Schizophrenia Article

Posttraumatic Growth in Family Members Living With a Relative Diagnosed With Schizophrenia

RACHEL D. MORTON and MELANIE J. WHITE School of Psychology and Counselling, Queensland University of Technology,

Brisbane, Australia

ROSS McD. YOUNG Faculty of Health, Queensland University of Technology, Brisbane, Australia

Family members living with a relative diagnosed with schizophrenia have reported challenges and traumatic stressors, as well as perceived benefits and personal growth. This study explored factors associated with posttraumatic growth (PTG) within such families. Personality, stress, coping, social support, and PTG were assessed in 110 family members. Results revealed that a multipli- cative mediational path model with social support and emotional or instrumental coping strategies as multi-mediators had a signifi- cant indirect effect on the relationship between extraversion and PTG. Clinically relevant concepts that map onto the multi-mediator model are discussed, and these findings are translated into clinical practice to facilitate naturally occurring PTG processes.

KEYWORDS posttraumatic growth, family, schizophrenia, coping, social support

Individuals diagnosed with schizophrenia and their families face many challenges associated with this illness (Switaj et al., 2012). Recently, there has been a greater focus on exploring the challenges and emotional burdens of the family members themselves when living with a relative with schizo- phrenia (Brady & McCain, 2005; Jungbauer & Angermeyer, 2002; Morton, 2013; Scazufca & Kuipers, 1996). Exposure to the impact of a chronic illness

Received 10 October 2013; accepted 26 November 2013. Address correspondence to Melanie J. White, School of Psychology and Counselling,

Queensland University of Technology, Kelvin Grove Campus, Victoria Park Road, Kelvin Grove, Queensland, Australia 4059. E-mail: melanie.white@qut.edu.au

Journal of Loss and Trauma, 20:229–244, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 1532-5024 print=1532-5032 online DOI: 10.1080/15325024.2013.863652

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on a relative can have trauma-like effects for the individual themselves, with most research conducted with relatives of cancer patients (Blount, Devine, Loiselle, & Reed-Knight, 2011; Teixeira & Pereira, 2013; Weiss, 2004). Despite the potentially traumatic impact of schizophrenia, recent research has found that family members also report beneficial or positive elements of their experience, such as personal growth (Barnable, Gaudine, Bennett, & Meadus, 2006; Chen & Greenberg, 2004; McKenzie, 2000; Morton, 2013; Wiens & Daniluk, 2009). The current study aimed to explore, first, whether these family members experience posttraumatic growth (PTG) and, second, how personality traits (e.g., extraversion), social support, and emotional or instrumental coping strategies influence the development of this growth. Understanding the experience and development of personal growth will help mental health professionals to better support families in the challenges they face while also considering the families’ strengths and potential positive outcomes.

Several qualitative studies have reported the benefits experienced by family members living with an individual diagnosed with schizophrenia, including personal growth, greater tolerance and compassion, stronger family relationships, and the illness providing meaning to their life (Barnable et al., 2006; Chen & Greenberg, 2004; McKenzie, 2000; Morton, 2013; Wiens & Daniluk, 2009). Tedeschi and Calhoun’s (1996) model of posttraumatic growth offers a useful framework to understand the positive outcomes that these family members describe as resulting from their stressful and at times traumatic experiences. Tedeschi and Calhoun (2004) define trauma as occurring after a highly stressful event where one’s adaptive resources are overwhelmed and one’s view of the self and the world is challenged. In family members with a relative diagnosed with schizophrenia, this trauma may occur directly as a result of the individual’s coping ability being overwhelmed, or indirectly through experiencing consequences of the relative’s illness (Blount et al., 2011; Thornton & Perez, 2006). Both of these pathways have the possibility to influence the development of PTG. There are five domains in the PTG model: new possibilities, stronger relationships with others, greater personal strength, spiritual development, and greater appreciation of life (Tedeschi & Calhoun, 2004). The findings of past research on perceived posi- tive outcomes of these families appear to map onto the PTG domains well. According to Tedeschi and Calhoun’s (2004) model, an individual’s pretrauma characteristics, the characteristics of the traumatic stressor, coping responses, cognitive processing, self-disclosure, and social support influence the devel- opment of PTG. This study used the PTG model as a theoretical guide to explore the influence of pretrauma personality, social support, and coping strategies on PTG.

