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The purpose of this study was to explore the coping processes used by family caregivers of individuals with schizophrenia to deal with compassion fatigue (CF).
Grounded theory was used in this study. For recruitment, purposive and theoretical samplings were used to recruit participants. Data were collected from 29 family caregivers through in-depth interviews and field notes. Data were analyzed using constant and comparative methods.
The study revealed a core process for dealing with CF as “Combating with compassion fatigue” that comprised three dynamic phases: strengthening attachment with the care recipient to increase willpower, learning how to deal with the illness, and self-empowerment to fight to the physical and mental fatigue.
Family caregivers of people with a diagnosis of schizophrenia use various strategies to fight to CF. These combine the past experiences of strategies that work and new approaches. Our research will allow mental health professionals to provide basic strategies to family caregivers of people with a diagnosis of schizophrenia to help them to cope with CF.
]. Family caregivers have limitations in caring for schizophrenic patients at home, which include lack of understanding about schizophrenia and its treatment, and communication with health professionals. In addition, family caregivers have poor assessment follow-up and guidance for medication compliance with respect to their schizophrenic patients [
Caregiving, whether it is over a long period or for an individual with an acute or severe illness, can lead to compassion fatigue (CF). CF occurs when the caregiver experiences strong empathy with his or her charge, resulting in a deep psychological response that may progress to physical, mental, social, or spiritual exhaustion [
]. CF manifests a range of emotions and behaviors, including helplessness, disappointment, stress, a feeling of endless hard work, guilt, uncertainty, social isolation, dissatisfaction, and reduced ability [
] showed that most family caregivers feel a strong duty of care due to their emotional attachment to their care recipient and gain satisfaction from providing this care. However, caregivers also experience feelings of guilt, helplessness, disappointment, uncertainty, and dissatisfaction in the face of the ongoing and extensive needs of the care recipient. Day and Anderson [
] reviewed the literature on CF among family caregivers of individuals with dementia. The results revealed that most caregivers experience CF, and this manifests in the feelings of disappointment, helplessness, and a lack of interest and positive intentions toward their charges. This ultimately results in the avoidance of caregiving duties of the family caregivers.
Previous research has also found that family caregivers experience problems such as depression, stress, feeling overburdened, impaired relationships with other persons, and health problems. Those problems also lead to poor care provision or the termination of caregiving [
]. In addition, a qualitative study revealed that family caregivers of schizophrenic patients experienced CF, the characteristics of which include living with stress for long periods, physical, or mental exhaustion or both, being disheartened, anxiety and uncertainty, and having difficulty sleeping [
]. No effective ways of coping among family caregivers have yet been found. Nurses need to be attentive to the needs of family caregivers. Hence, there is a growing need to identify strategies that will help family caregivers to mitigate the negative effects and cope with CF.
There is little known about such strategies for coping with CF, especially among family caregivers of people with a diagnosis of schizophrenia in Thailand. In view of this lack of basic knowledge, this study aims to explore the coping processes used by family caregivers of individuals with schizophrenia to deal with CF. The findings can benefit health professionals, provide effective intervention to reduce or prevent CF in family caregivers of people with schizophrenia. Our findings can also potentially be used to improve and expand mental health services that assist family caregivers in the ongoing provision of care to family members with schizophrenia. The authors hope the findings will also be beneficial for international readers who hope to learn more about coping with CF in family caregivers.
