Relationship between Problem Focused Coping and Social Support with Psychological Well Being in Families as Schizophrenia Caregivers

Relationship between Problem Focused Coping and Social Support with Psychological Well Being in Families as Schizophrenia Caregivers

Imas Serayu Hardiningrum¹, IGAA Noviekayati², Anrilia Ema Mustikawati Ningdyah³

^1,2,3Faculty of Psychology, 17 August 1945 University of Surabaya, Indonesia

ABSTRACT

 This study aims to prove the relationship between problem focused coping and social support with psychological well being in families as caregivers of schizophrenia. The subjects of this study were 120 families who were caregivers of schizophrenia. The approach used in the study was a quantitative approach with a data collection method using a scale that had been tested for validity and reliability. Data analysis was carried out using multiple linear regression correlation tests. The measuring instruments used were the psychological well being scale, the problem focused coping scale and the social support scale. The results of the study showed that there was a positive and significant correlation between problem focused coping and social support with psychological well being. The results showed that problem focused coping and support can improve psychological well being in families as caregivers of schizophrenia.

Keywords –  Problem Focused Coping, Social Support, Psychological Well Being of Schizophrenia Caregiver Famlies

INTRODUCTION

Mental health is a condition in which an individual can develop physically, mentally, spiritually, and socially, enabling them to possess the skills necessary to cope with stress, assess their own capabilities, work proactively, and contribute meaningfully to their community or group. Furthermore, mental health is characterized by a sense of well-being and happiness, proficiency in overcoming life’s challenges, acceptance of others as they are, and a positive attitude toward oneself and others (Health Law of the Republic of Indonesia No. 18 of 2014, in the Ministry of Health of the Republic of Indonesia, 2020).

In line with this, the World Health Organization (2022) defines mental health as a state of psychological well-being that enables individuals to cope with life’s stressors, recognize their abilities, learn effectively, work productively, and contribute to their community. However, if individuals fail to manage stressors such as pressure or life challenges, they may develop mental disorders, which are marked by cognitive, emotional, and behavioral dysfunctions that hinder their ability to perform daily life functions normally (Trigoboff, 2013, in Wardhani, 2022). Similarly, the American Psychiatric Association (2015, in the Ministry of Health, 2023) describes mental disorders as health conditions characterized by changes in thinking patterns, emotions, or behaviors. In some cases, individuals may experience a combination of these changes, leading to distress and impairments in their ability to function as individuals.

The World Health Organization (2016, in the Ministry of Health of the Republic of Indonesia, 2023) categorizes mental disorders into five types: developmental disorders, depression, bipolar disorder, dementia, and schizophrenia. Furthermore, in 2012, it was reported that 450 million people were affected by mental disorders, with approximately 35 million experiencing depression, 60 million diagnosed with bipolar disorder, 47.5 million suffering from dementia, and 21 million diagnosed with schizophrenia.

Davison (2010) defines schizophrenia as a psychotic disorder characterized by profound disturbances in thought, emotion, and behavior, where thoughts become disconnected and illogical, perception and attention are impaired, affect is flat or inappropriate, and motor activities become eccentric or delusional. Individuals with schizophrenia often withdraw from others and reality, frequently immersing themselves in a fantasy world filled with delusions and hallucinations. Schizophrenia typically manifests in late adolescence or early adulthood, with an earlier onset observed in males compared to females. DiMaggio (2001, in Davison, 2010) further notes that, in recent decades, the onset age of schizophrenia has been observed to occur earlier than previously recorded.

Glenasius (2023) reported that the World Health Organization (WHO) in 2022 released data indicating a significant global increase in schizophrenia cases, reaching approximately 24 million affected individuals. Furthermore, global data from 2016 revealed that Asia had the highest schizophrenia prevalence, with South Asia accounting for 7.2 million cases, East Asia for 4 million cases, and Southeast Asia for 2 million cases.

In Indonesia, mental disorders have been reported across all provinces. The Ministry of Health of the Republic of Indonesia (2023) revealed that the proportion of Individuals with Mental Disorders (ODGJ) in several regions includes 24.3% in DKI Jakarta, 18.5% in Nangroe Aceh Darussalam, 17.5% in West Sumatra, 10.9% in West Nusa Tenggara, 9.2% in South Sumatra, and 6.8% in Central Java.

