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 Table of Contents    
ORIGINAL ARTICLE
Year : 2019  |  Volume : 41  |  Issue : 5  |  Page : 440-447  

Perception about marriage among caregivers of patients with schizophrenia and bipolar disorder


1 National Institute of Nursing Education, Chandigarh, India
2 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission12-Jan-2019
Date of Acceptance16-Jun-2019
Date of Web Publication5-Sep-2019

Correspondence Address:
Prof. Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPSYM.IJPSYM_18_19

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   Abstract 


Background: Marriage has a complex relationship with mental illness. The marriage of a person with mental illness (PMI) is a controversial issue with varied opinions. There is a dearth of studies exploring perception about marriage among caregivers of patients with severe mental disorders. Materials and Methods: Thirty caregivers were interviewed in depth using a semi-structured interview schedule. Quantitative data were analyzed using MS Excel, while qualitative data were interpreted based on Colaizzi's framework. Results: About half (53%) of the caregivers believed that PMI should marry, and 46% of caregivers believed that marriage could worsen the mental illness of their patient. The qualitative analysis showed that factors that affect the decision among caregivers to get their mentally ill wards married include shovelling off the stigma of keeping the unmarried ward at home and to have somebody to take care of the unmarried ward after their death. Many caregivers believe that marriage and/or sexual intercourse can be a cure/treatment for various mental disorders. Conclusion: Caregivers of patients with severe mental illness have many misconceptions about the association of marriage and outcome of mental illnesses.

Keywords: Caregiver, marriage, mental illness
Key messages: Slightly more than half of the family caregivers of patients with severe mental illnesses believe that people with severe mental illnesses should get married. Family caregivers of patients with severe mental illnesses have many misconceptions about the association of marriage and mental illness.


How to cite this article:
Kumar P, Sharma N, Ghai S, Grover S. Perception about marriage among caregivers of patients with schizophrenia and bipolar disorder. Indian J Psychol Med 2019;41:440-7

How to cite this URL:
Kumar P, Sharma N, Ghai S, Grover S. Perception about marriage among caregivers of patients with schizophrenia and bipolar disorder. Indian J Psychol Med [serial online] 2019 [cited 2019 Sep 16];41:440-7. Available from: http://www.ijpm.info/text.asp?2019/41/5/440/266101



Marriage is a consensual and contractual relationship recognized by law.[1] According to historical perspective, marriage exists in one form or another in every culture, ensures social agreement to a physical union between man and woman, and acts as a building block for the family.[2] Besides the physical union, marriage is also associated with multiple emotional, social, and occupational demands.[1]

Marriage is an important institution in human society and particularly so in eastern countries. In India, it is almost compulsory for every individual to marry and “settle down” and is considered an important event of life which affects the social position of a person. In Indian society, being unmarried after a certain age is considered a stigma.[3]

Marriage has a complex relationship with mental health. Marriage is considered as an opportunity for growth and development in all spheres of life. It can provide social support and security for some people; at the same time, it can also act as a stressor and precipitate mental illness or crisis in vulnerable individuals.[4] The relationship gets even more complex when it is about the marriage of a person with mental illness (PMI). Data suggest that PMIs have higher rates of separation and divorce.[5] Chronic mental illnesses such as schizophrenia and bipolar affective disorder (BPAD) possibly reduce the abilities required for marital adjustment and increase the chances of marital disharmony.[6] However, for some, marriage can be a source of social support.[1]

Although marriage is a well-established norm in Indian society, when it comes to the marriage of a PMI, it is often associated with stigma and scepticism. Looking at the marriage of a PMI from the human rights perspective, it should not be in any way different from the marriage of any other individual. However, when one takes into account the various factors associated with the marriage of PMI, issues such as the risk of relapse, inability to carry out the responsibility, stigma attached to getting married to a PMI, and high probability of marital discord, the issue of marriage of PMI turns controversial. There are also cultural beliefs which suggest that marriage can be therapeutic for people with mental illness, and according to the prevalent myths, marriage is at times considered a cure for mental illnesses.[7]

While the public at large can be prejudiced about the marriage of a mentally ill individual, PMI and their family members may perceive the entire situation altogether with a different perspective. However, data with regard to the perception of the caregivers about the marriage of a PMI are grossly lacking. This study, thus, aimed to explore the perception of caregivers of patients with severe mental illness about the marriage of persons with severe mental illness.


