in
the study by Penny et al. (2009) with Pakistani families,
it is clear that families place more value on being an ac-
tive part of their relative’s care, usually as the main
carers. They experience it as an obligation, something
they owe to their relative, and they cannot and do not
want to delegate it to other people.
On the contrary, for families in more individualistic
cultures, state support and institutional resources, as
well as the conception of adulthood in the society to
which they belong, make them think about the possibil-
ity of their relative’s independence. In other cases, they
delegate their relative’s direct care, although they con-
tinue to be present in case they are needed (Stein &
Wemmerus, 2001).
Depending on the culture and its beliefs about illness,
the family may see its ill relative as a person without
value. This fact becomes evident in the study of families
in Taiwan, where some healthy siblings simply did not

121. accept their brother or sister with MI and considered
him or her as a ‘lazy’ because he or she did not work
(Huang et al., 2009). He or she did not meet the expec-
tations of their community, where work is a source of
pride for the family and society. This can lead them to
hiding the illness and rejecting their ill relative. Therein,
persons with SMI become isolated from society, as well
as the rest of the family, because of shame (Huang et al.,
2009; Sin et al., 2008).
The ways of coping or the ways in which the family
gets involved are related to their explanations and be-
liefs about the illness. As is evident in the studies of fam-
ilies from Pakistan or Taiwan, in some families, more
importance is placed on the social and religious compo-
nents inherent in the culture, thus shaping their expla-
nations and behaviours concerning MI (Huang et al.,
2009; Penny et al., 2009).
On the contrary, in Western cultures, the relevance of
biological and medical concepts on this subject leads to
whole families with different understandings and ac-
tions (Barker et al., 2001; Bedoya & Builes, 2013;
Saunders & Byrne, 2002; Stein & Wemmerus, 2001).
Discussion
This synthesis explores the relationship between SMI
and family identity. Our findings evidence that (i) fam-
ilies living with SMI experience a change in family iden-
tity that takes place in the meta context of the changes
in family life and in family relationships derived from
the experience of illness; (ii) this process entails a dy-
namic experience that goes through at least two phases,
the first is more intense and chaotic, whereas the later
one presents constant challenges derived from the ex-

122. perience of illness and a variable process of acceptance;
(iii) for most families, a strengthening and renovation
of family bonds arise, as well as a new form of relation-
ship among family members; (iv) the care and knowl-
edge garnered from the experience of SMI becomes a
Á. R. Acero et al.Family identity and severe mental illness
European Journal of Social Psychology 47 (2017) 611–627
Copyright © 2017 John Wiley & Sons, Ltd.620
part of their salient identity; (v) there is a constant
search to understand and make sense of who they are
and/or who their relative is; and (vi) every family iden-
tity is closely related to its sociocultural context and his-
tory as a family.
We consider that this synthesis adds, for the first time,
a family identity perspective to the experience of SMI.
Although other scholars have described the impact of
MI and stigma on personal and social identities, as well
as on families as a group (Fernandez, Breen, & Simpson,
2014; Forrester-Jones & Barnes, 2008; Goffman, 2009;
Larson & Corrigan, 2008; Phelan, Bromet, & Link,
1998; van der Sanden, Bos, Stutterheim, Pryor, &
Kok, 2013), up to now, there seems to be no scholarly
research focused on family identity in SMI. Therefore,
this article is likely the first piece of research on
this topic.
In what follows, we first discuss various methodolog-
ical aspects, including the limitations of this study,
followed by a discussion of changes in family identity,
which is structured by the initial questions that guided

123. this synthesis, as well as the relationships between SMI
and family identity, and cultural findings. Finally, the
implications of the study are addressed.
Methodological Aspects
There are several methods to perform a synthesis of
qualitative research (Barnett-Page & Thomas, 2009).
We chose the method proposed by Thomas and Harden
(2008), given its structure and its greater internal coher-
ence with the rest of the guidelines followed in our
synthesis (ENTREQ, PRISMA, and COREQ). One of
the drawbacks of this method concerns the third step
of analysis, in which it is encouraged to go beyond the
original information so as to give a new interpretation.
However, in this step, we adhered to previous theoreti-
cal concepts and to the research questions. As pointed
out by the authors of this method (Thomas & Harden,
2008), ‘the analytical themes are the result of interro-
gating a descriptive synthesis by placing it within an ex-
ternal theoretical framework’ (p. 8).
Concerning quality assessment of the papers, one of
the aspects deserving attention is to make explicit the
characteristics of the research team and reflexivity,
which allow readers to assess how these factors might
have affected authors’ interpretations and observations
(Elder & Miller, 1995; Malterud, 2001; Mays & Pope,
2000). This is one of the motivations for the implemen-
tation of guidelines to report qualitative research (Tong
et al., 2007).
Studies directly analysing identity in SMI are scarce.
This means that our thematic synthesis was carried out
on the basis of studies whose main objective was not
directed at analysing identity in depth. Five of these

124. studies were focused on siblings’ experiences, and
therefore, this study is possibly more skewed towards
this group than to other family members (spouses,
grandparents, etc.). There is also a lack of information
about the identity process when families experience
SMI in more than one family member.
Given that most of the studies reviewed included fam-
ilies that were willing to participate and that, to some
degree, continue taking care of their ill relatives, find-
ings described in this article are probably only applicable
to these sorts of families. This excludes families who
have decided to distance themselves or who, for a vari-
ety of circumstances, have not been able to directly ac-
company the process of their relative. What identity
processes unfold in these other families?
At the same time, because the majority of the articles
included involve families experiencing psychosis, the
findings can only be generalised to families in that situ-
ation. It is probable that specific analytic themes also
likely vary within the different SMIs.
The texts included in this article differ in terms of
methodology, objectives, participants, and places where
they were carried out (with different beliefs, health sys-
tems, and degrees of state support). These differences,
although they provide a wider outlook, entail the diffi-
culty that the results are not applicable to a variety of
families and cultures, and also, they present methodo-
logical challenges when translating concepts from one
paper to another. To solve the latter difficulty, the first
step included line-by-line codification; in addition, the
texts’ context and characteristics were considered
throughout the analysis (Thomas & Harden, 2008).

125. Changes in Family Identity
Process of change. An SMI changes a person’s be-
haviour, actions, and feelings and redefines how he or
she views his or her capabilities, relationships, and place
in the world. In conjunction with this changing view,
the family of a person with SMI goes through a process
by which relationships, roles, and expectations emerge
with a new configuration. This process usually implies
a loss of the former self or the family member, as well
as of expectations, dreams for the future, previous rela-
tionships, and a sense of security and certainty. For this
reason, several authors identify this change as a grief
process (Richardson, Cobham, Murray, & McDermott,
2011).
The process of loss and finding new meaning for one-
self and for the family as such has been found—as in the
present synthesis—to change over time (Godress,
Ozgul, Owen, & Foley-Evans, 2005). Initially, it is a very
intense process and later becomes more focused on get-
ting on with life. In line with these findings, other pieces
of research describe how families with SMI get through
the experiential and coping phases, highlighting their
challenging nature (Muhlbauer, 2002); several other
studies include the positive redefinition of the sense of
identity as a category of recovery (Leamy et al., 2011).
Findings in this line were also found in the study by
Buckley-Walker (2013) focused on family members’
personal identities when recovering from the impact of
their family member’s MI and/or substance abuse. In
that study, families were recruited from a support
Á. R. Acero et al. Family identity and severe mental illness

126. European Journal of Social Psychology 47 (2017) 611–627
Copyright © 2017 John Wiley & Sons, Ltd. 621
group, and personal identity aspects were assessed at
the beginning of the research and again after 12
months. They found that family members were initially
focused on their ill family member and perceived him or
her negatively, but 12 months later, they were more fo-
cused on themselves and were able to see the situation
in a more optimistic light regardless of their ill relative’s
recovery stage (Buckley-Walker, 2013).
Family identity. Findings suggest that family iden-
tity is modified in a variety of ways. In some families,
identity aspects are reinforced, whereas in other families
previous fissures become deeper and open the family up
to disintegration. In this synthesis, we found limited in-
formation with regard to the latter case. However, in
some families, when relationships are negatively im-
pacted, as can happen in the relationship between par-
ents or among siblings, affected family members may
begin to identify less with their family (Sani, 2012). To
what extent did those families consider themselves as
‘we’? How strong was their shared identity as a family
before the onset of SMI? By the same token, Kellezzi
and Reicher use the term ‘social curse’ to explain the ef-
fects of events, such as an MI, with a stigma attached to
them that then result in the denial of an established so-
cial identity. In this case, individuals do not share their
burdens; it is difficult for them to ask for help, and if they
do, there is no guarantee they will receive it (Kellezi &
Reicher, 2012; Stevenson, McNamara, & Muldoon,
2014). This might also result in one or several family

127. members employing avoidance strategies to cope (i.e.,
avoiding conversation about the illness and avoiding
contact with the relative), therefore impacting family
relationships (Kartalova-O’Doherty & Doherty, 2008).
In contrast, we found that, as Cigoli and Scabini
(2006) suggest, in some families, the elements that
identify a family as such are reinforced. Family bonds
become stronger, renewed, and revised, especially in
reference to their permanence and indissolubility.
Many families, in the face of this event that they share
as a common fate (O’Donnell et al., 2016), increase their
sense of unity and their identity as a family. They switch
to assume with more enthusiasm their family identity—
over each one’s personal identity—and make it become
more salient (Reicher, 1987), reassessing in the process
who they are as a group, as well as their values and
strengths. They change and endure in that process. To
this respect, the Social Identity Model of Change sup-
ports the idea that a family identity that is maintained
throughout can buffer SMI’s negative consequences
(Jetten & Pachana, 2012).
Regarding this point, King and Wynne (2004) pro-
posed the construct of family integrity to refer to a
personal sense of meaning, connection, and continuity
with the family that becomes more important in adult-
hood. Previous studies about perceived family conti-
nuity (PFC) showed how it is related to a sense of
belonging and to psychological well-being. In those
studies, the intermediate step between PFC and its pos-
itive psychological effect is found in family identification
(FId), which is the sense of belonging to a family
(Herrera, Sani, & Bowe, 2011). Along these lines, we
found that this sense is increased in some of the families

128. from the studies included in this synthesis. In addition,
FId and the sense of being one as a group show that
family members categorise themselves within the fam-
ily and that they feel that they belong to it. In other
words, family members’ sense of belonging to their fam-
ily makes them share a social identity, and this is the fact
that, as some have identified, has a potential influence
on health (Jetten et al., 2014). It also explains their be-
haviour, commitment, and, in some cases, sacrifices
(Turner et al., 1987). Greenaway et al. (2015) recently
have demonstrated that ‘groups nurture feelings of
personal control and help individuals to feel capable of
pursuing and accomplishing their goals’ (p. 69, empha-
sis in original), although it implies putting the collective
interest (directed to one person or group) ahead of one’s
own interests.
It is worth noting that, in intervention studies on so-
cial identities (Haslam, 2014), the group itself is the
main therapeutic agent. Experiences are shared in the
group, leading group identities to be based on solidarity
and connection. In our case, the family shares multiple
experiences while living with SMI (changes in personal
and family life and family relationships, grief over the
loss, multiple and intense emotions, permanent chal-
lenge, and, in some cases, acceptance), leading to the
presence of a bond and solidarity among the different
members. In some ways, family relationships are put
to test in a time of crisis, and previous family weaknesses
and strengths emerge (Cigoli & Scabini, 2006). In
contrast to identification with a stigmatised group
(Crabtree et al., 2010), the family and its members
identify and recognise themselves not only in light of
what makes them different and susceptible to stigma
but also in light of what unites them and makes them
a family. Groups (e.g., the family) become the ‘vehicle’

129. that brings change to fruition (Haslam, 2014) by
making their members feel supported, esteemed, and
capable (Greenaway et al., 2015). In this case, ill family
members are supported by their family, loved by their
family, and empowered by the fact of belonging to
their family.
The sense of obligation, responsibility, and giving,
which the family experiences, is found in similar pieces
of research (Rowe, 2012; Weimand, Hall-Lord,
Sällström, & Hedelin, 2013). Cigoli and Scabini (2006)
refer to this senses as both one of the characteristics of
the family bond, ‘the family bond rests on a foundation
of trust and hope, and develops if it respects justice, loy-
alty and obligation’ (Scabini & Manzi, 2011, p. 570, em-
phasis added), and as a dynamic component of what a
family is. The latter sense is grounded in giving and in
the debt acquired with the giving person. The exchange
starts with a gift and with gratitude, accompanied by an
acquired sense of debt. Weimand et al. (2013), for their
part, refer to the ambivalence that this dynamic gener-
ates when another person’s well-being trumps one’s
own well-being.
Á. R. Acero et al.Family identity and severe mental illness
European Journal of Social Psychology 47 (2017) 611–627
Copyright © 2017 John Wiley & Sons, Ltd.622
Another aspect that is reinforced for many families is
the way in which the family assumes the role of care-
giver, especially of the ill member, but also of the whole
family. As in previous studies, we found that the pre-
dominant role of the mother, the strain, and the difficul-

130. ties that arise are also present (Calderon, 2011; Millier
et al., 2014) and are consistent with other studies con-
ducted on chronic illnesses and family, as well as with
a significant number of publications on the effect of be-
ing a carer (National Alliance for Caregiving & AARP,
2009). However, it is worth noting the nuance of a
mandatory nature and the desire to take care of an ill
relative, something that has also been found in other
studies and that could be related to the fact that some
caregivers report positive effects on quality of life and
present a decrease in mortality (Brown et al., 2009) in
contrast to the outcomes typically reported (Millier
et al., 2014). In our review, we observe how families
do want to provide care during the time necessary in
spite of any negative effects and that they also become
subject matter experts. These findings are similar to
those found in Rowe’s (2012) article.
In this way, an experience that is at first glance indi-
vidual, such as SMI, is experienced collectively (i.e., in
families that take on the MI as a ‘common fate’), and
the needs that are initially personal transform each fam-
ily members’ identity and their relationships. The collec-
tive experience present in a family with SMI allows its
members to redefine their identity as a group, to rein-
force their characteristics as a family (bonds, relation-
ships, love for who they are, and mutual care), and to
achieve a stronger identification and salience of them-
selves as a group (shared social identity) (Cigoli &
Scabini, 2006; O’Donnell et al., 2016; Páez & Rimé,
2014). SMI thus emphasises existent aspects of family
identity, which include caring and nurturing, but it also
changes and transforms the family by redefining it pri-
marily in terms of its caring roles. This entire process is
framed within cultural understandings and individual
family stories of what it means to be a family.

131. Cultural aspects
Depending on the population in which research is per-
formed, cultural factors become more evident, as found
in studies by Bedoya and Builes (2013), Huang et al.
(2009), and Penny et al. (2009). These cultural factors
also likely define the different ways in which family
identity changes. These findings coincide with other
studies that have yielded differences between MI and,
for example, the type of culture and personality traits
(Caldwell-Harris & Aycicegi, 2006) or the prognosis
and outcomes in accordance with the level of the
country’s development (Kalra, Bhugra, & Shah, 2012).
In our synthesis, we specifically found that culture
shapes beliefs about what a family is and about SMI
and its consequences. Culture deeply influences how
and if a family considers itself primarily responsible for
an ill relative’s care (in familistic cultures) or how and
if a family identifies itself as belonging to a stigmatised
group (Huang et al., 2009). The former may result in
the salience of family identity leading to a larger source
of support, which could, in turn, be related to family
members providing more direct care in countries with
a predominately family-oriented culture (familism), in
contrast to countries with a predominately individualis-
tic culture (Lefley, 1996; Seeman, 1988). The latter case
may result in care being a greater source of stress and in
families getting involved in it less or in more difficulty
accepting their relative as a result of the ‘negative’ conno-
tations associated with their group identity (Branscombe,
Fernández, Gómez, & Cronin, 2012; Larson & Corrigan,
2008; Phelan et al., 1998; van der Sanden et al., 2013).
With the systemic theory and the ecological theory of

132. human development taken as a reference (Rosa &
Tudge, 2013), it seems fair to claim that family identity
represents the interrelationship between multiple con-
texts and systems. Therefore, the way in which family
identity changes in each case is shaped by multiple nu-
ances present in culture, a specific country’s economic
development, inherent family characteristics, family
members’ particular characteristics, the influence that
these unique elements have on each person and
family’s history and co biography, and so forth.
Implications
The findings herein explored are important because
when we understand how a family’s identity is trans-
formed, and the aspects that influence it, more effective
interventions can be implemented to ‘repair’ affected
relationships, to strengthen existing ones, and to bolster
the recovery process for both the ill person and the en-
tire family (Gehart, 2012b). For example, for many fam-
ilies, the experience of SMI offers a way to strengthen
their family identity and to effectively become a social
cure by means of the physical and psychological sup-
port, the feeling of being loved, and the increase of their
ability to control the situation—individually and as a
group. In this way, they are able to understand their
value as persons and as families, despite the illness and
its implications. This is to say, they can ‘…live a mean-
ingful life in a community (…) while striving to archive
his or her—and their—full potential’ (U.S. Department
of Health and Human Services, 2004). However, other
families experience negative identity aspects, such as
stigma, shame and rejection, chronic grief, or even the
breakup of family relationships (a dynamic that is close
to the ‘social curse’ described by Stevenson et al.,

133. 2014). This last point poses interesting challenges for re-
search and intervention, including (i) identifying previ-
ously established family identity aspects that facilitate
the former outcome; (ii) understanding the effect that
information and institutional support has on family
identity and how timeliness of such support influences
SMI (e.g., in first years after diagnosis); (iii) exploring
the importance of interventions on family belief systems
in countries where culture seems to play an important
role in making shame and stigma a salient part of family
identity; (iv) establishing additional interventions so
Á. R. Acero et al. Family identity and severe mental illness
European Journal of Social Psychology 47 (2017) 611–627
Copyright © 2017 John Wiley & Sons, Ltd. 623
that exhaustion and overall burden do not negatively
impact an otherwise united family; and (v) identifying
the special needs that families going through chronic
grief may have. Furthermore, other aspects need to be
explored, such as the differences in outcomes depend-
ing on who falls ill and who takes on the caregiver re-
sponsibility (parent caring for child, vs. child caring for
adult or wife caring for husband, vs. husband caring
for wife, etc.). Other fruitful research entails studying
SMI that is passed on genetically.
In other words, when dealing with the challenges of
SMI and resulting family dynamics, we must answer
the question of which local and cultural conditions facil-
itate a ‘social cure’ rather than a ‘social curse’ and what
can be done to facilitate those conditions.
Information garnered from these proposed lines of re-

134. search could be used to study and develop reinforcing
mechanisms of family identity—adapted to individual
families and cultures—which could facilitate increased
agency and resilience in families with SMI. The mecha-
nisms that reinforce family identity are found, for exam-
ple, in relation to conjoined narratives and identity
(Zaman & Fivush, 2013) or the eventual usefulness of
strengthening the family identity of a person and the
whole family so as to make coping with a specific situa-
tion easier—in this case SMI—as has been observed in
other health areas (Douglas, 2012).
In addition, it is important to note that of the studies
designed to explore family experiences only three in-
clude the ill family member. Future studies might bene-
fit from carrying out studies that include the family both
conceptually and methodologically, that is to say, stud-
ies in which the mentally ill relative takes part in inter-
views and narratives. This would make perfect sense
given the role of conjoined narratives in family identity
(Koenig Kellas, 2005).
All in all, the family is the first group to which human
beings belong and, for most people, it is the most signif-
icant. Therefore, family identity as a shared social iden-
tity deserves and requires major research and
intervention when it comes to living with, and recover-
ing from, SMI.
Conflict of Interest
The authors declare that there are no potential conflicts
of interest with respect to the research, authorship,
and/or publication of this article.

135. Supporting Information
Additional supporting information may be found in the
online version of this article at the publisher’s web-site.
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ORIGINAL PAPER
Family Influence in Recovery from Severe Mental Illness
Heather Michelle Aldersey • Rob Whitley
Received: 24 February 2014 / Accepted: 19 November 2014 /
Published online: 10 December 2014
� Springer Science+Business Media New York 2014
Abstract The aim of this study was to investigate the
perceived influence of family on recovery from severe

150. mental illness. 54 semi-structured interviews were con-
ducted with a diverse sample of people with severe mental
illness living in Montreal. Results indicated that family
both facilitated and impeded recovery processes. Specifi-
cally, family facilitated recovery through providing
(a) moral support, (b) practical support and (c) motivation
to recover. However family impeded recovery through
(a) acting as a stressor, (b) displaying stigma and lack of
understanding, and (c) forcing hospitalization. The study
indicates the importance of family psychoeducation in
promoting recovery.
Keywords Recovery � Family � Severe mental illness �
Canada � Quebec
Introduction
In recent years, definitions of recovery from severe mental
illness (SMI) have shifted from clinical perspectives
emphasizing symptom remission to more holistic per-
spectives that emphasize social and functional aspects of

151. life (Whitley and Drake 2010). In this context, recovery has
been defined as ‘‘living a satisfying, hopeful, and
contributing life, even when there are on-going limitations
caused by mental health problems’’ (Mental Health Com-
mission of Canada 2012, p. 15). In this sense, recovery is
an ongoing individual process toward improved quality of
life. This shifting perspective on recovery was led by
consumer/survivor groups seeking greater empowerment,
destigmatization and renewed hope for their future (Lefley
1997).
Much research indicates that aspects of the social
environment impact recovery from severe mental illness
(Schon et al. 2009; Topor et al. 2011). This research has
focused on areas including employment (Becker and Drake
2003), housing (Padgett 2007) and social connectedness
(Ware et al. 2007). One life domain which has received less
attention in the literature is the role of family. This may
represent an unwillingness amongst psychiatric researchers

152. to reopen a line of enquiry that was historically criticized
for implicitly stigmatizing, damaging and attacking family
members of people with mental illness (Luhrmann 2007).
This includes the now discredited notion of the
‘‘schizophrenogenic mother’’, which attributed mental ill-
ness to maternal overprotection and rejection (Bateson
et al. 1956; Neill 1990). These now outmoded views were
rooted in Freudian notions of dysfunctional family rela-
tionships being critical to mental illness onset, as well as
the post-war ‘liberation’ movements which perceived
families, especially parents, as a poisonous influence on
young adults (Laing 1967; Guarnaccia 1998). These
notions were rendered obsolete by careful research exam-
ining the relationship between parenting style and schizo-
phrenia (e.g. Hirsch and Leff 1975). That said, these
theories have left a tainted legacy that continues to per-
meate the practice and theory of psychiatry, with
researchers treading gingerly around family influences on

153. mental illness.
H. M. Aldersey (&)
School of Rehabilitation Therapy, Queen’s University, 31
George St., Louise D. Acton Building, Kingston, ON K7M 6A8,
Canada
e-mail: [email protected]; [email protected]
R. Whitley
Douglas Mental Health University Institute, 6875 LaSalle
Boulevard, Montreal, QC H4H 1R3, Canada
123
Community Ment Health J (2015) 51:467–476
DOI 10.1007/s10597-014-9783-y
http://crossmark.crossref.org/dialog/?doi=10.1007/s10597-014-
9783-y&domain=pdf
http://crossmark.crossref.org/dialog/?doi=10.1007/s10597-014-
9783-y&domain=pdf
One area of the family that continues to be the object of
some research efforts in psychiatry is the influence of
‘‘expressed emotion’’ on mental illness. Expressed emotion
refers to criticism, hostility, and over involvement

154. expressed by close kin toward a relative with schizophrenia
(Jenkins 1991). EE reflects a shift ‘‘away from the pre-
vailing psychiatric assumptions concerning the etiological
relevance of psychopathological (i.e., so-called ‘‘schizo-
phrenogenic’’) family features to the identification of
everyday family features that might figure into the course
of major psychiatric disorder’’ (Jenkins 1991, p. 391). This
moved the focus away from investigating families as a risk
factor for onset, instead examining the role families might
play in perpetuating any psychiatric disorder. Indeed, some
research does suggest that families reflecting higher levels
of EE negatively impact the course of psychiatric disorder
(Docherty et al. 2011; Pharoah et al. 2010). Indeed, EE
continues to be a relevant concept among researchers, and
has been used as a measure in other linkages between
family and health. This includes studies of bipolar disorder,
major depression, eating disorders, alcoholism, diabetes,
childhood epilepsy, and myocardial infarction (Leff 2013).