Additionally, the East Java Provincial Health Office reported that in 2022, there were 64,850 individuals diagnosed with schizophrenia who received treatment. By 2023, the number increased significantly to 70,348 cases. Furthermore, Sustrami (2022) detailed that Menur Psychiatric Hospital, located in Surabaya, recorded 9,994 outpatients with mental disorders, 70% of whom were male and 30% female. Moreover, the Sidoarjo Health Office (2020, in Yudin, 2023) reported 4,336 individuals diagnosed with mental disorders, with 4,241 receiving healthcare services. Meanwhile, in Surabaya, there were 5,575 schizophrenia cases recorded in 2023, including 26 cases in individuals aged 0–14 years, 4,864 cases in individuals aged 15–59 years, and 685 cases in individuals aged 60 years and older (East Java Provincial Health Office, 2023).

The Ministry of Health of the Republic of Indonesia (2023) also reported that based on the 2013 Basic Health Research (Riskesdas), the prevalence of depressive and anxiety symptoms in individuals aged 15 and above was approximately 6%, affecting around 14 million people. Meanwhile, the prevalence of severe mental disorders, such as schizophrenia, was estimated at 1.7 per 1,000 individuals, or approximately 400,000 people.

Individuals with schizophrenia typically experience multiple acute episodes. Although symptoms may not always be severe between episodes, they still disrupt overall functioning. Substance abuse is identified as a major contributing factor to schizophrenia, accounting for approximately 50% of cases (Kosten & Ziedonis, 1997, in Davison, 2010).

The negative symptoms exhibited by Individuals with Schizophrenia (ODS) result in significant functional impairments across various aspects, including employment, social relationships, self-care, and other life domains. Consequently, individuals with schizophrenia often rely heavily on others, such as family members, relatives, or other caregivers (Suaidy, 2006, in Amalia, 2020). According to the National Alliance for Caregiving (2010, in Qudwatunnisa, 2018), caregivers are individuals or groups responsible for meeting the daily needs of those requiring assistance.

Auliati (2023) elaborated that the World Health Organization (WHO) reported in 2016 that approximately 10% of the 21 million individuals diagnosed with schizophrenia died by suicide. Additionally, around 1 in 20 individuals with schizophrenia had attempted suicide at least once in their lifetime, with the highest incidence occurring among individuals aged 15 to 29 years.

Families or close relatives, as the primary support system for Individuals with Schizophrenia (ODS), often experience significant burdens while providing care, both during hospitalization and after the individual returns home (Suryenti, 2017, in Amalia, 2020). Various daily life challenges can lead individuals or families to feel confused and overwhelmed. In line with this, Fausiah (2005, in Wanti et al., 2016) previously stated that caring for a family member with a severe mental disorder can be a major source of stress for the family. The stress and burden felt by primary caregivers can manifest in both physical and psychological forms, and these burdens are even greater when they are responsible for a family member with a severe mental disorder (Wardaningsih, 2017, in Sugiarti, 2022).

Common stress factors experienced by families include financial concerns, ongoing stressful life events, and persistent interpersonal conflicts or other long-term issues (Maryam, 2017). Additionally, societal stigma, medical expenses, transportation costs, and disruptions to sleep patterns can contribute to the stress experienced by families caring for individuals with mental disorders (Magana et al., 2007, in Wanti et al., 2016). Negative stigma from society may also create barriers for individuals with schizophrenia in seeking mental health treatment (Danukusumah, 2022).

The World Federation of Mental Health (2010, in Qudwatunnisa, 2018) stated that caregivers often struggle to balance family responsibilities, work commitments, and caregiving duties, often at the expense of their own physical and mental health. Families serving as caregivers frequently experience chronic exhaustion, sleep disturbances, financial difficulties (Wardhani, 2013, in Veronia, 2018), and persistent anxiety about potential violent behaviors from the individual with schizophrenia, such as outbursts, throwing objects, or physical aggression, which create discomfort within the household (Isnaeni, 2015, in Veronia, 2018). The responsibility of caregiving can result in emotional instability and heightened stress levels, ultimately leading to diminished psychological well-being (Wardhani, 2013, in Veronia, 2018).

Sighn and Dubey (2016, in Qudwatunnisa, 2018) revealed that families serving as the primary caregivers of Individuals with Schizophrenia (ODS) are associated with increased levels of anxiety and depression, a higher reliance on psychoactive medication, lower reports of physical health, and an elevated mortality rate. This finding is supported by a study conducted by Marimbe (2016, in Riana, 2023), which indicated that 68% of caregivers for individuals with mental disorders are vulnerable to general mental health problems, ultimately leading some to contemplate suicide. Further evidence from Kurnilla’s (2017, in Riana, 2023) study found that among 23 caregivers of individuals with schizophrenia, 2 respondents (8.7%) experienced moderate stress, while 16 respondents (69.6%) experienced mild stress.