PTG levels have been shown to be similar in relatives of individuals who had a chronic illness (such as cancer) to those of the individuals who had the chronic illness themselves (Blount et al., 2011). Husbands of breast cancer

230 R. D. Morton et al.

survivors have reported positive life changes and growth (Weiss, 2004). Siblings of individuals diagnosed with a mental illness had higher levels of PTG than those who had siblings without a mental illness (Sanders & Szymanski, 2012). PTG has been positively associated with adaptive styles of emotion- or problem-focused coping (Bellizzi & Blank, 2006) and with social support from friends=family among cancer patients (Bozo, Gündoğdu, & Büyükaşik-Çolak, 2009; Prati & Pietrantoni, 2009; Swickert, Hittner, & Foster, 2012). There is also evidence that PTG and peer support have a posi- tive relationship in relatives of those with a mental illness (Aschbrenner, Greenberg, Allen, & Seltzer, 2010; Chien, Norman, & Thompson, 2006). A positive relationship exists between PTG and the Big Five personality traits of extraversion, agreeableness, openness to experience, and conscientious- ness (Linley & Joseph, 2004). Tedeschi and Calhoun (2004) noted that extraversion has a strong influence on the development of PTG, being the only Big Five trait to be positively correlated with all five PTG domains. Extraversion has been consistently positively correlated with measures of PTG (Boyraz, Horne, & Sayger, 2012; Sheikh, 2004; Wilson & Boden, 2008).

Research in the PTG field has progressed to exploring factors that mediate or moderate PTG relationships. Social support from a significant other has been shown to moderate the relationship between optimism and PTG, with high levels of optimism associated with PTG only when perceived social support was high (Bozo et al., 2009). In college students and older adults, females with high levels of empathy and social support reported great- er levels of PTG (Swickert et al., 2012). In bereaved individuals, social support mediated the impact of extraversion on both sense making and benefit finding (Boyraz et al., 2012). This finding implies that extraverted traits were likely to have encouraged individuals to create a supportive environment in which they could make more sense of their traumatic experience. Onder (2012) found that in cancer survivors, problem-focused coping was a significant mediator of the relationship between PTG and the Big Five personality traits of extraversion, openness to experience, conscientiousness, and agreeable- ness. Supporting these findings, in heart disease patients problem-focused coping was found to partially mediate the relationship between extraversion and PTG (Sheikh, 2004). Additionally, emotion-focused coping was a signifi- cant mediator of the relationship between PTG and the traits of conscientious- ness, agreeableness, and openness to experience, where higher trait scores were related to greater levels of PTG through greater use of emotion-focused coping (Onder, 2012). The factors that influence PTG in family members of an individual diagnosed with schizophrenia remain relatively unexplored.

HYPOTHESES

First, PTG in these family members was expected to be of a similar level to other studies where a relative had experienced a traumatic event. Second,

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it was predicted that social support and emotional support coping would have a sequentially mediating effect on the relationship between extraver- sion and PTG. This multi-mediated model was also tested using social support and instrumental support coping as the mediators. Extraversion was the personality variable of interest as it has consistently been associated with PTG. Extraversion is also considered to be strongly related to social sup- port (Swickert, Hittner, & Foster, 2010) and adaptive coping responses (Onder, 2012; Sheikh, 2004). Understanding the factors that influence PTG positions mental health professionals to provide better support and foster positive outcomes in those who have a relative with schizophrenia.

METHOD

Participants

Participants were required to be a first-degree relative and to have lived with their affected relative at some point since the individual received his or her diagnosis of schizophrenia. One hundred and ten people participated; how- ever, four participants were excluded as they were not first-degree relatives. This left a total of 106 relatives (93 females, 12 males, one undisclosed). Participants were recruited through Web sites and e-mail lists of peer support organizations (e.g., the Association of Relatives and Friends of the Mentally Ill, Queensland) and mental health awareness groups, through e-mail lists from the Queensland University of Technology (QUT) community, and through a QUT media release and a local radio interview. Participants were between 19 and 79 years old (M¼46 years, SD¼15 years). The sample was comprised of 53 parents, 27 siblings, and 26 children of an individual with schizophrenia.