This paper is a part of a larger research project entitled “Coping with compassion fatigue among family caregivers of persons with schizophrenia” that comprises two sub-studies. The first sub-study is “Compassion fatigue among family caregivers of schizophrenic patients” [
]. This current study was the second sub-study that uses grounded theory to explore how family caregivers deal with CF. The main purpose of grounded theory is to explore basic processes and generate theory from real-world situations and the perspectives of members of a given society. Grounded theory methodology explores the richness of human experience to generate and develop substantive theories. The approach allowed the researchers to explore, conceptualize, and generate substantive knowledge concerning the dealing with CF among family caregivers of persons with schizophrenia. The theories that emerge from such research in nursing frequently focus on behavioral concepts such as caring, coping, and parenting. In addition, these theories are helpful in their application to nursing practice [
The study was approved by the Research Ethics Review Committee for Research Involving Human Research Participants, Group 1. Chulalongkorn University (Approval no. 106.1/63). Approval was received before data collection began. Measures were taken to protect the anonymity of participants. Further, all participants who had experienced CF were made aware of their right to withdraw from the study at any time, and informed consent was obtained. The participants were selected using purposive and theoretical sampling to ensure complete and reliable data. The inclusion criteria were (1) the participants must be primary caregivers who provide care for schizophrenic patients over 20 years of age; (2) the participants must be family members (not hired for caregiving) with the main duties of looking after schizophrenic patients directly for at least two or more years without receiving any compensation; (3) the participants could explain their experience of coping with CF due to caring for schizophrenic patients; (4) they were able to communicate through Thai language their willingness to participate in this research. The first author conducted interviews in a private room of each hospital. Data saturation was reached at 29 interviews. All of the participants (24 females and 5 males) were interviewed about the strategies they use to cope with CF. The mean age of the participants was 51.5 years; 21 participants were married; 16 participants were educated to primary school level, and some participants had no formal education. The length of time 12 participants had been caring for a relative with schizophrenia ranged from 2 to 5 years, and 13 participants were mothers of the patients. Other demographic details were also presented in the first sub-study [
Data collection took place at a psychiatric hospital and a general hospital from August to December, 2020. Data were collected using in-depth interviews with 29 family caregivers who met the inclusion criteria. In order to maintain consistency, only the first author, who had more experience in in-depth interviewing in qualitative research, conducted the interviews with the participants after written consent was obtained. The first author used open-ended questions to encourage participants to share their experiences of coping with CF in the course of caring for their patients. The major questions used for gaining data with the family caregivers were how did you provide caregiving with schizophrenic patients at home? and how did you deal with your CF that was happening such as stress, physical, and mental exhaustion, being disheartened, anxiety, and uncertainty? The question was designed to invite the informants to answer freely and provide as many details as possible. During the interviews, the interviewer also mainly used layperson's language and empathic expressions in order to build rapport, trust, and to stimulate the participants to speak about their experiences of coping with CF. The duration of each interview was approximately 60 minutes. All interviews were audio-recorded and transcribed before data analysis. Field notes were also taken about facial expressions, tones of voice, and posture of the participants. Other details of data collection were explained in the first sub-study [
] was carried out alongside data collection during the research process. Data analysis comprised three stages. The first stage was open coding, in which the first and the second author independently read the transcribed conversations with each participant thoroughly and repeatedly. They then produced substantive theory code for each conversation. This incorporated consideration of the types of situations, activities, and behaviors were described by participants. Simultaneously, the authors compared the data relating to each situation, activity, and behavior extensively and developed categories for each type. The second stage of data analysis was selective coding. During this stage, the previously defined substantive codes were reduced to obtain variables or recurring issues and identify major categories through coded information classification. Those conversational units with the same or similar meaning were classified into the same group. Subsequently, the authors named all of the categories and sub-categories. The third stage was theoretical coding. The authors mutually agreed upon the relationships between categories and sub-categories, and these were then linked with theoretical codes to map the social process of coping with CF in family caregivers of people with schizophrenia.
] stated that the proper criteria for judging the credibility, fittingness, and stability of findings are based on flexible research. The credibility was evaluated through the vividness and faithfulness of the description of a phenomenon of coping with CF such as triangulation-method triangulation-in this study, selecting the appropriate participants who had the ability to tell their CF during care for people with schizophrenia. Semi-structured interviews and field notes were conducted by only the first author. The authors' background in qualitative research helped her to provide details and thick description to increase transferability. Then, peer debriefing with co-author and audit trail were employed to enhance stability of finding.
Combating with CF
The core process with which family caregivers cope with CF while providing care for individuals with severe mental illness was found that was called “Combating with compassion fatigue.” The process was comprised of strengthening attachment to the care recipient to increase willpower, learning how to deal with the illness, and self-empowerment to fight the physical and mental fatigue.