In line with these findings, Haresabadi (2012, in Safitri, 2021) also stated that the responsibilities and roles of caregivers for individuals with severe mental disorders, particularly schizophrenia, often result in psychological distress such as anxiety, sadness, anger, hopelessness, shame, guilt, and other emotional difficulties throughout the caregiving process. A study by Kartika (2023) on the quality of life among families serving as caregivers for individuals with schizophrenia found that among 58 respondents, 19 (32.8%) reported experiencing a mild to moderate burden, 31 (53.4%) reported a moderate to severe burden, and 6 (10.3%) felt an extremely heavy burden. Additionally, the study found that 19 respondents (32.8%) reported a moderate quality of life, while 23 respondents (39.7%) reported a poor quality of life. These findings suggest that schizophrenia caregivers experience moderate to severe stress levels and moderate to poor quality of life.

Families are encouraged to focus more on resolving various issues to manage their stress effectively. This means that families must develop adequate coping strategies, referred to as coping strategies (Ostlung & Pearson, 2014, in Maryam, 2017). Friedman (1998, in Maryam, 2017) explained that “coping” in families refers to a positive response used to resolve problems or reduce stress caused by specific events. These issues often arise due to the varying nature and conditions of schizophrenia. Therefore, families providing routine care for individuals with schizophrenia at home require effective coping strategies, such as open communication, role distribution, active involvement, and appropriate behavioral control (Wardhani, 2022). When families can implement coping mechanisms effectively, it positively impacts the overall functioning of the family (Sheidow, 2014, in Maryam, 2017).

Lazarus and Folkman (1984, in Wanti et al., 2016) broadly categorized coping strategies into two classifications: Problem-Focused Coping (PFC), which focuses on problem resolution, and Emotion-Focused Coping (EFC), which focuses on emotional regulation.

A study conducted by Sugiarti (2022) on stress and coping strategies among families acting as caregivers for individuals with schizophrenia in the service area of Puskesmas Purwokerto Utara II found that among 37 respondents, 14 (37.8%) utilized Problem-Focused Coping (PFC), while 23 (62.2%) employed Emotion-Focused Coping (EFC). The study further revealed that individuals utilizing Problem-Focused Coping (PFC) exhibited significantly lower stress levels, with only 21.6% experiencing stress compared to just 5.4% among those employing Emotion-Focused Coping (EFC). Additionally, individuals experiencing moderate stress in the Problem-Focused Coping (PFC) category accounted for only 13.5%, compared to 78.3% in the Emotion-Focused Coping (EFC) category. Furthermore, the study reported that only 2.7% of individuals using Problem-Focused Coping (PFC) experienced severe stress, whereas 8.1% of those employing Emotion-Focused Coping (EFC) experienced severe stress.

Zaman (2019) stated that coping strategies influence individual happiness and well-being. Happiness and well-being affect how individuals interpret and respond to situations, including when facing problems. Supporting this assertion, a study conducted by Sagone (2014) on psychological well-being among 183 university students in Italy found a positive relationship between problem-focused coping and psychological well-being.

However, if families serving as caregivers fail to effectively manage stressors through appropriate coping strategies, their quality of life may decline. Quality of life is defined as an individual’s subjective perception of their physical, psychosocial, and environmental conditions in daily life (Sugiarti, 2022). The burdens and challenges encountered by families as primary caregivers can hinder their ability to function optimally, leading to adverse effects on psychological well-being, such as burnout, decreased interest in life, lower self-esteem, and diminished empathy toward individuals with schizophrenia (ODS) (Suaidy, 2006, in Amalia, 2020).

This statement is reinforced by the World Health Organization (WHO, 2021), which reported that individuals with severe mental disorders, such as major depression and schizophrenia, face a 40–60% higher risk of premature mortality compared to the general population. This is due to frequently neglected physical health issues, including cancer, cardiovascular diseases, diabetes, HIV infections, and suicide. Suicide attempts among individuals with schizophrenia may result from the loss of familial empathy and the exhaustion and diminished will to live experienced by caregivers.

Ryff & Singer (2008, in Amalia, 2020) emphasized that social support is a crucial factor influencing psychological well-being. Social support enhances family functionality and facilitates the recovery process for individuals with schizophrenia. Conversely, a lack of social support may negatively impact family functioning, exacerbate psychiatric symptoms, and hinder individuals’ ability to engage with society. In line with this, Nasriati (2020) asserted that social support perceived by caregivers significantly contributes to more positive caregiving practices. Furthermore, Kulhara (2012, in Nasriati, 2020) noted that caregivers who adopt problem-focused coping strategies and actively seek social support tend to have more positive caregiving experiences and can prevent or mitigate negative psychological symptoms.