   Materials and Methods Top


Setting

This study was carried out in the Department of Psychiatry of a tertiary care hospital in north India. The department provides extensive mental health services at both inpatient and outpatient basis. The study was approved by the Institute Ethics Committee, and all the participants were recruited after obtaining written informed consent.

The study followed a cross-sectional design, in which all the participants were evaluated only once. The study sample was selected using purposive sampling.

To be included in the study, the caregivers required to have a family member diagnosed with either schizophrenia or BPAD by a qualified psychiatrist using the ICD-10 criteria,[8] who was aged >18 years and unmarried. To be included in the study, the caregivers were required to be biologically related to the patients and responsible for making the decision regarding the marriage of their relative with mental illness.

The selection of the study participants was done by the treating consultant who referred the patient to the researcher after briefing about the purpose of the study. The researcher further detailed them on the study objectives and obtained the written informed consent.

Research tool

Data were collected using an interview schedule which had guiding questions for further interview. The items on the interview schedule aimed to assess various aspects of the marriage of a PMI from a caregiver's perspective. The questions were formulated in such a way that there was a chance for expansion into various thoughts and views. The interview schedule was designed by a group of experts working in the area of mental health and aware of the prevalent cultural norms about marriage in the society. The schedule comprised a total of 24 questions. Each question aimed to explore distinct aspects of marriage and mental illness. Certain questions posed a generalized query, like “Should people with mental illness get married? If yes, why? If no, why?” Other questions were personalized to the family member of a PMI, like “What do you think about the marriage of your son/daughter/brother/sister?” The schedule was developed with an intention to get an in-depth understanding of the caregiver's perception. Thus, questions included exploration of the perception of association of marriage of PMI and relationship of marriage with cure, recovery, worsening, and the onset of mental illness. The issue of disclosing the mental illness to the family of the prospective partner was also evaluated. In addition, some of the questions evaluated the general understanding of the caregivers about mental illnesses and their expectations from treatment. Some of the questions used to assess these aspects included “According to you, what is the cause of your patient's mental illness?” and “Do you think anything else besides medications can help in the management of your patient's illness?"

The face validity of the interview schedule was established by seeking the opinions of experts in the fields of psychiatry, clinical psychology, psychiatric nursing, and psychiatric social work.

Procedure

The researcher had an initial rapport building session with the caregiver, and this was followed by an in-depth interview. The interviews were conducted on a one-to-one basis. The interview room provided a conducive environment and privacy. The time spent on each interview varied from half an hour to one hour, depending on the length of the responses given by the caregiver. While some caregivers gave elaborate responses, others preferred to be brief in their responses. All the interviews were audio-taped and transcribed within 24 h. Initially, the script was prepared in Hindi, and then, it was translated into English by experts who were fluent in both the languages. To ensure the trustworthiness of transcripts, these were double-checked by a bilingual translator who was competent in both Hindi and English.

Data analysis

The quantitative data were analyzed in the form of mean, standard deviation, frequency, and percentages. The qualitative data were interpreted by following the steps described by Colaizzi[9] and included reading and re-reading of participant's description to acquire feeling for their experience and making sense of their account. The first step of the analysis included reading each transcript several times to gain an understanding of the whole content. During the second stage of the analysis, the significant statements or verbatim were extracted and written on separate sheets, with corresponding participant code. After extracting the significant statements, two researchers (PK and NS) independently assessed the themes first and later cross-checked with each other and reached a consensus. In the third step of the analysis, the meanings for each significant statement were extracted and coded under categories. Then, both the researchers compared these formulated meanings and reached a consensus about including the descriptions/items. The whole statements and their meanings were checked by an expert researcher (SG, fourth author) who ensured that the correct process was followed and that the meanings of the statements were consistent. In the next step, the formulated meanings were categorized as clusters of the theme. Both researchers compared their clusters of themes and checked the accuracy of the overall thematic map. To establish the trustworthiness of the study findings, peer review of the emerging ideas was done through discussions with the study supervisors (SG and SG) and an independent researcher.


