Bad,burdened or ill? Characterizing the spouses of women with schizophrenia

Abstract

Background:

The husbands of women with schizophrenia have been variously characterized in the psychiatric literature as abusive, burdened and ill. The aim of this paper is to summarize what has been written about these three perspectives.

Method:

The search terms ‘schizophrenia’, ‘mental illness’, ‘marriage’, ‘spouse’, ‘partner’, ‘caregiver’, ‘caregiving’, ‘burden’, ‘assortative mating’ and ‘domestic abuse’ were entered into PubMed and Google Scholar. Criteria for inclusion of articles were relevance to the three identified themes of abuse, burden and mental illness in husbands of women with schizophrenia. The results show considerable variation, some of it cultural, with partial evidence for all three characterizations.

Conclusion:

There is a need for support and psychoeducation programmes that are specifically designated for spouses and that address their special concerns.

Keywords

Schizophrenia spouse domestic abuse caregiving burden assortative mating

Introduction

Approximately 30% of women with schizophrenia live, at least temporarily, with spouses (Jungbauer, Wittmund, Dietrich and Angerm, 2004) whose personal characteristics have been variously described in the psychiatric literature. The husbands have been suspected of abuse (Howard et al., 2010); they have also been viewed as co-victims (Kumar & Mohanty, 2007). From another perspective, their premarital mental health has been questioned (Parnas, 1985). This paper will summarize what is known about these varied aspects of men who marry women with schizophrenia, and will propose mental health interventions designed for spouses.

Method

The search terms ‘schizophrenia’, ‘mental illness’, ‘marriage’, ‘spouse’, ‘partner’, ‘caregiver’, ‘caregiving’, ‘burden’, ‘assortative mating’ and ‘domestic abuse’ were entered into PubMed and Google Scholar. Reference lists of the retrieved articles were then further searched. Criteria for inclusion were relevance to the three identified themes of abuse, burden and mental illness in husbands of women with schizophrenia without regard to sample size or methodology. Both quantitative and qualitative studies were included. The quality of the studies cited was not evaluated. Foreign texts were translated into English.

Results

Abusive husbands

Thirty to sixty per cent of severely ill psychiatric patients, diagnosis unspecified, report suffering physical violence at the hands of their partners (Howard et al., 2010), with 60% being a more accurate estimate when the patient is a woman and the spouse is a man (Khalifeh & Dean, 2010; Morgan, Zolese, McNulty & Gebhardt, 2010). A well-known literary example of this phenomenon can be found in Charlotte Brontë’s Jane Eyre. Bertha Mason, Mr Rochester’s first wife, was abused, restrained and locked away in an attic (Oyebode, 2004). When she attacks her husband, Grace Poole (her attendant) ‘gave him a cord, and he pinioned them [her arms] behind her: with more rope, which was at hand, he bound her to a chair’ (Brontë, 1981, p. 250).

The key phrase here is ‘When she attacks’. In a review of the literature on intimate partner violence against women with severe mental illness, Friedman and Loue (2007) found that not only were the women at increased risk of being victimized by their partners but, like Bertha Mason, they tyrannized their partners. Measures taken to prevent further violence, although perceived as abuse, could be objectively considered as acts of self-defence and justifiable attempts at restraint, as in the case of Edward Rochester. They could also, however, be acts of retaliation. The distinction is difficult.

Women with schizophrenia may become victims more readily than other women because of cognitive difficulties that make them less able than others to avoid dangerous situations. This is exemplified in Jane Eyre by Bertha Mason, who set the house on fire and burned to death despite Rochester’s heroic attempt to save her.

Women with schizophrenia, because of defects in social cognition (de Carvalho Monteiro, Martins, Crivelaro & Rodrigues Louzã, 2012), can, more readily than other women, be exploited by scoundrels (Rochester’s prime motive in marrying Bertha seems to have been to acquire her £30,000 dowry). Substance abuse in either or both partners also increases the risk of domestic violence and is highly prevalent in schizophrenia (Drake & Mueser, 1996; Gearon & Bellack, 1999; Golinelli, Longshore & Wenzel, 2009).

If abandonment is classified as abuse, many husbands of women with schizophrenia can be considered abusive. In India, it has been reported that 53% of men abandon wives who develop schizophrenia (Thara, Kamath & Kumar, 2003a). Sometimes, however, the women do the leaving. A well-known, real-life example of a woman with schizophrenia was Camille Claudel, sculptor and sister of the writer Paul Claudel, who was the mistress of Auguste Rodin. Even though Rodin had another mistress whom he eventually married, it was Camille who abandoned Rodin, becoming gradually delusional about his intentions towards her. For his part, he remained sufficiently committed to Camille to contribute to the expenses of her subsequent psychiatric hospitalization (Bastos, 2006; Oules, 1993).

