The Nuisance Factor: A Study of Daily Stress for People with Long-Term Psychiatric Disabilities.

In New Zealand, about two thirds of the admissions to psychiatric hospitals are readmission. It is well documented that stress is one of the major causes of deterioration of mental state (Klein, Lewinsohn, & Seeley, 1997; Liberman, 1992, Malla & Norman, 1992, Norman & Malla, 1993). Segal and Vander Voort referred to daily hassles or stresses as "concerns, worries, or events that disrupt a person's well being and daily life" (1993a, p. 276). The daily stresses, identified by the person as severe, reflect the important pattern of goals and life themes in the person's life (Gruen, Folkman & Lazarus, 1988). Daily stresses are the irritating, frustrating demands that occur during everyday transactions with the environment (Lu, 1997). They are the chronic strains associated with social roles and enduring characteristics of the environment (Nadaoka, Kashiwakura, Oiji, Morioka & Totsuka, 1997; Newman, 1994).

Coping is viewed as responses to perceived stress and defined as the "constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person" (Lazarus & Folkman, 1984, p. 141). Literature (e.g., Carver, Scheier, & Weintraub, 1989; Rippetoe & Roger, 1989) suggests that no particular coping methods can be inherently effective or ineffective, functional or dysfunctional. Coping methods such as active behavior or distraction may be beneficial for some people in some situations, whereas they may not be beneficial for other people in other contexts.

Level of mental health and daily stresses may be reciprocally related. Some daily stresses may result from the effects of poor mental health (Depue & Monroe, 1986). An individual's level of poor mental health may act to influence the amount of stress that is being experienced (Dohrenwend, Dohrenwend, Dodson, & Shrout, 1984; Norman & Malla, 1993).

Five studies (Klein et al., 1997; Miller & Miller, 1991, Norman & Malla, 1994; Ravindran, Griffiths, Waddell, & Anisman, 1995; Segal & VanderVoort, 1993b) that identified the types and level of severity of daily stresses for people with psychiatric disabilities were found in the literature. Miller and Miller (1991) concluded that the severity of stress rather than the number of stresses encountered appeared to be more critical for people with psychiatric disabilities compared with a general population sample. Segal and VanderVoort (1993b) found that stress scores were significantly related to major and minor physical health problems as well as increased psychiatric symptomatology. Norman and Malla (1994) were the first group of researchers to conduct a prospective study to examine the relationships between daily stresses and symptomatology. With regard to intervention, Ravindran and associates (1995) found that individuals with depression (both major depression and chronic low grade depression) reported significantly fewer minor stresses after the 8-week period of drug treatment. Klein and associates (1997) added that adolescents with a past history of chronic depressive disorder experienced significantly higher level of daily stresses than adolescents with no history of psychopathology. The present study intends to identify the types of daily stresses faced by people with long-term psychiatric disabilities in New Zealand and their reactions to stresses. Furthermore, the present study explores how the stresses and the reactions may be related to an individual's demographic characteristics.

Method

Participants

Participants were recruited from supported accommodations: sheltered workshop, drop-in centers, which provide support services for people in the Dunedin area suffering from long-term psychiatric illness, such as schizophrenia and affective disorder. Dunedin is one of the major cities in South Island in New Zealand. The city has a population of about 110,000. To meet the criteria for inclusion in the sample, each person had to have a history of mental illness, be receiving ongoing support and care from mental health services, be between the age of 18 and 60 years, reside in the Dunedin area and be able to sustain concentration for about 45 to 60 minutes.

Fifty people (31 men and 19 women) participated in the study. Participants ranged in age from 19 to 60 years (M=40.04, SD=9.57). Forty-four people identified themselves as European, three as European-Maori, two as Maori, and one as Samoan. Maori are the indigenous people in New Zealand. Participants had a self-reported history of psychiatric illness from 2 to 35 years (M=14.77, SD=9.40). Twelve of the participants indicated that they worked in a sheltered workshop. Another six identified themselves as involved in paid work on a casual basis.