A study by Moatamedy (2018) on psychological well-being in the elderly, focusing on stress management and social support, found that social support enhances individual health and helps them perceive stressful experiences as less threatening and more manageable. Social support also plays a crucial role in reducing negative emotions resulting from stress, thereby improving psychological well-being. Ultimately, this contributes to better disease management and alleviates symptoms that may arise due to prolonged exposure to stressful conditions, particularly for caregivers responsible for individuals with schizophrenia.

METHODOLOGY

This study employs a quantitative correlational research design. The sampling technique utilized is quota sampling, with data collected through questionnaire distribution via social media and direct surveys. The sample size was determined using G-Power, assuming an effect size of 0.3 (medium), a probability error of 5%, and a power of 0.85, resulting in a minimum required sample of 93 schizophrenia caregivers. Data analysis was conducted using IBM Statistical Package for Social Sciences (SPSS) version 25.

The prerequisite tests confirmed that all items measuring problem-focused coping, social support, and psychological well-being were valid and reliable, with Cronbach’s Alpha values of 0.922 for problem-focused coping, 0.930 for social support, and 0.916 for psychological well-being. Data analysis was performed using multiple linear regression analysis, t-tests, and the coefficient of determination test. The justification for these techniques includes the results of normality tests indicating a normally distributed data set, linearity tests confirming a linear relationship, the absence of multicollinearity indications, and no detected heteroscedasticity.

LITERATURE REVIEW

Schizophrenia

Schizophrenia is one of the most severe mental disorders, requiring extensive clinical observation, varying responses to treatment, and different levels of symptoms (Hemmati, 2002, in Moslehi, 2015). Schizophrenia impairs cognitive functions, language, emotions, social behavior, and the ability to perceive reality accurately (Noghabi, 2000, in Moslehi, 2015). Thus, schizophrenia can be understood as a disorder affecting multiple aspects of an individual’s life. Mohtasham (2006, in Moslehi, 2015) defines schizophrenia as a chronic, progressive disorder, where individuals experiencing acute symptoms often require repeated hospitalization.

Davison (2010) describes schizophrenia as a psychotic disorder characterized by severe disturbances in thought, emotion, and behavior. Individuals with schizophrenia exhibit fragmented, illogical thinking, distorted perception and attention, flat or inappropriate affect, and eccentric or delusional motor activity. These individuals often withdraw from social interactions and reality, immersing themselves in a fantasy world filled with delusions and hallucinations. Schizophrenia typically manifests in late adolescence or early adulthood, with an earlier onset in males compared to females. DiMaggio (2001, in Davison, 2010) further notes that in recent decades, the age of onset for this mental disorder has been occurring earlier than in previous generations.

According to the East Java Provincial Health Office (2022), schizophrenia is a complex mental disorder with diverse clinical presentations, disease progression, and treatment responses. Furthermore, the PPDGJ III (Indonesian Classification of Mental Disorders) describes schizophrenia as a syndrome with multiple etiologies, a broad disease trajectory, and influences from genetic, physical, social, and cultural factors. Schizophrenia is primarily characterized by fundamental distortions in thinking and perception (hallucinations and delusions) and abnormal or blunted affect. Although consciousness and intellectual capacity generally remain intact, cognitive decline may develop over time.

Additionally, based on the DSM-V, schizophrenia is diagnosed when an individual experiences at least one of three primary symptoms for a minimum duration of one month (or less if successfully treated), namely delusions, hallucinations, and disorganized or incoherent speech. Other symptoms may include catatonic behavior, severe disorganization, and negative symptoms such as diminished emotional expression or lack of motivation..

Psychological Well Being

According to Diener & Larsen (1993, in Amalia, 2020), psychological well-being is defined as happiness, reflecting an individual’s ability to experience freedom, as indicated by a balance between positive and negative aspects of life. Psychological well-being is broadly conceptualized as an individual’s subjective and comprehensive evaluation of their overall psychological and social functioning, characterized by high levels of positive emotions and low levels of negative emotions (Wright & Hobfoll, 2004). Ryff (2018, in Sari, 2020) further elaborates on psychological well-being as a concept of positive psychological functioning, comprising six key components: Autonomy – The ability to self-regulate, make independent decisions, and maintain self-determination, Environmental Mastery – The ability to creatively modify one’s environment through physical and mental activities while utilizing available opportunities, Purpose in Life – Active and meaningful engagement with life, Positive Relations – Establishing and maintaining meaningful connections with others, Personal Growth – Awareness of one’s potential and continuous efforts toward self-improvement, Self-Acceptance – Positive recognition of one’s strengths and weaknesses.

