Characteristics Associated with the Use of Limit-Setting Practices Towards Relatives with Psychiatric Disorders

Background and Purpose: Relatives often take on much responsibility for the care of persons with psychiatric disorders (PD) such as schizophrenia, bipolar, and major depression, and have been referred to as “de facto” and “auxiliary” therapists.  Similar to mental health practitioners, relatives often attempt to modify potentially problematic behaviors of persons with PD, with such attempts being termed limit-setting practices.  While limit-setting practices and other forms of coercion used by professionals have received considerable research attention, limit-setting practices by relatives have almost entirely been ignored.  Family limit-setting, however, is a construct of much importance.  Not only do family limit-setting practices hinder the autonomy of persons with PD, there is also evidence that they contribute to the subjective burden experienced by relatives and increase the risk of family conflict and violence.  As a result, it is imperative that we identify under what circumstances relatives engage in limit-setting practices.  The objective of the present analysis is to identify characteristics of persons with PD, their relatives, and the interactions they have with each other, associated with the use of family limit-setting practices. 

Methods: A cross-sectional design was used. Between 2014 and 2015, 573 adults with an adult relative with PD living in at least 42 states in the U.S., completed an online survey.  Recruitment occurred through advertisements made with a plethora of non-profit organizations across the U.S.  Respondents provided information regarding themselves, their relative with PD, and their interactions with each other.  Respondents completed a newly developed scale, the Family Limit-Setting Scale (FLSS), measuring the level of limit-setting practices engaged in towards relatives with PD.  The FLSS has psychometrically sound properties, including a two-factor structure (Routine Limit-Setting and Crisis Limit-Setting).  Negative binomial regression models were estimated, with dependent variables being level of Routine Limit-Setting and level of Crisis Limit-Setting.  Independent variables consisted of characteristics of persons with PD, their relatives, and their interactions with each other. 

Results: After controlling for significant covariates, the following were significantly correlated with Routine Limit-Setting: Person with PD—psychiatric hospitalization, mental health treatment attendance, arrest history; Interaction—co-residence, in-person contact, financial assistance and caregiving to person with PD.  The following were significantly associated with Crisis Limit-Setting: Person with PD—age, use of alcohol and illegal drugs, psychiatric hospitalization, use of psychiatric medications, arrest history; Interaction—financial assistance and caregiving to person with PD.

Conclusions and Implications:  Practitioners should assess the use of family limit-setting practices, particularly when parties are known to endorse characteristics associated with limit-setting.  Both routine and crisis limit-setting appear strongly related to treatment factors, arrest history, financial assistance, and caregiving.  Increasing treatment participation/adherence of persons with PD may decrease limit-setting practices used by relatives.  Similarly, limit-setting may be decreased by providing services to persons with PD that promote independent living among persons with PD and alleviate burden experienced by relatives (e.g. intensive case management, vocational rehabilitation).   Engaging persons with co-occurring psychiatric and substance use disorders in substance abuse treatment may decrease the use of crisis limit-setting practices by relatives.