The International Journal of Psychosocial Rehabilitation

Love among Couples Diagnosed with Schizophrenia

 

Brenda Geiger, Ph.D.

Safed Regional College- Bar Ilan University  

Juan Bar-El, MD, Mazrah Institution for the Mentally Ill

 

Friedman, G.

Ordan H.

 Lasry, A.

 Ohn, T.
 

Western Galilee College

 

 Citation:
Geiger, B., Friedman, G., Ordan, H., Lasry, A. & Ohn, T.  (2005). Love among Couples Diagnosed with
Schizophrenia.   International Journal of Psychosocial Rehabilitation.  10 (1), 105-122

 

Contact:

Brenda Geiger, Ph.D,.Bar-Ilan University, Western Galilee Campus, PO Box 2125, Acre 24121, Israel   E-Mail:  geigerb@netvision.net.il

 

 

 

Abstract

This qualitative study aimed at finding out what the experience of love and being loved meant to couples both  diagnozed with chronic schizophrenia in and out the mental health clinic and the impact of such a relationship in their psychosocial functioning. The sample included ten heterosexual couples treated with second generation“atypical” antipsychotic drugs.   Our primary research tool the in-depth semi-structured focused interview usually conducted with each one of the 20 partners separately. Content analysis of the interviews indicated that the actions partners engaged in to express their  love were circumscribed by the rules of the institution, the partners’ ethnicity and religion, and their level of sexual freedom. Yet, despite those constraints, the experience of love enhanced motivation and the desire to come out of social and emotional isolation and become aware of the loved partners needs and emotions. Love gave research participants the strength to escape despair, to take care of themselves, to hope and plan for their future.   No longer in a world of their own, couples requested some privacy and physical space in which they could be intimate in the institution or half-way house.   Other ethical issues addressed in this article are (1) the right to privacy and intimacy and (2) mixed couples, Jewish and Arab,  transgressing the normative constraints imposed by tradition and religion, (3) separation, and (4) being financially taken advantaged of.  Guidelines are proposed to accommodate the emerging needs of heterosexual couples diagnozed with schizophrenia in love within an institutional framework.
 
 
Background
Bertrand Russell (1929), and later Eric Fromm (1957), and Buber (1958),  saw in love much more than lust and the desire for sexual intercourse.  Love was the principal means to transcend loneliness in existence through the union with, and concern for, the loved person. The current study examines the experience of being in love and being loved meant to heterosexual couples both diagnosed with chronic schizophrenia and the impact of  such  love on  their socioemotional functioning.
 
Since Plato’s symposium (2001) several taxonomies of love have been formulated with the emphasis on reciprocity and caring and the development empathy (Rubin's, 1973 ; Selman, 1980; Sternberg & Grajek’s.   These components enable each one of the partners in a couple to go beyond a self-centered egocentric perspective in order to see things from the perspective of the loved partner (Selman, 1980).  Ceasing to focus uniquely on their own self, the partners in love become transformed as they reflect to one another their own needs, feelings, and emotions.
 
Awareness of self and others’ needs and feelings has historically been considered to be lacking in person diagnozed with schizophrenia. These persons been described as confused about their own identity, losing ego boundaries, and as having difficulty in adopting a third-party perspective (Carini & Nevid, 1992; Harrow & Quilan, 1984).  They typically exhibit reduced emotional responsiveness characterized by apathy, anhedonia, and blunted affect (Herbener & Harrow, 2002). Although they have the capacity to feel different emotions, they seem to have difficulty expressing and perceiving those emotions.  At times, persons diagnozed with schizophrenia also exhibit inappropriate emotional responses (Penn, D.L. Combs, D.S., Ritchie, M., Francis, J., Cassisi, J., Morris, S. & Townsend, M., 2000).  Their cognitive, social, and emotional skills have been described as deficient and characterized by looseness of association, distractibility, and inability to pay attention to and pick up interpersonal cues.  Such deficiencies usually impair interpersonal communication, and lead to social withdrawal, lack of social interaction and stigma (Asarnow, Carlso, & Guthrie, 1990; Elkins, 1992; McGlashan, 1986; Grillon, 1990; Penn, Comb & Mohammed, 2001; Penn, Kholmaier & Corrigan, 2000).  
 