155. Some parent and family members in the United States
organized themselves into a national movement known as
the National Alliance on Mental Illness (NAMI). This was
partly because they were frustrated with the blame attrib-
uted to families by the psychiatric profession (Harrington
2012). As witnessed by their publicity material, NAMI
advocates a biological basis of severe mental illness,
focusing more on the idea that this is a ‘‘brain disease’’ as
opposed to an illness with a biopsychosocial etiology
(Harrington 2012). Some research suggests that many
families remain invested in the biological model of SMI,
often in a manner which diminishes the family’s role in
aetiology or course of the illness (Callard et al. 2012;
Harrington 2012).
Until relatively recently, families have generally been
under a pathological gaze when examined by psychiatric
researchers. That said, researchers have begun to investi-
gate family as a resource for recovery, with some prom-

156. ising results. For example, Guarnaccia and Parra (1996)
argue that families often support recovery through the
provision of ‘‘instrumental help’’, which can be funds,
commodities, or logistical assistance to the family member
affected by mental illness. Similarly, Schon et al. (2009)
describe how families can provide practical assistance,
such as taking over chore responsibility, offering tempo-
rary housing, or cooking meals. In their study of recovery
from co-occurring severe mental illness and substance
abuse disorders, EnglandKennedy and Horton (2011) dis-
cuss family support for recovery, including ‘‘intangible
support,’’ or ‘‘emotional, structural, moral, spiritual, or
other interpersonal forms of encouragement’’ (p. 1225).
EnglandKennedy and Horton (2011) also argue that fami-
lies facilitate recovery by being available for their family
member, providing transportation, and voicing encourage-
ment. Topor et al. (2011) note that the simple continued
presence of family members is a form of support for

157. recovery as it is a ‘‘reminder of what the individual used to
be like and evidence of the fact that there is more to the
person than simply being a psychiatric patient’’ (p. 91).
With an increase in studies reflecting a more balanced
understanding of the family role, researchers have begun
identifying areas where family-related factors can both
facilitate and impede recovery. EnglandKennedy and
Horton (2011) argue that families can impede recovery
when there is a breakdown of trust and communication
between family members and their relation with SMI.
Family members can also negatively affect their relation
with SMI through negative actions and words. Some of
these problems originate from lack of information or mis-
information about mental illness among family members.
Other studies have noted that families can be detrimental to
the recovery process when they remain fixated on a helper
role and are unable to support an individual’s movement
toward autonomy and reciprocal relationships (Bradshaw

158. et al. 2007; Schon et al. 2009). In a study of individuals
experiencing severe mental illness, substance abuse, and
homelessness, Padgett et al. (2008) found that although
many family members could be a source of warmth and
nurturing, they could also reject and condemn their mem-
bers with mental illness, with their acceptance only con-
tingent on family notions of good behavior. Moreover, they
reported that family relationships could be strained when a
parent or sibling commits a participant for involuntary
treatment. Similarly, Gehart (2012) argues that many
individuals with mental illness are ‘‘estranged from family
and friends because of problems and incidents relating to
their symptoms, and often these support people are not
willing, interested, or available to participate in the
recovery process’’ (p. 452).
Some studies from different cultures have also shown
family to be a protective factor in recovery. Bresnahan
(2003) have argued that family involvement, acceptance

159. and support of individual members who develop SMI
reduce stress and increase resilience (Bresnahan 2003). A
study at a Nigerian psychiatric hospital found that family
involvement in treatment during hospitalisation was inde-
pendently associated with greater post-discharge appoint-
ment adherence in individuals with SMI (Adeponle et al.
2009).
Evidence suggests that families which are supported and
educated can better enhance their family member’s recovery.
One effective method for supporting and educating families
is the family psychoeducation (FPE) intervention. This is an
evidence-based practice that educates family members and
468 Community Ment Health J (2015) 51:467–476
123
friends about mental illness and how to help someone with a
psychiatric disorder. More than 30 randomized clinical trials
have demonstrated reduced relapse rates, improved patient

160. recovery, and improved family well-being for people with
SMI participating in FPE (McFarlane et al. 2003; Lincoln
et al. 2007; Lucksted et al. 2012).
In contrast to clinic-based FPE, there are also family-run
interventions to support and educate families that have
members with mental illness. Perhaps the most well-known
family-run model is the National Alliance on Mental Ill-
ness’ (NAMI) Family-to-Family (FTF) program. FTF is a
12-session course that covers a range of topics, including
emotional responses to mental illness, current information
on the major mental illnesses, research on the biology of
mental illness, and information on the evidence-based
practices that are most effective in promoting recovery
(Burland 1998; Lucksted et al. 2012). This information is
delivered to families by family members of an individual
living with mental illness. Research indicates that FTF can
reduce family anxiety, improve family problem-solving,
increase positive coping, and increase family knowledge

161. (Lucksted et al. 2012). Although the NAMI FTF program
originated in the United States, it is implemented in some
provinces in Canada, including Quebec (ASMFMH 2014).
This brief introduction indicates that the research litera-
ture on family influence on mental illness has evolved from a
solely pathological emphasis towards examination of family
as a resource for recovery. The present study is conducted in
the spirit of this shift in emphasis. The aim of the study is to
assess the perceived influence that family has on recovery
from the perspective of people living with severe mental
illness. Conducted from a position of equipoise, the study
attempts to elicit perceived barriers and facilitators to
recovery related to family, in a grounded qualitative inves-
tigation of people with severe mental illness.
Methods
Participants and Recruitment
54 people (26 women) living with a diagnosis of severe
mental illness were recruited to partake in a semi-struc-

162. tured interview about recovery. Participants were recruited
from three Montreal psychiatric outpatient clinics. Partic-
ipant inclusion criteria included: (a) must have had a
diagnosis of schizophrenia, major depression, schizoaf-
fective disorder or bi-polar disorder during the last 5 years;
(b) this must have lasted at least 3 years; (c) must currently
be using mental health or rehabilitative services; (d) must
be able to give informed consent; (e) must speak either
English or French; (f) must be 18 years of age or older; and
(g) must not currently be an in-patient.
Procedures
Mental health clinicians identified potential participants
from their clientele who fell into the study inclusion cri-
teria. They then asked the potential participants if they
would consider being involved in a research study on
‘recovery’. The details of those assenting were then passed
on to a member of the research team, who contacted the
person to further explain the study. Clinicians who assisted

163. in the recruitment of participants were aware of the
inclusion criteria of the study and used medical records and
charts to ascertain diagnosis.
After a researcher completely explained the study to the
participant, the participant was asked if he or she would
like to participate. Those answering in the affirmative gave
written informed consent for their participation. Consent
forms and study protocol were approved by the McGill
University research ethics board prior to the beginning of
the study. All data were de-identified and pseudonyms
were created for each participant. Participants were com-
pensated $20 for their time.
Interviews were conducted at a time and place of par-
ticipants’ choosing between 2011 and 2013. Locations
ranged from the participant’s home, university/hospital
offices, and neutral spaces such as a park or coffee shop.
Participants also chose the preferred language of their
interview (English or French). The aim of interviews was

164. to elicit individual perspectives on recovery in general.
Questions specifically probed for the role of family in
defining, facilitating, and impeding recovery.
Research assistants were trained in semi-structured
interview techniques, and they conducted the majority of
the interviews. Through the data collection process, the
second author (RW) listened to a sizable portion of the
audio-recordings to give further feedback on interviewing
techniques to the research assistants. In addition to the
semi-structured interview protocol a small socio-demo-
graphics form was used to collect basic demographic data
such as age, gender, marital status and parenthood. The
research assistants were trained to quickly scan demo-
graphic responses in order to integrate them into the course
of the interview—a recommended strategy in qualitative
studies (Maxwell 2005). Interviews typically lasted from
60 to 120 min, with the scope and pace of the interview
controlled by the respondent. For example, there were

165. pauses and breaks during the interviews, if the participant
so desired. All interviews were audio-recorded and
transcribed.
Analysis
As already noted, the second author (RW) listened to
portions of each interview directly after it occurred for
Community Ment Health J (2015) 51:467–476 469
123
quality control and feedback purposes. The insights gained
from this quality control served as the initial impetus for
the further examination of family as an important aspect of
recovery. Upon completion of data collection, we imported
all interview transcripts into Atlas-ti qualitative data ana-
lysis software. Research assistants initially coded all tran-
scripts for any themes falling under the broad category of
‘‘family’’. The first author (HA) then engaged in open-
coding within the family categorization, marking any

166. notable sub-themes for further examination. Both authors
then utilized the code manager function in Atlas-ti to
identify codes that occurred most frequently. Both authors
then discussed the open codes in light of code frequencies
and qualitative content of coded data and collectively
distilled the most salient codes into the six themes pre-
sented below. Transcripts were then coded according to
these six themes by the first author.
Results
As noted in the methods section, we recruited 54 people (26
women). Participants fell within four broad ethno-racial
groups: (1) Anglophone Euro-Canadian (n = 10); (2)
Francophone Euro-Canadian (n = 18); (3) Anglophone
African/Caribbean (n = 15); (4) Francophone African/
Caribbean (n = 11). Groups 3 and 4 contained a mixture of
first and second generation immigrants. Participants’ age
ranged from 20 to 69 years with a mean age of 40. 37 par-
ticipants (69 %) were single, 7 participants (13 %) were in a

167. relationship (dating someone or engaged), 5 participants
(9 %) were married, and 5 participants (9 %) were divorced
or separated. 14 participants (26 %) had children. Interest-
ingly, although the sample of participants was diverse across
age, gender, and ethno-cultural background, we were unable
to identify any discernible patterns specific to any one group
related to family-related variables. Moreover, our data did
not indicate key differences of family as a facilitator or
barrier depending on family member type (e.g., spouse,
sibling, parent); yet this may also be an important topic to
examine in future studies. Rather, the themes given below
were present across all of the participant characteristic
groups, and represent common barriers and facilitators to
recovery, as related to family.
For ease of comprehension, the results are divided into two
separate sections. The first details significant ways in which
family acted as a facilitator to recovery; the second details
ways in which family acted as an impediment to recovery.

168. Facilitators
Three factors emerged as significant facilitators of recov-
ery, as perceived by participants in this study. We label
these factors (a) moral support; (b) practical support;
(c) family as a motivating factor for recovery.
Moral Support
Moral support from family was manifested in a number of
different ways in the recovery process for participants.
First, respondents remarked that simply having family
‘‘there’’ for them (either physically present or otherwise in
communication) was a positive influence on recovery.
Family presence enabled participants to understand that
they are not alone in their recovery efforts and that there
are other people that care about them. This family presence
appeared to provide the constancy and stability that many
respondents reported as necessary for recovery. Partici-
pants cited the importance of being able to trust and confide
in their family members throughout the recovery process.

169. Respondents often characterized their family members as
‘‘loving’’ and ‘‘supportive’’. In the context of social support
from families, many echoed Justine, a 20-year old fran-
cophone Euro-Canadian who said ‘‘if something happens,
they’re always gonna be there.’’
More tangibly, participants cited visits and phone calls
from family in the hospital and in their homes as important
forms of support. Interestingly, telephone conversations
and visits were perceived to be of benefit to recovery by not
addressing issues surrounding mental illness. Rather, con-
versations or mutual exchanges about everyday life helped
many consumers feel ‘‘normal’’ or forget about their ill-
ness. As Alice, a 34-year old Anglophone African/Carib-
bean, remarked:
I think definitely the support from friends and family
helps a lot. When you get visitors, phone calls, like
that is one thing for myself; typically when I am get-
ting a lot better. I just spend time on the phone in the

170. hospital; I literally sit down in the booth for like hours
just talking on the phone because communication with
the outside world, knowing that I have friends and
family that care. Even if they can’t come and visit, but
just doing what I would do at home; talking on the
phone. Just communicating, knowing what is going on
in their lives, they know what I am doing. That support
and just knowing that you have people that support
you and care about you and love you. That helps a lot.
Oftentimes, participants, like John, a 41-year old
Anglophone African–Caribbean, noted that in addition to
visiting their member in the hospital, family members can
assist recovery by getting their relation out of the house and
better connected with the local community:
My brother he take me out the other night, he take me
out and buy me a beer, so next time I say I wanna go
470 Community Ment Health J (2015) 51:467–476
123

171. downtown, and play pool, just to be interactive with
people make me feel alive again, not like a crazy
person.
The data indicate that family can further provide social
support for recovery through the rationalization or nor-
malization of mental illness. Respondents argued that
family members have helped them to put mental illness in
perspective, to see it as any other type of health problem.
Family members played an important role in helping par-
ticipants understand aspects of their mental illness, often-
times discussing family history to provide insight about
potential genetic factors of mental illness. Many respon-
dents noted their own surprise that their family members
accepted the diagnosis of mental illness and either under-
stood or made efforts to understand the mental illness and
its appropriate treatment. As Jennifer, 48-year old Anglo-
phone Euro-Canadian noted:

172. You have to accept it, and you have to be happy. I
could’ve had a house, I could’ve worked, but my
mother-in-law said to me, ‘‘be happy with what you
have’’ because I worked before, I worked for ten
years, so I was able to get a little pension that I’m
supposed to have to help my family. […] A lot of
people are sick; it’s not your fault she said.
Finally, further support from families is evidenced
through the encouragement of consumers to continue with
their treatment. This could be by advising the family
member to continue taking his or her medication, telling
him or her to continue attending psychiatric appointments
or sessions at rehabilitation centers, or encouraging him or
her to abstain from alcohol, drugs, or unhealthy
relationships.
Practical Support
Although moral support was the most pervasive type of
support provided by family that was cited in this study,
many participants also highlighted practical support from

173. family as key to their recovery. Family often provides
practical support in the form of resources for participants
during their recovery. Financial support came through the
provision of housing, paying a separate rent for the indi-
vidual, providing meals, giving pocket money, or buying
the individual gifts. Financial assistance is often an
important facilitator to recovery, given that many respon-
dents were unable to obtain or hold a job. Michel, a 40-year
old Francophone African–Caribbean notes that his family
‘‘always take me out to eat. […] They bought me things.
They bought me presents. They have really helped me.’’
In addition to financial support, respondents noted that
family provides other forms of practical support to aid in
their recovery. This can be anything from providing
transportation to the store or to doctor’s appointments to
helping the individual fill out forms or get registered in
school programs. Participants also discussed when family
members would take over their familial responsibilities and

174. household chores during periods of illness when they were
unable to do them. Adam, a 35-year old Anglophone
African–Caribbean remarked: ‘‘They’ll make sure that I
have the support—the medical support—that my bills are
paid, that my dog is taken care of, that if I need anything –
well, everything. They do everything.’’
Family as a Motivation for Recovery
The data indicate that the mere presence of family can
often influence recovery without explicit effort. Specifi-
cally, participants cited family as an intrinsic motivator
behind their efforts toward recovery. In some cases,
respondents like Peter, a 41-year old Anglophone African–
Caribbean, focused on recovery because they saw this as a
path to having a family in the future.
It took me time because I don’t want to marry
somebody that will say ‘I don’t really know that I
married a sick person,’ do you understand because
when I get sick, will that person really care for me?

175. And will they say, ha, this guy. …Maybe one time I
will go off, that is if I am kind of sick. So it took me
time… But getting married…It excites me, it mean I
want to have kids; I want to make family.
Results related to family as a motivator for recovery show
that participants were not cynical about families and indeed
saw the creation or maintenance of family as an important
component of individual recovery. For example, some
respondents aspired to having a spouse and/or children and
believed that this would be the ultimate marker that they
were in recovery. For others, like Joe, a 45-year old Anglo-
phone African/Caribbean, it was the desire to provide for
their existing family that motivated them to recovery.
I am teaching them not to give up; you fight, fight, fight
and fight. Until you can’t fight anymore. Oh yeah, I
have a reason to keep going: it is my kids. … And when
they see me struggle, some days I struggle to go to
work, to do that. I do it and then come back home. And
they know how hard it is for me, but when I see their
face and they smile, it helps me. Like I just didn’t give

176. up and say ok, fine I quit. No, I keep going. So, no, you
need that. My motivation, you asked me that before, is
my kids.
Participants in this study clearly showed that just as
parents can have an influence on their children’s health and
wellbeing; children can also have an influence the health
Community Ment Health J (2015) 51:467–476 471
123
and wellbeing of the adults in their family. Francine, a
61-year old Anglophone African–Caribbean told us about
her ultimate motivator for recovery:
I have a grandson, and my grandson is four years old.
And I would like to know him more and do things for
him and with him; you never know what can happen in
life. You know, maybe his mother might get sick and
never know what can happen. I want to be able to be
there for him. So I want to keep myself healthy, so I

177. am available if a problem arises and boom: there I am.
For still others, like Luke, a 37-year old Anglophone Euro-
Canadian, recovery was a way to reconnect with family whom
they had hurt during their experience with mental illness.
I’d spend my days and nights drinking and smoking
weed and cigarettes and getting into trouble and not
having a very good relationship with my family and
friends and it was the wrong path. It’s the opposite of
the path that I’ve been taking now. Making amends
with family and friends and trying to be there for
them and trying to stay out of trouble and be pro-
ductive is just so much more important than it ever
was before because I wasted so much time.
Barriers
Three factors emerged from the data as significant barriers
to recovery. Barriers exist when family (a) acts as a
stressor; (b) displays stigma and lack of understanding; or
(c) forces hospitalization.