   Results Top


[Table 1] depicts the sociodemographic profile of the caregivers. Most of them were the parents of PMI.
Table 1: Sociodemographic profile of caregivers of mentally ill patients (n=30)

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Perception about marriage and mental illness

Based on the responses to the in-depth interview, some quantitative findings were generated [Table 2]. About 53% of the caregivers felt that people with mental illness should get married, and 26.7% of the caregivers felt that marriage could be a cure for mental illness of their ill relative. About 30% the caregivers felt that marriage could help in improving the mental illness of their patient and 46.7% of the caregivers felt that marriage could worsen mental illness of their patient. In terms of searching for an alliance, 90% of the caregivers reported that they had never looked for an alliance for their mentally ill ward. Surprisingly, only 16% of the caregivers ever discussed the issue of marriage of their mentally ill ward with their treating doctor. Around 53% of the caregivers believed that one purpose of getting married is to fulfil the sexual desire and 40% of the caregivers believed that fulfilment of sexual desire within or outside the wedlock could improve the mental illness of their patients. About 73% of the caregivers were optimistic about their patient's ability to take up the responsibilities of the family after marriage.
Table 2: Frequency distribution of themes of responses on semi-structured interview

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Qualitative responses

When the caregivers were asked “should people with mental illness marry?"53%gave a response in assertion, while 10% responded contrary to this. About one-third (36%) of the caregivers were not sure about the same and responded that the issue would depend on the situation. On further enquiry, those who had responded in affirmation elaborated that “marriage can improve mental illness and that marriage is important to shovel off the stigma of keeping an unmarried ward at home, especially a female. Parents of males with mental illness reported that there would be someone to care for a patient after the death of the parents, that marriage is an important part of life, and that it is a rule of society and an age-old norm.” Some of the caregivers reported, “Getting their child married is a desire and responsibility of every parent—Hence, irrespective of mental illness, all the parents should be allowed to fulfil their desire and responsibility.” The 10% of caregivers who reported that a patient with mental illness should not marry felt that “marriage and related discord can worsen mental illness and lead to relapse.” One of them also cited the risk of hereditary transmission as one of the reasons for not getting their mentally ill relative married. One-third of the caregivers felt that there cannot be one clear-cut answer to the question and elaborated that the decision of marriage of mentally ill persons is contingent upon various factors such as the patient's ability to earn or care for self (n = 2), severity of mental illness (as the patients with illness of less severity can consider marriage (n = 8), and the patient's own willingness for marriage (n = 1). The other factors to be considered were the risk of relapse and hope for recovery with treatment/medication.

When asked specifically about the marriage of their own ward/relative, about one-fourth of caregivers (n = 7) were considering getting their mentally ill relative married only after recovery. Six of the caregivers wished that their ward should get married, but only after some improvement, if not complete recovery. Another group of caregivers felt that they would consider getting their ward married only after he or she becomes self-dependent, gets a job, or attains the ability to rear children (n = 3). A caregiver of a female patient expressed that “doing household work would be enough to make their child eligible for marriage.” A father showed ambivalence with regard to the marriage of his mentally ill son, “I'm not sure whether to get him married or not—There is always a risk due to the episodic nature of the mental illness.” One of the caregiver was even ready to compromise in terms of getting their patient married with a partner from low socioeconomic status. One of the caregivers also reported that they have not been able to take any decision regarding the marriage of their relative, owing to which they have started avoiding social gatherings and functions.