While antipsychotic medications have been effective at reducing positive symptoms such as hallucinations and delusions only the advent of atypicial antipsychotic medications was able to alleviate those negative symptom  related to  cognitive and emotional impairments exhibited in schizophrenia (Bilder, R. M., Goldman, R. S.,  Volavka, J., Czobor, P., Hoptman, M., Sheitman, B.,  Lindenmayer, J.,  Citrome, L., McEvoy, J., Kunz, M., Chakos,  M., Cooper, T. B. Horowitz, T. L.,  & Lieberman, J. A. 2002; Kane, J. M., Marder, S.R. Schooler, N.R., Wirshing, W. C. Umbricht, D., Baker, R. W. Wirshing, D. A., Safferman, A., Ganguli, R., Mcmeniman, M., & Borenstein, M., 2001).  Once treated with such atypic antipsychotic medication persons diagnozed with schizophrenia were found to be better able at monitoring the cues that guide and shape ongoing interactions.  Consequently the  inappropriate and eccentric affective responses that used to interrupt the flow of mutual expectations and disrupt interpersonal communication greatly diminished  (Heinssen & Cuthbert, 2001; McGlashan, 1986; Samem, Kring, & Kerr, 1996).  When added to medical treatment,  staff’s accessibility, and acceptance, social skill training, and rehabilitative techniques were found to ameliorate schizophrenics’ interpersonal skills and change distorted and anxiety-producing schemata of attachment relationships thus allowing them to come out of their social isolation (Bengtsson-Tops & Hansson, 1999;  Heinssen &  Cuthbert, 2001; Nisenson & Berenbaum, 1998).  As a result, the natural propensity for attachment and love relationship among these persons emerges in and out of the mental health clinic.
 
The development and maintenance of a love relationship among couples, both of whom were diagnosed as chronic schizophrenic, has rarely been studied. The reason for this  neglect may be related to the fact that such a relationship was often assumed to be nonexistent. This topic is, however, of great significance to the field, since to love and feel loved by another person requires self-awareness and awareness of the other, as well as mature emotional and cognitive capacities for empathy and interpersonal communication (Erikson, 1959; Kohlberg, 1969).  The goal of this qualitative research is, therefore, to discover what the subjective experience of loving and being loved meant to chronic persons diagnozed with schizophrenia at different stages of their love relationship, and the impact of such a relationship on each one of the partners’ mental health,  and socioemotional functioning.
 
Method
Sample Description
The sample included 20 heterosexual partners in a love relationship. Each one of the partner was diagnosed as chronic schizophrenic  by two ward psychiatrics using Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 2000).  All  members of the couples were treated with second generation “atypical” antipsychotic drug [1]  They were all enrolled  in verbal and nonverbal interpersonal  and motor skill training.   Some of the couples also worked outside of the institution in a rehabilitation factory specially designed for them.    Five of the couples lived in a mental-health institution, a sixth lived in assisted living and would come to the institution only during the day.  The remaining  couples resided in the community in half-way houses for the mentally ill.  Most of the couples had several times been hospitalized in a in patient mental-health institution located in Northern Israel.  Except for one couple in which the female was 8 years older, females was younger than their male partner.  The age range of female partners was 28 to 38 years, Mean=33.5, Median=35.   The age range of males was  between 22 to 60 years,  Mean=43; median=45. The widest age difference between a male and a female partner was 25 years.  In seven out of ten couples both partners were Jewish.  Two other couples were ethnically mixed, with the female partner being Muslim and the male partner Jewish whereas in the last couple both partners were Muslim.
 
No requirement was placed on the length of relationship, which was found to vary from one month to five years. In many cases, the partners knew each other either from the mental health institution or their place of work several years before they had become a couple. Six out of the 20 members in the couples had previously been married or had had a close relationship with another partner in the past. Although four participants had children from a prior marriage,  only male and one female were regularly visited by them.    One of the females in the sample had seven young children whom she has lost touch with.  For cultural reason no family member brought the children to visit.   The purpose of the research was explained to the research participants prior to obtaining their consent.  Confidentiality and anonymity were guaranteed; all names and identifying information were replaced by pseudonyms.
 

Procedure
The in-depth semi-structured focused interview was chosen as the most appropriate research tool to examine what the experience of love and being loved meant at different stages of the relationship.   Focused interviews have been viewed as a “directional conversation that elicits inner views of respondents' lives as they portray their worlds, experiences, and observations" (Charmaz, 1991, p. 385).  Questions included in the interview guides aimed at exploring the degree to which interviewees were aware of their own needs and feelings, and of those of their partners, what were  the cues particants relied on to express their love and understand that they were loved.  Additional questions inquired about the raison d'être of the love relationship, its costs and benefits, the needs it satisfied, and the support it provided.  Questions regarding physical attraction and sexual intercourse were included. Questions were asked about the extent to which the love experienced had influenced the partners’ daily living and future plans.
 
The interviews, which lasted two to three hours, were conducted at the partner’s place of residence, either in the mental health institution, or the half-way house.  For eight  out  of  ten couples, each one of the partners was interviewed separately.  The remaining two couples were interviewed together due to the inability of one of the partners to communicate in Hebrew. All the interviews were conducted in Hebrew, except for one which was conducted in Arabic.  To allow for the interviewee's narrative to flow naturally, the interviewers (one male and one female)  kept interference to a minimum and waited until the end of the narrative to inquire about topics appearing in the interview guide which had not been addressed by the research participant. Participant comportment and nonverbal expressions were also noted.
 