The sample was primarily Caucasian (94 people), with five people identifying as Asian and seven as other. Most had a university degree (58.5%). Forty percent of the sample was in full-time employment, 20% part-time, 14% casual, 19% students, 6% volunteers, and 9% unemployed; 17% reported being primary carers. Twenty-eight people reported having a mental health condition. The family members in this study reported that the duration of their relative’s illness ranged from 1 to 80 years, with a mean of 17 years (SD¼13.4 years). Participants reported living with their relative with schizophrenia between 1 and 48 years, with a mean of 19 years (SD¼9 years).

Measures

A demographic questionnaire obtained information about participants’ background, medical history, mental health history, their relative’s illness, and use of peer support services.

The Big Five Inventory (BFI) is a 44-item questionnaire of short descrip- tive phrases (e.g., ‘‘I am a person who is outgoing and sociable’’) characteristic

232 R. D. Morton et al.

of each of the five major personality factors ( John, Donahue, & Kentle, 1991). Participants respond on a 5-point Likert scale, and five subscale scores were created by averaging the corresponding items. The BFI has been used extensively with sound reliability (Thalmayer, Saucier, & Eigenhuis, 2011). In the present study, the internal consistency was in an acceptable range (extraversion a¼ .86, agreeableness a¼ .80, conscientiousness a¼ .86, neuroticism a¼ .79, and openness a¼ .83).

The Perceived Stress Scale (PSS; Cohen & Williamson, 1988) is a 10-item questionnaire assessing the perception of stress symptoms (e.g., ‘‘How often have you felt difficulties were piling up so high that you could not overcome them?’’). The instructions ask participants to respond in relation to the past month on a 5-point Likert scale. The total PSS scale score ranges from 0 to 40, with higher scores indicating greater perceived stress. This scale is psychometrically sound (Lee, 2012), and the internal consistency in this study was satisfactory (a¼ .87).

The Impact of Event Scale-Revised (IES-R; Weiss, 1995) gives a measure of posttraumatic symptoms experienced after a specific stressful incident (e.g., ‘‘Pictures about it popped into my mind’’). The instructions asked for responses related to the stress associated with living with a relative with schizophrenia experienced over the past week. The 22 items are responded to on a 5-point Likert scale. Items on the three subscales are averaged to determine the subscale score, and a total score is generated from the subscale scores. The internal consistency of the scale in this study was strong (total a¼ .92, intrusion a¼ .87, avoidance a¼ .82, and hyperarousal a¼ .84).

The Brief COPE scale has 28 items assessing 14 coping approaches an individual may employ to cope with a stressful event (Carver, 1997). A sample item is ‘‘I’ve been getting emotional support from others.’’ Items are responded to on a 4-point Likert scale; the two items in each subscale were summed. This frequently used scale has good psychometric support and adequate internal consistency (Carver, 1997). The alpha coefficients from the current study (active coping a¼ .66, self-distraction a¼ .61, denial a¼ .47, substance use a¼ .80, emotional support a¼ .81, instrumental support a¼ .87, behavioral disengagement a¼ .74, venting a¼ .54, positive reframing a¼ .85, planning a¼ .74, humor a¼ .83, acceptance a¼ .61, religi- on a¼ .86, and self-blame a¼83) were similar to Carver’s original results. All subscales except denial and venting were above .60 and considered to be just acceptable given that the Cronbach’s alpha coefficient underestimates reliability in two item subscales (Eisinga, Grotenhuis, & Pelzer, 2012).

The Multidimensional Support Scale (MDSS) is a 16-item scale that measures the availability and perceived adequacy of social support (Winefield, Winefield, & Tiggemann, 1992). The wording of the three sections can be altered to reflect the interested sources of support. In this study, the three social support groups were close family or friends, peers in similar circumstance (e.g., support groups for those with a relative with mental

Posttraumatic Growth in Family Members 233

illness), and mental health professionals (e.g., relative’s psychiatrist or psy- chologist). Availability of support is rated on a 4-point Likert scale, and per- ceived adequacy is scored on a 3-point Likert scale. There are six subscales, availability and adequacy of support for each of the three groups, which were calculated by averaging the corresponding items for that subscale. The scale has good internal consistency across the six subscales, .8 and above (Wine- field et al., 1992). In this study, the internal consistency was at a high level (family=friend availability a¼ .87, family=friend adequacy a¼ .76, peer avail- ability a¼ .94, peer adequacy a¼ .93, mental health professional availability a¼ .94, and mental health professional adequacy a¼ .96).

The Posttraumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996) is a 21-item questionnaire measuring positive outcomes associated with a traumatic or intensely stressful experience. Participants were asked to answer the questions in reference to stress experienced as a result of living with their relative diagnosed with schizophrenia. Each item is rated on a 6-point Likert scale. A sample item is ‘‘I have developed new interests.’’ A total score and five subscale scores (new possibilities, relating to others, personal strength, spiri- tual change, and appreciation of life) are generated. The content validity of the PTGI was previously confirmed in a study that used a qualitative assess- ment method in trauma survivors (Shakespeare-Finch, Martinek, Tedeschi, & Calhoun, 2012). The internal consistency of the total scale score is strong, from .90 in Tedeschi and Calhoun’s (1996) original article to .94 in a recent study of relatives of those with a serious illness (Blount et al., 2011). In the current study, the alpha coefficients were satisfactory (total PTGI a¼ .93, new possibilities a¼ .85, relating to others a¼ .82, personal strength a¼ .83, spiritual change a¼ .85, and appreciation of life a¼ .78).

Procedure

Ethical approval for this study was obtained from QUT’s Human Research Ethics Committee. Various mental health organizations, peer support groups, and online community news and message boards were contacted to advertise the study to their consumers. Potential participants who viewed the advertise- ment went directly to the online survey link or contacted the research team for more information. The online survey first displayed the participant infor- mation sheet and informed participants that by submitting their survey their consent to participate would be implied. The survey took approximately 25 minutes to complete. Seventy-three participants chose to enter the appreci- ation draw for one of two $50 shopping vouchers.

Data Analysis

Descriptive statistics for the demographic variables and bivariate correlations between key variables were explored. On the PTGI total score, there was a

234 R. D. Morton et al.

significant difference by gender, Mann-Whitney U¼343.00, p¼ .03, with females (mean rank¼55.31) scoring higher than males (mean rank¼35.08). The male sample size was too small (n¼12) for model assessments to be conducted separately. Therefore, gender was included as a covariate. Box’s M test was not significant, Box’s M¼30.33, F(30, 17451.6)¼0.93, p¼ .581, indicating that the covariances were not significantly different in the parent, sibling, and child subsamples, justifying combining these relatives to maxi- mize power (Swickert et al., 2012). The SPSS PROCESS macro developed by Hayes (2013) was used to conduct the mediation analyses. PROCESS uses a regression-based path analytical framework in complex mediation and moderation analyses. A bootstrap resampling approach was used, with 95% bias-corrected confidence intervals obtained from 5,000 bootstrap resamples. Mediation analysis indirect effects (IEs) and 95th-percentile bootstrap confidence intervals are reported.

RESULTS

Data Cleaning and Assumption Checks

At least 80% of all questionnaire item data points were required to create the subscales. A large amount of missing data (25%) was observed on the MDSS adequacy subscales, which is likely the result of the screen layout of the response boxes, meaning participants may not have seen them. Therefore, this variable was not included in any further analyses. Missing value analysis revealed that no single variable had more than 5% missing data. Little’s miss- ing completely at random test was not significant, indicating that the items were missing at random, v2(1145, N¼106)¼1,179.45, p¼ .234. Using SPSS 21.0 missing value analysis, missing data were imputed through the expec- tation maximization algorithm, chosen for its accuracy over mean substitution or case deletion (Schafer & Graham, 2002). There was no significant differ- ence between the results when conducted on the raw or the imputed data, and therefore the results of the raw data analysis are presented. All relevant assumptions were met. Heteroscedastic consistent standard errors were used, obtained from inbuilt procedures of the PROCESS macro, to control for potential homoscedasticity breaches.