When asked “can marriage cure mental illness of your ward/relative?” one-fourth of the caregivers expressed that marriage can be a cure for mental illness of their relative with mental illness. Those who felt so believed that marriage could cure mental illness through a reduction in mental stress and a diversion of mind. On the other hand, a few caregivers (n = 5) felt that marriage could not cure mental illness. One of the parents stated that “the concept that marriage improves mental illness is an outdated one. Understanding about mental illness has increased over the years.” A caregiver clearly reported that “marriage is not a medication” and that “It is a misconception in the society that an illness like schizophrenia is curable by any available means."

On enquiry about “can marriage improve mental illness of your ward/relative?” 30% of the caregivers felt that marriage could lead to an improvement in the mental illness of their patient. Furthermore, some of them elaborated that the improvement is likely to occur through a reduction in stress through communication with the partner. One of the caregivers quoted a real-life practical example, mentioning a patient who recovered after marriage, had children, and was leading a comfortable life. Another caregiver described that “after marriage, the routine of the life gets organized, which helps in the recovery of the mental illness."Four caregivers felt that marriage could not improve mental illness, as marriage is not a medication for it, and three caregivers felt that there is no relation between marriage and mental illness. Six caregivers felt that improvement in mental illness after marriage depends on marital adjustment, marital understanding, and love with the partner. One of the caregivers said “If the mentally ill person is treated with love, there is a likelihood of improvement, and if the potential partner understands the patient's nature, then the illness can improve.” Afew caregivers stated that improvement in mental illness after marriage would be dependent on the cause of the illness and the medication compliance after the marriage. While most of the caregivers attributed the outcome of marriage to factors related to a potential partner, one of them attributed it to the patient's mental makeup and desire as well as his or her ability to maintain discipline in day-to-day life activities. Another caregiver reported that the outcome of marriage would depend on medication compliance after marriage and not on marriage per se.

When asked “Can marriage worsen mental illness of your patient?” about half (47%) of the caregivers agreed that marriage could worsen mental illness of their patient. They felt that marriage is a stressful phase of life for a normal person as well. Two caregivers felt that worsening of mental illness is also possible if information about their patient being suffering from a mental illness is concealed from the other party. Lack of cordial relation with the partner, lack of adjustment with the partner, and conflict and quarrel with the partner can cause worsening. Some of the caregivers believed that marriage could not worsen mental illness, as other family members will also be available for care for a PMI. Some of the caregivers felt that the impact of marriage on the outcome of mental illness is contingent upon certain factors such as the presence of a mutual understanding between the partners and medication compliance. One of the caregivers felt that the worsening of mental illness can also depend on the patient's ability to carry out his or her responsibilities.

In terms of looking for a match, when enquired “did you ever look for a match for the marriage of your ill relative?” the majority (90%) of caregivers revealed they never did so, taking into account the patient's poor will power and inability to take independent decisions. While one of the caregivers was not mentally prepared for the marriage of the ward, a few others felt they would consider marriage of their mentally ill ward after the marriage of other children. Some of the caregivers expressed that they were waiting for their child to attain appropriate age for marriage, while others felt they would consider marriage after the child completes education. One of the caregivers mentioned that they would consider their ward's choice in his or her marriage. A small fraction of caregivers (10%) had looked for a match for their mentally ill ward. They too expressed doubts about the sustainability of marriage. The caregivers were even ready to compromise on the economic background of the prospective partner.

When given a hypothetical situation, “Suppose you are looking for a match for one of your other child or a relative (who does not have mental illness) and you are told that the prospective match which you have selected has a mental illness, would you agree for the marriage?” only 13.3% of caregivers agreed that they would go ahead for such an alliance, and about two-third disagreed to get their children married to a PMI. However, on further probing, one of the caregivers agreed that they would go ahead with such an alliance, provided everything is revealed about the mental illness by the other party. Some of the caregivers said that marriage with a mentally ill person would pose an additional burden. They felt that marriage with a mentally ill person could lead to problems. Two of the caregivers asked “Why should a normal person marry a mentally ill person?” Another caregiver expressed that “getting their child married with a mentally ill person means putting their own child in turmoil.” It was also felt by one of the caregivers that “everyone expects a suitable match, PMI do not make a proper match.” About one-fourth of the caregivers gave a situation-based response regarding the marriage of their normal ward with a PMI. Three caregivers expressed that they would agree if there is a scope of improvement in the mental illness in the future. Another group of caregivers told that if the disease is serious, they would not agree. Three caregivers responded that if the patient is stable with medication or gets cured, they would agree. A few of the caregivers also felt that if the person is self-dependent, can manage the family, and can adjust with the spouse, they would agree.