This study adopts Ryff’s (2018, in Sari, 2020) psychological well-being theory, as it provides a comprehensive framework for understanding an individual’s psychological well-being. This perspective is particularly relevant for schizophrenia caregivers, who are at high risk of experiencing psychological distress and disruptions in their positive psychological functioning.

Problem Focused Coping

Coping strategies are defined as cognitive and behavioral efforts to manage specific external or internal demands that are appraised as taxing or exceeding an individual’s resources. Coping strategies also refer to the process of transitioning from one condition to another as a means of dealing with unexpected situations (Lazarus & Folkman, 1984, in Wanti et al., 2016). Furthermore, Zaman (2019) states that coping strategies influence individual happiness and well-being, which, in turn, affect how individuals interpret and respond to situations, particularly when facing challenges.

Lazarus and Folkman (1984, in Wanti et al., 2016) categorize coping strategies into two main types: Problem-Focused Coping (PFC) and Emotion-Focused Coping (EFC). PFC includes confrontive coping, planful problem-solving, and seeking social support. EFC consists of distancing, self-control, accepting responsibility, positive reappraisal, and escape/avoidance.

This study adopts the definition of Problem-Focused Coping (PFC) as described by Lazarus and Folkman (1984, in Maryam, 2017), which defines PFC as an action-oriented approach to problem-solving. This definition is particularly relevant to schizophrenia caregivers, who often experience confusion and exhaustion in the process of managing and caring for individuals with schizophrenia (ODS).

Social Support

Cassel (1976, in Glanz, 2008) suggests that social support serves as a protective factor in the psychosocial context, reducing an individual’s vulnerability to the harmful effects of stress. Supporting this claim, Glanz (2008) further emphasizes that social support aims to provide assistance rather than negative interactions such as criticism, anger, or disruptive behaviors.

According to Sarafino (1983, in Hamonangan, 2023), social support is defined as the presence or availability of others who can be relied upon, demonstrating love and concern for the values upheld by an individual.

This study adopts Sarafino’s (1983, in Hamonangan, 2023) definition of social support, emphasizing that the presence of reliable individuals who offer love and care can help caregivers cope with the challenges and concerns associated with managing and caring for individuals with schizophrenia.

Regression Analysis

In this study, regression analysis was conducted to identify the correlation or impact of Problem Focused Coping and social support on Psychological Well Being.

Table 1. Coefficientsa

Table 2. Model Summary

Table 3. ANOVA

Based on the research summary obtained through regression analysis, it was found that there is a significant positive correlation between Problem-Focused Coping and Psychological Well-Being (β = 0.690; p = 0.000 < 0.05). This indicates that the higher the Problem-Focused Coping score, the higher the Psychological Well-Being score. Additionally, a significant positive correlation was also found between Social Support and Psychological Well-Being (β = 0.418; p = 0.000 < 0.05). This implies that the higher the level of Social Support, the higher the level of Psychological Well-Being. Furthermore, the R² value was 0.860, indicating that Problem-Focused Coping and Social Support together contribute 86% to the improvement of Psychological Well-Being.

DISCUSSION

Based on the research findings, there is a significant positive correlation between Problem-Focused Coping and Social Support with Psychological Well-Being. This means that Problem-Focused Coping and Social Support influence and assist caregivers in improving their Psychological Well-Being. In other words, caregivers of individuals with schizophrenia who apply Problem-Focused Coping strategies and receive Social Support tend to have better Psychological Well-Being. Problem-Focused Coping is a more effective strategy for reducing stress levels and enhancing psychological well-being. Additionally, Social Support helps caregivers become more optimistic, feel valued, and have a greater sense of control over their situations.

These research findings align with Sagone’s (2014) study, which examined 183 university students in Italy and found a significant positive relationship between Problem-Focused Coping and Psychological Well-Being. This suggests that problem-solving-based coping strategies contribute to psychological well-being. Furthermore, Glanz (2008) emphasized that Social Support aims to provide positive assistance rather than negative interactions such as criticism, anger, or destructive behaviors, which could otherwise worsen an individual’s mental state.

CONCLUSIONS

In this study, it was found that Problem-Focused Coping and Social Support can significantly enhance the Psychological Well-Being of Families as Schizophrenia Caregivers. The greater the Problem-Focused Coping and Social Support, the higher the potential for Psychological Well-Being among these caregivers. These two coping strategies are among the most effective approaches that can be utilized by Families as Schizophrenia Caregivers to manage stress and maintain their overall well-being.

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