Category 1: strengthening attachment to the care recipient to increase willpower
Family caregivers strengthen attachments with care recipients to increase their willpower using three strategies: recognizing the care recipient as a good person to increase willpower, maintaining love and sympathy, and engaging in shared activities with the care recipient. The strategies helped caregivers to maintain their desire to care for the care recipients. Three sub-categories were identified, as follows.
Recognizing the care recipient as a good person
Most participants believed their care recipient to be a good person. The believe liked this could help them to have more power and encouragement. The participants shared positive behaviors they had seen in their care recipient such as abstaining from cigarettes and alcohol, doing the housework, and going to the temple to do good things. Other care recipients helped with home maintenance and repairs and worked to earn money. The good nature of a care recipient encouraged their caregiver to continue providing care despite physical and psychological exhaustion. Participants said:“He still has auditory hallucinations. He always tells me about that. However, he does not use cigarettes or alcohol. Besides, he is a good person. He likes to go to the temple to make merit every week. He helps me to do housework. He cooks and cleans the house.” (P 29)“He is a good guy. He takes care of his father and mother in everything. He buys food for his mother and father. He reconstructed the house. Before he was diagnosed with schizophrenia, he worked to earn money to help the family with things such as paying for a car. I understand his illness.” (P 12)
Recognizing the care recipient as a good person was an important strategy with which the participants strengthened their connection with the care recipients. The participants had positive thinking by acknowledging of the goodness of the care recipient invited them to be willing to continue caring.
Maintaining love and sympathy
In caring for people with a diagnosis of schizophrenia for a long period, the participants experienced physical and mental exhaustion. However, they continued providing care because of their love and sympathy for the care recipients. Many of the participants would remind themselves that they love their care recipient. Care recipients are often a significant other, child or close family member of the caregiver. They expressed their love to the care recipients verbally but also non-verbally through their caregiving. Despite not knowing when the care recipients would recover from their illness, the participants understood that they must be patient and provide indefinite ongoing care. The participants said:“I could say that I am very physically and mentally exhausted. I tell myself that he is my son. I love him. I must fight. If I do not, who will care for my son? I also work so hard every day to earn money and buy food. I prepare food for the patient when he cannot do it for himself. When I take a break at noon, I come back home to care for him.” (P 24)“I was very tired. But I do it because I love her. I tell myself that she is my wife. I love her so much; I would do anything for her. I want her to get better. She might not do any work. It's alright by me. I am always ready to care for her. She might do many things when she is better.” (P 2)
Engaging in shared activities
Engaging in activities together was another method used to strengthen the bond between caregivers and the individual for whom they cared. Most participants said that they invite the care recipients to join in activities with them such as going to the temple and going on weekend trips. The participants also found that shared activities were a good way to allow them to engage more as a family. In addition, activities with the care recipients could be a source of relaxation for both. One of the participants said:“Usually, our family likes to do activities together such as making merit, meditation, and travelling. One day, I went to a temple in another province. I invited him and my husband. We took meditation. I think that it's helped us relax. I like to invite him to activities. We are comfortable doing that.” (P 5)
Another participant shared their feelings of love and sympathy for their son with schizophrenic. The participant encouraged their son to do exercise and housework every day.“I live alone with my son who was ill. We do not have any relatives. I love him and sympathize. I often invite him to exercise with me. Some days, I invite; some days the patient invites me. I am very happy, comfortable, and more bonding. I felt that. I want him to get well.” (P 26)
Strengthening the attachment to the care recipient to increase willpower was seen as a good way to cope with CF. When the participants felt physical or mental exhaustion or were otherwise suffering, they would recall nice experiences and their positive relationship with the care recipient. Their love and sympathy helped to maintain good feelings and a willingness to continue caring for the care recipients. Later, the participants' CF could be decreased.
Category 2: learning how to deal with the patient's illness
Learning how to deal with the patient's illness was the second stage of the coping process. The participants not only provided love and sympathy to their care recipients but also tried to learn how to deal with them. This way helped the participants to be able to care for and manage the patient's illness. One important thing that associated with CF was lack of knowledge to care for the schizophrenic patient. This was achieved in two ways: understanding the care recipient's conditions and finding information about caring for them. Learning care strategies improved participants' competence at care provision. It also increased the participants' well-being and decreased the caregiving burden as well as CF. Two sub-categories were identified, as follows.