Abandonment can follow many frustrating years of trying to make a very difficult marital relationship work. Here is a woman’s account of finally divorcing her husband, ill with schizophrenia, after 20 years of trying to help him:

I felt guilty because I could neither ease his suffering nor give him the confidence he lacked so dramatically. But most of all I felt guilty because I began to resent the endless struggle of dealing with Jon’s strange world and the endless daily complications it brought about. The strain of being the only link between him and the outside world, of having to translate his behavior to our daughters, of not being able to talk to them without being accused of collusion, of having to adapt to his unpredictable moods and having to live with ghosts, all this wore me down. I was frustrated at not being able to have normal, trusting relationships with other people without being suspected of disloyalty. I felt like fleeing from this situation, but how could I abandon him? Of course I knew none of this was Jon’s fault, but my resentment was so strong that I couldn’t suppress it, and I became increasingly snappy and irritable. And the nastier I became, the guiltier I felt. We were caught in a vicious circle. (Anonymous, 1994, p. 229)

Helping the abuser

In summary, it is probable that some spouses of women with schizophrenia are exploitative and abusive. It must be remembered, however, that not all reports of abuse can be taken at face value. Some are fabricated for particular purposes, especially in child custody cases (Austin, 2000; Bow & Boxer, 2003). Women need to be asked about domestic abuse, allegations need to be investigated, and potential contributory factors alleviated. Addressing financial and respite issues, helping with substance abuse, and providing help for both partners caught in the cycle of domestic violence are mandatory components of mental health services to this population (Howard & Trevillion, 2011; Trevillion, Agnew-Davies & Howard, 2011).

Burdened husbands

Burden and resilience

The burden of marriage to a person with schizophrenia has been examined from the perspective of several cultures, but most of the published work comes from Germany. Jungbauer et al. (2004) studied 52 spouses of men and women with schizophrenia in Leipzig as a part of the larger research project on the health and financial burden of caregivers of mentally ill patients. The first episode of psychosis was described as the most frightening because the spouses did not yet understand that their partner’s irrational behaviour was a result of illness. They were initially horrified by the coercion implicit in involuntary hospitalization and shocked by their first encounter with psychiatric treatment. With time, they were better able to cope, but continued to be watchful and worried. The spouse gradually took over more and more of the household duties as the patient was often disabled by negative symptoms or by medication side effects. Financial pressures mounted. Personal needs were neglected and there was more marital conflict, sometimes accompanied by violence. Sexual pleasure diminished. Side effects of antipsychotics often undermined a wife’s attractiveness (Seeman, 2011) and made her less desirable as a sexual partner. Thoughts of separation inevitably came to the fore when the spouse could no longer cope with the perceived burdens.

Many spouses in the Jungbauer et al. (2004) study, however, continued to find the marital relationship satisfying. In some cases, both partners suffered from schizophrenia and this appeared to work because both were happy with their relative social isolation and quiet everyday routine. Mutual affection, respect and understanding often persisted, especially where religious norms encouraged the insolubility of marriage. Some of the spouses interviewed by Jungbauer et al. (2004) appeared to emerge strengthened from struggles with the illness. This same pattern of burden and resilience had earlier been found in a US study of spouses of people with mental illness (Mannion, 1996).

On the whole, however, Angermeyer, Kilian, Wilms and Wittmund (2006) found that, compared with the general population, the quality of life in Germany of spouses of individuals with severe mental illness suffered, especially in the areas of well-being and social relationships. The more severe the illness, the worse the quality of life of the spouse.

Cultural differences

Married life in the context of schizophrenia appears to hold different meaning in different countries (Naheed, Akter, Tabassum, Mawla & Rahman, 2012). In western countries, marriage is thought of as a union of two people but, in some parts of the world, it is viewed as a merger of two families. This makes dissolution of a marriage, no matter how burdensome, more difficult.

In a recent study of 12 husbands of schizophrenia patients in Japan (Mizuno, Misuzu & Sakai, 2011), most of the husbands interviewed uncomplainingly accepted their wife’s illness. They changed jobs in order to be available to their wife, they were careful to monitor their wife’s medications, they protected her against spiteful reactions from neighbours, and they ensured that marital time spent together was always pleasant. They admitted to the interviewer that there was little communication at home, but this did not appear to be a major concern. The husbands’ affectionate feelings for their wife remained unchanged. None of the interviewees considered divorce, although they admitted to worrying about the future. They stated that it was the man’s responsibility to protect his wife, and that they could not consider leaving her. They did not expect more from their wife than she was able to do. Even when upset by some of their wife’s behaviours, the husbands accepted these behaviours as manifestations of the illness.