178. Family as a Source of Stress
The results indicate that stress from family can come from
both intentional actions or from less intentional stressors.
Participants noted numerous common sources of stress. These
include family members being judgemental, making the
individual feel weak or incapable, or speaking to the family
member as if he or she is a child. Participants noted that they
became stressed when family members saw different life
paths for them, pushing them in directions they did not want to
go, particularly as it relates to education, career, marriage, or
children. Similarly, participants reported stress when family
membersdisagreedwitheverydaychoices,forexample eating
or dressing habits. Divorce and other family conflicts were
also seen as stressful and an impediment to recovery. Some
participants reported that their recovery gathered pace when
family members moved out. Marie, a 58-year old Franco-
phone Euro-Canadian stated:
I got sick again after, because my sons came back to

179. the house and that went very bad. It caused me to get
sick again. […] Then, at a given moment, I was
capable of saying to my son, ‘‘I will give you X many
months to find an apartment.’’ So, to find solutions to
the problems I was facing. Then, when he left for his
own apartment… he started doing better, and me as
well. This was a something that really helped me.
Participants were influenced by the illness, suicide, or
accidental death of family members, or the feeling of
responsibility to provide and care for family members.
Claire, a 42-year old Anglophone African–Caribbean,
demonstrates an important theme: Family is important, but
family responsibility can also become overwhelming.
I would like more independence. It is not really
preventing recovery, but I would like more indepen-
dence but I am torn between like familial obligations
cause my brother just went through a separation. My
mother’s health isn’t the greatest. No I have a feeling
like that they need me around, even though suppos-

180. edly I am not all there or whatever that they think, if
they need me. You know, I don’t want to desert them.
[…]You know, it is my family.
Many participants reduced contact with stressful family
members. However most participants (like Claire above)
accepted family members as important components in their
lives and did not see lessening responsibility or reducing
contact with family as a viable option to facilitate recovery.
Stigma and Lack of Understanding
Some participants like Francine, a 61-year old Anglophone
African–Caribbean, noted that within their family they felt
stigmatized because of their mental illness and that this was
a barrier to recovery.
Now there is a big stigma of mental illness when you
don’t know about it. When you don’t know about it, it
is the end of the world for certain members of the
family. And my daughter falls into that category. She
has not educated herself in my illness. And she views

181. it like a plague; like she gets too close to it she is going
to get it. … She avoids me because she doesn’t want to
be associated with me. She thinks it is bad and she
doesn’t want people to know that her mother is sick. If
she has a friend, if her friends see her with me, she
doesn’t want. She is ashamed if I would react in a way
that would not be normal to her. … So when she sees
me, she sees me in areas that are very remote; very,
very, places where her friends wouldn’t come to.
Because of the stigma associated with mental illness,
participants reported that family members would be
ashamed of their member in recovery, would deny that
472 Community Ment Health J (2015) 51:467–476
123
member actually had a mental illness, and would try to hide
the mental illness from the extended family or the wider
community for fear of a ruined family reputation. Some
participants noted that stigma may also have a cultural

182. basis for them, as they experienced stigma among family in
their community of origin (e.g. Haiti) more than in Canada.
Participants noted that they experienced barriers to recovery
when their family did not understand or did not make efforts to
understand their experience with mental illness. Family would
deny that an individual had mental illness or would not believe
that mental illness was the reason behind an individual’s
behavior. One participant noted that her father insisted that she
was just ‘‘making it all up’’. Sometimes, participants reported
that their family members would understand neither the etiol-
ogy of the individual’s specific diagnosis nor the individual’s
experience with the diagnosis and treatment. Anne, a 34-year
old Anglophone African/Caribbean, notes.
Like I invited my dad more than once to come to a
doctor’s appointment with me and he is always late and
this and that. So he never made it. And it would be nice
if my family could be more informative. Like get
themselves informed, find out what the causes are of

183. bipolarism, like how to deal with it. Like come, attend a
workshop or whatever. Read stuff. Like I had my
cousin, he was really helpful. And he still is. He went
online and he read up about it. And he informed him-
self. Like do stuff like that. Don’t just think it is because
I am not taking my medication and that is where it all
starts. And that is where it all ends. That is not it. Inform
yourself and find out about the illness. See what causes
it. See what cannot cause it and stuff like that and how
you can help and how you can be supportive. And stop
just passing the buck and thinking oh, it is because of
your friends, oh it is because of whatever, past rela-
tionships. It is not, and don’t take the blame on for
yourselves, too. Because family stress also adds to it.
As indicated above, participants noted a need for increased
family education about mental illness and how to best
support the family member in his or her recovery. Although
many participants noted a lack of understanding from

184. family members, many others noted how their family truly
made efforts to understand the mental illness by talking to
doctors or looking things up on the internet. Others noted
that their family members, to their surprise, did actually
understand mental illness and this facilitated recovery.
Family Forcing Hospitalization
This is the theme which was the most difficult to classify as
a facilitator or a barrier. Participants were quite divided
about whether forcing hospitalization was a barrier or a
facilitator, though many saw it more as a barrier. The data
indicated that family members often play a key role in
detecting mental illness symptom onset and/or initiating
treatment. Participants that were forcibly or voluntarily
hospitalized often noted that it was their family that either
called the police or ambulance or drove the individual to
the hospital to have them admitted. When it was considered
a barrier to recovery, participants like George, a 40-year
old Francophone African/Caribbean, believed that they had

185. been unjustly hospitalized.
I had an altercation with my two sisters and they
conspired against me. They signed a paper that forced
me to go back to the hospital. Just for a small dis-
cussion about nothing. It’s my sisters who made me
return to the hospital under a false motive.
Some participants admitted that they were more likely to talk
to friends about their mental illness than their family as they
feared that the family would rush to have them hospitalized,
rather than just listen to them. Participants often indicated
feeling a sense of betrayal when family members initiate
treatment. This sentiment is well expressed by Anne below, a
34-year old Anglophone African–Caribbean.
And my dad like dragged me back there one time. I
went with my dad and my friend and my friend
promised me that no, we are not going admit you
back. And my dad is like ‘yeah, we are not.’ And then
you are waiting in the waiting room and it was taking

186. so long. And he went behind my back and he went in
and he asked, he commanded to see my doctor. And
she came out and he came out and they both dragged
me basically like on my butt saying ‘oh you are not
taking your meds, you are not taking your meds and
all.’ And it is just like yes I am. They put me back in
and they increased the dosage.
As we note above, although more respondents noted forced
hospitalization as a barrier, other individuals were grateful
to their family for taking them to hospital when in crisis.
Jean-Claude, a 25-year old Francophone African/Carib-
bean, felt that such a hospitalization was a pivotal and
positive force in his recovery.
They brought me to the hospital because when my
father saw that I wasn’t leaving my room, and
because I was keeping my distance from everyone,
and because I hardly ever spoke. I wanted to flee, and
I had just taken my things and ran outside. My father

187. ran behind me, excuse me to say this, but he was in
his boxers in the winter. He ran behind me. After,
when he brought me back to the house, I became
aggressive. Then, after that he was a little scared so
he had no choice but to call the police or the
Community Ment Health J (2015) 51:467–476 473
123
ambulance. Then the police came and they brought
me to the hospital. It was that day that my recovery
began.
Discussion
These findings demonstrated that family can be a facilitator
of recovery by providing moral support, practical support,
and by serving as an intrinsic motivation for recovery. Far
from being cynical about family, most respondents in this
study truly loved and appreciated having family in their
lives and considered this as an essential aspect of recovery.

188. Yet, family could also be a barrier through stress, stigma,
and lack of understanding. Many participants reported that
forced hospitalizations initiated by a family member were
inimical to recovery, though others saw this as a positive
nodal point in their recovery journey.
Participants in our study reported that criticism or over-
involvement from family members increased their stress
and worked against recovery. Contrariwise, warmth and
positive regard from family members was considered as a
facilitator of well-being. These findings are somewhat
consistent with the extant literature on expressed emotion,
indicating that emotional expression within families can
indeed have an impact on recovery (Wearden et al. 2000).
However expressed emotion theory is insufficient in
explaining the complete findings from this study. We
identified numerous facilitators to recovery unrelated to
emotional expression, for example practical and instru-
mental support. As such, our results caution against an

189. overreliance on theories of expressed emotion in explain-
ing the relationship between family dynamics and
recovery.
Findings around family as a barrier indicated that
recovery-oriented concepts such as autonomy and agency
can be complicated by family ties and family norms of
reciprocity and duty. Likewise, some of the participants’
reports of paternalistic and infantilizing family perspec-
tives indicated that some families may still possess out-
dated notions of mental illness, believing in the limited
capacity of the consumer to lead a self-directed life.
This demonstrated the ongoing need and desire for
improved mental health literacy among family members.
To date, families have gained knowledge of mental illness
through various arenas, including interventions such as
family psychoeducation and NAMI’s peer-led Family to
Family program. These interventions have been shown to
be effective in increasing knowledge and improving

190. mental health literacy (McFarlane et al. 2003; Lincoln
et al. 2007; Lucksted et al. 2012). However critics of
family interventions argue that they are often prescriptive,
with some commentators noting that the ‘‘content of many
of the most empirically validated family interventions
were designed in the 1970 s and 1980 s and embrace
more of a ‘successful management of a chronic illness’
theme rather than a recovery orientation’’ (Glynn et al.
2006, p. 455). Our findings, especially those regarding the
importance of autonomy and agency, support the con-
tention that family interventions must ‘‘consistently reflect
the mental health recovery paradigm to ensure that the
intervention…address consumers’ and family members’
real-life concerns and aspirations’’ (Lucksted et al. 2012,
p. 112).
Our results indicated the importance of listening and
honoring consumer preferences about family involvement
in recovery, rather than assuming that family is either a

191. universally positive or negative force. This finding con-
verges with other studies showing that most people with
severe mental illness desire some sort of family involve-
ment, though a substantial minority do not (Cohen et al.
2013). When revising family interventions to better reflect
a recovery orientation, it might be appropriate to put an
even greater emphasis on the importance of consumer
choice and agency regarding the involvement of family.
Revised or novel interventions should include ways to
assess how exactly consumers want their families to be
involved in their recovery (if at all).
Our data also suggest that family interventions might
better emphasize the importance of mutuality in relation-
ships, highlighting the importance of contribution rather
than just receiving aid in family relationships. Indeed, in
one study, families that ‘‘emphasized the importance of
giving rather than just receiving were related to increased
optimism about recovery as well as increased self-confi-

192. dence and self-esteem’’ (Pernice-Duca 2010, p. 22).
Although we argue here that family has the potential to
greatly impact individual recovery efforts, it is also
important to note that an individual’s recovery may, in
turn, have great impact on the family. This can lessen
family stress and caregiver burden (Lefley 1997) and
enable the individual in recovery to contribute to overall
family economics, wellbeing, and quality of life.
Consumer agency is also important in determining the
most appropriate role for family involvement, given that
our results demonstrated that the very same family of a
consumer can function as both a protective and a risk factor
for recovery. Related future research might examine how a
provider, a consumer, and/or a family member could
identify what is helpful or harmful within the family sys-
tem. Emerging patterns will likely vary depending on
individual-level factors, such as family characteristics or
severity of illness and will in turn lead to new research

193. questions that further research could examine. Finally, our
data did not indicate key differences of family as a facili-
tator or barrier depending on family member type (e.g.,
474 Community Ment Health J (2015) 51:467–476
123
spouse, sibling, parent); yet this may also be an important
topic to examine in future studies.
Limitations of the Study
This study has numerous limitations. First, we did not
complement our interviews with observational methods
examining in situ interactions of participants with their
family members. Additional observational methods would
have allowed us to triangulate data to corroborate patient
perspectives. Second, this study was conducted solely from
the point of view of the consumers of mental health ser-
vices. Thus, the findings presented in this article represent
the viewpoint of one subset of the family. Further studies

194. would be wise to interview both consumers and other
family members in order to get a more balanced view of
the role of family in the recovery process. Indeed, families
may have very different perspectives on the facilitators and
barriers that they may present in the recovery process, and
this is an equally important perspective that we must take
into consideration when evaluating and improving family
and consumer interventions for recovery. Finally, we did
not sample individuals based on experience of family
interventions. Indeed none of the participants reported
being involved in any form of family intervention. Further
research may need to assess how far such interventions are
consistent with the recovery model and related concepts
such as agency, autonomy and choice. In spite of these
limitations, we believe that this study provides useful
insight about the role of family in the recovery process.
Conclusion
In conclusion, this article described family as a crucial

195. component of recovery from severe mental illness. With
this research, we strive to contribute to the ongoing shift in
pathological-modeled research to focus on more positive,
solutions-based scholarship, looking at how to build upon
naturally-existing resources to facilitate recovery from
severe mental illness. Our data indicate that family can
provide important moral and practical support and can
serve as a motivating force for recovery. But the data also
indicate that family members can be a source of stress, lack
understanding, and force their member with mental illness
into the hospital against his or her will. We hope that this
knowledge will be useful to clinicians working with
patients and families, ultimately enhancing recovery and
well-being for people with severe mental illness.
Acknowledgments We would like to express appreciation to the
clinicians and consumers whose participation made this study
possi-
ble. We also gratefully acknowledge Marie-Eve Boucher, Anna
Miller, and Aldric Reid for their work as research assistants on
this

196. project. We would like to thank the Canadian Institutes of
Health
Research who funded this research through an Open Operating
Grant
(231520).
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en.pdf
http://dx.doi.org/10.1002/14651858.CD000088.pub3
Copyright of Community Mental Health Journal is the property
of Springer Science &
Business Media B.V. and its content may not be copied or
emailed to multiple sites or posted
to a listserv without the copyright holder's express written
permission. However, users may
print, download, or email articles for individual use.
Family Influence in Recovery from Severe Mental
IllnessAbstractIntroductionMethodsParticipants and
RecruitmentProceduresAnalysisResultsFacilitatorsMoral

205. SupportPractical SupportFamily as a Motivation for
RecoveryBarriersFamily as a Source of StressStigma and Lack
of UnderstandingFamily Forcing
HospitalizationDiscussionLimitations of the
StudyConclusionAcknowledgmentsReferences
April 2011
Vol. 27, No. 4 • ISSN 1058-1073
Online ISSN 1556-7575
Highlights…
Dr. G. Oana Costea discusses the
complex relationship between a child and a
parent with mental illness.
Drs. Robin Everhart and Daphne Koinis-
Mitchell examine ways to help parents care
for a child with asthma, including a family-
focused project targeting Latina women.
✦ ✦ ✦
Keep Your Eye On… See page 2
• RCT of melatonin for sleep problems in autism
• Strep infections and exacerbations
in tic and OCD symptoms
• Obesity program targets ethnically
diverse population
What’s New in Research… See pages 3–4

206. • Restricted elimination diet in children
with ADHD
• Pediatrician experiences in collaborating
with child psychiatrists
Editor's Commentary
• Misguided gun legislation would make
children less safe
— By Gregory K. Fritz, M.D.
See page 8
✦ ✦ ✦
Free Parent Handout…
Are you concerned that you
or your child has asthma?
Parental Mental Illness
Considering the children of parents with mental
illness: Impact on behavioral and social functioning
By G. Oana Costea, M.D.
In the context of increased availabil-
ity of community-based mental health
treatment, rehabilitation programs, and
advances in psychopharmacology, more
patients with serious mental illness are
now parents, many with young children.
Consequently, there has been increased
attention toward the potential impact on
children of parental mental illness.

207. National Comorbidity Survey data indi-
cate that about 31% of American women
and about 17% of men have a 12-month
prevalence of at least one psychiatric dis-
order (not including substance abuse),
and of those 65% are mothers and 52% are
fathers. The literature supports the asso-
ciation between parental mental illness and
adverse pediatric outcomes in terms of
cognitive, emotional, social, and behavioral
functioning. The rates of psychiatric diag-
nosis among children of parents with men-
tal illness were shown to be 30–50%, com-
pared to an estimated rate of 20% among
the general child population. The risk is
even greater if both parents are mentally ill.
The parenting experience
Research suggests that for many par-
ents with mental illness, their relation-
ships with their children are a source of
great personal satisfaction and fulfillment,
which can enhance their confidence and
parenting motivation. However, a study
Caregiver Quality of Life
Supporting caregivers in the management
of childhood asthma
By Robin S. Everhart, Ph.D., & Daphne Koinis-Mitchell, Ph.D.
Approximately 8 million children in the
United States have asthma (NHLBI, 2007),

208. with children from racial and ethnic minor-
ities at greater risk for asthma prevalence
and morbidity. It’s well understood that
children with asthma are at an increased
risk for experiencing emotional, social, and
behavioral difficulties. They may experi-
ence emotional distress due to their asthma
symptoms (e.g., shortness of breath, chest
tightness), or due to the limitations imposed
by their disease (e.g., not being able to keep
up with others during recess).
But what about the emotional dif-
ficulties of the parent? Parents or other
caregivers must assume the lion’s share
of responsibility in the day-to-day manage-
ment of the child’s asthma, in addition to
the demands of the rest of their family. It
is up to them to ensure that medications
are taken daily, prescriptions are refilled on
time, and daily asthma triggers are avoided.
Such responsibility has the potential to
add significant stress and feel burden-
some, which can affect the psychological
Monthly reports on the problems of children and adolescents
growing up
See Asthma, page 6…
Published in cooperation with Bradley Hospital
See Parents, page 5…
View this newsletter online at wileyonlinelibrary.com •
DOI: 10.1002/cbl.20137

209. The Brown University Child and Adolescent Behavior Letter
April 2011
5
Continued on next page…
Parents
From page 1
involving Japanese mothers with chronic
mental illness found that some mothers
reported “feeling sorry” for their children,
with the potential for bringing anxiety into
the parent-child relationship.
Parents’ perception of their children’s
attitudes toward their illness must affect
their parenting practices. While anxiety
about being hated or rejected can lead
to greater psychological burden, feeling a
child’s compassion may result in feelings
of fulfillment and strength.
Parents worry about the impact of their
mental illness on their children, which
can lead to unrealistic expectations of
children’s development and behavior, or
a tendency to see children’s behavior as
pathological. In that context, they may feel
responsible or blamed for their children’s
problems. These parents may also interpret
their own very normal struggles as a parent

210. as an illness-related personal deficit, rather
than the realities of being a parent.
It is well known that parents benefit
from a sense of community, and the stigma
of mental illness may lead to social isola-
tion. Additionally, parents with mental ill-
ness are more likely to be living without a
partner. And while family members may be
a primary source of support, they can also
be a source of added stress.
Impact on child outcomes
Twin and adoption studies support the
role of genetics in transmission of mental
illness from parent to child. In addition to
genetics, research suggests a multitude of
protective and risk factors that influence the
impact of parental mental illness on chil-
dren, including biological, illness-related,
environmental, and child-related factors.
Biological factors: Infants of moth-
ers with schizophrenia have been found
to face a higher risk for low birth weight,
premature delivery, and fetal or neo-
natal death. Maternal depression could
contribute to a higher risk of delivery
complications, lower Apgar scores, and
lower tonus. Research has shown addi-
tional neurobiological effects of maternal
depression, including alterations in fron-
tal lobe activity of preschool-age children
that correlate with diminished empathy
and behavioral problems.

211. Further, higher serum cortisol concen-
trations were found in children of mothers
with depression, which correlated with the
mother’s severity of illness. And finally, a
mother’s health behaviors and prenatal
care could be affected by the mental ill-
ness, with subsequent impact on preg-
nancy and fetal development.
Illness-related factors: A range of fac-
tors appear to be closely related to child
outcomes in terms of enhancing resilience
or risk: a) severity of symptoms and chronic-
ity of illness; b) compliance with treatment;
c) parents’ adaptive functioning; d) level of
parental awareness of the illness and insight
into the effects on self and children.
ADHD
Parental ADHD appears to be associ-
ated with higher levels of family conflict, and
offspring without ADHD in those families
showed poorer school performance.
Bipolar disorder
Research suggests that the offspring of
bipolar parents have elevated levels of mood
disorders (5%–67%), increased rates of other
psychopathology (particularly attentional
and behavioral problems; 5%–52%), and
greater academic difficulties.
Depression

212. Parental Major Depressive Disorder
(MDD) was associated with increased risk
of MDD in offspring, as well as greater
likelihood of anxiety disorder and alcohol
dependence. Having a father with MDD may
increase a child’s risk for conduct disorder,
while having a mother with MDD increases
the risk for substance misuse.
Schizophrenia
Children of parents with schizophrenia
are at increased risk of developing the dis-
order given a suggested heritability of 75%.
Data show that the risk of developing the
illness was reduced in families with good
parental relationships.
Substance misuse
Children of substance misusers show
elevated rates of psychopathology and dif-
ficulties in academic, social, and family
functioning. Offspring of fathers with both
substance dependence and antisocial per-
sonality disorder tend to have significantly
more abnormal scores on the Child Behav-
iour Checklist and may be more likely to
have a deviant peer group.
Environmental factors
Parenting behavior: Research suggests
that mental illness affects parenting behav-

213. ior, which subsequently has a strong influ-
ence on child outcomes. For example, moth-
ers with schizophrenia show decreased ver-
bal and emotional responsiveness, includ-
ing less anger, compared to well parents.
Mothers with depression, on the other hand,
express greater levels of negative emotions
(i.e., hostility, irritability, sadness). These
parenting attributes are risk factors that may
be associated with disrupted attachment
and developmental delays in language,
attention, and social competence in infants
and toddlers. The quality of the mother-
child interaction seems to be a stronger
predictor of disrupted attachment than the
parental depression itself.
The child portion of the Sequenced
Treatment Alternatives to Relieve Depres-
sion (STAR*D) study, a large multisite effec-
tiveness study, showed that successful psy-
chopharmacological 3-month treatment of
depression in mothers to remission was
associated with reduced psychopathology
in children. Children who were asymptom-
atic at the initiation of treatment were sig-
nificantly more likely to develop symptoms
if their mothers did not remit during the
treatment period.
Marital or partner relationship and
family functioning: Marital discord and
divorce are more common in families where
a parent has a mental illness, and such dis-
cord may be a stronger predictor of child
problems than even the mental illness itself.

214. On the other hand, the presence of one sup-
portive spouse or partner can have a positive
impact on child outcomes.
Even without marital discord per se,
households with a parent with mental ill-
ness are prone to be more chaotic envi-
ronments, with lower family cohesion,
increased parent-child discord, and poor
communication. Not surprisingly, such
an environment has a negative impact on
children’s emotional and behavioral func-
tioning, including higher rates of offspring
Research suggests that mental
illness affects parenting
behavior, which subsequently
has a strong influence on child
outcomes.
The Brown University Child and Adolescent Behavior Letter
April 2011
6
Continued from previous page...
depression, substance misuse, and conduct
disorders.
Factors such as poverty, less education,
single parenthood, young parenthood, and
social isolation are also found to increase
vulnerability for adverse outcomes in chil-
dren of parents with mental illness.