Data collection procedure

The first method of recruitment was to approach potential participants while they were on the premises of the various community agencies. The second method of recruiting participants was through staff of the agencies. A semi-structured interview format was used rather than a self-administered questionnaire. The interview format was used because it engages participants maximally in the data collection process and provides the opportunity for clarification of any confusing aspects of the questions. Participants were also informed that two staff members from the agency that the participants were attending would be asked to comment on their mental state and daily functioning over the last two weeks. Staff was blind to how the participant responded in the interviews.

Measures

Daily hassles scale. Participants' daily stresses were measured with a shortened version of the Daily Hassles Scale developed by Lazarus and his colleagues (Delongis, Coyne, Dakof, Folkman, & Lazarus, 1982; Kanner, Coyne, Schaefer, & Lazarus, 1981). With reference to previous studies (Miller & Miller, 1991; Segal & VanderVoort, 1993a), the scale was reduced to 72 (73 for women including the item on "menstruation") of the original 117 scale items, given that some of the original items had little relevance to this sample (e.g., "property, investment," "too many meetings"). The validity of using a shortened version of the Daily Hassles Scale was supported by other research (Delongis, Folkman, & Lazarus, 1988; Gruen et al., 1988, Lazarus, 1990).

To maximize participants' abilities to respond accurately, they were asked to report stresses they had experienced over the last two weeks. A 5-point scale was used in the present study. The "0" indicated that the event or situation had not occurred at all. The "1" indicated that it was not stressful even though the event or situation had occurred. The next three levels of responses indicated that the event or situation had occurred and that it was a mild, medium, or severe stress.

Stress coping scale. The measure(1) used by Stone and Neale (1984) was adopted as the basis for selecting and defining the items for the Coping Scale. One or two short sentences were used to describe each coping method. Participants were asked to rate their level of using each coping method on a 4-point scale (0=did not use this method at all; 3=used this method a great deal).

Symptoms and functioning. The participant's current level of mental health was measured by the modified from Global Assessment of Functioning Scale (GAFS) (American Psychiatric Association, 1994; Endicott, Spitzer, Fleiss & Cohen, 1976). For this study, the symptoms and functioning dimension of the GAFS was split into two separate scales -- Symptoms Level and Functioning Level. Each scale gave a single rating for measuring the level of the participant's psychiatric symptoms or daily functioning on a hypothetical continuum of mental health-illness. The scale values range from 1 (severe symptom or extremely low level of psychosocial functioning) to 90 (no symptom or very high level of psychosocial functioning). The time period that was assessed was the two weeks just prior to the data collection interview.

Results

Data on the average severity score of stress indicated that participants on the whole experienced a medium level of severity of stress (M=2.81, SD=.68) on a 5-point scale. On average, participants reported only 19 (SD=12.6) out of the 72 (73 for women) events or situations as stressful. The mean total stress score was 54.6 (SD=39.7) out of possible total 288 (292 for women). It was found that only the number of stresses correlated (r=-.31, p [is less than].05) with the level of mental wellness (as indicated on the Symptoms Level); otherwise there was no significant correlation between participants' stress scores and mental health scores.

A rank-ordered list of the total stress scores is reported in Table 1. The eight most severe stresses were also reported to be the most frequent, with additional concern about past decisions and fear of confrontation. The participants tended to regard certain stresses as severe and as frequent.

Table 1

Ten Most Severe Daily Stresses

Daily Stress                            Total Scores

1. Thoughts about the future                 81
2. The Weather                               73
3. The weather                               71
4. Low Energy                                71
5. Rising Price of Common Goods              70
6. Smoking Too Much                          67
7. Fear of Rejection                         66
8. Not Enough Money for Entertainment        63
9. Getting up in Morning                     62
10. Having Too Much Time                     61

Note. The values represent the total scores from 2 to 4 on the Hassles

Scale. Maximum score (Q=50) for each daily stress = 200.

Table 2 shows that the top three reported coping methods were: (a) active thinking, (b) active behavior and (c) reinterpretation and growth. All the coping methods had averages in the range of 1.54 to 1.92 (i.e., used this method quite a bit), except the coping method of blaming self and alcohol-drug disengagement. It was found that none of the coping methods correlated significantly with Symptoms Level, Functioning Level or demographic data.