The results of small studies cannot be generalized because the spouses who volunteer for interviews are likely to be the ones, on the whole, who are coping better. The overall marriage rate of women with schizophrenia in Japan is not reported in the literature but, in India, it is 70% (Thara & Srinivasan, 1997), a high rate for schizophrenia, perhaps explained by the fact that the illness is frequently concealed from the spouse- to-be in the hope that marriage will cure it, a prevalent belief in India (Loganathan & Murthy, 2011). More than half of husbands thus deceived abandon the marriage or divorce their wives without paying alimony (Thara, Kamath & Kumar, 2003a, 2003b).

Gender differences

A study of 120 spouses of chronic schizophrenic patients in India showed that wives, especially those in small nuclear families, experienced more burden than husbands (Kumar & Mohanty, 2007; Kumar, Rani, Jain & Mohanty, 2009). Male schizophrenia patients required more physical care than female patients (Janardhana, Shravya, Naidu, Saraswathy & Seshan, 2011). Men did not pay attention to hygiene and needed to be reminded and persuaded to take their medicines. The women, when reminded, were able to take care of their own personal hygiene. Outbursts of anger were much less frequent among the female than the male patients. Assaults against family members occurred only among the men. The stress on spouses was greatest when they tried to enact roles that did not fit into accepted gender stereotypes, such as when a husband had to look after his wife’s physical hygiene or a wife had to control a violent husband (Janardhana et al., 2011).

Although, in general, the caregiving role is a more difficult one for men than for women (Fraser & Warr, 2009), this is not the case in the context of schizophrenia. In their review of the caregiving burden literature in schizophrenia, Awad and Voruganti (2008) noted that several studies had examined the role of gender and had reported that relatives of male patients experienced more social dysfunction and disability than relatives of female patients.

Mental health consequences

The spouses of psychiatric patients (at least in Germany) have shown a tendency to depressive disorder as a result of their caretaking burden (Wittmund, Wilms, Mory & Angermeyer, 2002). A narrative analysis of 23 in-depth interviews found that spouses experienced severe distress in the form of fear, despair and loss of control (Jungbauer, Bischkopf & Angermeyer, 2001). In Norway, a study of 9,144 couples of which one member suffered from a psychiatric disorder (diagnosis unspecified) suggests that, for the most part, spouses experience only moderate levels of burden, and that this does not usually last beyond the initial caregiving period (Idstad, Røysamb & Tambs, 2011). Although effect sizes for burden were moderate, they were nevertheless highly significant. Spouses of persons with mental disorder scored significantly lower on subjective well-being and significantly higher on symptoms of anxiety and depression when compared to spouses of persons without mental disorder (Idstad, Ask & Tambs, 2010).

Intimacy and finances

The onset of a schizophrenic disorder was found to be a particularly burdensome time for caregivers, with consequences differing somewhat for parents and spouses. The greatest impact for spouses was the status of the marital relationship itself, especially its intimacy (Jungbauer & Angermeyer, 2002). Husbands had the difficult task of negotiating intimacy with their ill wives as the women moved through recurrent episodes of psychosis and recovery (Henderson, 2001). The frequency of burnout, whether defined as emotional exhaustion, depersonalization or interference with personal accomplishment, did not differentiate spouses from nurse caregivers. About one quarter of each group was affected (Angermeyer, Bull, Bernert, Dietrich & Kopf, 2006).

Financial burden was a frequently enunciated problem (Jungbauer, Mory & Angermeyer, 2002) but was considered less important than the less tangible costs of caregiving (Mory, Jungbauer, Bischkopf & Angermeyer, 2002) and did not appear to differ significantly across types of illness, whether schizophrenia, depression or anxiety disorder (Wilms, Mory & Angermeyer, 2004). In one study, the global burden of caregiving for spouses was not different in depression and schizophrenia. As seen earlier, the effect of illness on the marital relationship was the important issue, regardless of diagnosis (Wittmund, Nause & Angermeyer, 2005).

Coping strategies

Twenty-eight in-depth interviews with spouses of schizophrenia patients focused on the various coping strategies that spouses used. Information seeking and crisis planning proved to be important at the beginning of the illness (Jungbauer & Angermeyer, 2003), while relaxation, time out and disengagement became increasingly important once the situation was viewed as ongoing. Over the long term, cognitive strategies, such as reappraisal of the illness and of one’s own efficacy, were more often reported by the interviewees. Jungbauer and Angermeyer (2003) reached the conclusion that the nature of coping strategies has a strong influence on the spouses’ perception of burden, their marital satisfaction and their commitment to the marriage.