215. Child-related factors
A child’s personality or characteristics
can influence the parents’ symptoms and
behavior, which in turn affects children’s
outcomes. For example, a child’s difficult
temperament (defined as irregular in feed-
ing and sleeping patterns, poor adapt-
ability, negative mood, and intense reac-
tions) can significantly challenge parenting
abilities, leading to a higher likelihood of
behavioral problems in childhood.
While research is inconsistent regarding
whether boys or girls are more adversely
affected by parent mental illness, studies
suggest that girls are more likely to develop
depression and boys, conduct problems.
Younger age at the onset of parental illness
is associated with increased vulnerability.
Child factors that promote resilience
and serve as protective factors include:
greater intelligence, positive self-esteem,
good physical health and positive body
image, strong interpersonal skills, posi-
tive peer relationships, good problem-
and current trauma, and family and marital
relationships.
Child-focused interventions: The litera-
ture notes that children often report feeling
ignored by professionals, as they are not
given information about their parents’ ill-

216. ness and its impact on the family. Children
are often ashamed of their parents’ mental
illness, sometimes living with the mixed
emotions of loyalty and concern, while feel-
ing guilty about their own feelings of resent-
ment. Add to this their perceptions that
their parent is stigmatized by others.
Therapeutic and supportive interventions
include: a) age appropriate psychoeducation
regarding parents’ illness; b) provision of
information and access to services pertain-
ing to parent hospitalization and respite; and
c) individual therapy and support.
✦ ✦ ✦
G. Oana Costea, M.D., is Clinical Assistant Profes-
sor of Psychiatry and Human Behavior at Brown
Medical School and Director of the Children's
Inpatient Program at Bradley Hospital.
References
Nicholson J, et al.: Critical issues for parents with
mental illness and their families. Center for Men-
tal Health Services Research, University of Mas-
sachusetts Medical School.
Leverton T: Parental psychiatric illness: The impli-
cations for children. Current Opinion in Psychiatry
2003; 16:395–402.
solving skills, interest/success in school,
and healthy interests outside the home. An
understanding that the parent is ill (and
therefore that the child is not to blame) can

217. help a child view the situation realistically
while building resources for support. Of
course, having a sense of being loved by
the ill parent, as well as stable and support-
ive relationships with other healthy adults,
can enhance children’s ability to cope.
Therapeutic interventions
Paying attention to and soliciting the input
of the children, and addressing the needs of
both the parent and the child, are important
in effectively treating a mentally ill parent.
Adult-focused interventions: Profes-
sionals working with mentally ill adults
need to inquire about their status as parents
and their family circumstances, including
age and gender of all children, their liv-
ing and caregiving arrangements, custody
or visitation issues, and children’s mental
health and emotional development.
Target areas for interventions include:
a) psychoeducation about their mental ill-
ness; b) support and education regarding
reproductive decision making and perina-
tal healthcare; c) coping with custody loss
and visitations; d) parenting skills, includ-
ing understanding normal child develop-
ment and how to stimulate and play with
children; and e) a focus on coping with past
Asthma
From page 1

218. functioning of a parent, specifically by
affecting their quality of life.
Caregiver quality of life
For parents of children with asthma,
caregiver quality of life refers to how the
parent is adapting to the child’s illness,
how burdensome the caregiver finds
management of the child’s illness, and
how much the child’s illness affects the
caregiver’s emotional functioning and
ability to complete daily activities. For
instance, a caregiver might find him or
herself worrying about the child’s symp-
toms throughout the day, might find it
hard to sleep at night, or might have to
take multiple days off from work to care
for the child with asthma.
In turn, parents experiencing a poor
quality of life have the potential to mis-
manage their child’s asthma. The conse-
quences of poor caregiver quality of life
might include an increase in the child’s
asthma symptoms, hospital visits, or even
child emotional distress.
It’s important to recognize that parent
quality of life has significant implications
for child health outcomes in many pedi-
atric chronic illnesses other than asthma.
For example, in a recent study assessing
maternal depression in pediatric epilepsy,
Dr. Mark Ferro and colleagues (2011)
found that factors such as poor family

219. functioning, fewer family resources, and
greater family demands put a mother at
risk for more depressive symptoms.
Healthcare providers, clinicians, and
others working with children are in a
unique position to increase awareness
about the parents’ quality of life and in
this way enhance the overall management
of a child’s disease.
Sociocultural environment
Quality of life can be influenced by
an individual’s socioeconomic condi-
tions and environment, and related daily
stresses can affect how the illness is man-
aged. For example, parents from urban
backgrounds may experience their child’s
asthma in the presence of environmen-
tal and financial stressors. For caregivers
who are already burdened with stresses
related to urban living (e.g., keeping their
child safe), managing their child’s asthma
effectively and navigating the healthcare
system appropriately may prove to be
challenging. This would be particularly so
for families with limited English fluency.
In addition, cultural beliefs about the
causes of asthma, the necessity of med-
ications, alternative means for treating

220. Copyright of Brown University Child & Adolescent Behavior
Letter is the property of John Wiley & Sons, Inc.
and its content may not be copied or emailed to multiple sites or
posted to a listserv without the copyright
holder's express written permission. However, users may print,
download, or email articles for individual use.
‘You Just Lose the People You Know’: Relationship Loss and
Mental Illness
Amy E.Z. Baker ⁎, Nicholas G. Procter
School of Nursing and Midwifery, University of South
Australia, Adelaide, Australia
a b s t r a c t
The purpose of this qualitative study was to explore the nature,
scope and consequences of losses resulting from
mental illness. This paper presents findings from a key theme of
this study—the loss of relationships. Thematic ana-
lysis revealed two categories: loss of intimate relationships,
which included subcategories of (i) spouses/partners,
(ii) children/parenthood, (iii) family, and (iv) friends; and (2)
people within the community, such as people at
church and support groups. Relationships are seen as one of the
most crucial yet challenging elements to recovery
and wellbeing for people affected by mental illness.
© 2014 Elsevier Inc. All rights reserved.

221. Humans need other humans for countless reasons, including to
help
construct and validate our life stories (Jeffs, 2009), to sustain
us, and to
help us discover alternative possibilities for the future
(MacIntyre, 2009).
For people with a mental illness, relationships and the presence
of sup-
portive others comprise a key part of the recovery process
(Jeffs, 2009).
Recovery in mental health is viewed as a way of living a
satisfying, hopeful
and contributing life, despite the limitations caused by illness
(Anthony,
1993). Reflecting on his own experiences of mental ill-health,
psychiatrist
Fisher (2003, p. 67) described several relationships crucial to
his recovery:
‘The most important elements in my recovery were a therapist
who be-
lieved in me, the support of my family, steadfast friends, and
meaningful
work.’ Relationships need to be steeped in certain qualities,
such as trust,
understanding, and safety (Fisher, 2003), which may provide a
source of
hope (Davidson, 2003) and validation, as Jeffs (2009, p. 183)
notes:
The more fragile we are the more validation we need. Yet
mental ill-
ness may cause us to lose those people around us who can give
us
that validation.
Many people with a mental illness experience loneliness or

222. perceive
that their social needs are not addressed adequately (Borba et
al., 2011;
Nilsson, Nåden, & Lindström, 2008), with lost relationships or
contacts
being a major contributor (Mauritz & van Meijel, 2009).
Relationship
losses reported to affect people with a mental illness, include
the loss
of: friends (Borba et al., 2011; Chernomas, Clarke, &
Marchinko, 2008,
Mauritz & van Meijel, 2009, McKay, 2010, Nilsson et al.,
2008), partners
or spouses (Nilsson et al., 2008), family (Borba et al., 2011),
children
(Borba et al., 2011; Fernandez, Breen, & Simpson, 2014) and
colleagues
(Mauritz & van Meijel, 2009, Nilsson et al., 2008).
Relationship losses for people with a mental illness have been
described in terms of a lack of fellowship and relief (Nilsson et
al.,
2008), ‘not belonging’ and the loss of place in a social milieu
(Mauritz
& van Meijel, 2009). Roles or other aspects related to
relationships may
also be lost, such as the loss of a sexual self (Quinn & Browne,
2009),
loss of social status or credibility and loss of a sense of
parenthood in
losing relationships with children (Fernandez et al., 2014).
Factors
thought to lead to a loss of relationships or social opportunities
for
people with a mental illness include: stigma (Proudfoot et al.,
2009),

223. frequent changes in living arrangements, lost employment or
educa-
tional opportunities (Chernomas et al., 2008), as well as their
mental
health condition itself (Borba et al., 2011).
Despite the range of losses reported to result from mental
illness, few
studies have set out to explore this topic (Baker, Procter, &
Gibbons,
2009). Furthermore, as a research topic, loss from mental illness
has been
confined due to design, such as pre-determined surveys (e.g.,
Stein,
Dworsky, Phillips, & Hunt, 2005) or by assumptions, e.g., grief
or mourning
must occur in response to loss (e.g., Mauritz & van Meijel,
2009). The pur-
pose of the current study was to explore the nature, scope and
conse-
quences of losses that may result from mental illness. This
paper presents
findings from a key theme of this study—loss of relationships.
PARTICIPANTS AND METHODS
Setting and Participants
This study took place at a community mental health centre
(CMHC) in metropolitan Adelaide, South Australia. Inclusion
criteria
were adults who had been diagnosed with a mental illness and
who
attended the CMHC. Participants were recruited through conve-
nience sampling over a period of 9 months, during which the
first

224. author promoted the project via weekly information meetings
and
flyers. Sixteen participants chose to participate (see Table 1 for
further information about participants).
Archives of Psychiatric Nursing 29 (2015) 96–101
Work carried out in the School of Nursing and Midwifery,
University of South Australia.
⁎ Corresponding Author: Amy Baker, PhD,
BHlthSc(Hons)(OccTh), BAppSc(OccTh),
School of Nursing and Midwifery, University of South
Australia, City East Campus, GPO
Box 2471, Adelaide SA 5001.
E-mail address: [email protected] (A.E.Z. Baker).
http://dx.doi.org/10.1016/j.apnu.2014.11.007
0883-9417/© 2014 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
Archives of Psychiatric Nursing
journal homepage: www.elsevier.com/locate/apnu
http://crossmark.crossref.org/dialog/?doi=10.1016/j.apnu.2014.1
1.007&domain=pdf
http://dx.doi.org/10.1016/j.apnu.2014.11.007
mailto:[email protected]
http://dx.doi.org/10.1016/j.apnu.2014.11.007
http://www.sciencedirect.com/science/journal/
Study Design and Methods

225. A participatory action research (PAR) approach guided this
study,
selected for its social nature and responsiveness towards topics
that
are meaningful to participants (Rempfer & Knott, 2001;
Schneider,
2012). PAR engages participants as co-researchers in order to
study,
analyse (Rempfer & Knott, 2001) and deepen understanding of
issues
of interest (Brydon-Miller, Kral, Maguire, Noffke, & Sabhlok,
2011),
and ultimately regain control over their lives (Hutchinson &
Lovell,
2013)—ideals shared with the recovery approach in mental
health
(Rempfer & Knott, 2001). Though focus groups were mainly
used in
the later stages of the study, findings presented here stem from
the ini-
tial phase (reconnaissance)—the longest phase of this study—
which
involved gathering initial descriptive data and identifying issues
from
participants' perspectives (Kemmis, McTaggart, & Nixon,
2014). Semi-
structured, in-depth interviews were chosen during this phase.
Inter-
views were conducted by the first author and occurred in a
private
room at the CMHC, varying in length from 30 minutes to 2
hours. Key
interview questions asked of all participants included:
Do you think your experience of mental illness has resulted in

226. loss(es)?If so, can you tell me about the loss(es) you
experienced
from mental illness?What were the consequences of the loss(es)
you think resulted from mental illness?
The interviewer asked probing questions to explore responses in
further detail. As participants engaged differently in the
interview process,
ultimately it was necessary to be flexible in framing questions
(Green &
Thorogood, 2009).
Data Analysis
Interviews were transcribed verbatim and returned to
participants for
member-checking. Thematic analysis, guided by Dey's (1993)
processes
for qualitative analysis, was undertaken and assisted by the use
of NVivo
(version 9) and mind-mapping techniques. Analysis involved
moving
between a detailed approach (interactive reading and annotating
each
transcript to identify all relevant ‘data bits’), a middle-order ap-
proach (clustering ‘data bits’ and mapping each participant's
story),
and a broader holistic approach (mapping across participants'
stories
to establish themes).
Rigor and Trustworthiness
During all preparation, data collection and analyses, a journal
was
maintained to document experiences and theoretical ideas. The

227. follo-
wing strategies were adopted to ensure reliability and
trustworthiness
in this study: member checking; using thick, rich description to
convey
findings and self-reflection through journaling.
Ethical Considerations
The study was approved by the University of South Australia's
Human Research Ethics Committee and the Ethics of Human
Research
Committee within the Central Northern Adelaide Health
Service. All
participants provided informed consent via a written consent
form,
witnessed by a staff member and one other person at the CMHC.
All
identifiable information was removed, e.g., names are
pseudonyms.
Findings
Though presented elsewhere—being reported within a different
theme from this study—this introductory section summarises
important
background information to the findings reported in this paper.
In the
current study, lost relationships were the most prominent type
of loss
that participants described as a possible cause for their illness.
Relation-
ship losses participants viewed as causes or contributors to the
onset of
mental illness included the loss of family through death, loss of

228. accep-
tance or support from others due to prejudices, loss of intimate
relation-
ships, and the loss of supportive or nurturing relationships in
childhood
due to abuse or neglect (Baker & Procter, 2013).
Findings for the theme reported here were organised into two
core
categories, loss of: intimate relationships (partners, children,
family or
friends), and people in the community (e.g., people at church).
Partici-
pants' perceived reasons for losing relationships and the impact
of
these losses are also described throughout the findings.
Meanings par-
ticipants assigned to relationships were also clear, such as this
quote
by one participant, Casper:
I lost my sociability…I was going to the bottle-shop…getting a
six-
pack, going home and drinking it all by myself. Drinking is a
sociable
thing. Man is a sociable animal.
The recognition of humans as ‘sociable animals’ or the desire to
be
social beings was interwoven throughout many participants'
accounts
of loss.
Loss of Intimate Relationships
This category includes the subcategories of the loss of: spouse

229. or
partner, children, other family, friends, including the roles
associated
with these relationships. Before exploring each of these types of
loss,
it is important to note that often these losses did not occur in
isolation.
The interconnectedness of losses was explained by several
participants,
such as Grace:
…to do with the loss of husband, the marriage…the loss of my
dream house and property…everything I'd worked for…that all
co-
incides with my illness, because that was the cause of it.
From Grace's viewpoint, mental illness not only caused the loss
of a
key relationship in her life but dismantled long-term plans
associated
with this relationship.
Loss of Spouse or Partner
The loss, or potential loss, of a spouse or partner was
experienced by
12 participants, with most attributing the relationship
breakdown to
mental illness. Sue, who experienced a loss of marriage whilst
unwell,
encountered another relationship loss when her partner died by
suicide.
Consequently, Sue was faced by the impact of her mental illness
and her
partner's. Hospitalisation also contributed to the loss of a
spouse or

230. partner, such as for Dianne:
Table 1
Participant Characteristics.
Characteristic Study participants (N = 16)
Gender Female (n = 11); male (n = 5)
Age Mean age = 48; range 39 to 59 years
Diagnosisa Major depression (n = 9); bipolar disorder (n = 7);
anxiety disorder (n = 3); schizoaffective disorder
(n = 2); borderline personality disorder (n = 2);
schizophrenia (n = 2); obsessive compulsive
disorder (n = 1)
Time since diagnosis b5 years (n = 4); 5–10 years (n = 1); 10–
15 years
(n = 4); N15 years (n = 7; range = 18 to 32 years)
Work status at time
of study
Not working (n = 12); part-time (n = 2);
casual (n = 2)
Relationship status at
time of study
Divorced or separated (n = 11); single (n = 2); married
(n = 2); widowed (n = 1)
Religious affiliation Christian (n = 8); none (n = 8)
a Self-report of diagnosis from a health professional; includes
multiple diagnoses for 10

231. participants. Some participants had received two (n = 7), three
(n = 2), or four (n = 1)
different diagnoses.
97A.EZ. Baker, N.G. Procter / Archives of Psychiatric Nursing
29 (2015) 96–101
I lost my husband. He dropped me off at [the psychiatric
hospital]
and said he didn't want [anything] to do with me…he couldn't
take
care of me anymore because of my mental illness, which means
I lost
my whole home and everything.
Dianne's experience further shows how one loss may perpetuate
others. One participant separated temporarily from her husband
and
was hesitant about the relationship's future due to her spouse's
lack of
awareness about mental illness. Mick decided not to tell his
wife
about his mental illness, through 20 years of marriage and
despite se-
veral major breakdowns in this time. The decision to disguise
his illness,
and the lack of trust this harboured, were major factors in the
demise of
Mick's marriage:
I was in a terrible turmoil whether I should tell her or not…if I
told
her, she definitely wouldn't have married me…I was also
thinking

232. that I could be passing it on, if we had children…I felt terribly
guilty
that I didn't tell her…because I felt like…she's just wasted 20
years
of her life being married to me.
Guilt and other feelings such as sadness, devastation and
loneliness,
were often noted in relation to losing a partner. Grace felt
responsible
for losses to others after divorce, such as lost friendships
between her
family and ex-husband. The loss of a ‘normal married life' was
also
expressed by two participants, including Sue:
I always had this…idea of getting married and having
children…
but it's never worked out, so in a way it's a loss of having a
normal
married life.
Loss of Children and Parenthood
Of the 13 participants who were parents, 10 described losing
their
child(ren) in some form. Three women experienced the death of
their
child, including one whose baby died in a house fire and
another
whose son died by suicide. For Dianne, although her baby son
died,
parenting experiences prior to his death were lost due to being
unwell:
…I lost him through death…but I lost a bit of the time [and]

233. freedom
I had with him because I was put in a mother and baby home be-
cause people…didn't think I could take care of him.
Eight participants associated the loss of their child(ren),
whether
temporary or permanent, with mental illness. Avril believes she
lost
the relationship with both of her children due to mental illness,
adding
how her children acted disrespectfully towards her, e.g., taking
video
footage of her whilst unwell. Avril wanted the relationship with
her
children to be restored yet indicated she had relinquished this
dream.
Several participants described losing a sense of being a parent
and ac-
knowledged how this affected their children. For example, two
women noted they were not interested in interacting with their
teenage
daughters because of the way depression affected them, as Avril
ex-
plained: ‘I think [my daughter] craved a lot of love, which, I
couldn't pro-
vide for her at the time.’ Mick describes how mental illness
impacted on
his sense of being a father:
I've lost…the ability to act natural with my son, and feel like
I'm…a
proper father…I lost that, father–son thing…it's at the point
where I
don't really want him to come over, but I do because I love him
so
much…but when he comes over, I don't know what to do with

234. him.
One participant described her distress at not knowing who her
chil-
dren were when they visited hospital, recounting how strange it
felt. For
Grace, a loss of motherhood occurred when she was affected by
severe
postnatal depression. Compounding her feelings of loss, Grace
could
not remember this period in her life, saying she ‘missed out’ on
those
early moments of parenthood. Lost relationships with children
often oc-
curred due to lost relationships with partners. Jane only saw her
children once a fortnight as her ex-husband believed she was
incapable
of caring for them. This had severe implications for Jane's
relationship
with her children and role as a mother, describing this as her
most
significant loss. Jo described a different reason for losing her
child:
…he lives with his father… I didn't do anything about that
because I
thought that if I went to court and they said that I had a mental
ill-
ness…it probably wouldn't be worth fighting for. I always see
the
bad outcome before even trying…I don't know these things for a
fact
because I don't follow through.
For Jo, the threat of having to disclose her mental illness was

235. the rea-
son for not seeking joint custody of her son.
Loss of Family
Four participants spoke about losing family members due to
mental
illness or related factors. Three participants discussed this loss
in the
context of being hospitalised, such as Bonnie:
I lost my sister-in-law's respect. She…couldn't handle the fact
that
I'd been in [a psychiatric hospital]…that nearly killed me…my
sister-in-law's attitude.
Loss of family was one of many things Ruth perceived had been
lost
from her time in hospital. Two participants noted a strained
relationship
with family due to the taboo of mental illness, leading to a loss
of sup-
port, including a lack of understanding about the need to take
medica-
tion. Bonnie felt she lost the position in her family as a
functioning
person but did not elaborate on this issue.
Loss of Friends
Twelve participants described losing friends due to mental
illness. A
loss of friends was the first thing Sandy noticed when he first
became
depressed:

236. Friends would come and see you, one came, I'd been going
fishing
with him every Friday night for about 10 years…he saw me
once
in hospital and I haven't seen him since…you wondered why,
what
had you done wrong? Had you offended them?
Sandy was left pondering and confused about why his friends
left
him. Others provided suggestions for why their friendships
disintegrated, such as Avril who sensed friends thought she was
odd
and Dianne who believed her friends had lost patience with her.
Several
people noted how friends did not understand their illness or
believe
they were unwell, causing strain and the eventual loss of some
friend-
ships. Loss of friends also precipitated from other losses in
participants'
lives, such as lost employment or mutual friends lost from
divorce. Is-
sues of reciprocity also contributed to the loss of some
friendships. For
example, Faye, Jack and Hills believed they gave, without
receiving,
friendship in return. In contrast, Casper acknowledged that loss
of his
friendships occurred as both parties were not making an effort:
Not only were they not…coming and seeing me, I stopped going
and
seeing them because I felt so depressed.
Sue recalls losing friends early in her experience of mental

237. illness,
when voices told her that her friends hated her. Sue
‘disappeared’ in-
terstate for a year, returning to find her friends had moved on.
Sue
and others described losing friends as sad, devastating and
isolating,
as well as regretful in the cases where participants felt
responsible
for the friendship breakdown. Two people described the loss of
friendships as the main loss from mental illness. Jo stated it was
the most important loss in her life, in the sense of both losing
past
friends and in forming new friendships. Jo attributed the loss of
friends to her fright, worry and paranoia about what people
thought
of her and noted how alcohol would assist her to mask these
issues.
98 A.EZ. Baker, N.G. Procter / Archives of Psychiatric Nursing
29 (2015) 96–101
Jo also wanted to share her experiences with friends but felt it
would
result in the following outcome:
…if I tell my friend that I have a mental illness, then they won't
want
to know me anymore…so I won't…it's a loss of my friends so I
don't
tell them.
Several people spoke about how their friendships were confined
to

238. other clients at the CMHC, as was the case for Faye:
…they say come here…I enjoy that but I don't have a friend like
at
the weekend to catch up with…just watching the telly and
always
by myself.
Faye was one of three women who lost friends when her
marriage dis-
solved, explaining she did not realise, until much later, the
importance of
friends. Faye also used the metaphor of doors opening and
closing to
explain her struggle to gain new friendships:
All the doors just seemed to shut off and there's nothing
opening up,
so that's why…I got so upset and felt like…nothing's changed.
Faye's story also revealed a lack of ‘authentic friendships’. This
was
also apparent for Jack, who noted having acquaintances but not
‘real’
friends, a concept that was explored further:
Researcher: how would you define a ‘real friend’, what…would
you
be looking for-
Jack: −someone that's open. Big point, very big point, honest…
someone that's real, not deviants, liars…I've had enough of that.
Factors that affected participants' ability to form new
friendships in-
cluded a loss of self-confidence, outgoingness and ability to

239. relate to
others; as Dianne added:
…it's rebuilding friendships because people get hurt as well
when
you start thinking [they are] a devil and you have to attack
them…
or a voice tells you they were against you so you have
to…protect
yourself from them, and that can be a violent way…you have to
spend a long time trying to build up their trust again…after
you've
treated them like that…you don't always get that, and you lose,
you just lose the people you know.
Dianne explained how mental illness impacted on others and the
difficulties she had in making amends with friends, particularly
in rela-
tion to trust. The issue of trust was also discussed in terms of
partici-
pants no longer being able to trust others, with this generally
being
linked to incidents where participants were taken advantage of,
or
where others were dishonest with them. Hope that relationships
would be restored or gained was also expressed.
Loss of People in the Community
Four participants described losing people within their
community
including people at church, support or community groups, and
health
services. For two participants who lost people at church, this
occurred
after periods of psychosis. Dianne had attended a church for 16