Analysis
Content analysis of interviews was, therefore, chosen as the most appropriate research tool to analyze the  experience of such close relationships. (Brunner, 1990; Coles, 1989; Denzin, 1989; Holsti, 1969; Richardson, 1990).  The  analysis followed the constant comparative method (Glaser & Strauss, 1967; Strauss, 1987). Interviews were transcribed and repeatedly listened to while reading the transcript.  Then, each interview was deconstructed into core themes and compared to other interviews for similarities and differences. Comparisons and contrasts allowed to inductively infer composite themes that reflected the participants’ shared practice and common meanings (Lincoln & Guba, 1985). The researchers were not interested in establishing the accuracy of the participants' answers, but in finding out the participants’ subjective truth, the truth the participants perceived, interpreted and communicated at the time of the interview (Gergen, 1980).  Partners’ accounts of their love relationship were, therefore, supported by autobiographical information and direct quotes from the interviews (Stiles, 1993). 
 
Findings
As residents of a mental health institution or half-way house, all the research participants, except for one couple residing in the community, were not concerned with paying the bills or cooking. haTheir basic needs were taken care of, they had plenty of time to be with each other, socialize, and fall in love! In the words of Hanna, who lived in a half-way house,
Here we do not have to worry about anything. Your meals are scheduled, your food is on time. You can shower, you have a room. We have here everything.  So we have love and love is much more sweet like that,  with more concern,  with compliments, with love.  Love with sweetness.
 
Proximity in space was an essential criterion to initiate a relationship.  It allowed each one of the partners to read and understand the other partner’s cues expressing interest and/or to feel personal attraction.  For instance, Dany who for eight years had been seeing Osnat going through the revolving door of the institution but never approached her, until  they sat, next to each other on a  bench.  Dany remembered:  “It was in the canteen, she sat next to me and smiled at me.  I understood she wanted me!”   Tony also told us how Linda had attracted him: “She came to me. I was in Unit 2.  She came to the window and brought me pizza and other food!”
 
Physical Appearance and Attraction
For some partners, physical appearance was an important issue, for others it was not. In the former case, both partners were aware of each other  desire.  For instance,  Dany was seduced by his girlfriend Osnat’s appearance, “She is tall and thin, she is like a model! She is funny, she is energetic!” By contrast, Osnat was repelled by Dany’s weight:
He has a nice looking face, the problem is his body. Is it possible to help him?; to explain to him about the food he eats.  Even his sister calls him ‘fatso.’  I want a man who is athletic. He would be happy if you could help him lose weight. 
 
Dany who was interviewed separately,  was fully aware of Osnot’s conerns: “She [Osnat] is not happy with my body!”  Sam had similar complaints about his girlfriend Rina. While describing characteristics of the ideal woman, Sam explained,
 I love her delicate face, a very beautiful face, and her nose and her lips! To tell you the truth, her face is beautiful, but her body is a catastrophe!….I love a woman with class, very intelligent, very delicate, this is the woman I love!  I do not love her face or her body… I love her style! (Sam)   
 
Rina was perfectly aware that Sam was not satisfied with her obesity.  In her own words, “He does not want me to eat too much, because it is not healthy for the heart (Rina).”
 
For two other couples, having no teeth or being overweight was of no concern to them.  For instance, Barry who during all the interview had been complaining that Natalie, his girlfriend, had not showered for two days and who was disturbed by her body’s odor, never commented on  her heavy appearance.  He just wanted her to take a shower!  [2] Vadim,  remarked that beauty was in the eyes of the beholder when he described his girlfriend  “She has long hair brown black hair. To me she looks beautiful, to another person she might not.”
 
Personal Qualities
Female participants often mentioned the comfort, support, and protection their partner gave them. The way their partner treated them and his largeness were additional reasons for loving them.  In the words of Rina,
He is good, he behaves nice to me, he protects me. He is not cheap, he bought me presents… He gives everyone cigarettes and does not ask from anyone anything!… He is the most loyal of all men I know! Only on  him I can count. He is a great guy!
 
Similarly, Fatana loved the serenity of her male partner. It  did not bother her  that her partner had no teeth and had been an alcoholic. For her  “to love is to love a person with all his drawbacks, to understand him, and be patient!” In contrast,  Mustafa  had found in Yisha the perfect mix of  internal and external beauty. In his own words,
Look at her  beauty, her softness and her kindness!   Is there anything  better than that!  Who wants more? Who could find anything more beautiful than that?  We love each other [Yisha smiles].
 