Understanding the condition
Understanding the care recipient's disturbance was a further strategy that the participants used to deal with the care recipients' illness. The understanding also helped the participants to have more power and confidence to provide continuous care. The participants used various self-devised strategies to achieve this, including observing the care recipient's symptoms, the effects of the medicine, and other behaviors. Learning by observation improved understanding of the illness and how to care for their charges. As one participant said,“I live with my ill brother, so I have time to observe his symptoms. In the beginning, I did not know or understand what was happening to my brother. After a while, I began to know what the patient needed. For instance, I tactfully monitor his symptoms and delusions. I know that it's not real. The delusions are a symptom.” (P 18)
Another method used to improve understanding of the illness of the participants was to ask the care recipient about their symptoms and experiences. The questions asked by the participants primarily focused on the medicine and its side effects. One participant said,“I always ask him about taking medicine. I remind him to take medicine. I knew that if I don't ask, he won't take it. I asked him about the side effects and it helped me understand why would want to remain abnormal. It is because of the side effects of the medicine.” (P 9)
Finding information about caring for people with schizophrenia
Finding information about caring for schizophrenia was a strategy used by the participants to learn how to deal with the condition. Most of the participants had told sought knowledge about schizophrenia and how to care for schizophrenic people by asking mental health nurses. Family caregivers had telephone numbers for the mental health nurses involved in their relatives' treatment. They called the nurses to talk about the care recipients' symptoms and disturbances, how to deal with refusal to take medication, and how to manage the care recipient's behaviors. They also discussed health outcomes. Receiving such information helped the participants to learn how to care for their care recipients appropriately. The participants said:“I called the nurse and asked her what to do when the patient forgot to take their medicine. The nurse was very nice and kind to me and the patient.” (P 20)“Sometimes, he has delusions. he walks around the home and runs away from home. I did not know what to do so I called the nurse. I asked the nurse what to do, how to care for the patient. The nurse gave me some preliminary advice and then she came to my home.” (P 14)
The participants used understanding the care recipient's disturbances and finding care information to improve their ability to deal with the care recipient's illness. After the participants could provide effective care for their care recipient to be better, the participants would be fine as well. This was found to be a good way of helping the participants to cope with CF.
Category 3: Self-empowerment to fight the physical and mental fatigue
The participants used self-empowerment to cope with CF. This was achieved using three strategies: maintaining hope the care recipient will get better, believing that the caregiving is their responsibility, and finding ways to release stress. These strategies gave the participants strength and confidence, and strengthened their resolve to continue caring for the care recipients. Three sub-categories were identified, as follows.
Maintaining hope that the care recipient will get well
Maintaining hope that the care recipient will get well was a strategy used for personal empowerment by the caregivers in this study. Most participants expressed this hope and said that their hope increased when the care recipients' symptoms lessened. This reduction of psychotic symptoms in the care recipient gave participants more energy to care for their relatives with schizophrenia. One participant said:“I hope that he keeps doing well. In the beginning, he could not stop smoking and drinking alcohol. He often went out drinking with his friends. Then, he had active symptoms many times. However, he went to see the doctor and took the medicine he was prescribed. He got better and stopped having psychotic symptoms; This makes me hope that he will get better again and then I feel more able to care for him.” (P 25)
Another participant talked about their care recipients increased ability to undertake tasks and activities such as housework. The participant felt good and was optimistic about the care recipient's improved condition. The participants said:“I told the patient to do housework. He can do it by himself and when I saw that, I felt so good and I thought that he will be better or recovered from the disease soon. I understand him. I also sympathize with him. He might feel lonely. I hope that he will get better.” (P 27)
Believing that the caregiving is a responsibility
Another strategy used for empowerment was to regard caring for the care recipient was as a responsibility. The participants would often tell themselves that caring for the care recipients was an important duty. This was particularly so because of their close familial relationships with the care recipients. When participants found themselves physically and mentally exhausted, they would remind themselves of the importance of their responsibility and feel empowered to continue caregiving. The participants said:“I must care for him. If I did not, no one would care for him. He is my only brother. I take him to the hospital. I must. When I think like that it gives me the strength to keep caring for him.” (P 29)“I am so tired. But I must be patient and fight for our family. she is my mother. I must care for her. I am her son. It is a responsibility that I must uphold. Sometimes, I go out to relax for a few hours. I come home because I must make sure my mom takes her medicine. I want to see my family members happy.” (P 4)
Finding ways to release CF
Another means participants used to cope with CF was to find the outlets for CF release. Methods used to achieve this included spending time with other people, spending time working hard, undertaking regular religious activities, and engaging in exercise and hobbies. These strategies that could help the participants to decrease the CF were identified, as follows.