240. years,
but felt the people at church did not understand mental illness:
Sometimes my own mental illness caused a great deal of…loss
with
the church when I started thinking that they're the devils in my
house…I had religious delusions but the church couldn't see it
as re-
ligious delusions.
Similarly, Faye felt people at her church did not understand
mental
illness properly:
I had schizophrenia but I didn't know it then…I was hearing
voices
and…getting into my Bible study…preaching all the wrong
stuff…
that's when they say…Satan gets in.
Faye describes being ‘not allowed’ to attend this church after
she was
involved in an inappropriate affair with her church minister. At
this
stage, Faye was undiagnosed, untreated and without suitable
supports,
noting that: ‘everything just got mixed up’. Faye felt she was
poorly
treated by people at this church and not accepted in other
churches
she later attended. For example, Faye recalled being scolded in
front of
fellow churchgoers at one church for being unable to ‘speak in
tongues’,
leaving her feeling embarrassed and excluded. Dianne identified
why

241. church was not a suitable environment when she was unwell:
Being in the church was the last place I should have been…it
was ac-
tually feeding my religious delusions…making it even worse for
the
church until in the end I started shouting and screaming at God
in
the church service…after that they didn't want me there.
Although people at the church tried to ‘hang in there’ alongside
Dianne, there became a point where they ‘could not handle’ her
behav-
iour anymore, resulting in her being banned, which left her
feeling
rejected and suicidal. Dianne suggested many of the losses she
experi-
enced with individuals and groups in the community were her
‘own
fault’ but also noted how others did not understand enough
about men-
tal illness:
When they start to see you get better they expect instant
perfection,
‘this person's better, therefore this person should be behaving
well’,
but they don't understand that you've lost that ability…to know
how
to…just talk or relate to someone…you haven't practised them
for
so long, you've been in the hospital…you've lost relating to
people
in the real world.
Faye was particularly concerned about the lack of reciprocity in

242. her
relationships with members of community groups she was
involved
in, noting: ‘unless I ring up they don't ring me at all’. Loss of
relationships
in the community also included loss of people in healthcare
services.
Ruth acknowledged the constant loss of mental health
specialists within
the public health system as a problem:
For years it was ‘…how are you going, need a script?’ and
‘Won't see
you next time because I'm becoming a radio announcer’…then
you
go three months time and you'd have to divulge
…saying…negative
stuff over and over to doctors didn't really give you a positive
feeling.
When Ella became unwell, she experienced a loss of health
services
which she thought tied to a loss of trust and privacy from health
profes-
sionals with whom she worked for at the time. Dianne also
experienced
a loss of health services on being ‘thrown out’ of the CMHC
three times
as a worker did not understand her needs. Though rocked by a
series of
losses and difficulties in her relationships, Dianne was
determined to re-
build her relationships, yet acknowledged it as challenging:
I've tried to rebuild again. Each episode everybody remembers
and

243. you get a reputation, and so it gets harder and harder each time.
DISCUSSION
All participants in this study experienced the loss of one or
more
relationship(s) in their lives due to mental illness or related
factors. A
range of issues, including emotions, behaviours and others' lack
of un-
derstanding of mental illness, were perceived to cause or
contribute to
the loss of relationships, with consequences ranging from
emotional re-
actions to further losses for participants. To further understand
the na-
ture and consequences of relationship losses, it is critical to
examine
the wider context of how participants perceived relationships,
including
99A.EZ. Baker, N.G. Procter / Archives of Psychiatric Nursing
29 (2015) 96–101
the meanings or goods participants assigned to these
relationships.
Explored alongside perceived reasons for losing relationships,
these
meanings further highlight the consequences of such losses.
Considera-
tion of the reasons, impact and meanings associated with
relationship
losses helps to explain people's ability or inability, desire or
aversion

244. to seek out new relationships and rebuild lost ones. Fig. 1
summarises
these elements, with the left hand side showing perceived
reasons for
relationship losses and the subsequent impact of these losses,
labelled
with a quote from Dianne: ‘You just lose the people you know’.
The
right hand side of Fig. 1, depicted by Casper's statement, ‘Man
is a socia-
ble animal’, shows factors perceived as important to gaining or
main-
taining relationships and the impact of such relationships.
Beginning with ‘Factors contributing to the loss of
relationships’ (top
left-hand quadrant of Fig. 1), behaviour and beliefs influencing
relation-
ship loss included times when symptoms were not controlled,
‘weird’
behaviour, or the belief—often during psychosis—that friends
hated
them. Perceived lack of support or understanding from others
was
also noted as a contributing factor, including that participants
were en-
gaging in deliberately bad behaviour, were lazy or could ‘snap
out of it’.
Some relationship losses were thought to occur from other
losses, such
as the loss of: work, another relationship or social skills.
Though not in
reference to the same losses noted here, Mauritz and van Meijel
(2009) also described how, in the context of schizophrenia, a
loss of
contacts and quality of interaction with others stemmed from

245. other
losses, such as cognitive ability. Lack of authenticity referred to
several
concepts, including a loss of reciprocity, trust and honesty
within rela-
tionships. Participants in a study by Chernomas et al. (2008)
also reported
the importance of reciprocity in friendships. In line with
recommenda-
tions of Chernomas and colleagues, further study into this
concept
is warranted.
In the lower left quadrant of Fig. 1, ‘Impact of losing
relationships’, a
range of emotions and reactions were associated with lost
relationships,
including sadness, devastation and suicidal ideation. Some
feelings indi-
cated lost relationships affected participants' sense of place in a
social
milieu, as described previously by Mauritz and van Meijel
(2009),
such as feeling: isolated, rejected, disrespected, abandoned and
excluded.
Regret, remorse and guilt were also experienced by some
participants
who felt responsible for lost relationships and the effect upon
others in
their life. Due to prior lost relationships, and to avoid further
relation-
ship losses, several people refrained from disclosing their
mental illness.
Several participants observed that some losses resulted in losses
to

246. others also, such as loss of relationships for family members
after a mar-
riage breakdown. Many people observed that lost relationships
gene-
rated other losses, such as the loss of a house, children or
financial
security. Thus, not only were some relationship losses thought
to result
from other losses in participants' lives, but some were perceived
to
generate losses also.
The consequences of lost relationships were compounded by
dif-
ficulties in maintaining relationships and gaining new ones
(bottom
right-hand quadrant of Fig. 1). Despite attempts and strategies
to
gain new friendships, several participants talked about the
dearth
of opportunities for meeting new people, a situation described
else-
where (Chernomas et al., 2008). The hope of forming new
relation-
ships was further complicated by a perceived inability to
disclose
one's mental illness, as described under the previous quadrant.
A
range of qualities and attitudes were thought to assist or
constrain
the ability to build and preserve relationships, including having
self-confidence, self-belief, social skills, hope and courage,
particu-
larly after losing social skills from hospitalisation or in times
whilst
unwell. Perseverance, though not stated directly, was also

247. implicit
in many participants' stories of gaining or maintaining
relationships.
For participants who had experienced relationships marked by
dis-
honesty, having trust in others was thought to affect their
ability to
gain and maintain relationships. Reactions from others, such as
for-
giveness, empathy, and others' understanding of mental illness
also
contributed to whether relationships could be built or kept, the
latter
being reported previously (Mauritz & van Meijel, 2009).
Finally, as shown in the top right hand quadrant of Fig. 1, many
par-
ticipants discussed, or alluded to, the importance of
relationships. For
some participants, this was not directly articulated but evident
within
their stories of lost relationships and hope for the mending of
old, or for-
mation of new, relationships. The importance of socialising was
men-
tioned by several participants, such as Casper's observation that
humans are ‘sociable animals’. Some participants desired
someone to
bond with, lean on, or provide support. It was also noted that
others
helped to fulfil norms or roles, such as being married or a
parent.
•
•

248. •
•
•
•
•
•
•
•
•
•
•
•
•
•
Fig. 1. ‘Man is a sociable animal’ but with mental illness ‘you
just lose the people you know’.
100 A.EZ. Baker, N.G. Procter / Archives of Psychiatric
Nursing 29 (2015) 96–101

249. Fig. 1 is cyclical to demonstrate the interconnectedness of the
value
of relationships and the impact when relationships are lost. The
cycle of
loss and restoration of relationships was also central to many
partici-
pants' experiences, as Dianne describes:
I'm trying to restore some of the losses…it's always this
rebuilding,
and then losing, and then rebuilding again, and then you get
sick
and you lose again…you think well what's the point…because
every
time you keep rebuilding, you have an episode and then you
lose
again…it's this constant thing all the time.
Some of the losses that may be faced by people with a mental
illness,
such as the loss of reality, ability to communicate, or self-
respect, may
lead people to inadvertently sever ties with their loved ones.
Karp
(1996, p. 28) describes this as the paradox of greatly desiring
connec-
tion whilst being: ‘simultaneously deprived of the ability to
realize it’.
This dilemma creates challenges for both people who have a
mental ill-
ness trying to reach out to others, and in others trying to reach
out to
them. One important strategy for supporting people to restore or
develop
relationships and avoid further relationship loss involves a

250. sustained
effort to build awareness about mental illness in the community.
In this
study, the value and meaning participants assigned to people in
their
lives, suggests the work of restoring, rebuilding or developing
relation-
ships is a vital part of being in recovery and flourishing as a
human
being; work which therefore must be pursued by those who wish
to help.
Important to acknowledge is that this study focused on the
experiences
of a relatively small number of adults, affected by a range of
mental ill-
nesses, at one community mental health centre. Thus, the
findings
should be approached with caution. However, relatively few
studies
have sought to explore the topic of loss from mental illness and
so the
findings are important in shedding light on this matter. In
particular,
this study showed how relationship losses can be understood
within
the context of meanings attributed to relationships. The factors
that
are important to gaining and maintaining relationships, from the
per-
spective of people with lived experience of mental illness,
require fur-
ther attention within practice and research. Furthermore, the
resources
people with a mental illness and their supports perceive would
help in

251. responding to relationship losses are currently unknown,
warranting
further research.
Acknowledgment
The authors wish to acknowledge Bellberry Ltd for their
generous
support in providing a research scholarship to the first author.
We also
wish to thank the participants and support from staff at the
community
mental health centre where this study occurred.
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©2015 Elsevier
Regina S. Baker University of Pennsylvania
The Changing Association Among Marriage, Work,
and Child Poverty in the United States, 1974–2010
Marriage and work have long been central

257. to debates regarding poverty and the family.
Although ample research has demonstrated
their negative association with child poverty,
both marriage and work have undergone major
transformations over recent decades. Conse-
quently, it is plausible that their association with
child poverty may have also changed. Using
10 waves of U.S. Census Current Population
Survey data from the Luxembourg Income Study,
this study examined the relationships among
marriage, work, and relative measures of child
poverty from 1974 to 2010. The results indicated
that both marriage and work still decrease the
odds of child poverty. However, time interac-
tions showed marriage’s negative association
with child poverty has declined in magnitude,
whereas work’s negative association with child
poverty has increased in magnitude. These
findings underscore the historically varying
influence of demographic characteristics for
poverty. They also suggest the limitations of
overemphasizing marriage and the growing
importance of work for reducing child poverty
in America.
The United States stands out for its failure to
significantly reduce child poverty over the past
few decades and its unusually high child poverty
rates relative to other rich countries (Gornick
& Jäntti, 2012; Rainwater & Smeeding, 2004).
Department of Sociology, University of Pennsylvania, 218
McNeil Building, 3781 Locust Walk, Philadelphia, PA
19104 ([email protected]).
Key Words: employment, inequality, marriage, poverty.

258. Accordingly, there has been vibrant scholarly
literature concerning poverty among chil-
dren and families (see Edin & Kissane, 2010;
Lichter, 1997; Seccombe, 2000). Marriage and
work have been central to this scholarship and
related policy debates. The continued focus on
marriage and work in alleviating child poverty
is salient given the major transformations in
these institutions. Whereas a married couple
with children was once the norm, nonmari-
tal births and single-parent households have
become commonplace. Moreover, divorce rates
remain relatively high; cohabitation is increas-
ing; Americans are choosing to marry later, if
at all; and marriage has become a more selec-
tive institution (Cherlin, 2009; Raley, 2000).
The attributes and patterns of work have also
changed greatly. Median wages have stagnated,
earnings inequality has worsened (Bluestone
& Harrison, 2001; Mishel, Birens, Gould, &
Shierhotz, 2012), and female labor force partic-
ipation has increased dramatically (Lichter &
Crowley, 2004). There has also been a decline in
well-paid blue-collar work, growth in part-time
jobs, and greater job insecurity (Kalleberg,
2007; Mishel et al., 2012). Although it is well
documented that marriage and work decrease a
child’s odds of being poor, these changes raise
the question of whether their associations with
child poverty have also changed over time. In
this study I addressed this query.
Background
Theories Why Marriage and Work Are

259. Associated With Poverty
There are several causal explanations for why
marriage affects child poverty. First, marriage
1166 Journal of Marriage and Family 77 (October 2015): 1166–
1178
DOI:10.1111/jomf.12216
Marriage, Work, and Child Poverty 1167
increases the number of potential adult earners,
and thus income, in the household. Relat-
edly, dual-earner households are more able to
absorb the shock of income losses compared
to single-earner households. Second, marriage
benefits families through economies of scale.
By sharing expenses (e.g., rent and other house-
hold goods and services), married couples can
save more, support a higher standard of living,
and invest for the future (Amato & Maynard,
2007). Thus, from an income-to-needs perspec-
tive, married households fare better financially
(Thomas & Sawhill, 2005). Third, according to
Becker’s (1981) theory of household special-
ization, married couples have greater flexibility
in how they divide their time between home
and market production and thus can maximize
household earnings (Amato & Maynard, 2007).
However, marriage does not benefit all children
equally: White children typically experience
greater economic benefits from marriage than
do Black and Hispanic children (Manning &
Brown 2006).

260. Although marriage may lead to greater levels
of income, employment, and other available
resources, selection into marriage also con-
tributes to the relationship between family
structure and child poverty. The adults most
likely to form and maintain two-parent married
households are more stable, well adjusted, and
resource rich (Brown, 2010). Furthermore,
unmarried, low-income parents are more likely
to marry after experiencing increases in earnings
(Gibson-Davis, 2009). Thus, failure to consider
preexisting differences that influence selec-
tion into marriage can lead to overstating the
causal effects of family structure (McLanahan
& Percheski, 2008).
Regarding the association between work
and child poverty, having paid earners in the
household generates earnings, earnings are the
dominant source of income for households, and
income is the basis for defining poverty. Indeed,
Rainwater and Smeeding (2004) concluded that
ensuring at least one parent is employed is the
most important step to avoiding child poverty,
and they found that having multiple earners in
the household further lowers this risk. More-
over, low employment and low wages translate
into large differences in earnings capacities
(Sigle-Rushton & McLanahan, 2002), which
underscores the necessity of work for avoiding
poverty.
Given the role of marriage and work in
avoiding child poverty, ample research has
examined related trends. Several studies have

261. found that changes in family structure—namely,
the rise in nonmarital births—largely explain
increases in child poverty from the 1970s to
the mid-1990s (Christopher, 2005; Lichter &
Crowley, 2004; Nichols, 2013). Accordingly,
scholars have shown that poverty rates would
have declined greatly had single parents been
married (Sigle-Rushton & McLanahan, 2002;
Thomas & Sawhill, 2005). Conversely, in more
recent decades it has been changes in work,
not family structure, that most explain child
poverty trends (Chen & Corak, 2008; Lichter &
Crowley, 2004; Nichols, 2013). For example,
after the 1996 welfare reforms, greater maternal
employment accounted for most child poverty
in single-parent families, especially among
Blacks and Latinos (Lichter & Crowley, 2004).
Similarly, Nichols (2013) found that increased
parental work effort mainly drove declines in
child poverty from 1993 to 2011.
Indeed, these studies illustrate how composi-
tional changes in family structure and parental
work help explain fluctuations in child poverty.
However, one nuanced but key gap in the liter-
ature regarding marriage and work is precisely
how the magnitude of their association with
child poverty has changed. There are plausible
reasons to expect these associations could have
gotten either weaker or stronger from the 1970s
to the present.
The Case for Changes in the Association
Between Marriage and Child Poverty
Women’s marriage and fertility trends provide

262. at least one reason why marriage may have a
stronger negative association with child poverty.
As a whole, women are delaying marriage more,
but although delayed childbearing has increased
among highly educated women, less educated
women still tend to have children earlier (Wilde,
Batchelder, & Ellwood, 2010). Delayed child-
bearing leads to substantial increases in the
earnings and work hours of both mothers and
fathers (Miller, 2010; Wilde et al., 2010). More-
over, children born to low-skill women tend
to come early, when the mother often has few
earnings and is more likely to be unmarried,
and children born to high-skill women tend to
enter a married family during their peak earn-
ing years (Wilde et al., 2010). The result is that
1168 Journal of Marriage and Family
married households have increased advantages
over unmarried households. Thus, a stronger
negative association between marriage and child
poverty may have occurred from the 1970s to
2010.
Conversely, there are at least two plausible
reasons why the association between marriage
and child poverty may have gotten weaker.
First, an increasing number of children are
living with cohabiting parents (Manning &
Brown, 2006). Even in the short term or on
a transient basis, these households potentially
benefit from economies of scale and having two
earners, given that they generally fare better

263. economically than single-parent households
(Manning & Brown, 2006; Thomas & Sawhill,
2005). Therefore, any penalty for a child being
in an unmarried household may have weakened
because of rising cohabitation, which has cre-
ated more dual-earner nonmarital households.
Second, single parents have generally become
less homogeneous. Employment among single
mothers has risen dramatically (Lichter & Crow-
ley, 2004). Single motherhood has increased
even in the middle of the education distribution
(Ellwood & Jencks, 2004), and single fathers,
who have greater income and are more likely to
cohabitate than single mothers, are on the rise
(Livingston, 2013). Thus, single parents have
become less uniformly disadvantaged, which
could have weakened the negative association
between marriage and poverty.
The Case for Changes in the Association
Between Work and Child Poverty
One factor that may have led to a stronger neg-
ative association between work (i.e., number of
earners) and child poverty is the long-term stag-
nation in median worker earnings that increased
pressure on dual earners. Earnings inequality
rose dramatically in the 1980s, and by the late
1990s most families had experienced declines
in real incomes (Bluestone & Harrison, 2001).
In part as a result, female labor participation
increased (Bianchi, 2000; Lichter & Crowley,
2004), and women’s incomes have constituted
a growing share of family income in all fam-
ily types (U.S. Department of Commerce, 2011).
This may explain why increases in women’s

264. employment coincided with declines in child
poverty (Lichter & Crowley, 2004). In addi-
tion, families have had to increasingly rely on
paid earnings because of dramatic decreases
in welfare receipt and the value of welfare
transfers following the 1996 welfare reforms
(Danziger, 2010). Further, the earned income
tax credit, which requires that one be employed,
has expanded greatly into the largest family
assistance program (Danziger, 2010), and con-
siderable evidence demonstrates that the EITC
reduces child poverty (Handler & Hasenfeld,
2007). Thus, the transition from work-free wel-
fare to social assistance contingent upon work
may have increased the necessity of work for
avoiding child poverty.
Conversely, the changing nature of jobs and
greater job insecurity may have weakened the
association between work and child poverty.
There has been a decline in well-paid blue-collar
jobs, abundant low-wage work, and technologi-
cal changes that contributed to skill and spatial
mismatches that have disadvantaged low-skilled
and low-educated workers (Kalleberg, 2007).
Despite rising consumer costs, workers with
less than a high school education or some col-
lege are earning increasingly less, and those
with at least a bachelor’s degree are making
only slightly more than those in the 1970s
(Bureau of Labor Statistics, 2013). Furthermore,
the Great Recession has exacerbated job inse-
curity, with racial/ethnic minorities and the less
educated most adversely affected (Bureau of
Labor Statistics, 2012). These changes, in light

265. of the increasing poverty among workers (Brady,
Baker, & Finnigan, 2013), suggest work may be
less protective against child poverty.
Method
To scrutinize the potentially changing relation-
ships of marriage and work with child poverty
over time, I use Current Population Survey
data from the Luxembourg Income Study (LIS)
Database (http://www.lisdatacenter.org). The
LIS is advantageous because of its high-quality
measure of disposable household income that
incorporates taxes, transfers, and tax credits
such as the EITC. Because disposable house-
hold income provides a more comprehensive
and accurate measure of household income than
even the underlying Current Population Survey,
calculations of poverty that are based on it are
more valid and reliable (Brady, 2003; Rainwater
& Smeeding, 2004). I used all available U.S.
waves: 1974, 1979, 1986, 1991, 1994, 1997,
2000, 2004, 2007, and 2010, and included
only households with children under age 18. I
Marriage, Work, and Child Poverty 1169
weighed households using a LIS-constructed
child weight accounting for the number of chil-
dren in the household. Thus, the unit of analysis
was 192,547 individual children.
Variable Measures

266. The dependent variable included two measures
of child poverty. Following recent studies that
have used LIS data (Brady et al. 2013; Chen &
Corak, 2008; Gornick & Jäntti, 2012; Rainwater
& Smeeding, 2004), I employed a standard
relative measure of poverty in which the thresh-
old is 50% of median equivalized, posttax and
posttransfer household income. All children in
households below this threshold are poor. My
second measure used an anchored threshold
based on the 1974 median adjusted for inflation
over time (using the Consumer Price Index)
so that the measures are fixed (Chen & Corak,
2008). Although the standard relative measure
may be less sensitive to the business cycle
and improvements in standards of living and
economic development, the anchored measure
should be more responsive. Compared to the
official poverty measure, not only do these
measures (and the income definition underlying
them) better capture the resources available
to families, but they are also more consistent
with leading conceptualizations of poverty, such
as social exclusion and capability deprivation
(Chen & Corak, 2008; Deaton, 2006).
The first key independent variable was a
binary measure indicating whether the head of
household is married. Although some children
resided in households where a parent was not
the head, 96% of the heads of household in my
sample lived with their own children under 18.
My second key independent variable was the
total number of earners, which encompassed all
persons with positive earnings in the household.
In a variety of sensitivity analyses, I experi-

