The International Journal of Psychosocial Rehabilitation

Perceived Freedom and Life Satisfaction for
People with Long-Term Psychiatric Illness



Kim WanYoung , PhD
University of Bristol, U.K.

Correspondence:
Hong Kong Sheng Kung Hui Welfare Council
1A, Lower Albert Road,
Central, Hong Kong
Phone: +852-98500822
Fax  :+852-28733707
E-mail: dyoung@skhwc.org.hk

Abstract
This study aims at exploring the relationship between individual’s perceived freedom and subjective life satisfaction for people with long-term psychiatric illness. Research sample included 146 subjects, coming from two large residential homes in Hong Kong. Results showed that individual’s perceived freedom was found to be a good predictor of overall life satisfaction.  Also perceived freedom was found to have stronger predictive power than other variables including demographic variables, medical variables, social functioning and current psychiatric symptoms.  Program element in promoting perceived freedom was suggested to be included in residential home care.
Key words: Quality of Life, Perceived Freedom, Mental Illness
  Introduction
People with long-term psychiatric illness are so disabled and impaired that they are difficult to be placed in the community [1].  In the past few decades, several models of community care program for these people have been developed in the Western countries [2-6]. However, these community care models are not widely developed in the community. In fact, the majority of people with long-term psychiatric illness live in residential settings such as hostels and nursing homes.  

In the past few decades, there is an anti-residential care movement [7]. Some research studies found that large residential homes, such as nursing home and board and care home in U.S.A., were characterized by poverty of social environment [8-9].  These researchers criticized that these residential homes became other asylums in the community and took over the functions of the mental hospitals and that moving long-stay patients from mental hospitals means only a transfer from one institutionalizing situation to another [8-9].

This anti-residential care bias is based on the influence of the “literature of dysfunction” in relation to residential care, which is both conceptually limited in its analysis and scientifically flawed in terms of methodology [7]. Research evidences tend to show that residential care has its own value and has numerous advantages [10]. For example, Timko et al. [11] conducted a randomized control study of nursing home care in U.S.A. and found that, as compared with the hospital in-patients, nursing home residents had better choice, control in policies, more social and recreational activities while their subjective life satisfactions remained positive and unchanged. Similarly, Horan et al. [12] reported that residents of hostels and boarding houses in Australia were satisfied with their quality of life although they had negligible participation in daily activities, few family contacts and limited finances. Barry et al. [13], in a one year follow up study of a cohort of 65 long-stay patients who were discharged from mental hospital in U.K. and lived in supported housing schemes and group homes, found that residents had significant improvement in their social functioning and objective quality of life such as having more comfort, autonomy, social interaction, leisure activities and use of community facilities, while their overall life satisfaction remained positive and unchanged.

Although much have been done in exploring the quality of life of people with mental illness living in residential care, few research studies have been done in identifying those program elements leading to a better subjective life satisfaction for them. Indeed, mental health research is often confronted with the problem that the intervention or program under study takes place in a “black box”, which makes it difficult to assess the relative importance of various components of the intervention [14].    Moreover, even with programme that have demonstrated successful outcomes, it is difficult to specify which components of the intervention are responsible for the observed outcomes [15]. Thus more research is needed in identifying those essential elements of residential home leading to life satisfaction or quality of life for its residents.

Among the few research studies in this area, Zissi et al. [16], in a cross sectional study of 54 people with long term mental illness living in a community based hostel in Greece, reported that individual’s subjective life satisfaction were significantly and directly associated by autonomy and positive self-concept. However, the reliability and validity of the scale in measuring individual’s autonomy has not been reported.

Rosenfield [17] has proposed a theoretical framework relating individual’s autonomy to subjective life satisfaction, and stressed the importance of empowerment approach in psychiatric rehabilitation. Based on the research study of Rosenfield [17], program elements adopting empowerment approach could enhance individual’s sense of mastery which in turn could lead to a better overall life satisfaction for people with long-term mental illness

The Sense of Mastery Scale, which has been developed by Pearlin et al. [18], was employed in the study of Rosenfield [17].  However, when the author interviewed several persons with long-term psychiatric illness with that scale as a pretest, the respondents had difficulties in understanding the relatively abstract concept of “mastery”. Most respondents preferred to use the term “freedom” or “restrictions encountered” in their current living place.  It may due to the fact that the characteristics of people with long-term psychiatric illness in Hong Kong were different from the studied group done by Rosenfield.  People with long-term psychiatric illness were too impaired and disabled to have independent living, and in Hong Kong, most of them have to rely on residential or hospital care rather than independent living.  Another reason may due to the cultural difference.  People with long-term psychiatric illness in Hong Kong were mainly belonged to lower class and may not be familiar with the concept of “sense of mastery”, which had been originated from the western culture.  Result from the above pretest showed that respondents concerned whether they could enjoy certain kinds of freedom, including the freedom to go outside, freedom to enjoy community facilities, or whether the management of their current living place were restrictive in their daily routine.  It indicated that respondents were familiar with the term freedom, rather than mastery, and concerned it very much.  So, this study decides to measure individual’s perceived freedom rather than sense of mastery.