Descriptive Statistics

Table 1 presents the means, standard deviations, and correlations of the subscales with the dependent variable, PTGI total score. The total PTGI scores reported in the present study were similar to those seen in adult children of can- cer patients (M¼58.0, SD¼22.0; Teixeira & Pereira, 2013), relatives of people with serious physical illnesses (M¼54.93, SD¼22.90; Blount et al., 2011), and husbands of women with breast cancer (M¼47.0, SD¼22.9; Weiss, 2004).

Posttraumatic Growth in Family Members 235

Correlations

PTG was significantly and positively correlated with extraversion, agreeableness, and openness. However, no significant correlation was observed for PTG and conscientiousness or neuroticism. There were no significant correlations between PTG and either measure of stress (PSS or IES-R). PTG was positively associated with active coping, emotional support, instrumental support, venting, positive reframing, planning, acceptance, and

TABLE 1 Descriptive Statistics and Correlations with PTGI Total Score for Key Variables

Variable M SD Correlation with PTGI total score

Big Five Inventory Extraversion

a 3.31 0.89 .386��

Agreeableness 3.99 0.65 .303��

Conscientiousness 3.82 0.75 �.015 Neuroticism 3.02 0.76 �.141 Openness 3.87 0.65 .202�

Perceived Stress Scale 17.38 6.91 �.151 Impact of Event Scale

Total 23.66 16.29 .059 Intrusion 9.13 6.73 .141 Avoidance 8.89 6.55 .007 Hyperarousal 5.64 5.48 �.004

COPE Self-distraction 5.07 1.90 .071 Active coping 5.57 1.92 .424��

Denial 2.17 0.67 .166 Substance use 2.56 1.17 .153 Emotional supporta 4.97 1.86 .388��

Instrumental supporta 4.76 2.06 .416��

Disengagement 2.91 1.42 �.160 Venting 4.01 1.52 .204�

Positive reframing 4.83 2.11 .487��

Planning 5.48 1.95 .321��

Humor 3.48 1.82 .126 Acceptance 6.53 1.55 .338��

Religion 1.02 2.14 .427��

Self-blame 3.57 1.71 �.033 Multidimensional Support Scale

Avail. family=friendsa 2.71 0.77 .236�

Avail. peers 1.77 0.93 .182 Avail. mental health professionals 2.16 0.89 .042

Posttraumatic Growth Inventory Relating to others 19.65 8.03 .863��

New possibilities 13.46 6.35 .863��

Personal strength 13.49 4.96 .831��

Spiritual change 3.82 3.56 .560��

Appreciation of life 10.59 3.48 .784��

Total scorea 61.01 21.26

a Variable used in the mediation analysis. �p� .05; ��p� .01.

236 R. D. Morton et al.

religion. These coping responses could be seen as adaptive approaches to handle stress. A significant positive correlation existed between PTG and social support from family=friends. There was no relationship between PTG and receiving support from caregiving peers or health professionals.

Mediation Analyses

There was a significant correlation between extraversion and social support from family=friends (r¼ .272, p¼ .005). However, there were no significant correlations between extraversion and social support from peers (r¼ .039, p¼ .693) or extraversion and social support from health professionals (r¼ .125, p¼ .203). Social support from family=friends was the support vari- able tested in the multi-mediation model. The coping strategies of emotional support and instrumental support were correlated with extraversion (r¼ .278, p¼ .004 and r¼ .226, p¼ .022, respectively). Social support was moderately correlated with both emotional support coping (r¼ .429, p < .001) and instru- mental support coping (r¼ .303, p¼ .002).

The multi-mediated model assumes a serial process whereby extraver- sion influences social support received from family=friends, social support then influences the experience of emotional or instrumental support coping strategies, which then influences PTG. Figure 1 displays the results of the multi-mediation analysis, which tested whether extraversion influences PTG through both social support from family=friends and emotional support coping. The results indicated a significant partial multiplicative mediational path, IE¼0.68 (0.15–1.93), indicating that PTG increases indirectly through social support from family=friends and emotional support coping by 0.68 for every one-unit increase in extraversion (on a 4-point scale). It was not possible to obtain a beta weight or kappa squared effect size, which is the preferred measure of effect size, for these analyses because of the inclusion of the gender covariate in the model (Preacher & Kelley, 2011). This finding indicates that when social support from family=friends and emotional support

FIGURE 1 Multiplicative mediation model of social support and emotional support coping with path coefficients. All path coefficients are standardized with 95% confidence intervals in parentheses. �p < .05; ��p < .01; ���p < .001.