267. mented with alternative work variables: the total
weekly work hours, annual full-time hours, and
annual part-time hours among all earners in the
household. The main conclusions were generally
consistent with these alternative work measures.
However, because of issues with missing data
and model nonconvergence for these alternative
work measures, I focused on number of earners
in this study.
Following previous research (Brady et al.,
2013; Chen & Corak, 2008; Christopher, 2005;
Rainwater & Smeeding, 2004), I adjusted
for several variables associated with poverty:
age, education, race, and household composi-
tion. Age of the head of household and Age2
were measured in years, and a binary vari-
able indicated whether the head is under age
25. Two binary variables indicated whether
the head of household’s education was “less
than high school” or “a college degree” (refer-
ence group = high school diploma and some
college). “Black,” “Latino,” and “Other”
were binary measures of the head of house-
hold’s race/ethnicity (reference = White). I also
included measures of the number of working-age
(18–64) adults in the household, the total num-
ber of children under age 18 in the household,
and whether adults over age 65 resided in the
household.
Analytic Strategy
After presenting descriptive trends, I present

268. logistic regression models to assess the relation-
ships of marriage and work with child poverty.
The first analysis pooled the 10 waves into one
combined sample so I could examine the associ-
ations of marriage and work with child poverty
when interacted with linear time. I used a count
measure for each of the 10 LIS waves based on
years (i.e., 1974 = 0, 1979 = 5 . . ., 2010 = 36).
Because the results may vary in a nonlinear way,
the next analyses included interactions with year
binary variables (reference year = 1974). Indi-
vidual year measures also control for unobserved
year-specific factors (e.g., business cycle).
Results
Descriptive Trends
All variable means, by year, are displayed in
Table 1. Both child poverty measures had similar
trends, with anchored poverty consistently hav-
ing lower rates than relative poverty. From 1974
to 1991, relative and anchored child poverty
rates increased from 15% to 25% and 23%,
respectively. From 1994 into the early 2000s,
child poverty declined slightly and has remained
fairly stable since. In 2010, child poverty was
21% (relative) and 15% (anchored).
The percentage of children who lived in a
household with a married head of household
has steadily declined since 1974 (with the slight
exception of 2000). Whereas in 1974, 84% of all
children lived in married-headed households, by

269. 1170 Journal of Marriage and Family
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308. he
ad
of
ho
us
eh
ol
d.
Marriage, Work, and Child Poverty 1171
Figure 1. Child Poverty by Head Marital Status, 1974–2010.
0
10
20
30
40
50
60
%
C

309. hi
ld
P
ov
er
ty
Year
Relative Child Poverty by
Marital Status of Head
Married Head Unmarried Head
0
10
20
30
40
50
60
%
C
hi
ld

310. P
ov
er
ty
Year
Anchored Child Poverty by
Marital Status of Head
Married Head Unmarried Head
2010 only 68% of children did. This decrease
in children living in households with a mar-
ried head of household is consistent with the
declining marriage rates among adults in gen-
eral, which fell from 72% in 1970 to 51% in 2011
(Fry, 2012).
The mean number of earners increased from
1.78 in 1974 to 1.83 in 1979, then declined
in 1986 and changed little through the 1990s.
However, by 2000 the mean number of earn-
ers increased to 1.81 and then declined until
2010, when children had only 1.63 earners in the
household, on average, the lowest mean of all
10 time points. Of course, the long-term trends
in the number of earners combine both a rise in
two-earner households and the number of house-
holds containing only one working-age adult
(e.g., single-mother households)
Given the nature of this study, in addition
to descriptive trends of the pooled sample it
was also important to consider trends in poverty

311. rates by parental marital status and the number
of earners in the household. These descripted
trends are depicted in Figure 1 and Figure 2.
Child poverty rates for unmarried-headed house-
holds were much higher than married-headed
households, as expected (see Figure 1). In 1974,
child poverty rates for unmarried and married
households were 47.8% and 9.3%, compared to
2010 rates of 40.4% and 11.7% (relative mea-
sure) and 31.4% and 7.4% (anchored measure),
respectively. As both figures illustrate, the gap in
child poverty rates between married and unmar-
ried households has narrowed over time.
Figure 2 shows the child poverty rates by
number of earners (i.e., no earners, one earner,
and two or more earners). In 1974, child poverty
rates for children in no-earner, one-earner, and
two-or-more-earners households were 83.4%,
19.6%, and 7.2%, respectively. In 2010, the
corresponding child poverty rates were 88.5%,
30.2%, and 6.2% (relative measure) and 82.3%,
20%, and 3.5% (constant measure). Despite
some fluctuations here and there (e.g., the
decline in anchored child poverty to 4.5% in
2010), these graphs illustrate an overall trend
that the child poverty gap between number of
earners has widened over time.
Pooled Analyses With Linear Time Interactions
Table 2 displays the logistic regression results
for marriage and earners on child poverty for
the pooled sample. Across all models, mar-
riage and the number of earners decreased the

312. odds of both measures of child poverty. For
instance, in the baseline Model 1, having a mar-
ried head of household reduced relative and
anchored child poverty by a factor of 2.71 and
2.74. (N.B. the factor is calculated by dividing
1 by the odds ratio [OR], e.g., 1/.369 = 2.71;
1/.365 = 2.74.) Each additional earner reduced
1172 Journal of Marriage and Family
Figure 2. Child Poverty by Number of Earners in Household,
1974–2010.
0
10
20
30
40
50
60
70
80
90
100

313. %
C
h
il
d
P
o
v
e
rt
y
Year
Relative Child Poverty by
Number of Earners in Household
No Earners
One Earner
Two or More Earners
0
10
20
30
40

314. 50
60
70
80
90
100
%
C
h
il
d
P
o
v
e
rt
y
Year
Anchored Child Poverty by
Number of Earners in Household
No Earners

315. One Earner
Two or More Earners
relative and anchored child poverty by factors of
3.73 (1/.369) and 3.98 (1/.251).
Model 2 interacted marriage and number
of earners with linear year. Both marriage and
number of earners still remained significant
and decreased the odds of child poverty; how-
ever, the interactions suggest a divergence in
their relationships with poverty over time. The
marriage and year interactions for both relative
(OR = 1.022) and anchored (OR = 1.025) child
poverty suggest an overall weakening in the
negative association between marriage and
child poverty. However, the number of earners
and linear year interactions for both relative
(OR = 0.981) and anchored (OR = 0.976) child
poverty suggests a stronger negative associ-
ation with work and child poverty. Both sets
of interactions are statistically significant, thus
indicating a noteworthy change in the magnitude
of the association between marriage and work
and child poverty over time. It is important to
note that these results are consistent with the
trends in child poverty by marital status and
number of earners displayed in Figure 1 and
Figure 2.
Pooled Analyses With Nonlinear Time
Interactions
Because the observed trends for marriage and
work in Model 2 might vary in a nonlinear way,

316. Model 3 included binary variables for each year
(reference year = 1974) and interactions with
marriage and work with each year. As in Model
1 and Model 2, having a married head of house-
hold led to reduced odds of relative and anchored
child poverty by a factor of 4.61 and 4.57,
respectively. However, the main effect of the
number of earners had a weaker association than
in Model 2; it reduced the odds of child poverty
by a factor of only 2.70 and 2.66. Overall, the
interactions in Model 3 also suggest change over
time. With the exception of 1979 and 1986 in the
relative poverty model and 1979 in the anchored
poverty model, all interactions were signifi-
cant. Compared to the reference year 1974, the
association between marriage and child poverty
weakened in both the relative and anchored mod-
els. By contrast, the interactions for the number
of earners illustrated the opposite trend.
For substantive interpretation, Figure 3 graph-
ically displays the inverse odds of the interac-
tions from Model 3 in Table 2. An increasingly
negative association implies a greater reduction
in the odds of child poverty. Panel A of the
figure displays results for the marriage and time
interactions. Over time, the magnitude of the
negative association between marriage and child
poverty weakened. More specifically, most of
this change took place between 1974 and 1991
(as shown in the top four bars in Figure 3, Panel
A). From 1991 to 2010, the association between
Marriage, Work, and Child Poverty 1173

317. Table 2. Logistic Regression Models of Child Poverty, Pooled
Sample 1974–2010, Odds Ratios
Relative poverty Anchored poverty
Variables Model 1 Model 2 Model 3 Model 1 Model 2 Model 3
Married (ref.: no) 0.369*** 0.225*** 0.217*** 0.365***
0.216*** 0.219***
Number of earners 0.268*** 0.381*** 0.371*** 0.251***
0.386*** 0.376***
Married × year 1.022*** 1.025***
Earners × year 0.981*** 0.976***
Married × 1979 1.084 1.080
Married × 1986 1.381 1.385
Married × 1991 1.890*** 1.897***
Married × 1994 2.023*** 2.007***
Married × 1997 1.947*** 1.827***
Married × 2000 1.897*** 2.008***
Married × 2004 2.050*** 2.095***
Married × 2007 1.795*** 1.732***
Married × 2010 1.896*** 1.867***
Number of earners × 1979 1.061 1.046
Number of earners × 1986 0.759* 0.714*

318. Number of earners × 1991 0.678*** 0.637***
Number of earners × 1994 0.642*** 0.622***
Number of earners × 1997 0.588*** 0.549***
Number of earners × 2000 0.686** 0.580***
Number of earners × 2004 0.541*** 0.446***
Number of earners × 2007 0.594*** 0.461***
Number of earners × 2010 0.482*** 0.379***
Year 1.005*** 1.016*** 0.986*** 1.002
Year 1979 1.042 0.955
Year 1986 2.186*** 1.893**
Year 1991 2.012*** 1.776***
Year 1994 1.991*** 1.754***
Year 1997 2.073*** 1.568**
Year 2000 1.853*** 1.170
Year 2004 1.857*** 1.250
Year 2007 2.027*** 1.339
Year 2010 1.988*** 1.381*
Age of head 0.924*** 0.997*** 0.918*** 0.935*** 0.928***
0.927***
Age of head2 1.001*** 1.001*** 1.001*** 1.000*** 1.001***
1.001***

319. Head under age 25 (ref.: no) 1.758*** 1.759*** 1.21***
1.787*** 1.784*** 1.871***
Education (ref.: high school
degree/some college)
No high school diploma 2.918*** 2.887*** 2.939*** 2.799**
2.761*** 2.828***
College degree 0.295*** 0.293*** 0.296*** 0.324*** 0.325***
0.328***
Race of head (ref.: White)
Black 1.795*** 1.775*** 1.769*** 1.724*** 1.704***
1.699***
Latino 1.904*** 1.890*** 1.901*** 1.738*** 1.732***
1.746***
Other race 1.560*** 1.553*** 1.584*** 1.524*** 1.519***
1.582***
Number of working age 1.063** 1.123*** 1.125*** 1.045
1.109*** 1.100***
Number of children 1.442*** 1.438*** 1.446*** 1.398***
1.393*** 1.404***
Adults over age 65 (ref.: no) 0.546*** 0.547*** 0.534***
0.529*** 0.531*** 0.514***
N 192,547 192,547 192,547 192,547 192,547 192,547
BIC 46,693.3 46,508.52 46,488.86 42,214.75 41,965.97
41.842.87
Note: ref. = reference category; head = head of household; BIC

320. = Bayesian Information Criterion.
*p < .05. **p < .01. ***p < .001.
1174 Journal of Marriage and Family
Figure 3. Association Between Marriage, Number of Earners,
and Child Poverty Over Time, 1974–2010.
–5 –4 –3 –2 –1 0
1974
1979
1986
1991
1994
1997
2000
2004
2007
2010
PANEL A
Married × Time
Relative Anchored

321. –8 –6 –4 –2 0
1974
1979
1986
1991
1994
1997
2000
2004
2007
2010
PANEL B
Number of Earners × Time
Relative Anchored
)esrevnI(oitaRsddO)esrevnI(oitaRsddO
Note: The figures illustrate results from Model 3 of Table 2. To
calculate the inverse odds ratio, I used the following equation:
(e.g., for the year 1979): −1 / (Married79 Odds Ratio * Married
Odds Ratio).
marriage and child poverty remained rather sta-
ble, with some slight fluctuations. As shown in

322. Panel B of Figure 3, from 1974 to 1979 the
strength of the association between number of
earners and child poverty was relatively stable.
From 1986 onward, however, the number of
earners had an increasingly greater reduction on
the odds of child poverty (despite small declines
in 2000 and 2007).
Especially noteworthy is that, when we com-
pare the association between marriage and child
poverty in 1974 and 2010, we see that the mag-
nitude of the relationship declined by more than
half; however, the magnitude of the relation-
ship between the number of earners and child
poverty from 1974 to 2010 more than doubled.
The observed trends are even more pronounced
for the anchored poverty measure than that of
relative poverty. This offers further support of
a noteworthy change in the association among
marriage, work, and child poverty over time.
Beyond these results, three additional sensi-
tivity analyses warrant mention. First, because
the sample size increased more than threefold
from 1986 to 1991, I conducted a robustness
check to ensure that changes in sample sizes
were not affecting the results by reestimating the
analyses with random samples of 4,200 per wave
(the minimum N of all years). Second, to address
the concern that marriage and number of earners
were inherently conflated, I estimated all models
without number of earners in the model. Third,
I reestimated the analyses as linear probability
models. The results for all these sensitivity anal-
yses are consistent with the presented results.

323. Discussion
Motivated by the fundamental changes in mar-
riage and work (i.e., household earners) over
the past four decades, in this study, I exam-
ined the extent to which the magnitude of the
associations among marriage, work, and child
poverty has changed. The regression results sug-
gested that although marriage and work have
both maintained a negative association with
child poverty, marriage has generally become a
weaker defense against child poverty, whereas
work has become a stronger defense against
child poverty. These results are consistent with
Marriage, Work, and Child Poverty 1175
a narrowing of the child poverty gap in unmar-
ried and married households (see Figure 1) and
a widening of the child poverty gap among
no-earner, one-earner, and two-or-more-earner
households (see Figure 2). Furthermore, these
findings demonstrate the historically varying
relationship of demographic characteristics and
poverty over time and illustrate that sources of
stratification in modern society are not static.
The overall weaker association between
marriage and child poverty may be attributable
to either or both of two factors: (a) the increased
proportion of children in cohabiting households
and (b) the increased heterogeneity among
unmarried parents, which makes them less uni-

324. formly disadvantaged. Conversely, the stronger
association between work and child poverty
may be attributable to either (a) economic
changes that have created increased pressure
for multi-earner households and/or (b) welfare
changes that have made employment more
essential for staying out of poverty. Although
it is beyond the scope of this study to fully
analyze these plausible explanations, additional
descriptive characteristics of children in married
and unmarried headed households shed some
light (see the Appendix). Although the mean
number of earners increased from 1.15 to 1.24
for children in unmarried-headed households, it
decreased in married-headed households from
1.90 to 1.81. Both households with married and
unmarried heads of households had increases in
total weekly and annual work hours in the house-
hold and the education of the head of household.
Particularly noteworthy, however, is that among
children in unmarried households, the percent-
age of heads of household with less than a high
school degree decreased from 45.31% in 1974
to 20.91% in 2010, whereas the percentage with
4 or more years of college increased from 7.29%
to 14.55%. These findings illustrate the changing
characteristics of both married and unmarried
households, providing possible insight into this
study’s findings.
There are several areas in which future
research would be valuable. First, although
this study has provided plausible explanations
for the changing associations among marriage,
work, and child poverty, future research to
test the extent to which these mechanisms

325. account for the observed trends is necessary.
For example, longitudinal data would allow for
the examination of families with children over
time to explore potential causal mechanisms
(e.g., cohabitation, welfare supports, etc.) that
may help explain the outcomes observed in this
cross-sectional data. (Unfortunately, LIS data
do not enable precise over time comparisons of
cohabitation because cohabitation data are not
available or are not precisely identified in some
years.)
Second, this study concerned only 10 time
points. Replication of the analyses with data
for consecutive years could reveal important
nuances in results unobserved in this study.
Third, given the distinctively higher poverty
among Black and Latino children and racial
differences regarding changes in family struc-
ture and work patterns (e.g., Lichter & Crowley,
2004; Nichols, 2013), future research to exam-
ine possible differences by race is necessary. In a
sensitivity analysis, I reestimated the final model
for Whites, Blacks, and Latinos. Although the
results reflected similar general trends across
races, there were notable differences in the non-
linear analyses, such as the negative association
between work and poverty being strongest for
Blacks but not consistently increasing for Lati-
nos. Thus, the role of racial/ethnic differences
warrants more thorough inquiry.
Finally, this study has implications for
antipoverty policies. The observed weakened
relationship between marriage and child poverty

326. is notable for a society that has placed a rather
strong emphasis on marriage and “family val-
ues” in its antipoverty policy (Cherlin, 2009).
Although it is clear that marriage still has a
strong, positive impact on children’s economic
well-being, perhaps policymakers have relied
too heavily on marriage alone. As Haskins
(2014) noted, “the changes in family composi-
tion have been proceeding for more than four
decades and show no signs of abating, despite
a host of efforts by policy makers.” Moreover,
almost half of unmarried parents would have
continued to earn below the federal poverty line
even if they were to marry (Sigle-Rushton &
McLanahan, 2002), and earnings have a positive
influence on marriage selection, in particular
among low-income mothers (Gibson-Davis,
2009; McLanahan & Percheski, 2008). These
findings, coupled with the present study, suggest
that focusing on increasing parents’ earn-
ings will not only help improve children’s
economic well-being, but perhaps also increase
the probability of financially stable marriages,
which in turn could further reduce child poverty.
1176 Journal of Marriage and Family
That the results indicate the negative asso-
ciation between work and child poverty has
strengthened should also inform policy debates.
The analyses demonstrate how essential employ-
ment is for the economic security of fami-
lies with children. Rainwater and Smeeding
(2004) found that employment, the labor mar-

327. ket, and work supports (e.g., work tax cred-
its, child care subsidies) have the largest impact
on a country’s child poverty rate, yet this has
been relatively neglected in American poverty
policy discussions. Instead, emphasis on work
has often focused on simply getting people to
work and cultivating their work ethic. How-
ever, it is equally important to have policies that
help families maintain employment. Because
single-parent households are more vulnerable to
child poverty and such families are less likely to
have multiple earners, it is essential to facilitate
the gainful and secure employment of single par-
ents. Furthermore, even though employment is
essential, it does not guarantee an escape from
poverty, given that working-poverty rates remain
relatively high in the United States (Brady et al.,
2013). Therefore, policies designed to boost
wages for typical workers and expand work sup-
ports (see Sawhill & Karpilow, 2014) would also
help to effectively reduce child poverty.
Note
I gratefully acknowledge David Brady and Linda Burton for
their valuable feedback and suggestions and Ryan Finnigan
for providing helpful statistical advice. I also thank the fol-
lowing for comments on previous versions of this article:
Amie Bostic, Sandra Danziger, Lane Destro, David Eagle,
Lisa Keister, Sancha Medwinter, Cyrus Schleifer, S. Philip
Morgan, Feng Tian, and audiences at the annual meetings
of the Southern Sociological Society (2012) and the Asso-
ciation for Public Policy Analysis and Management (2013).
This research was supported by the American Sociological
Association Minority Fellowship Program and the Center for
Child and Family Policy at Duke University.