Spending time with other people
Most participants had found positive ways to relieve stress. Stress as a characteristic of CF happening with the participants. The participants used time with other people such as family members and friends to talk about the care recipients' illness and treatments and about methods of caregiving. After talking with others, they felt more able to provide care, more relaxed, and less stressed and anxious. One of the participants said:“When I am stressed, I go out to talk with my friends. We talk about the patient behaviors and drink alcohol. My friends, they always listen to me. I need to do this because I am so stressed. My friends also find jobs for me. So, I feel better and get the jobs.” (P 4)
Participants spent time working hard to forget distresses from CF. Busying themselves with jobs provided a distraction from tension or suffering. Participants found that they enjoyed doing the jobs and forgot their troubles.“Sometimes, I am exhausted. I am disheartened because I care for the patient alone. I also have difficulty sleeping. I must do more jobs to forget things. I do housework such as cooking, washing clothes, and cleaning the house. I am then comfortable and can carry on.” (P 26)
Undertaking religious activities in daily life was another strategy that helped the participants to let go, relax, and increase their understanding of life. The participants could let negative consequences due to CF. The religious activities that participants incorporated into their daily lives included chanting, meditation, and good works. Some participants practiced dharma through acts such as offering food to monks each morning. One participant said:“I practice dharma every day. I liked to give alms to the monks in the morning. I do this every day. I invite my son who was ill to do it with me. Sometimes, he does but sometimes does not. I meditate every week, which helps me to feel better. Sometimes, I am so stressed and this makes it better.” (P 23)
Exercise and hobbies
The participants accepted that caring for the care recipients could be hard. They engaged in exercise and hobbies such as gardening, jogging, and walking to help themselves to relax and unwind and relieve stress. One participant said:“I am very tired. I tell myself that I must fight. When I have a little time, I walk or jog around my home, which helps me to feel better. I invite him to exercise, but he does not like to.” (P 11)
In this study, coping with CF was found to be a basic process that occurred between family caregivers and care recipients. It is also a dynamic process. The participants strengthened their attachment with the care recipient to increase willpower in providing care by using three sub-strategies: recognizing the care recipient as a good person, maintaining love and sympathy, and sharing activities with the care recipient. At the same time, the participants used the strategy of learning how to deal with the care recipient's illness through understanding the care recipient's disturbances and finding information about caring for people with a diagnosis of schizophrenia. This phase, the participants could improve their ability to deal with the care recipient's illness. The participants also used another strategy of self-empowerment to fight the physical and mental fatigue, with three sub-strategies: maintaining hope that the care recipient will get well and regarding caregiving as an important responsibility, and finding positive outlets for CF release. When the time passed, the participants can move back and forth to use the strategy of strengthening attachment with the care recipient to increase willpower or finding ways to deal with the care recipient's illness again. The relationships between the three phases can be conceptualized as circular and iterative, as shown in Figure 1.
Schizophrenia is recognized as a severe mental illness requiring long-term treatment need [
]. Taking care of a schizophrenic family member can be a tremendous burden upon the caregiver who must deal with stigma, misunderstanding, damaged and disturbed relationships, negative effects on their own mental health, and difficulty coping [
]. Our findings highlight the strategies used by family caregivers to cope with CF that were called “Combating with compassion fatigue”. These strategies comprise three stages: strengthening attachment with the care recipient to increase willpower, learning how to deal with the care recipients' illness, and self-empowerment to fight to the physical and mental fatigue. Lazarus and Folkman [
] have defined coping as a process that uses cognition, decision making, planning, and support-seeking to manage problems and life. Our participants availed themselves of both emotion and problem-focused coping strategies.