Research Aims and Hypothesizes
The aim of this research study is to explore the relationship between individual’s perceived freedom and subjective life satisfaction for people with long-term psychiatric illness.

The research hypothesis is that individual’s perceived freedom predicts subjective life satisfaction well. In other words, individual’s perceived freedom could lead to a better subjective life satisfaction for people with long-term psychiatric illness.

Research Design and Sample
In this study, the studied group of people with long-term psychiatric illness came from two large residential homes, named long stay care home (below referred as LSCH) which have been opened in 1990s in Hong Kong. In each LSCH, four to five residents lived in the same bedroom. It contained a large occupational unit. Various kinds of professional and non-professional staff had been employed to provide 24-hour personal care services for its residents. Staff to resident ratio is about 1:4.

Those residents, who were being assessed by registered psychiatric nurse as mentally stable, had suitable comprehensive and communicative skills, and discharged from mental hospitals and then lived at LSCH for more than one year, were eligible for being selected into the studied sample.  Finally 146 residents had given their written consent and were interviewed by the author successfully. Data of the studied groups were collected and completed in 1998.

Measuring Scales and Data Collection
1)  Quality of Life Interview scale
In this study, Lehman’s Quality of Life Interview [19] is adopted to measure the subjective life satisfaction of respondents. The reliability and validity of the scale are well established [19-20] and the scale has been widely used [13, 21-22]. In this study, the reliabilities of sub-scales of overall life satisfaction as well as subjective QoL in various life domains have been tested to be satisfactory (Cronbach’s = .73 for overall life satisfaction sub-scale; and Cronbach’s  ranked from .67 to .98 for other subjective QoL sub-scales.).

2)    Perceived Freedom
When measuring perceived freedom of people with long-term psychiatric illness, it would be better to relate the measuring items to their daily lives as well as the management practice of their current living places.  So the author has developed a measuring scale, named Perceived Freedom, for this study which is designed for the use in residential setting.  It contains 18 items.  It divides into two main sub-scales: perceived sense of freedom and perceived restriction.  The perceived restriction sub-scale is a binary yes / no scale.  The perceived sense of freedom sub-scale covers nine areas: money management, going out, bed time, bathing time, dressing, hair cutting, meal and vocational training as well as overall sense of freedom. Each of these items is rated at a four-point scale. The reliability of this scale has been tested to be satisfactory (Cronbach’s = .66 for whole scale).

3)  Social Behaviour Schedule (SBS)
The Social Behaviour Schedule (SBS) is chosen for use in this study as this scale is especially designed for measuring the functioning in 21 areas such as hygiene, initiating conversations, depression, violence, etc. for people with long-term psychiatric illness [23]. The reliability and validity of the scale has been reported to be satisfactory.

4)  Specific Level of Functioning Assessment (SLOF)
The Specific Level of Functioning Assessment (SLOF) is designed to measure more directly observable behavioural functioning and daily living skills of people with chronic mental illness [24]. The reliability and validity of the scale has been reported to be satisfactory.     
                  

Below describes the characteristics of the studied sample which came from two LSCHs, i.e.  LSCH1 group (n=77) and LSCH2 group (n=69).  Results showed that these two groups of respondents did not differ in almost all demographic factors, except in age and financial situation.  Taking together, the whole studied group had slightly more male than female. Most of them were aged under 60 (mean 53 years), schizophrenic, single and had reached primary school level. Their illnesses were so chronic that most of them had been ill for more than 20 years and had a mean continuous hospital stay of 7.5 years just before admitting into LSCH. Half of them had admitted into mental hospital for three times or more. Also, about two fifth of them had at least one physical illness. Most were single or divorced, and had few contacts with their families. They did not have any friends outside the hospitals and LSCH.  Most of them were lack of employable skills and attended some forms of vocational training. Almost all of them had to rely on governmental social security schemes to support their lives.

Social Functioning and Current Psychiatric Symptoms
Social functioning of the studied group was measured by the Specific Level of Functioning (SLOF) scale. About half of them showed at least one functioning problem or disability and (i.e. score < 4).  Many of them had impairments in their work skills, community living skills, and interpersonal relationships.  On the other hand, current psychiatric symptoms of studied group were measured by Social Behavioural Schedule (SBS).  More than half showed at least one significant behavioural problem (i.e. score >1) that needed staff’s intervention, while one third showed three psychiatric symptoms or more. About one third (30%) showed at least one positive symptoms such as laughing and talking to themselves, while one fifth showed at least one negative symptoms such as poor personal appearance and hygiene.

Research Results

On each life domains, two thirds or above of studied group expressed satisfaction.  In particular, they were most satisfied with the living situations, followed by leisure activities and personal security, while they were least satisfied with their family relationships and financial situations (please refer to Table 2 for your reference). Moreover, their reported overall life satisfaction was satisfactory (mean score >5). According to these research results, the studied group viewed their lives as positive at LSCH and community after their discharge from mental hospitals.