Table 2

Reported Use of Coping Methods

Coping Method                     M      SD

Active thinking                  1.92    .99
Active behaviour                 1.86   1.09
Seeking social support           1.68   1.10
Wishful thinking                 1.56   1.22
Distraction                      1.54   1.22
Blaming self                     1.34   1.06
Alcohol - drug disengagement      .36    .90

Note. Range for all coping methods = 0-3.

Participants were rated at the upper end of Symptoms (M=72.6, SD=15.2) and Functioning Level (M=73.0, SD=12.9). Symptoms Level correlated moderately with Functioning Level (r=.59, p [is less than].01).

The relationships between demographic characteristics and variables measured in this study were tested using Chi-square test. It was found that individuals who were engaged in employment tended to report fewer stresses (i.e., below the median number of total stress = 44.5) than those who were not employed, [chi square] (1, n = 50) = 4.25 at p [is less than].05. Otherwise, there was no difference in stress scores across the age and gender variables.

Discussion

Miller and Miller (1991) found that people with severe psychiatric disabilities had an average severity score of 2.72 (SD=.91) on a 5-point scale similar to the one used in the present study. The participants in the present study recorded a medium level of severity of stress, 2.81. Another similarity was the trend for participants from both of these studies to report few items as stressful in their lives; when they did report stress, however, those events or situations were rated as bothersome.

Participants from the present study and the studies in United States (Miller & Miller, 1991; Segal & VanderVoort, 1993a, 1993b) had concerns about the future, concerns about interpersonal relationships (e.g., being alone, difficulty in expressing oneself; fear of rejection), and financial concerns (e.g., not enough money for entertainment, rising prices of common goods). Research participants from United States had concerns about crime, concerns about managing work around the house (e.g., household chores, planning meals, shopping), and bigger concerns about boredom (e.g., nothing to do, wasted time) than the present sample. This variation in concerns may be explained by the "different world context" phenomenon, as cited in Lepore, Palsane and Evans (1991, p. 1034). Miller and Miller's sample was selected from an urban residential population in New York State, and participants involved in Segal and VanderVoort's study came from California, whereas the present sample was selected from a relatively small city in New Zealand. Dunedin residents have less concern about crime rates. The availability and geographical accessibility to activities in Dunedin are relatively better than in New York.

The impact of stress depends not only on the frequency and perceived severity of stress but also on their content and meaning in the person's life (Benedittis & Lorenzetti, 1992; Fernandez & Sheffield, 1996). For example, the item of "thoughts about the future" was reported by the participants to be both the most frequent and the most severe stress. The participants had concerns about where they will live, and whether they will have enough money to survive in the community. Interestingly, this item, "thoughts about the future", was also identified by a sample of 120 adults, randomly selected from a city in North Island in New Zealand, as the most frequently reported stress (Chamberlain & Zika, 1990). Therefore, it is not clear whether "thoughts about the future" is a stress specific to people with mental health problems or whether it is a broadly-experienced stress identified by individuals in the wider community.

The present findings were consistent with a growing number of studies (Billings & Moos, 1984; Felton & Revenson, 1984) showing that coping methods generally have only modest effects on well-being. For example, Wineman, Durand and McCulloch (1994) found that coping methods were not significant predictors of emotional well-being in persons with multiple sclerosis or a spinal cord injury. Roberts (1995) asserted that even though college students matched the methods of coping with the appraised controllability of their daily stresses, they reported a high level of psychological symptomatology. Before concluding that coping methods are of little value, it has been argued that several factors may affect the complex relation between coping methods and mental health outcome. First, evaluation studies on the relationship between coping methods and well-being ought to focus on the specific problem for which coping methods were executed rather than measuring the effect of coping methods on general health outcome (McCrae & Costa, 1986). Second, current coping inventories may omit coping methods that are used by certain groups of participants. For example, in the present study, some participants responded that their coping methods included praying and sticking to daily routine. Third, most of the studies reviewed did not delineate the contextual appropriateness, vigor, or skills in using those coping methods, nor the sequence in which multiple coping methods were used.