328. References
Amato, P. R., & Maynard, R. A. (2007). Decreas-
ing nonmarital births and strengthening marriage
to reduce poverty. The Future of Children, 17,
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APPENDIX
Variable Means for Children by Marital Status
Variable 1974 1979 1986 1991 1994 1997 2000 2004 2007 2010
Panel A: Married-headed household
Relative poverty (%) 9.34 10.99 12.42 14.76 14.02 12.95 13.56
12.49 12.91 11.66
Anchored poverty (%) 9.34 10.03 10.60 12.84 12.48 9.64 8.62
8.12 7.52 7.41

334. Number of earners 1.90 2.01 1.95 1.94 1.94 1.95 1.96 1.87 1.86
1.81
Weekly work hours 57.13 64.07 71.44 67.77 67.94 65.26 62.35
63.27 60.25
Annual full-time hours 2441.03 2711.06 3001.40 2998.95
2887.88 2752.26 2820.14 2643.09
Annual part-time hours 254.89 330.35 347.06 322.89 281.53
273.62 266.57 274.96
Number of working-age adults 2.22 1.98 2.19 2.23 2.22 2.21
2.24 2.23 2.24 2.28
Age of head 38.43 38.23 38.04 38.45 39.03 39.42 39.35 39.54
40.10 40.45
Head under age 25 (%) 5.87 4.36 2.56 2.43 2.30 1.96 2.75 2.65
2.23 2.00
No HS diploma. (%) 27.34 22.65 15.91 15.87 15.15 15.07 14.39
13.44 12.52 12.08
College degree (%) 19.17 23.98 25.47 26.24 28.50 28.81 30.48
32.44 34.98 37.23
Black head (%) 7.37 9.00 8.20 8.57 8.38 8.96 9.07 8.36 8.48
7.96
Other race head (%) 1.22 2.32 3.03 3.84 4.16 5.07 5.56 7.52
7.79 8.39
Latino head (%) 5.04 7.40 8.51 11.39 12.51 13.98 15.56 17.91
19.24 19.19
Number of kids 2.31 2.55 2.11 2.42 2.39 2.41 2.45 2.42 2.43
2.42
Adults over 65 (%) 3.01 1.13 2.54 2.41 2.58 2.85 3.11 3.60 3.77
4.23
N 3,844 4,711 3,251 16,138 15,493 13,377 12,747 23,469
22,049 20,772
Panel B: Unmarried-headed households
Relative poverty (%) 47.78 50.04 50.92 51.91 49.24 45.49 42.45
40.51 42.47 40.38
Anchored poverty (%) 47.78 48.29 47.50 48.82 46.62 39.74
31.61 31.40 31.49 31.37
Number of earners 1.15 1.18 1.15 1.12 1.17 1.27 1.41 1.29 1.32

335. 1.24
Weekly work hours 26.93 33.70 38.23 35.06 38.95 42.14 39.41
40.04 36.85
Annual full-time hours 1004.76 1299.73 1468.95 1591.56
1761.79 1642.35 1671.02 1485.33
Annual part-time hours 180.18 204.75 220.07 215.36 214.42
197.93 204.16 228.71
Number of working-age adults 1.33 0.97 1.44 1.52 1.53 1.53
1.60 1.60 1.61 1.70
Age of head 37.70 37.42 37.27 37.04 36.84 37.44 37.15 37.60
38.02 37.78
Head under age 25 (%) 11.86 9.95 8.82 9.15 10.68 10.72 12.37
11.84 10.67 11.40
No HS diploma. (%) 45.31 39.44 29.89 31.00 28.73 27.73 23.99
23.61 21.39 20.91
College degree (%) 7.29 7.36 11.17 8.84 8.79 9.58 10.95 12.07
13.62 14.55
Black head (%) 30.54 35.97 30.57 34.52 34.25 31.91 31.52
29.80 29.49 28.57
Other race head (%) 1.13 1.80 1.87 3.03 2.38 3.17 4.07 5.76
6.00 6.54
Latino head (%) 8.03 7.87 12.51 14.08 15.38 16.20 17.55 20.37
21.46 23.45
Number of kids 2.29 2.61 2.01 2.46 2.43 2.44 2.31 2.33 2.34
2.31
Adults over 65 (%) 5.46 3.36 4.13 4.45 4.47 4.68 4.93 5.35 5.53
5.73
N 767 1,296 1,046 6,091 6,134 5,628 5,374 10,276 10,065
10,055
Note. There were no data available for weekly hours in in 1979
and annual hours in 1974 and 1994. This is why the
alternative work measures are not included in the main analyses
of this article. However, to compare trends among children
in married versus unmarried households over time, the work
hour data that are available are displayed in the table. HS =

336. high
school.
Procedia - Social and Behavioral Sciences 132 ( 2014 ) 148
– 153
Available online at www.sciencedirect.com
1877-0428 © 2014 The Authors. Published by Elsevier Ltd.
Open access under CC BY-NC-ND license.
Selection and peer-review under responsibility of HUM-665
Research Group “Research and Evaluation in Intercultural
Education”.
doi: 10.1016/j.sbspro.2014.04.291
ScienceDirect
6th International Conference on Intercultural Education
“Education and Health: From a
transcultural perspective”
The Impact of Poverty on the Family System Functioning
Andrea Banovcinovaa*, Jana Levickaa, Martin Veresa
aTrnava university of Trnava, Faculty of Health Care and
Social Work, Univerzitné námestie 1, 918 43 Trnava, Slovakia
Abstract
This study aims to examine how life in poverty affects the
functioning of family system. We focused on family functioning
in
the dimensions based on McMaster model. We employed The

337. Family Assessment Device.
The result shows that there is an association between poverty
and disrupted family functioning. Family functioning in
different
dimensions is in the range of "unhealthy", mainly in
communication, behaviour control and family role. Family
stress caused by
problems with the fulfilment of the family economic function,
affects the way parents fulfill their parental role.
We consider it necessary to focus on effective interventions to
help families living in poverty in the restoration of family
functioning in different dimensions.
© 2014 The Authors. Published by Elsevier Ltd.
Selection and peer-review under responsibility of Encarnación
Soriano, Christine Sleeter and María Antonia Casanova.
Keywords: Poverty; Family functioning; Family system; Family
Assessment Device
1 Introduction
Poverty is a social problem, which is given a big coverage in
society and new strategies are continuously being
developed in order to minimize and reduce its impact. However,
we might conclude that under the social-economic
development in Slovakia, the at-risk-of-poverty rate has
currently an increasing tendency. The National Social
Report for 2012 (ec.europa.eu) shows that there is a significant
increase in the number of people living in
households with a very low intensity of work within individual
indicators. These families are one of the groups at
highest risk in terms of falling into poverty. Based on the
findings of the Statistical Bureau of the Slovak Republic,
as regards poverty, the most endangered households are
predominantly those with two adults and with three or

338. * Corresponding author.Andrea Banovcinova. Tel.: +421-033-
5939-491
E-mail address: [email protected]
© 2014 The Authors. Published by Elsevier Ltd. Open access
under CC BY-NC-ND license.
Selection and peer-review under responsibility of HUM-665
Research Group “Research and Evaluation in Intercultural
Education”.
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149 Andrea Banovcinova et al. / Procedia - Social and
Behavioral Sciences 132 ( 2014 ) 148 – 153
more dependent children. Nearly one third of them (32,6%) was
at risk of poverty. The next risk group were the
households made of one parent with at least one dependent
child, thus incomplete families (26,4%)
(www.portal.statistics.sk). With respect to the prognosis of
development of macroeconomic indicators until 2015, it
can be assumed, that in spite of the measures adopted, no
significant decrease in poverty risk or social exclusion
will occur in that period.
The life in poverty has a negative impact on whole families
(Dodge et al., 1994; Gedbery, Bodnárová
a Filadelfiová, 2007; Currie a Stabile, 2003 etc.). For instance
Gedbery, Bodnárová a Filadelfiová (2007), but also
Bodnárová, Džambazovič at al., (2005) highlight both the
important role of nuclear family, which influences the
development and growth of a child, and transference of
inequality from one generation to another. Children raised

339. in the families with lower income are disadvantaged in
numerous aspects in comparison with those from
economically well established families. Studies conducted by
Currie and Stabile (2003) demonstrate that children
from families, which can be classified as poor, have lower birth
weight, higher risk of infant mortality. Duncan et al
(2004) examined the influence of economically disadvantaged
environment on the behaviour of children. Their
research shows that those children are more frequently
diagnosed with behavioural disorders. Likewise, Havemen
and Wolfe (1995) came to similar conclusions and furthermore
they discovered worse school results of children
from economically disadvantaged environment. After
completion of their education they experience difficulties
with employment in the labour market (Gregg a Machin, 1999)
and they have health problems more frequently
(Currie et al, 2004). Consequently, all these facts have impact
on the employment options and subsequently on the
individual´s income rate (Jenkins, Siedler, 2007).
The presence of poverty in a family limits also the development
of children through budget restrictions of family
sources, which parents invest into them. However, experts
(Becker In Kalil, 2003) emphasize, that these sources
cannot be viewed only through market value and costs for
quality care. The investment of a parent is also the value
of time. Sources can include not only income, but also non-
financial sources such as education, access to
information, etc. Families living in poverty can have a
restricted access to sources on both levels – in the access to
material sources ( cost of living, food expenses, cognitively
stimulating toys for children, books, etc.) but also to
immaterial sources (for instance in the area of education, in the
access to information, in possibilities of
development of one´s experiences and skills etc.). This
indicates that families with lower income are not able to

340. invest sufficient human capital into their children.
However, poverty, apart from the direct impact on individual
family members, endangers and disrupts the
functioning of the family system as a whole. The family
functioning is a multi-dimensional construct reflecting
family interactions and activities. Effectiveness or
ineffectiveness of family activities and interactions determines
whether the family is able to fulfill its aims, provide its
members with material and emotional support and well-
being, support their prosperity and development (Walsh, 2003).
Pezzullo et al. (2010) characterize the family
functioning through a variety of family governance frameworks,
emotional attributes, cognitive engagement and
development characteristics, physical health habits,
intra�familial relationships and social connectedness.
Currently, there is no consensus in basic dimensions of the
family functioning. Specification of dimensions and
key areas of family functioning varies depending on the
specialization of the author of given concept or model. In
the assessment of family strengths Orthner, Jones-Sanpei and
Williamson (2004) considered 6 dimensions:
economic stability, communication skills, problem-solving
skills, family cohesion, social support and presence of
risky factors. The outcome of this assessment demonstrates that
the economic insecurity, which families are
confronted with, correlates with lack of problem-solving skills
and eroded family cohesion. Furthermore, the
analysis also discovered considerable differences in
communication skills and provision of social support in the
observed low-income families.
2 Methodology
In order to achieve our objectives and evaluate the functioning

341. of the family system, we took into consideration
the McMaster model of family functioning. The model is based
on systems theory and its crucial assumptions are
as follows: ( 1) All parts of the family are interrelated; ( 2) One
part of the family cannot be understood in isolation
from the rest of the family system, ( 3) Family functioning
cannot be fully understood by simply understanding
150 Andrea Banovcinova et al. / Procedia - Social and
Behavioral Sciences 132 ( 2014 ) 148 – 153
each of the individual family members or subgroups; ( 4 ) A
family´s structure and organization are important
factors that strongly influence and determine the behaviour of
family members; ( 5) The transactional patterns of
the family system strongly shape the behaviour of family
members.
In order to assess family functioning, similarly to the McMaster
model, we concentrated on 6 dimensions of
family life: problem solving, communication, family roles,
affective responsiveness, affective involvement and
behaviour control. As noted by Epstein et al. (1993), in order to
fully understand such a complex entity as a family,
it is necessary to evaluate many dimensions. However, the
dimensions in our chosen models are not an exhaustive
calculation of all aspects of family functioning. The authors
describe only those considered important in the clinical
context. Their goal was to conceptualize and operationalize the
dimensions in a way that would allow their easy
and helpful usage in research.
Purpose of the study: Determine whether poverty affects the
family functioning in all its dimensions and identify

342. the most affected dimensions.
2. 1 Participants
The sample consisted of 332 participants divided into two
groups. The first group consisted of 172 participants
(mean age= 28.38 ±15.38, range =12 – 67) living in families
with income below the level of subsistence minimum.
The subsistence minimum in the Slovak Republic is recognized
by the state as a poverty line. The second group
was control group consisted of 160 participants (mean age =
30.19 ± 14.56, range = 13 – 67) living in families with
standard income.
2. 2 Measures and procedure
In order to evaluate family functioning, Family Assessment
Device (FAD) questionnaire was used. It is a 60 -
item self-assessment tool. It is designed to assess selected
dimensions of family functioning and is based on the
McMaster model of family functioning. Assessed dimensions
are the following: (a problem solving - a family's
ability to resolve problems at a level that maintains effective
family functioning, (b) communication – how
information is exchanged within a family (the focus is on verbal
exchange) , (c) roles – the recurrent patterns of
behaviour by which individual members fulfil family functions ,
(d) affective responsiveness – the ability to
respond to a range of stimuli with the appropriate quality and
quantity of feelings, (e) affective involvement - the
degree to which the family shows interest in and values the
activities and interests of individual family members,
(f) behaviour control – the pattern a family adopts handling
behaviour in specific situations.
The last dimension is general functioning – the overall health or

343. pathology of a family (Epstein, Baldwin,
Bishop, 1983). The task of a participant was to identify how
well the statement describes his family (on a scale
from strongly agree - agree - disagree - strongly disagree).
3. Results
The results were analysed using statistical software SPSS.
Table 1. Mean scores of family functioning dimensions (Family
assessment device)
Dimension Cut-off Score Mean Score Minimum Maximum
Problem solving 2,20 2,22 1,20 3,40
Communication 2,20 2,24 1,00 3,17
Roles 2,30 2,60 1,50 3,50
Affective Responsiveness 2,20 2,44 1,50 3,33
Affective Involvement 2,10 2,59 1,43 3,57
Behavior Control 1,90 2,37 1,44 3,11
General family functioning 2,00 2,32 1,00 3,75
151 Andrea Banovcinova et al. / Procedia - Social and
Behavioral Sciences 132 ( 2014 ) 148 – 153
As shown in Table 1, comparing average scores of individuals
living below the poverty threshold with Cut-off
Score, the largest differences were observed in the dimension
Affective Involvement (mean score 2.59) and in the
dimension Behaviour Control (mean score 2.37).

344. Table 2 Differences in family functioning dimensions
Dimension Group N Mean Rank U Z P
Problem Solving
Group 1 172 164,51
13418,500 -,397 ,692
Group 2 160 168,63
Communication
Group 1 172 187,01
10233,000 -4,066 ,000
Group 2 160 144,46
Roles
Group 1 172 211,48
6023,500 -8,900 ,000
Group 2 160 118,15
Affective Responsiveness
Group 1 172 188,60
9959,000 -4,399 ,000
Group 2 160 142,74
Affective Involvement
Group 1 172 217,28
5026,000 -10,044 ,000
Group 2 160 111,91

345. Behavior Control
Group 1 172 180,85
11291,500 -2,846 ,004
Group 2 160 151,07
General Family Functioning
Group 1 172 206,28
6917,000 -7,843 ,000
Group 2 160 123,73
*Group 1 – income below the poverty threshold
Group 2 – standard income
The findings in Table 2 show that the results of Mann Whitney
U test, applied to compare the average score in
the dimension Communication show a significant difference
between the group of participants living below the
poverty threshold and the group of participants with a standard
income (Z = - 4.066 , p = 0.000). The average score
of the group living below the poverty threshold was 187.01 ,
while in the group of participants with a standard
income, the mean score was 144.46 . In the dimension Roles
was found also a significant difference ( Z = -8.900 ,
p = 0.000 ) between the group of participants living below the
poverty threshold ( mean rank 211.48 ) and the
group of participants with a standard income ( mean rank
118.15 ) . The analysis of the results showed a
statistically significant difference ( Z = -4.399 , p = 0.000 )
between the participants whose income is in the range
of poverty ( mean rank 188.60 ) and the participants with a
standard income ( mean rank 142.74 ) also in the
dimension Affective Responsiveness . Another comparative
dimension was Affective Involvement. Similarly, this

346. dimension showed statistically significant differences ( Z = -
10.044 , p = 0.000 ), where the group of participants
living below the poverty threshold reached a mean rank of
217.28 and the group of participants with a
standard income reached a mean rank of 111.91 . The
dimension Behaviour Control demonstrated a statistically
significant difference ( Z = -2.846 , p = 0.004 ) between the
participants whose income does not exceed the poverty
threshold ( mean rank 180.85 ) and participants with a standard
income ( mean rank 151.07 ) . The only dimension
which showed no significant difference between the two groups
was Problem Solving ( Z = 0 - , 397 , p = 0.692 ) .
The group of participants living in poverty reached in this
dimension a mean rank of 164.51. Mean rank of the
participants with a standard income was 168.63.
The last evaluated dimension was General Family Functioning.
This dimension demonstrated a significant
difference in average score ( Z = -7.843 , p = 0.000 ) between
the group of participants whose income is below the
legal poverty threshold ( mean rank 206.28 ) and the group of
participants with a standard income ( mean rank
123.73 ) .
152 Andrea Banovcinova et al. / Procedia - Social and
Behavioral Sciences 132 ( 2014 ) 148 – 153
4 Discussion and conclusion
The family functioning is determined by family structure, level
of societal development, cultural background
and by social – economic status of a family (McCreary –
Dancy, 2004). The influence of life in poverty on
individual is undeniable, thus both in past and in present it has

347. been a subject of numerous studies. Nonetheless,
a very little attention in research has been focused on the
influence of life in poverty on a family as a whole and on
its functioning. For this reason, we aspired to determine
whether poverty affects the family functioning in all its
dimensions. Moreover, we wanted to know which dimension
was the most affected. We applied the self-report
inventory Family Assessment Device, through which we
monitored the average score in each dimension.
Subsequently, we compared the results from families living
below poverty line and the control group of
respondents living in families with a standard income. The
adopted inventory enabled to discover the degree to
which the family functioning was disrupted, yet it did not
indicate through what this disruption manifested itself.
Therefore, it will be indispensable to conduct a qualitative
investigation in families, aimed at an elaborate analysis
of functioning in all dimensions.
The analysis of results showed that respondents from the
observed group proved an average score below the
cut-off score in all dimensions. The highest degree of disruption
of our respondents was shown in the dimension
Behaviour Control. Miller et al (2000) relates this dimension to
behaviour in three types of situations. The first
type involves situations connected with physical threat of
family members. The second type is defined by
situations connected with fulfilment of basic psychobiological
needs. The third type concerns situations involving
interpersonal socializing behaviour towards family members but
also towards the environment in which the family
lives. Further findings were proposed by Dodge et al (1994) or
Papp et al (2009) who noted that the long-term
economic stress leads often to less effective parenting. The
studies also indicate that parents apply coercive and
punitive parenting styles more frequently. Corporal punishments

348. are frequently used, opposed to negotiations and
argumentations (Sampson, Laub, 1994). In addition, a higher
risk of violence against partner, a development of
various addictions or a criminal behaviour was found among
parents living in a long-term poverty (McLoyd,
1990; Hasima, Amato, 1994). Behaviour of individual members
of family is closely linked with the manner in
which they hold their roles. Disruption of this dimension was
clearly proved in our research, too. In the families
with low income, the conflict between the parental role and the
working role occurs more frequently. The conflict
between these two roles consists in an excessive pressure on
parents to provide for the family and to meet the
needs of all family members from the economic point of view.
Another area which proved the impact of poverty on the family
functioning in our research was the Affective
Involvement. This dimension reflects the degree to which the
family shows interest in values and activities of
others. (Epstein et al, 1978) Likewise, the disruption of
Affective Involvement dimension was proved also by
Dodge et al (2004), in that the poverty and its accompanied
factors both reduce the ability of parents to engage in
affectionate and supportive interactions with their children and
increase the risk of negative or repressive
behaviour. This behaviour of parents was identified as a crucial
mechanism, through which poverty affects the
development of children. Not only Gershoff et al (2007) but
also Fine and Finchman (2013) highlight the fact that
the stress caused by constant economic pressure results in
instability of family relationships. As a consequence of
increased conflicts imposed by financial problems not only the
functioning of a couple is endangered. Due to stress
the disruption of supportive parent-child relationships often
occurs.

349. As the results suggest, poverty is a negative-acting factor in the
family functioning. It has been proved that all
its dimensions are influenced by an insufficient income. It is
necessary to pay further attention to qualitative
analysis of all dimensions of the family functioning in families
living in poverty. Knowledge about the specific
dimensions and aspects which are most affected by poverty and
by which means are essential especially for the
selection of the most effective strategy and the most appropriate
methods for work with family.
Acknowledgements
This study was supported by grant from the Trnava University
in Trnava no. 11/TU/13.
153 Andrea Banovcinova et al. / Procedia - Social and
Behavioral Sciences 132 ( 2014 ) 148 – 153
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353. 105
Poverty, Homelessness,
and Family Break-Up
This study examines the extent and
correlates of family separations in
families experiencing homelessness.
Of 2,307 parents recruited in family
shelters across 12 sites, one-tenth
were separated from partners and one-
quarter from one or more children.
Additional separations before and
after shelter entry and reasons, from parents’ perspectives,
were documented in qualitative interviews with a subsample
of 80 parents. Separations were associated with economic
hardship, shelter conditions, and family characteristics.
Acknowledgements: This study was supported by the National
Institute of Child and
Human Development, grant # 5R01HD066082. Survey data
collection was funded
by contract C-CHI-00943, Task Orders T-0001 and T-0003 from
the Department of
Housing and Urban Development to Abt Associates. We thank
Abt Associates, Inc., Emily
Holt and Meghan Henry for conducting the interviews and
Lindsay S. Mayberry and
Chase Darmstadter for contributions to coding.
Marybeth Shinn
Vanderbilt University
Jessica Gibbons-Benton
Vanderbilt University

354. Scott R. Brown
Vanderbilt University
Child Welfare Vol. 94, No. 1
106
Poverty and homelessness are associated with the break-up of
families. A number of studies have documented that children
in families who experience homelessness frequently become
separated from their parents. In a national sample in 1996, Burt
and colleagues (1999) found that three-fifths of women served
by
homeless programs had children under the age of 18, but only
65%
of the mothers lived with any of their children. Park and
colleagues
(2004) found that 24% of more than 8,000 children who entered
shelter with a parent for the first time in New York City in 1996
received child welfare services within five years of shelter
entry—
three-quarters of them after the family became homeless. Many
smaller, local studies document associations of housing
problems and
homelessness with elevated rates of foster care placements and
far
higher rates of informal child separations unknown to child
welfare
authorities (for reviews, see Barrow & Lawinski, 2009;
Courtney,
McMurty, & Zinn, 2004).
Fewer studies have sought to explain these separations. In

355. studies
of the general population, poverty is related to child
maltreatment,
especially neglect (Sedlak et al., 2010) and to “substandard”
parenting
(Berger, 2007). Among families experiencing homelessness,
Park
and colleagues (2004) found that recurrent and longer shelter
episodes and domestic violence predicted child welfare
services.
They suggest that families in shelters are subject to stress and
lack
of privacy, and also heightened scrutiny: a “fishbowl effect”
may lead
staff to report to child protective services. Similarly, McDaniel
and
Slack (2005) suggest that life events, such as a move, may make
low-income parents more visible, leading to protective service
reports. Cowal and colleagues (2002) compared mothers who
entered shelter with continuously housed mothers using public
assistance and found that drug abuse, domestic violence, and
any
institutional placement of the mother predicted separation for
both groups, but homelessness was by far the strongest
predictor.
Barrow and Lawinsky (2009) found that the same factors, along
with children’s needs, were important in a sample of mothers
107
Shinn et al. Child Welfare
experiencing homelessness, but described precarious housing as
“a

356. constant backdrop.” In the face of crises that came “in twos and
threes,” mothers negotiated with fathers, maternal and paternal
kin,
and agencies to find “better choices among troubling
alternatives”
(pp. 166-167) for themselves and their children.
The current mixed-methods study uses survey data to document
the extent of child separations in a large multi-site sample of
2,307
families recruited in homeless shelters, and uses both
quantitative
and qualitative data to examine explanatory factors posited in
the
literature. In particular in the survey data, we examine
associations
of separations with the parent’s prior homelessness, substance
abuse, domestic violence, felony conviction (a proxy for
institutional
placement), and foster care placement in childhood, along with
parent and child demographic characteristics. The quantitative
data
also allow examination of the extent to which separations vary
by
site and shelter, suggesting policy differences in the homeless
service
and child welfare systems that may affect separations.
Qualitative
interviews with a subsample of 80 families elucidate from
parents’
perspectives how poverty, housing problems, and the homeless
service system contribute to separations.
Although our primary focus is on child separation, we
additionally
examine the extent to which partners are separated from each