When the caregivers were asked about the purpose behind getting their ward married, the most commonly expressed purpose was to have one's own family, which was reported by 10 caregivers. The other commonly reported purpose of marriage was family proliferation, taking forward the family name, and completion of the family cycle. The other caregivers cited fulfillment of parental responsibility as the purpose of marriage. “Companionship” was also cited as one of the purposes by a caregiver. A few caregivers also felt that marriage is important to obtain some moral and social support.

When the caregivers were asked whether the purpose of marriage is to fulfill the sexual desire, more than half (53.3%) expressed that this was true, and on further elaboration, the most common theme was “sex is a part of marriage; however, the purpose of getting married is not to fulfill the sexual desire only.” However, other caregivers answered the question in a negative way.

When an attempt was made to understand the relationship of marriage with sexual intercourse and the caregivers were asked”Can the fulfillment of sexual desire in a wedlock or outside the wedlock improve the mental illness of your patients?” a majority of the caregivers (60%) agreed that fulfillment of the sexual desire of a PMI could lead to an improvement in mental illness. A smaller fraction of caregivers felt that sexual intercourse will provide momentary diversion and can aid in recovery. A few caregivers felt that mental illness could improve by mutual cordial communication and not by fulfillment of sexual desire. One caregiver felt that sexual relationships could act as a diversion but not a treatment. One of them said “medications are the only form of treatment.” Some of the caregivers were ambivalent and verbalized that sexual intercourse may or may not improve mental illness. A caregiver expressed that “sex cannot be a cure for mental illness—if it had been so, married people would not have mental illness, but this is not true."

When asked if their patient/ward will be able to take responsibilities of his or her family after marriage, three-fourths (73%) of caregivers were optimistic about it. Nine caregivers felt that since their ward is able to perform household works, he or she has the ability to take responsibilities of his or her family after marriage. Two caregivers also felt that because the patient is already engaged in other family responsibilities and is performing well outside, there are chances that he or she shall be able to take responsibilities of his or her family after marriage. One of the caregivers felt that his ward was not abusing any drugs nor had any other bad habits, so he will be able to take up the responsibilities. Two other caregivers were optimistic, yet they felt that the real picture would be revealed only after marriage.

When asked whether they discussed the issue of marriage of their patient with their doctor, only a minority (n = 5) told that they had discussed it with the treating psychiatrist. Two caregivers said that the doctor suggested revealing about mental illness to the other party. Another common advice offered by the doctor was not to hurry for marriage. One of them explained that the doctor advised to marry the patient only after he or she becomes independent.


   Discussion Top


Marriage is one of the important social institutions which provides an opportunity to both the partners to satisfy their physical, psychological, social, cultural, and economic needs. It also permits an opportunity for the couple to establish a stable relationship with each other to form a family.[2] In a country like India, marriage is a social institution of extreme importance. However, the issue turns controversial when it comes to the marriage of a PMI. There is a great deal of stigma associated with mental illness per se, which makes the marriage of a PMI an issue.[10],[11] Treating mental health professionals are often asked about the possibility of getting their mentally ill child married, and there are no clear-cut answers. Furthermore, many a time, mental health professionals encounter situations where they find that patient has been married, despite parents being explained the pros and cons of the same on the course of mental illness.