Outward Expressions of Love and Affection Holding hands, kissing and hugging, and saying “I love you!”, were the many ways partners expressed their love and conveyed to one another their feelings.    In the words of some of the participants:
She tells me she loves me with a kiss. She says ‘I am crazy about you!’ or only kisses me.  I also tell her I love her!    I feel we are a couple. I even called ERAN [the emergency hot line]  to tell them that I had a girlfriend. It is good to be with her. She is beautiful! I am ready to give her anything…. I want to live with her all my life (Dany).
 
She gives me everthing! She gives me love, she gives me a good heart. She kisses me….   She hugs me (Barry).


Presents:  Love was also expressed by giving presents and seeing the joy the partner experiences. In the words of Sam, 
Love is the greatest word in the universe!  But what is love?… I will tell you!  I saw a pair of pants and I bought it for her.  When I saw the joy on her face it was for me all the world!
 
Dany told us about the very special present he had given to Osnat.  It was an underwear that he had purchased long ago for his imaginary model girlfriend who had now become a reality. Dany recounts,
Once I went to the store [lingerie store] and told them that I had a girlfriend who was a model and wanted to buy an underwear. I did not have a girlfriend then.  I gave it to Osnat.
 
Inward Signs of  Love
Being loved and loving made the partners feel good!
 
He tells me:” Come !” and gives me a big hug. His hug and love give me a warm feeling (Osnat).
 
He gives me a good feeling, he appreciates me (Rita).
 
 
Escape from Loneliness, and Depression
For all the participants, love provided an escape from despair and isolation.  To love was no longer to be alone; it was to be together.   In their own words:
When we are together and listen to the music I feel like a couple. To be a couple is to be together. Without a girlfriend, it is only one world.  With a girlfriend, it is two worlds (Dany).
 
I was alone! To live alone is not the same.  I have also lived alone. It is not good to live alone! It is terrible! A person alone is like a blind man. [italics added for emphasis]. It is not good to live alone! (Ed).  
 
After recanting about his mother divorcing his father and leaving for Germany, his father abandoning him and his first girlfriend suddenly dying of an overdose of Vodka, Barry told us how much his present girlfriend, Natalie,  had helped him. He  recounted,
I was alone, I stayed alone, I was lonely. This is why I get depressed.   With Natalie I am less lonely, I have someone with me. I  go away from depression.
 

Awareness of  One’s Own Needs and Those of One’s Partner

Being in a romantic relationship made  the participants concerned about their own appearance, which they had previously often neglected. In their own words,

When I did not have Natalie I did not want to take a shower or comb my hair. I had mental depression; I was neglecting myself  (Barry).

 

When you live with someone you want to be clean and orderly; you want to change clothes! (Ed).

 

Similarly, destructive behaviors were rejected as no longer needed.  For instance, once in a relationship with Waffa, Vadim no longer needed to drink

I drink when I do not feel good. She makes me feel good! When she comes I dress nicely and put on perfume. When I was drinking I was neglected. I was not okay! 

 

Awareness of the Partner’s Needs

To love was to be aware and to take care of one’s partner’s needs. Dany and Osnat would obtain a pass from 1pm  to 6pm  to go to the apartment that Dany shared with his mother. In his room, Dany helped Osnat relax while listening to music.  In the words of Osnat,

He puts music, he helps me relax.  We sleep together in the afternoon. He likes music, quiet music like me (Osnat).

 

Dany echoed Osnat’s sentiments,

 

 If she wants me to make coffee, I make coffee.  If she wants me to bring her a slice of bread with spread cheese, I bring it to her.

 

Sam and Mustafa perceived themselves as knights protecting their “ladies” from evil figures around them.  In the words of Sam,

 She needs someone to protect her from all these dogs!   She is too easy! She runs very easily to men. Anyone throws a good word at her and he buys her. I just leave and they all jump on her.     

 

Speaking about his girlfriend’s husband, Mustafa explained.

He does not help her, worry for her or take care of her.  I do anything for her. Yesterday he came to visit her, but did not bring her anything. I want to help her.  I want to do everything for her.   Her husband does not give her a shekel [equivalent of 21 cents].  He takes all of her Biteuch Leumi [social security].    

 

For Waffa,  to take care of Vadim was to cook the food he liked: “I know that Russians love fish, and Kaviar, so I cook fish with potatoes, it tastes good. He likes it.”  

 

Participation in Joint Activities

When in love, partners wanted to share their recreational activities.  In the institution this meant sitting on the grass, talking, holding hands, eating together, and at times buying ice cream at the minimarket nearby.  In the words of Mustafa,

We eat together. The kids bring food and things, and we eat together.  Then I go to rest a little and then I go back to her.   We also eat breakfast together.   I do not work or anything. I can be with her all the time.

 

The one couple who lived in assisted living and came daily from 7:30 am to 1 pm to the institution, was much more autonomous and could engage in a  wider range of activities.  Ed recounts,

We cook together, do the laundry, shop together.  We do everything together!    I prepare the food, she cooks it.  I cut the potatoes; she fries them.  We hang out together, we go out to restaurant, we take care of the dog together. 