In the present study, employment status (36% of the participants were engaged in some form of work) was found to have a significant effect on the total number of stresses reported. This finding was consistent with the current discussion about the benefits of engaging in work activities for people with psychiatric disabilities. Work provides an income and security and it has been shown to positively affect mental health (Bell & Lysaker, 1995; Bell, Lysaker & Milstein, 1996; Janlert, 1997). In our society, employment provides a major life role and is a primary source of self-esteem. Engagement in work activities provides "a feeling of full participation in society through performance of expected adult roles" (Blankertz & Keller, 1997, p. 51). On the other hand, work can also be a major source of stress for example, work may decrease opportunities for autonomy and self-development (see Cohen, 1990 for a comprehensive review on work from sociopolitical and psychological perspective). Thus these very differences in employment status between individuals reporting stress support the notion that stress experienced is role-related and environmentally determined (Folkman, Lazarus, Pimley, & Novacek, 1987; Segal & VanderVoort, 1993a).

The present study has several implications for rehabilitation for people with psychiatric disabilities. Firstly, the Daily Hassles Scale may be used as a clinical instrument to help identify the level of stress experienced by individuals with psychiatric disabilities, the features of individuals' environment, and the individuals' important life themes. Measure of daily stresses may also be a useful way to predict the level of personal adjustment and community integration (Blankstein & Flett, 1992). Secondly, the training and support for people with psychiatric disabilities on coping with daily stresses may be more effective if the training is focused on coping methods for specific problems. Additionally, the individuals' environment, persistence and skill in using the coping methods should not be underestimated. Lastly, the present study reinforces the value of helping individuals with psychiatric disabilities to engage in structured and purposeful occupations including paid work. The employment rate for individuals with severe mental illness is far from satisfactory. Krupa (1998) suggested that, based on North American employment statistics, only 5-15% of people who recover from long-term psychiatric disorders are competitively employed. Anthony (1994, p. 17) stated, "In fact, a person [with long-term mental illness] discharged from a psychiatric inpatient unit has a better chance of returning to the hospital than of returning to work!"

Several limitations of the present study must be acknowledged. First, the sample size is small, constraining the representativeness of the sampled participants to their population. Second, the non-random nature of the sample limits the application of the findings to the wider population of people with psychiatric disabilities. Finally, it is very tempting to infer causal relationships among variables in the present study. However, since all the data were obtained retrospectively and the analysis was based on a cross-sectional design, it is inappropriate to make and evaluate the causal inferences. Despite the methodological limitations, the present study is an important step in studying daily stresses for people with long-term psychiatric disabilities in the context of New Zealand. The present study suggests the daily stresses reported by the participants were greatly determined by their life roles and the context of their environment. Maori, New Zealand indigenous people, are overrepresented in New Zealand mental health statistics. A challenge for future research of studying daily stresses in New Zealand or the United States is to use a valid stress scale that will reflect the life experiences of consumers of mental health services in that country. Another challenge is to develop longitudinal studies of coping with daily stresses in samples of people with long-term psychiatric disabilities.

(1) Item (1): Seeking social support was described as the process to find advice or emotional support from significant others, friends or professionals. Item (2): Blaming self was described as a passive strategy to direct inwardly rather than toward the problem. Item (3): Active thinking was to plan about how to cope with a stressor. It involved coming up with action plans, thinking about what steps to take and how best to handle the situation. Item (4): Wishful thinking was to wish that the situation will go away or somehow be over with. Item (5): Active behavior was described as the process to take active and direct steps to try to remove the stressor or to alleviate the stress level. Active behavior included initiating direct action, increasing one's effort and trying to execute a course of action generated from the coping method of active thinking. Item (6): Alcohol-drug disengagement referred to the use of alcohol or nonprescripted drugs to try not to think about hassles. Item (7): Reinterpretation and growth was described as the coping method to appraise stressful situation positively as a form of emotion-focused coping. Item (8): Distraction was described as the process to divert individual's attention away from hassles by thinking about other things or engaging in some activities.

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Samson Shu-Ki Tse, Department of Occupational Therapy, Otago Polytechnic, Private Bag 1910, Dunedin, New Zealand. Email: [e-mail]3