Posttraumatic Growth in Family Members 237

coping are entered in the same model, they have a sequential mediation effect on the relationship between extraversion and PTG.

The multi-mediational model involving instrumental support coping with gender as a covariate was next explored (see Figure 2). The results again indicated a significant partial multiplicative mediational path, IE¼0.51 (0.06–1.72), indicating that PTG increases indirectly through social support from family=friends and instrumental support coping by 0.51 for every one-unit increase in extraversion (on a 4-point scale). This finding indicates that social support from family=friends and instrumental support coping have a sequential mediation effect on the relationship between extraversion and PTG.

DISCUSSION

The purpose of this study was to explore the factors associated with PTG in family members of individuals diagnosed with schizophrenia. As expected, participants reported high levels of PTG that were of a similar level seen in studies exploring PTG in family members of those with serious illnesses (Blount et al., 2011; Teixeira & Pereira, 2013; Weiss, 2004). The positive correlations of PTG with extraversion, openness, and agreeableness were replicated in this study (Linley & Joseph, 2004). Coping strategies typically considered adaptive, such as emotional or instrumental support and positive reframing, were moderately positively correlated with PTG (Bellizzi & Blank, 2006). In support of past findings, there was a positive correlation between PTG and social support from family=friends (Prati & Pietrantoni, 2009). Support from peers who also had a relative diagnosed with schizophrenia was not significantly correlated with PTG, which was inconsistent with studies where individuals reported peer support to be beneficial (Aschbrenner et al., 2010; Chien et al., 2006). Over half of the current sample stated that they had not experienced peer support. Additionally, there was no relationship observed between support from health professionals and PTG.

FIGURE 2 Multiplicative mediation model of social support and instrumental support coping with path coefficients. All path coefficients are standardized with 95% confidence intervals in parentheses. �p < .05; ��p < .01.

238 R. D. Morton et al.

In the multi-mediated model, social support from family=friends and emotional support coping were significant sequential mediators of the relation- ship between extraversion and PTG. Similarly, social support from family= friends and instrumental support coping also significantly and sequentially mediated the relationship. These pathways indicate that individuals high in extraversion perceived a high level of support from family=friends, which in turn meant this support facilitated use of an emotional support coping strategy or instrumental support coping strategy, which led to a greater level of PTG. These results are congruent with previous research that found social support and instrumental coping strategies were single mediators of the relationship between extraversion and PTG (Boyraz et al., 2012; Onder, 2012; Sheikh, 2004). The results of the current study diverge from past findings because emotional support coping strategies did mediate the extraversion and PTG relationship. Onder (2012) found that emotion-focused coping did not mediate the relationship between PTG and extraversion in breast cancer patients. This divergence may reflect a potential difference in the development of PTG in individuals with a physical illness compared to relatives of those diagnosed with a long-term mental illness. The chronic nature of schizophrenia may require relatives to use more emotionally supportive coping responses.

The findings of this study can be interpreted alongside Tedeschi and Calhoun’s model of PTG (2004). This study empirically tested the relationship between the pretrauma characteristic of extraversion and PTG as influenced by social support and coping strategies used to handle emotional distress. Other studies have examined the role of rumination and religious coping (Bosson, Kelley, & Jones, 2012), control appraisals (Frazier, Tashiro, Berman, Steger, & Long, 2004), and posttraumatic stress symptoms (Blount et al., 2011; Saccinto, Prati, Pietrantoni, & Pérez-Testor, 2013) in the development of PTG. There are a number of pathways within the PTG model where testing these variables would enhance the current understanding of the factors that lead to the development of PTG.

Calhoun and Tedeschi (2012) offer ways to translate PTG research into clinical practice. The findings of the current study have clinical relevance for family members living with a relative diagnosed with schizophrenia, as well as mental health clinicians who support these families. Based on the model tested, a clinician working with a family member who has extraverted personality traits may facilitate ‘‘naturally’’ occurring PTG processes by encouraging the person to engage in social support from family=friends, which will provide emotional support or practical support and lead to poss- ible benefits from the individual’s stressful experiences (e.g., increased sense of personal strength or resilience, improved attitude toward caregiving).