 

Sharing Problems and Worries 

The extent to which the partners shared problems and worries depended on their  personal idiosyncracies.  Some of the partners felt the need to share.  Similarly, some of the partners more than others were better at listening, and at focusing on their lover’s needs.  For instance, while Dany and Andre listened at length to their girlfriend’s concerns, they were less able to share their own feelings. In their own words,

She does not keep things inside, she says it, she gets angry.  I shut up and keep quiet.  There are things I want to tell her, but I do not. I do not know if she can take it (Dany).

 

I keep everything inside.  I do not tell anyone!   She shares with me her feelings and thoughts. I listen to her and try to help her, and answer her, but what I feel, how I feel, she does not know! (Andre).

 

Barry, on the other hand, felt no need to share his problems with Natalie.  The social worker would fulfill that purpose.  With Natalie he spoke of love.   In his own words,

I do not talk about my problems.  I talk to her about love.  I talk to her about what is good in my soul!  About my problems, I talk to Olga, the social worker. 

 

The capacity for empathy and sensitivity for the partner’s suffering were best captured by one of the research participants, Ed.  Ed was stayin  up all night to be there for his girlfriend Linda who worried about  her sick father. 

Ed: Yesterday she did not sleep all night! She is a little worried,  her dad is sick!

Interviewer: How do you know that she is worried about her dad?

Ed: She calls him on  the phone! 

Interviewer: Does she tell you she is worried?

Ed:  No, I hear her voice on the phone.  So I know. 

Interviewer: And  when she does not sleep, do you sleep?

Ed:  No,  we both stay up and watch the TV show “Life of Love”.

 

Expressing Negative feelings

Love led  partners  to experience negative feelings such anger and jealousy.   Sam  and Andre  were experiencing these feelings because of the rumors they heard  circulating about their girlfriends’ unfaithfulness. In their own words,

Sam: They try to flirt with her. She had many boyfriends in the half-way house, not only one― four.

Interviewer: How do you feel when other men talk to her?

Sam: I am jealous. It makes me mad, because she is not guilty. He takes advantage of her.

 

As the interview progressed, Sam also revealed that he had hit his girlfriend, who was now fearing him. 

I like to be with her, but I think she is a little scared of me. A couple days ago I hit her. She is okay. She always asks me if I want to be alone, if she disturbs me. I tell her “Enough! Do not feel that I do not want you or reject you!”

 

Maia, Andre’s girlfriend  knew that he was angry because she had kissed someone else. She noted that “There is here another guy who is crazy about me. He all the time looks for me! I would not say that in front of Andre, because he is very jealous.“ 

 

 

Future Orientation, Love, and Personal Strengths

Each one of these romantic episodes, unique in its autobiographical details, progressed along a timeline.  Some of the partners, at the beginning of their love relationship, were still unsure of their love and therefore, could not enjoy the psychological security that would have allowed them to escape loneliness.  For instance, Andre,  22 years old,  was still feeling depressed even though  had a girlfriend, Maia 30 years old, whom he had met three months ago.  In the words of Andre,

I am a little depressed. My life here is empty. I want to be home, to find a job and live my life.…Maybe we will live together. I am not sure.

 

 Comparing past and present relationships, Andre did not feel for Maia the same  love  he had felt  when he was 16 years old.  He recounted,

I loved her so much.  I was a little kid and until today I still love her! I do not yet feel those things for Maia. I do not know if it is serious,  I have to live with her and see.  I want to see how she is at home, her nerves, see everything, then decide maybe if she will fit me. If I love her,  I will marry her.

 

In contrast,  the partners who were deeply in love had acquired the strength  and motivation to plan for the future. Barry’s future plans were very clear― He wanted e wantto spend his life with Natalie!  “I want to marry Natalie, I am big already!  Thirty-five years old!  I want to live with her―that’s it.”

 To achieve this goal, Barry had applied for subsidized assisted living and was on a three-month waiting list.  Barry was also planning to have children:  “I want a boy and a girl” (Barry).

  

Similarly, the love Waffa had for Vadim had given her the strength to think about  finishing her bachelor’s degree. In her own words,

I love him. Without him I was desperate, now I have hope. I do not want to be in the hospital. It destroys your confidence. I want to work, to study, to have fun.  I want to go back to school. Studying is important. It gives you confidence and dignity.  I want him to be released from the hospital.  I want him to work, that we have a life, a home, and money!

 

Despite some disassociative thinking, and inappropriate laughter Osnat also shared with us her plans for the future as she explained:

You cannot climb a ladder all at once, you will slip! [laughing] I like to joke!

[Three sentences later she explained]

Me and Dany love each other terribly. We have decided on a wedding date January 10th next year, and the place of the wedding.  I want a wedding without a dress and without guests because they drive me crazy (Osnat).