357. other.
Families experiencing homelessness are often headed by single
parents
(Rog & Buckner, 2007), but this is partly a consequence of
shelter
and housing program policies that exclude men (U.S.
Conference of
Mayors, 2006). Thus we examine how separations of parents
from
partners they consider a part of their family vary by site and
shelter,
and reasons families give in qualitative interviews.
Methods
Participants
The Family Options study enrolled 2,307 families with children
15 years of
age and under who had spent at least one week in one of 57
emergency
Child Welfare Vol. 94, No. 1
108
shelters in 12 sites,1 drawn from all regions of the United States
and varying housing and labor markets, from September 2010 to
January 2012. Families were recruited into an experiment in
which
they received priority access to housing and service
interventions.
Very few families (n = 13) declined to participate, although 183
who
failed to pass eligibility screening for available interventions
were

358. not enrolled. (Common reasons for exclusion included
insufficient
income or lack of employment, family composition, size of
available
units, poor credit history, criminal convictions, and lack of
sobriety.)
We interviewed one adult at study enrollment, prior to random
assignment, giving preference to mothers in two-adult families,
because when parents are separated, children more frequently
stay
with the mother.
The adult respondents were predominantly female (91.6%), with
a median age of 29. Over a quarter (27.4%) had a spouse or
partner
with them in family shelter. A plurality (43.7%) had one child
with
them in shelter but 11.1% had four or more. In half of the
families
(49.9%), at least one child was under age 3. Study families were
41%
African American, 21% white, non-Hispanic, 20% Hispanic (all
races),
7% Asian/Pacific Islander, and 11% mixed or other (with
Hispanics
excluded from all remaining categories). Families were deeply
poor—
median annual household income was $7,440—and many came
from
poverty: during childhood, 15.9% of respondents had been
homeless
and 27.1% had lived in foster care, a group home, or an
institution.
Poverty was also longstanding: 62.8% had experienced a prior
episode
of homelessness and 84.6% had been doubled up (living in the

359. same
unit with another family) as an adult because they could not pay
the
rent (for details see Gubits, Spellman, Dunton, Brown, & Wood,
2013).
We conducted semi-structured qualitative interviews with a
non-
random subsample of 80 families—77 mothers and 3 fathers—
from
1 Sites were Alameda County, California – Oakland, Berkeley,
Haywood, Alameda; Atlanta Georgia; Baltimore,
Maryland; Boston, Massachusetts; Connecticut – New Haven,
Bridgeport, Norwalk, Stamford; Denver, Colorado;
Honolulu, Hawaii; Kansas City, Missouri; Louisville,
Kentucky; Minneapolis, Minnesota; Phoenix, Arizona; and
Salt Lake City, Utah.
109
Shinn et al. Child Welfare
four geographically dispersed sites (Alameda County,
Connecticut,
Kansas City, and Phoenix) an average of 6.4 months after
random
assignment. Demographic characteristics of the subsample were
similar
to those of the full sample (for detail, see Mayberry, Shinn,
Benton,
& Wise, 2014).
Measures

360. The adult respondent (in the full sample) reported on all family
members
who were with her in shelter and also about spouses, partners,
and
minor children “who are part of the family but are not living
with you
right now in [shelter name].” Additional variables are shown in
Table 1
and described in detail in Gubits and colleagues (2015).
The qualitative interviews covered family composition, housing
decisions, family routines and rituals, and social supports. The
family
composition section that is the focus here asked the respondent
about separations from children (for any reason) and from
partners
(if associated with housing or housing programs). Additional
questions probed for reasons for separation and how it unfolded,
how long the respondent expected the separation to last,
whether
the respondent had reunified with the child and on what that
depended, and whether the respondent felt the separation was
the
best option for the child. Respondents who had never separated
from a child were asked whether there was ever a time when
they
had considered doing so, and why. Interviews averaged about an
hour, with interviews where respondents reported separations
taking
longer than others. Interviews were recorded and transcribed.
Analyses
Quantitative predictors of child separation (listed in Table 1)
were analyzed in SAS using logistic regression at the level of
the
child, with standard errors corrected for clustering of children

361. within families. Because we were interested in separations from
partners only if they were related to housing, we did not
examine
Child Welfare Vol. 94, No. 1
110
individual level predictors, but tested only whether the
proportion of
families with a spouse or partner living elsewhere at the time of
study
enrollment differed by site and shelter. Analyses for shelter
included
the 42 shelters with at least 20 enrollments.
Qualitative interview transcripts were analyzed using NVivo9.
Research team members each read a subset of the interviews.
The team
then developed a thematic coding scheme inductively for each
section
of the interview. Next, two analysts refined the coding scheme
for a
specific section of the interview and examined inter-rater
reliability.
Reliability for existence of and reasons for separation for
children (across
32 interviews) and partners (across 20 interviews) were kappa =
.85
and .91 respectively. Discrepancies were resolved by consensus.
One
analyst completed the remaining coding, but both discussed
difficult-
to-classify cases. We coded all instances of separation of the

362. respondent
from children, including normative separations (e.g. due to
custody
after divorce). For partner separations, we considered only
separations
related to housing and housing programs.
Results
The quantitative interviews provide data on the extent of
separations
among families experiencing homelessness. In the full sample
of families
who had spent seven days in shelter, 10.1% of adult respondents
reported
that a spouse or partner was living elsewhere. Nearly a quarter
(23.9%)
had a minor child who was not in the shelter with the family
(living
with other relatives, friends, in foster care, or in other living
situations).
Only 0.7% of respondents reported that a child was in foster
care. Rates
of separation in the quantitative data for the qualitative
subsample of
80 were similar (10% for partners, 25% for children).
The quantitative interviews also allow for the identification of
adult
and child characteristics associated with child separations.
Table 1 shows
the results of a logistic regression predicting child separation.
Child age (categorical variable) was strongly associated with
the
likelihood of separation. A third (33.7%) of children age 13 to
17
were separated compared to 22.2% of children age 8 to 12,

363. 13.4%
111
Shinn et al. Child Welfare
of children age 3 to 7, and only 4.5% of children age 0 to 2.
There
was little variation in separations by child gender, with 15.5%
of
girls and 16.7% of boys being separated, and no interaction
between
child age and gender (p=.86). Younger parents and those with
more
children, previous experiences of homelessness, and prior
felony
convictions were more likely to be separated from their
children.
Race and income (categorical variables) also mattered.
Households
that reported less than $5,000 in annual income had 2.6 times
higher odds of having a separated child compared to households
with incomes of $25,000 or more. White non-Hispanic
respondents
had 1.5 times the odds of having a separated child compared to
black non-Hispanic respondents, with no differences between
black
non-Hispanics and other groups. Interestingly, alcohol and drug
abuse, domestic violence at any time in adulthood, and having
been
in foster care as a child were not predictive of separations.
Rates of child separations ranged across sites from 9% to 24%
of

364. children (leading to a significant site effect controlling for
parent and
child characteristics). Separations were most common
(exceeding 20%
of children, 39% of families) in Salt Lake City, and Baltimore,
and
least common (below 10% of children, 13% of families) in
Boston and
Connecticut. Child separation rates differed by shelter (F(1, 41)
= 4262.90,
p < .0001) without other controls. Partner separations were also
associated
with site (F(1, 11) = 70.60, p < .0001) and shelter (F(1, 41) =
119.53,
p < .0001), with separations highest in Baltimore (24% of all
families;
88% of those with a spouse or partner) and lowest in Honolulu
(4%
of all families and 5% of those with a spouse or partner).
Spousal
(but not child) separations were generally higher in the East
than in the
Midwest or West.
The qualitative interviews help to explain the circumstances of
these
separations and others that occurred before and after the survey
and
how separations were influenced by poverty, housing, and
housing
programs. Of the 80 participants, 43 (54%) reported 57
instances in
which they had been separated from a total of 78 minor
children; if a
family separated from two or more children at the same time,
under

365. Child Welfare Vol. 94, No. 1
112
Table 1. Logistic regression predicting child separations from
parent and family
characteristics (N = 5,165 children)
Variable OR 95% CI
Male child 1.07 [0.90, 1.26]
Number of children in household 1.35 [1.24, 1.46] ***
Parent age 0.93 [0.92, 0.95] ***
Single parent 0.83 [0.64, 1.06]
Previously homeless 1.43 [1.11, 1.83] **
Alcohol abuse 1.13 [0.81, 1.57]
Drug abuse 1.27 [0.93, 1.73]
Foster or institutional care in childhood 1.13 [0.87, 1.46]
Prior felony conviction 1.84 [1.31, 2.58] ***
Adult domestic violence experience 0.90 [0.70, 1.16]
Categorical variables df Chi-square
Child age group 3 248.99 ***

366. Household income category 5 23.85 ***
Race/Ethnicity 4 11.29 *
Site 11 22.57 *
Note. OR = odds ratio; CI = confidence interval. 231
observations excluded due to missing
values. Chi-square indicates joint significance of categorical
variables in the full model.
Standard errors adjusted for clustering of children in families.
*p < .05, **p < .01, ***p < .001.
the same circumstances, we considered this one instance. If a
family
separated from the same child on two occasions, we coded each
instance
separately. Most separations occurred during periods of
homelessness
or housing instability.
Reasons for Child Separations
Table 2 displays reasons for separation coded into eight
categories with
combinations of reasons coded into the uppermost category
(row) on
the list, because we deemed this more central. Thus, for
example, if a
respondent attributed her inability to feed her children
adequately to
lack of money for food, we coded this as hardship rather than
inability

367. 113
Shinn et al. Child Welfare
Table 2. Reasons for separation of parent from minor children
(with multiple
reasons for a single instance counted in uppermost category on
the list)
Code Definition Instances of
Separation
Families
Affected
Children
Affected
Shelter Issues related to entries or
living in shelter, including
conditions of shelter,
shelter rules that separate
families, not wanting the
child to be exposed to
shelter.
9 9 13
Arrest Respondent was arrested. 8 6 10
Protective
Services
Protective Services
removed child for reason
other than parental arrest.

368. 6 3 10
Hardship Respondent chose
separation due to poverty,
housing instability,
unemployment, hunger,
or inability to provide
for child.
15 15 20
Inability to
parent to own
or family’s
standards,
reasons other
than hardship
Respondent was unable
to parent the child
appropriately in her own
judgment, or that of family
members who intervened.
Includes respondent’s
substance abuse.
5 5 6
Child behavior Child’s behavior was
dangerous to him/herself
or others, or otherwise
unacceptable, and
respondent was unable to
address the behavior.

369. 3 3 3
Child safety Respondent chose
separation due to
unsafe living situation.
Includes domestic and
neighborhood violence.
5 4 6
Normative
other parent
or relative
custody
Other parent or family
member has custody of
child by respondent or
child choice or custody
decision, unrelated to
issues above.
6 6 9
Total A child or family could
have multiple instances
57 43 76
Child Welfare Vol. 94, No. 1
114
to parent to own or family standards, or if protective services

370. removed
a child upon a respondent’s arrest, we coded this under arrest
rather
than protective services. Most of the children stayed with their
other
parent or another relative during the separations, but we coded
these
separations as normative (six families and instances) only if
they were
unrelated to the other reasons on the list. Half of the non-
normative
separations (24 families and instances) were related to
economic and
housing hardship, or shelter.
Hardship
Economic hardship unrelated to shelter was the most common
reason
for separations (15 families and instances). In most cases, the
family
was experiencing housing instability, living in motels or
doubled up
with others because they could not afford their own place, or
moving
from place to place. Respondents described wanting their child
to have
stability and a sense of normalcy. In four instances, parents
were unable
to provide the children’s basic needs.
At the time I was pregnant, and we were living in motels. I
found
myself getting broke. We were eating fast foods. I got paid from
my job and I called their dad, and I said, “[Ex-Partner], I love
my boys, I know you love them too, but I need help right now.”
We met and he took the boys … I didn’t have a refrigerator or

371. nothing like that, so I don’t want my boys to … it was
beginning
to be too much.
Shelter
Nine families separated from children either upon shelter entry
or
during a shelter stay (sometimes one occurring before the
study),
typically so that children could avoid exposure to shelter
conditions:
… it took its toll on my children. They were going to sleep in
class because of the babies waking up in the middle of the night
at the shelter.
115
Shinn et al. Child Welfare
I was letting her grandmother take her out of the shelter because
she was losing weight and she was getting bad. She hearty but
she was getting bad like the other kids.
In two cases, the shelter could not accommodate all minor
children.
Nor would shelters typically take extended families. When a
three-
generational family was evicted, the mother and grandmother
each
took a child so both could go to family shelters. In another
instance
(not in Table 2), an adult child, age 20, was excluded from a
shelter but

372. later rejoined his mother and siblings in housing.
Parenting or Child Safety
Several categories of reasons for separation reflect the parent’s
inability
to care adequately for the child or to maintain a safe
environment.
Six respondents (eight instances) were arrested (all before study
entry), and five (five instances) were unable to parent according
to
their own standards, or those of their family, most commonly
due to
substance abuse. Several of these parents sought treatment, and
some
were reunited with children afterwards. In three cases, relatives
took
the child from the parent because of the parent’s youth or
substance
abuse. Four respondents (five instances) cited child safety due
to the
environment inside or outside of the household. Typically,
separations
coded under Safety were related to hardship and housing
instability
but safety was the proximal issue. For example, one respondent
had
to move somewhere she deemed unsafe after an eviction;
another left
an unsafe area and moved in with a violent boyfriend. Three
families
(six instances) were separated by a protective services agency
due to
parental substance abuse and neglect. In all but two other
instances,
both involving arrest, the respondent arranged for family
members to

373. take the child without formal agency involvement.
Child Behavior
In three families (three instances), separations began because of
children’s behavior. In two cases, children reacted badly to a
move away
Child Welfare Vol. 94, No. 1
116
from relatives, and the respondent sent them to those relatives;
in the
third, the child was picked up by police and sent, briefly, to a
mental
health facility.
Best Option
Although many parents who were separated from a child
described a
sense of loss and reported that the child missed them, 34 of the
43
parents considered the painful decision to be the best option
among
difficult choices because the child was stable and better
provided for.
Separations enabled the child to remain in a good school or to
develop
a bond with extended family.
As much as it hurt me to be separated from my daughter, you
know, sometimes you have to make sacrifices. You have to put
them first. You have to think about what’s best for them for that
time until things get better or you figure something out.

374. Other children had negative experiences, including one who was
molested and another who was physically abused during the
separation.
No Separations from Children
Among parents who had not been separated from children, 13 of
37 had
considered a separation, typically for reasons associated with
hardship
or shelter:
Maybe before we got into the shelter, because it was hard to get
into that shelter… So instead of taking my kids to a park, there
was numerous shelters I had called. And there was one shelter
where the woman said, “we can take your kids for the night so
they don’t have to sleep outside. We’ll take them, but we can’t
take you.” And I was like, well, if I have to sleep in a park, my
kids are definitely going to go there. ‘Cause I don’t want them
to do it. But—so yeah. I considered it then, but it didn’t happen.
Thank God!
117
Shinn et al. Child Welfare
Partner Separations
Of the 80 respondents, 12 (14 instances) had been separated
from a
partner for housing-related reasons. Half of the partner
separations
had to do with rules of shelters or housing programs that
excluded
men, unmarried couples, or people with criminal convictions.

375. Although
respondents felt they had no housing options that would allow
partners
to stay together, many of them described the resulting strain:
[T]hen I had to move all the stuff out, and there wasn’t no
help at the time, because it was just a shelter for women and
children. He wasn’t with me ... so it was like – if he was here, it
would be so much easier, but they didn’t allow that.
Two respondents left doubled-up situations that had
accommodated
partners to obtain housing that they deemed better for
themselves
and their children. Two others moved into doubled-up situations
that
required separating from partners. One of these families was
living in
their car:
And it was just better for him [partner] to send me back to my
family for me to get a support down there than it was for me to
stay here. Because everybody was telling us that Children and
Youth would come take my daughter if they found us in a car
and all this. So we just wasn't willing to risk that. So he just—
we just sold the furniture and stuff that we had, and he bought
us tickets and sent us back home.
Most respondents who experienced a housing-related separation
from
their partners reported negative impacts on their children.
…when [partner] did move in with us the baby was kind of like
he knew who he was but it was kind of like hmm, I haven’t seen
this guy in a while. Like where’d you come from? …. He didn’t
really know who [partner] was and then he finally figured, oh

376. yeah, this is my dad so he’s supposed to be around me.
Child Welfare Vol. 94, No. 1
118
Reunification with Children and Partners
All but five respondents anticipated that the separations from
their
children would be temporary. However, 20 of 57 separations
(35%)
lasted longer than the parent anticipated, often because it took
her
longer than expected to secure stable housing or to become
financially
able to care for the children.
Of the 57 incidences of separation from children, 34 had ended
in reunification at the time of the qualitative interview.
Respondents
indicated that securing adequate housing permitted 14 of these
reunifications. Nine parents reported that ongoing separations
would
continue until the parents secured housing. These parents were
living in
shelter or transitional housing (five), doubled up with other
households
in the same apartment (three), or in a subsidized apartment that
was
too small to accommodate all children (one). Thus the ending of
nearly
half of all separations (23/57) depended on housing.
Similarly, nine of the 14 separations from a partner had ended

377. in
reunification at the time of the qualitative interview, typically
because
the respondent or the partner was able to secure housing that
could
accommodate the entire family. Reunification in three
additional cases
depended on housing.
No parent indicated that shelters or other housing services
attempted
to reunite them with their families. Rather, shelter and housing
programs tended to consider only members present with the
respondent
in evaluating housing needs, resulting in assignment to places
too small
for the full family. Respondents also reported that staff in
shelters and
transitional housing threatened to involve protective services if
parents
did not comply with shelter rules (Mayberry et al., 2014), and
this led to
one removal (where the parent violated a shelter rule about
substance use.)
Discussion
As in other studies in the literature, this study shows that
separations
from children are rampant in families who experience
homelessness.
In our large 12-site sample, nearly a quarter of families who had
spent
119

378. Shinn et al. Child Welfare
a week or more in shelter were living apart from one or more of
their
children, although fewer than one percent had a child in foster
care.
Including separations at other times, over half of the qualitative
subsample had been separated. Other studies have found that
both
separations and foster care placements often increase in the
months
following shelter entry (Cowal et al., 2002; Park et al., 2004),
so the
numbers may continue to grow.
Family demographic characteristics were associated with the
likelihood of separations. Older children are much more likely
to
be separated from their families, with children age 13 to 17
being at
particularly high risk. Mothers may be more likely to keep
younger
children with them, with older children more likely to stay with
other
relatives so that they are not exposed to shelter conditions or
can
maintain continuity in schooling. Despite some shelters having
policies
excluding older male children, no evidence of an interaction
effect
between age and gender was found. Larger households also
faced greater
difficulty staying intact or reunifying, perhaps in part due to
constraints
on unit size. White families are likely to have more resources to

379. stay
out of shelter than families of color; those who nonetheless
become
homeless may be more troubled, leading to higher rate of
separations.
Both the quantitative and qualitative data point to the
importance
of extremely low incomes and resulting hardship in tearing
families
apart. Parents faced agonizing choices between keeping children
with
them and protecting them from shelter conditions or providing
for
their welfare. As in the study by Barrow and Lawinski (2009),
most
separations involved parental agency in difficult circumstances,
and most
separations were arranged informally between parents and other
relatives.
Parental behavior also mattered. Arrests and felony convictions
were associated with separations in the qualitative and
quantitative
data respectively. Substance abuse, perhaps surprisingly given
previous
studies, figured only in the qualitative data, and having
experienced
domestic violence as an adult was not associated with
separations,
perhaps because of the long time frame. Relatives sometimes
intervened
when they thought the respondent was not parenting
appropriately.

380. Child Welfare Vol. 94, No. 1
120
Local policies also influenced parental options and choices, as
evidenced by the fact that rates of separation varied
substantially by
site and shelter. Partner separations contributed to, but did not
fully
explain, the lower numbers of two-parent families in the East
(as has
been found in other studies, c.f. Rog & Buckner, 2007).
Although some
shelter staff threatened to call protective services in order to
induce
compliance with rules and did so in one case, the additional
visibility of
parenting under the watchful eyes of service providers does not
explain
informal separations. Children were rarely taken into foster
care.
This study is the first to document the extent to which poverty
and
homelessness lead partners to separate from one another. One in
ten
parents had a partner living elsewhere while the family was in
shelter.
The quantitative and qualitative data clearly implicate shelters
in
separations of partners, although the fact that over a quarter of
families
in shelter had two parents suggests improvements over past
years in
shelters’ ability to accommodate at least nuclear families.

381. Housing
voucher programs also separate parents where one has a
criminal
record. The interviews show that the forced separation of
fathers from
their families is hard on mothers and children.
Implications for Research and Policy
We recruited families who had spent at least a week in shelter,
and it is
possible that families who can resolve homelessness quickly
would have
lower rates of separation than the families surveyed here.
Nevertheless,
results are troubling with implications for both research and
policy. With
respect to research, the fact that studies of children who
experience
homelessness exclude those who are separated from their
parents
means that samples are seriously biased. Whether child
separations
reflect hardship, parental behavior, or child behavior, children
who
are separated are likely to be faring worse than children who
remain
with their families. Estimates of effects of homelessness on
children
may be underestimates. Shelter policies excluding men may
have led
researchers to exaggerate the role of single parenthood in
homelessness.
121

382. Shinn et al. Child Welfare
With respect to policy, programs that work with poor families,
from
income support and housing programs to shelters and
transitional
housing programs to correctional institutions to substance abuse
treatment programs, should pay more attention to preserving
families
Separations are hard on both parents and children, and
separation from
parents in the family of origin is a predictor of future
homelessness in
adults (Rog & Buckner, 2007).
Family preservation may conflict with other policy goals. For
example, in a congregate shelter or transitional housing
program, one
family’s husband and father may be seen as a potential danger
to the next
family’s child, and public housing rules designed to preserve
the safety
of the community by excluding criminals separate parents from
their
families. Welfare time limits may encourage adults to work, but
lead
to hardship, hunger, and ultimately separations for families.
Prisons are
designed to isolate and punish inmates, but the separation also
punishes
children and partners. Naming and quantifying the problem at
least
allows it to be taken into consideration in policy choices.
Scatter-site
homeless and housing programs, alternative sentencing, and

383. substance
abuse treatment programs that permit children to stay with
parents
may be able to reduce family separations. Housing programs
should
take family members living elsewhere into account in assigning
units,
to permit reunification. Child welfare authorities in particular
should
serve as advocates for minimizing separations of children from
parents,
and reunification when separations cannot be avoided.
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