Figure 3 expands on the multi-mediated model by suggesting clinical concepts that may be related to particular pathways of the model. Those with extraverted traits seek social support (Onder, 2012), which allows them greater opportunities for self-disclosure with others. Social support from

Posttraumatic Growth in Family Members 239

friends=family may translate into an emotional support coping strategy through the mechanisms of non-judgmental listening, being able to process the emotion with another, obtaining assistance in regulating negative affect, and developing a shared understanding of the illness within the family (Morton, 2013). Additionally, the mechanisms translating social support into an instrumental support coping strategy may include obtaining information about the illness and advice on treatment and caring tasks (Morton, 2013). Having the opportunity to process the trauma and related emotional reactions is important to facilitate individuals’ change in self-narratives and schemas, which then leads to PTG (Tedeschi & Calhoun, 2004). Being better informed may result in a sense of self-efficacy, leading to the development of the personal strength component of PTG.

Limitations and Future Research

This study has several limitations that should be noted. There was no corre- lation with PTG and perceived support from peers and health professionals, despite these being important in qualitative studies (Chien et al., 2006; Morton, 2013). An alternate measure that may better capture this support is the Sources of Social Support Scale (Carver, 2006), which was developed for the purpose of exploring different sources and aspects of social support in cancer patients. This study sought to obtain information on the adequacy of support, not just its availability; however, this variable was unusable because of the large proportion of missing data, presumably due to its survey screen placement. Adequacy or satisfaction with support may be important in predicting PTG (Teixeira & Pereira, 2013). A measure better able to capture the full range of the stress experienced could also be useful, because the PSS and IES-R only assessed recent stress experiences. Research suggests that

FIGURE 3 Multi-mediator model path diagram with clinical implications (italicized).

240 R. D. Morton et al.

a curvilinear relationship exists between posttraumatic stress symptoms and PTG, which is an area for future research to explore how the relationships in this study may be affected by stress symptoms (Kleim & Ehlers, 2009).

The generalizability of our findings is limited due to the sample being mostly female and relatively homogenous in their cultural backgrounds. Future research would be useful to explore cultural and gender differences in the development of PTG. Separate analyses of parents, siblings, and chil- dren were not possible due to the small sample sizes after separating these three groups. Future research with a specific focus on testing relationships within one type of relative group could provide more specific information about the characteristics and predictors of PTG for those subgroups, allowing for more specific clinical interventions to be designed. This was a cross- sectional study, and therefore causal relationships cannot be definitively concluded. The models hypothesized in this study were based on empirical evidence; however, longitudinal studies may offer a way to further test the relationships uncovered here and alternate pathways (Yanez, Stanton, Hoyt, Tennen, & Lechner, 2011). Additionally, it would be beneficial for future research to continue exploring the variables and mechanisms through which PTG develops in family members and translate these theoretical understand- ings into clinically relevant practices.

Conclusion

This study found that family members of a relative diagnosed with schizo- phrenia experience PTG at a similar level to individuals with a serious illness or relatives of those with a physical illness. Social support from family=friends and emotional support coping and instrumental support coping mediated the relationship between extraversion and PTG. By better understanding the mechanisms through which PTG develops, it may be possible for clinicians to not only offer support but be able to foster PTG and positive family experi- ences in those seeking assistance. Information from the current study and future studies could be applied to designing intervention programs to assist families through their journey, with a focus on social support and emotional or instrumental coping strategies to encourage the development of PTG in family members.

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Rachel D. Morton completed her Doctorate in Clinical Psychology with the School of Psychology and Counselling at the Queensland University of Technology. Her research has focused on personality based individual differences, psychosocial stress response, and the lived experience of mental illness, specifically schizophrenia.

Melanie J. White is a senior lecturer in the School of Psychology and Counselling and Institute of Health and Biomedical Innovation, Queensland University of Technology. Her research program is broadly focused on the interplay between physiological and psychosocial (particularly stress) influences on cognition, personality, and complex behavior.

Ross McD. Young is executive dean of the Faculty of Health at the Queensland University of Technology. His areas of research specialization include substance misuse, genetics, schizophrenia, and PTSD.

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