 

In the case of ethnically mixed couples, love also gave the partners the courage to fight a desperate battle against religion and tradition.   For instance,  Vadim, a Russian Jew, was ready to convert to Islam to marry Waffa.  In Vadim’s words, “On the paper it will be written that I am an Arab. But in my heart, I will stay Jewish!”  Waffa, Vadim’s girlfriend, was full of apprehension.  She feared that even a conversion would not suffice. Waffa knew she could have a civil wedding in Cyprus which would be recognized de facto Israel since none is performed  in Israel.  However this alternative was a solution for her  since  she did not want to have trouble with her family.  Her parents had died, and her uncle had already rejected one of the students who proposed to her. She remembered,  “They sat and drank and then he kicked the guy out.   I became sick.”  Now she was scared to approach her brother. She exclaimed: “They will not accept the marriage!” 

 

Mustafa and Yisha, both Muslims, and already married, were deeply in love and dreamt about an impossible future together. The fact that Mustafa was married did not represent a problem, since according to the Muslim religion men are allowed to have up to four wives. Mustafa reported that

My wife will go crazy if get married to her. But I do not care.  I was living alone.   I cannot live with my wife! My children  know her and love her very much. They respect her very much. I told them I want to marry her.

 

However,  a different destiny awaited Yisha outside the institution.  Death and bloodshed were the price unfaithful Muslim women had to pay, as family members avenge the honor of their family through murder. One of the interviewers reminded Yisha of these facts while speaking in Arabic, since she did not understand Hebrew. Yisha’s face immediately became sad and stern.  Mustafa switched from Hebrew to Arabic to clarify his intentions to Yisha.  In case she does obtain a divorce, they would remain forever in the insitution.  Mustafa explained that

I want to speak in Arabic so she understands where we are going.  We shall talk to him [her husband]  and ask him to divorce her.  We shall get married, ‘in sha Allah’ (if God pleases).  If her husband leaves her or divorces her, we shall get married.  If he does not let her, we shall stay here.   Here we are with one another.  Maybe rather than killing her, God will take his soul instead!

 

 

Coping with Separation

At times, the future meant being temporarily separated from each other.   Osnat and Dany had planned to get married, yet, Osnat was about to leave to a half-way house located 2 hours from the insititution where both partners presently resided.  Dany’s script of the separation was unclear.  He told us that he would travel by bus to go and visit Osnat and maintain phone contact with her.   When addressing the eventuality of a permanent separation, Dany explained that he would be sad for one or two weeks, call ERAN (the emergency hot line),  and forget about it!! 

 

Similarly, Sam seemed quite detached when facing a hypothetical separation

When I leave a place, I detach myself from it. It is my defense mechanism!  Without wanting to detach myself,  I detach myself!  I find something more interesting to do!   I look forward, not backward.  Sick people have to understand that here it is not their house! What is love?  Far away from the eyes, away from your heart!  What do you want me to feel? That day and night I think about her because I love her? I love many things!  I also love cigarettes!  If I do not have any I go crazy!   

 

Separation had become a reality for one of the participants at the time of the interview. Heartbroken, Itzak (53 years of age) was longing for his beloved girlfriend, Lisa (38 years), who for the past three weeks had stopped coming to the half-way house in which he resisded.   Lisa was upset with him because he had refused to give her 300 shekels [about 65 US dollars].   Repeatedly squeezing his neck as if he strangulating himself, Itzak explained that he had been warned that Lisa was only after his money but he disagreed:

Since  the time she came and asked me for 300 shekels  and I did not  give it to her,  she stopped coming. I simply did not have money in my pocket! I could not give it to her.  Since then she did not come… I know her from a long time! I want her! I love her…. I know her, but I did not have money, so she got mad at me! She is a good girl, a good soul! She will come back!

 

Interviewer: Does she take advantage of you financially?

Itzak: She does not take advantage! For a girl you do everything!  [Itzak knew she was seeing other men] This girl goes one time with this guy, another time with that one. [Yet, she showed concern for him]  She also washed my laundry and put it in my room!

 

Longing for Lisa, whom he had known for so many years, Itzak continued,

I love her, so I give her!  She will come back! We shall be friends! Every man wants a woman! She hugs me and kisses me. She makes me feel good! She makes me feel  love!

 

Listening to this sad tale made the researchers wonder whether Itzak was really being taken advantage of, or simply exchanging money for kindness and an illusion of love many “healthy” people were also ready to pay for! 