B. Perceived Freedom
Almost all (97.9%) LSCH resident reported that they were restricted in at least in one area of their lives. About half of them reported there were restrictions in four areas mostly involving:  managing pocket money, going out, sleeping time and attending vocational training. Although there were restrictions, most restrictions were not strict, and so most residents (72.2%) reported that could enjoy freedom in their overall life at residential home.

C. Perceived Freedom and Overall QoL
Correlation and regression analysis was performed with the data of 146 respondents by using SPSS for Windows. Overall life satisfaction was found to relate to individual’s overall perceived freedom (Pearson correlation coefficient=.385, p=.000), but not related to the total number of perceived restrictions. By using regression analysis, perceived freedom could explain 14.9 % of the variance in overall life satisfaction (Please refer to Table 3).

D. Comparison of predictive power of perceived freedom with other variables.
In order to explore the strength of relationship between perceived freedom with subjective life satisfaction, it is better to compare the predictive power of individual’s perceived freedom with other variables such as demographic variables, medical variables, social functioning and current psychiatric symptoms. (Please refer to Table 3).

All of the demographic variables including sex, age, education, income, marital status, religion, place of birth, income, having a physical illness, and period of stay at LSCH were found not related to overall life satisfaction. Overall life satisfaction were found related to the following medical variables: having a diagnosis of schizophrenia (Cramer’s V =.351, p=.030 < .05),  number of hospitalization (Pearson correlation coefficient =-.330, p=.000), and hospitalization period just before admission to LSCH (Pearson correlation coefficient =-.170, p=.046 < .05).  By using regression analysis, medical variable could explain 2.79 % of the variance in overall life satisfaction. (Please refer to Table 3).

On the other hand, most current psychiatric symptoms as measured by Social Behavoural Schedule were not related to overall life satisfaction.   Only one symptoms, i.e. hostile social contacts, was found to be moderately correlated with overall life satisfaction (Pearson correlation coefficient =-.324, p=.007). Besides, overall life satisfaction is weakly correlated with physical functioning (Pearson correlation coefficient= .183, p=.027 < .05) and inter-personal skills (Pearson correlation coefficient= .164, p=.048 < .05), but not in other skills including: personal care, social acceptability, community living and work as measured by SLOF. By using regression analysis, current psychiatric symptom (i.e. hostile social contacts) and social functioning (i.e. physical functioning and inter-personal skills ) could explain 4.2 % and 4.8% of the variance in overall life satisfaction respectively (Please refer to Table 3).

Based on the above research results, among all the variables discussed above, perceived freedom was found to have the strongest predictive power for overall life satisfaction.

Table 3  Independent Predictive Power of various variables and Overall Life Satisfaction

Discussion
Perceived Freedom and Overall life satisfaction
In this study, it is found that individual’s perceived freedom is found to be good predictor the subjective overall life satisfaction for people with long-term psychiatric illness. This finding is supported by other research studies.  For example, Rosenfield [17] identified sense of mastery, while Zissi et al. [16] identified autonomy as good predicator for subjective life satisfaction. Moreover, in this study, individual’s perceived freedom is found to be a stronger predictor than other variables including: demographic variables, medical variables, social functioning and current psychiatric symptoms.

After identifying individual’s perceived freedom as good predictor for overall life satisfaction, program elements in enhancing individual’s perceived freedom should be included in residential home care.  This suggestion is supported by the study done by Timko et al. [11] who reported that the policy of encouraging residents’ control on management of residential home was found to be related to residents’ reported life satisfaction for people with mental illness.  

Other predictors of overall life satisfaction
In this study, a number of demographic and social variables are found relating to and predicting overall life satisfaction. These research findings are reviewed as below.

All of the demographic variables including sex, age, education, income, marital status, religion, place of birth, income, having a physical illness, and period of stay at LSCH are found not related to subjective overall life satisfaction. Thus none of these demographic variables is predictor of overall life satisfaction. These research findings are supported by a number of research studies which have found that demographic variables are unrelated or at most weakly related to overall life satisfaction [21, 25-29].

Overall life satisfaction is found related to having a diagnosis of schizophrenia and number of hospitalization. These results are supported by other studies [19, 26, 30]. However, the finding that latest hospitalization period just before admission to LSCH is related to overall life satisfaction is not supported by other studies [21, 26].

Consistent other studies, overall life satisfaction is found to be negatively correlated with current psychiatric symptoms [19, 21, 26, 29].

With regard to correlation between social functioning and overall life satisfaction, there are inconsistent in research studies. Some studies reports that overall life satisfaction is positively related to social functioning [11, 21, 31], while some studies do not confirm this result [13, 28].  This research study adds evidence to the finding that overall life satisfaction is positively related to social functioning.

Conclusion
In mental health field, few studies have been done in identifying program elements which predict or lead to individual’s life satisfaction.  This research study has demonstrated that individual’s perceived freedom is a good predicator for subjective life satisfaction for people with long-term mental illness. Program elements in enhancing individual’s perceived freedom are suggested to be included in residential home care. In this study, research design is based on cross-sectional study.  In future, a large-scale longitudinal study should be carried out in order to confirm the above research findings.

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