The general public has a preconceived negative notion about mental illnesses,[10],[12] which influences the marriage decision and prospects. Although the general public has a negative view about the marriage of mentally ill subjects, little is known about what their caregivers, who actually decide about the marriage of the mentally ill relatives, think. Although some studies have evaluated the impact of mental illness on marriage and vice versa,[13] little is known about what the parents/caregivers of patients with mental illness think about the marriage of mental illness. This study attempted to explore the beliefs of caregivers of patients with mental illnesses regarding the marriage of PMI in general and the marriage of their own mentally ill family member. The basic question addressed in the study was, “Should a PMI marry?” As there are no previous studies on this topic, it is not possible to compare the findings of this study with the existing literature. In view of this, an attempt is made to discuss the findings in the context of the existing sociocultural norms and what can be done by the mental health professionals to change the behavior and attitude of caregivers toward the marriage of PMI.

This study reveals that in general, parents/caregivers of patients with mental illness are inclined to get their child/relative married. This is possibly fuelled by the existing social structure with respect to marriage and presence of other beliefs which suggest that marriage and/or sexual intercourse can lead to improvement/cure of mental illness.[3],[14] This is despite the fact that the relatives/parents are aware that marriage can worsen mental illness. This study also reflects that it is not just the social norm of getting married that influences the parental decision of getting their children with mental illness married. Other social factors such as having someone to care for the patient after their death and their desire to get their children married also influences the decision of marriage. Furthermore, the decision for marriage is also influenced by the belief of the parents/relatives that PMI will be able to take responsibility for the family after marriage.

This study also reflects that most of the parents/relatives do not discuss the issue of marriage with the treating psychiatrists. This possibly also shows the apathy of the treating psychiatrists toward this social issue or possibly reflects their presumption that they will not be able to do anything about such issues. Accordingly, it can be said that psychiatrists should be proactive in discussing the issue of marriage with the caregivers and explain the pros and cons of the same. During psychoeducation about the illness, the mental health professionals should devote sufficient time to discuss the issue of marriage and clear the myths in the minds of the parents/caregivers. The caregivers should be clearly explained about the association of worsening/relapse of mental illness with different stressors arising as part of the wedlock. In addition, mental health professionals should also explain the caregivers as to how supportive relationships can prevent relapse and improve the overall outcome of mental illness. This could possibly help the caregivers to take an informed decision. The mental health professionals must also inform them about the legal status of the marriage of a PMI and about the consequences of not informing the family of the partner about mental illness prior to marriage, especially if the illness is of serious nature.

In general, it is believed that most people in the society consider mental illness as a disqualification for marriage and would not consent to marriage if told directly about the presence of mental illness in the other party. The finding of this study supports this general belief. This study also reveals that although the parents want their relatives with mental illness to get married, they are not prepared to accept a match of a PMI for their children/relatives who do not have a mental illness. This finding shows the double standards being followed in the society and stigma attached to mental illness. Accordingly, if it is desired that the attitude of society changes toward the marriage of people with mental illnesses, there is a need to reduce the stigma associated with mental illness. Furthermore, there is a need to amend the laws related to the marriage of PMI in the country. According to the Hindu Marriage Act, marriage can be annulled if any of the party is not capable of giving a valid consent for marriage as a result of unsoundness of mind, or even though capable of giving consent should not be suffering from a mental illness of such a nature or extent that makes them unfit for marriage and procreation of children and should not be suffering from recurrent attacks of insanity. Some of the authors have argued that with the advancements in treatment of mental illnesses, there is a need to amend the law.[15] This will possibly reduce the stigma associated with the marriage of PMI.

This study has certain limitations. It is known that attitude toward mental illness and marriage differs across different regions of the country. Accordingly, the findings of this study must be interpreted in light of the same. As most of the patients were on treatment for long, it is quite possible that the attitude and belief about marriage could have been altered by the encounter with mental health professionals. The demographic factors such as the educational and social status of caregivers also can play a major role in the formation of beliefs and attitude, which was not studied in the present investigation. Thus, it is recommended that future studies must attempt to overcome these limitations.


   Conclusions Top


The present study suggests that a significant proportion of caregivers of patients with severe mental illnesses have many misconceptions about the association of marriage and the outcome of severe mental disorders. Accordingly, the clinicians should always discuss the issue of marriage with the caregivers and try to clarify the misconceptions about the association of mental illness and marriage.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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