 

For one of the women, the love relationsihp had turned into a nightmare!  Nava, a 36-year old Muslim woman, had fallen in love with a Jewish man while in the institution.  Once released, the couple had eloped to Cyprus to get married.  Nava up to this day never revealed to her brothers she had been married, and divorced.  Nava’s romantic relationship lasted four years. However, once out of the institution,  her spouse stop taking his medication.  The relationship rapidly deteriorated. In her own words:

He played it cool in the institution! In love! When we went out he stopped taking medicine. He also cheated the doctors. He told them “I take the medicine! I feel good,  I love my wife!” He told me:” The doctor did not give medicine.”  But, I knew that he was lying.”. Before the wedding, everything was okay!  He used to sleep with me, but after he cheated on me. I saw him kiss a woman on the lips! I told him: “What is this?”  He said: “She kissed me!”  In 1997 we got married…the social worker arranged that I work as a cleaning woman.   I gave him all my money and did not buy anything for myself.  He spent all the money on his friends, to buy cigarettes and beer for them. When I told him ”It cannot continue like that!” arguments started! the problems started!”

 

Nava had lost all illusions about love! She reported that,

 

He told me “I will protect you! I love you! Nonsense! I do not believe in love!   I do not want to fall in love!  Love is blind! It disappoints you! 

 

Falling out of love all that Nava now wanted was to be independent. She told us: 

I do not want men who tell me what to do,  who decide for me what to do! I want to be divorced, free with myself!    I want my own home.  I only look for a guy to speak with,  to spent time with! They make me feel good.  I do not care what other people say!

 

Sex and Lack of Privacy

Love relationships were not always consummated in sexual intercourse.   The level of sexual intimacy of the participants had reached was usually determined by the level of religiosity and sexual freedom of the female partner.   Five of the ten couples did not have sex based on  cultural and religious grounds. The female partner was the one who set the limits concerning how far she was willing to go by either wearing traditional clothes or indicating outright to her partner that sex was not the right thing to do outside of marriage.  Osnat, who was 28-years old, stated “We love each other, but with limits! What I like about myself  is that I watch myself.”

For Mustafa and Yisha, the Muslim couple, sex was out of question.   Yisha was religious. She was wearing a white scarf on her head.  When asked about sex, Mustafa exclaimed:

No! It is forbidden! She is religious!… She prays!  It is forbidden! It is a sin .  But God will help us.

 

The male partners complied with their girlfriend’s request.  For instance, Osnat went  to Dany’s apartment in the afternoon and layed next to him in bed while listening to music.  Yet Dany never took advantage of the situation to force sexual intercourse on her.   Vadim, a Russian immigrant, also respected his girlfriend’s  wishes, when he explained:

 Vadim:  Only kisses, no sex, until after marriage                     

 Interviewer:    This is what she wants?

 Vadim:  Yes!

 

Nevertheless, the limits set by the female partners did not prevent male partners’ from fantasizing about better days!  When asked: “Why is it good to be together?” Vadim replied: “Because of sex!”  Similarly, Dany who never had a girlfriend before expressed the same longing for sex:

 Dany: To love! To get married! To have sex!  To tell you the

 truth, after many years you can have a lot of sex!

 Interviewer:  Do you like sex?       

 Dany:    Of course, every man likes sex.         

 Interviewer:  Does she give you sex?         

 Dany:    Yes! In the future!  [Italics added for emphasis]

 

For those female partners  who were sexually liberated, sex was a natural thing when you are in love.  In the words of Rita,

A boyfriend is something natural! If a woman does not have sex with a man it is not worth it!! I did not have sex for 15 years….. A woman who has a boyfriend and has sex loses weight. A boyfriend is good for your soul, except those who hit….the truth is that we did not have sex…but here and there!

 

For Maia, to have sex was a way to achieve serenity:

 

Without sex there is no bond, no communication, no hugging and kissing… and they are the moments when your partner is calm and you are calm and you enjoy doing things together.  You go on the grass and drink coffee together, we sit in canteen or we look for something to do together.

 

Making love was not easily accomplished within the narrow confines of the institutional framework. Whether in the half-way house or in the closed institution, there was no physical space allocated for couples to be intimate with each other.  The staff seemed to close their eyes and ignore the issue, while fully being aware of the existence of those relationships.   Maia recalls that

The female doctor said: “How was it! Or watch yourself!   People have a big mouth!   But they do not make problems!    It’s like there is no law that says not to have sex in the hospital”

 

Andre explains that everyone finds a corner of his own to have sex.   Mattresses have been  placed in all kind of “secret places” for that  purpose! 

It is allowed, but not in….In the institution, I do not know!  In the rooms it is forbidden. You have sex where you find a place.  There are places where there are mattresses, you can go there.

 

Nava told us about a greenhouse in the mental institution called “the agriculture,” which was the most popular place to have sex.  She explained:

I go with them to the agriculture [a greenhouse]! There is there a “suite” between the trees! There is a mattress and a bed that the guys have fixed!…But there is another place and no one knows about it!