Support for spouses

In summary, the spouse of a woman with schizophrenia appears to be burdened somewhat differently in different cultures. Expectations of marital partners differ, but, in general, the effect on the personal relationship looms large for spouses. The marital partner can, at times, develop psychiatric problems in the context of the stress of caregiving. Support groups for caregivers of patients with schizophrenia are usually targeted to the needs of parents. Since spouses often have different needs and different burdens, it is important for mental health services to also target spouses (Mannion, Mueser & Solomon, 1994).

Mentally ill husband

Given that mental illnesses can arise from the many problems associated with being married to a woman with schizophrenia, it is not easy to determine whether prior mental illness may lead a man to enter into marriage with a woman predisposed or already suffering from schizophrenia. The literature suggests that partners’ perceived affinities lead to marriage. Pearson (1903) first noted the tendency for individuals to be attracted to and marry those whom they resemble. There is a long literature in psychology on similarity breeding attraction (Byrne, 1971) and, in the social sciences, on familiarity (which induces similarity) promoting romantic attachment (Ebbesen, Kjos, & Konecni, 1976).

A 2006 Australian study of 3,808 couples showed significant marital concordance on scores on a mental health scale that were independent of shared life events, neighbourhood stress or socio-economic circumstances (Butterworth & Rodgers, 2006). A year later, 103 health concordance research articles were reviewed and the evidence was overwhelming in support of concordant mental and physical health, as well as health behaviours, among married couples (Meyler, Stimpson & Peek, 2007).

Maes et al. (1998) showed small but significant correlations between spouses for alcoholism, generalized anxiety disorder, major depressive disorder, panic disorder and phobias. For schizophrenia, however, a study of 20 couples of which one partner suffered from schizophrenia, showed the well spouses to be similar in their mental health to the average population (Buddeberg & Kesselring, 1978). The authors did notice behaviour disorders in the non-schizophrenic spouses, but considered them to be reactions to the patient’s symptoms. A study comparing concordance of symptoms among a variety of pairs of relatives concluded, however, that the results supported assortative mating in schizophrenia (Rao, Morton, Gottesman & Lew, 1981). The following year, a study of the spouses of 103 schizophrenia and depression patients concluded that they did not differ in personality or well-being, but, instead, that whatever mental health symptoms both groups had correlated with the fluctuations of illness in the patient (Hell, 1982).

Parnas (1985) compared husbands of women with schizophrenia who were mothers with control spouses. The former were more likely than the latter to receive a psychiatric diagnosis (not necessarily schizophrenia) and a personality diagnosis. Parnas proposed that defective emotional rapport or sub-psychotic features constitute the phenotypic traits by which assortative mating might operate in schizophrenia.

Consequences of assortative mating

None of these studies provide a definitive answer to the question of how often assortative mating has occurred in the context of schizophrenia, but it is likely, in the future, to become more prevalent. Psychiatric rehabilitation programmes (Seeman, 2012), traditional matchmaking services (Jordan, 1997) and modern online dating services (e.g. Online Social Community for Adults with Mental Illness: http://www.nolongerlonely.com) increase the opportunities for similarly disabled people to meet, become attracted to one another, and marry (Wilson, 2002).

The consequence may be that more children will be born to parents who both struggle with symptoms of schizophrenia, increasing the need for parenting support to this population.

Conclusion

Because of the difficulties of living with a spouse who suffers from schizophrenia, in these families the risk for domestic violence, abuse, neglect, abandonment and the abuse of substances will be high. The person with schizophrenia may be exploited and victimized. Mental health services need to be aware of such possibilities, need to monitor what is happening in the home, and be prepared to intervene effectively for the sake of the marital couple and of any children. While women whose husbands suffer from schizophrenia appear to shoulder a greater burden than husbands whose wives bear the diagnosis, caregiving is usually a more difficult task for the man, and, in some cultures, may be disparaged (Janardhana et al., 2011). Mental health services need to be sensitive not only to family burden, but also to its cultural implications. Burden may lead to severe marital discord so that marital support and counselling become critical (Whisman & Baucom, 2012). This will be difficult to implement, but extremely important if both spouses suffer from mental illness. In these situations, the safety and healthy development of children of the marriage must be especially targeted. Support and psychoeducation for caregivers of patients with schizophrenia should keep spouses in mind. They have special needs, different in kind from those of parents (Mannion et al., 1994). Here, too, cultural differences in the roles played by marriage partners and the meaning of marriage in one’s community will need to shape the content of therapeutic interventions.

Spouses of women with schizophrenia may be ill and may need help for their personal problems; they may be burdened and need support and instrumental aid; they may not adequately discharge their responsibilities as caregivers and may further victimize wives already made vulnerable by illness. Whatever the circumstance, the family will require assistance.

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