Emotion-focused coping strategies included recognizing the care recipients as good people, maintaining love and sympathy, sharing activities with the care recipient. These strategies manage and minimize negative emotions and maximize positive emotions [
]. Strengthening attachments helped the participants to communicate and have more positive relationships with the care recipients. They also encouraged participants to continued caregiving and improved overall well-being. A strong attachment to the care recipient helped our participants to cope with the negative emotion that are manifestations of CF. This finding also is consistent with a study by Blair and Perry [
] that revealed the family caregivers feel a strong duty of care due to their emotional attachment to the care recipient. Besides, the family caregivers gain satisfaction from providing this care.
The participants also used problem-focused coping strategies to fight to the CF. These focused on looking for ways to manage the care recipient's illness. This was achieved through understanding the care recipients' disturbances and finding information about caring for people with schizophrenia. Sub-strategies of this included observation of the care recipients' symptoms, other behaviors, and their medicine and its effects to increase their understanding. This is regarded as part of the role of a family caregiver [
]. The participants sought ways to manage the problem inherent in caring for their charges and dealing with their care recipients' active symptoms. Thus, some participants took their lead from health professionals through informal health assessment and data analysis that informed their caring activities. These problem-focused coping strategies and autodidactic processes helped to build the caregivers' knowledge about the illness and caregiving skills, leaving them better equipped to cope with the caregiving burden [
Self-empowerment to fight the physical and mental fatigue was another way that was performed by participants. Taking care of the afflicted family member for long periods at home impacted the participants' physical and psychological health and quality of life. The less able the caregiver felt, the greater the negative effects and CF [
]. The participants described methods they used for self-empowerment while providing care to fight to their physical and mental fatigue. These included maintaining the belief that the care recipient was a good person and the use of distracting activities. The strategies used demonstrate that the participants engaged in cognitive self-adjustment. Participants also made emotional adjustments such as spending time with friends, meditation, doing good works, exercise, and hobbies. They also attempted to modify their daily routines to allow for their caregiving duties. These strategies gave the participants more energy to continue caring for the care recipients. Previous research with primary caregivers of elderly individuals with dementia showed a similar self-empowerment, that including enhancement of care ability, emotional management, and life management [
In this qualitative study focused on an in-depth exploration of the experiences of a small sample of family caregivers of people with a diagnosis of schizophrenia and only two hospitals. It may therefore not be generalizable to family caregiving with other types of care recipients.
Caring for schizophrenic patients can be difficult for family caregivers. The family caregivers who participated in this study used numerous strategies to cope with CF. We found that the family caregivers of schizophrenic patients in Thailand engaged in a specific coping process. The findings can be used to provide guidelines for family caregivers who are suffering from CF. Health care professionals, including mental health nurses and psychologists can apply this coping process to family caregivers with CF. Each stage of the process can be adapted for greater efficacy and flexibility. In addition, the process can be applied to help family caregivers who dealing with patients with aggressive behaviors or poor medication adherence. Mental health policymakers may consider our findings as a foundation upon which to build strategies that empower family caregivers via mental health facilities. Further research should look for factors influencing to CF among family caregivers. In addition, the effective interventions should be developed.
Data availability statement
The data that support the findings of this research are available from the corresponding author upon reasonable request.
This research received ethical approval from the Office of the Research Ethics Review Committee for Research Involving Human Subjects: The First Allied Academic Group in Health Sciences, Chulalongkorn University. The research project number is 106.1/63.
Data were collected and analyzed, and the manuscript was written, by RU and WS.
Conflict of interest
The authors have no conflict of interest to declare.
The authors are especially grateful to the family caregivers who participated in this study. This work was supported by the Thailand Science Research and Innovation Fund Chulalongkorn University (CU_FRB640001_36_2); (CUFRB65_soc(4)_004_27_04); and Thinking and Disposition STAR Research (TDSR) group, Faculty of Education, Ratchadapiseksompoch Fund (social science) (STF 6500227001-1).
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