 

The lack of privacy, whether in the institution or half-way house, was a major problem encountered by those couples who wanted to be intimate with each other. Maia explained how difficult it was to find privacy “We have to look all the time for a place.” When asked about the greenhouse, she exclaimed: 

Maia:   No! Out of the question! Imagine that everyone would come to the agriculture. It would end being a very cheap place.  To be discreet is the nice part about it.       

Interviewer:  What would that be like? 

Maia:   I would have liked that they give us a private place to sleep together.   Its like a prison here!

 

Barry, who lived in a half-way house, also had to confront institutional rules that prevented him from being intimate with Natalie. Even though Natalie had her own room, it was against the regulations to spend the night together. In Barry’s words,

 

There is an hour where everyone has to go to sleep. At 11 pm we have to go to our room.  If I stay they make me go up.  The night guard yells and tells me go to sleep!

 

Barry expresses his feelings concerning the lack of privacy,

 

Interviewer:   Are you lacking anything here?

Barry:   I lack being alone, that they do not watch us all the time.                  

Interviewer:  You mean privacy?

Barry:  Yes! There is no privacy here!   If I had a home we would feel closer.  Here you cannot do anything, sleep together, kiss or pet. They  see everything. 

 

Female partners revealed problems related to sexual intercourse such as vaginal infection,  pregnancies, and abortions.  In their own words,

I have a sexual problem….I am ashamed to tell you!  It is always itching down there (Osnat).

 

It is forbidden to have sex. I am itchy.  I have to go to the doctor to be checked! (Rita).

 

 

Discussion

This qualitative study aimed at examing what the experrience of love and being loved meant to  heterosexual couples both  diagnozed  with schizophrenia who resided in the mental health institution or in the community mental health setting.  Content analysis of in-depth semi-structured focused interview were conducted with each member of 10 heterosexual couples treated with “atypical” antipsychotic drugs.  Despite some looseness of association, and eccentric affective responses, research participants told us clearly what the experience of being in love meant to them.

 

In the participants’ love relationship, each unique in itself, emerged all the nuances and shades of feelings of love and affection,  jealousy, and anger.  The importance of the proximity and attractiveness in initiating a love relationship has also been indicated in previous research conducted with healthy couples (Berg & Mcquinn, 1986; Hatfiled &  Traupmann, 1980; Walster, Berschied & Walster, 1978). (Berg & Mcquinn, 1986; Hatfiled &  Traupmann, 1980; Walster, Berschied & Walster, 1978).   For most of the interviewees, the benefits of a love relationship far exceeded its costs.  For most of the interviewees, the benefits of a love relationship far exceeded its costs.  To the research participants to love meant to feel good, to receive and give affection,  to become aware and take care of one’s needs and those of the loved partner. To love meant wanting to be with the other and doing things together.  To kiss, hug  and have sex or dream about it were included in the experience of love and so was the feeling that someone is there when you needed him or her.  To love meant no longer being alone, or depressed. The experience of love allowed research participants to come out of social and emotional withdrawal while focusing on their partners' feelings and wants.  Love gave the purpose and meaning to lives of the research participants. Together, they had the strength and courage to look toward the future, to have their own apartment, to get married, and for some to plan on having children.

 

The findings of the study indicate that once negative symptoms related to cognitive, emotional, and social skill deficiencies were ameliorated by “atypical” antipsychotic medication such as Clozapine, persons diagnozed  with schizophrenia’ natural capacity for love and attachment emerges (Bowlby, 1969).  Love in turn improves motivational deficit,  sharpens attentional and socioemotional skills.  Partners in love exhibited various of degree self-awareness and awareness for each other’s needs and feelings  as well as  empathy. No longer withdrawn in a world of their own,  the couples in love planned a future in which they could love and live together
 

Aside from capturing the subjective experience of the respondents, this study identified concrete problems arising in the institutional framework that must be addressed to accommodate for the emerging needs of schizophrenic couples. Research participants’ most pressing needs for privacy and intimacy conflicted with the very norms of the asylums and those of the institutional framework (Goffman, 1964). Yet, residents need priviacy, love,  and to make love with dignity.  Leaving old mattresses throughout the institution in clandestine places, allowing the residents to find “secret places” to make love, and pretending that staff is unaware of this practice,  is far from effective hospital administration. Therefore, a separate unit for couples and other institutional arrangements could be established. 

 

This study clearly shows the beneficial impact of loving and being loved on the motivational, and socioemotional functional of persons diagniozed with chronic schizophrenia.  Mental health professional must, therefore, recognize and reinforce love relationships  as one of  the best indicators of recovery.

 


 

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Endnotes

____________________________________________________
[1] The second-generation atypical antipsychotic medication most often used by the psychiatrist were Risperidone, Olanzepine, Quetapin, Zyprazidon.

[2] At the end of the second interview, the researchers saw Natalie coming down the stairs with wet hair, and another dress.  Barry was smiling―she had taken a shower!






 


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