Expectations, aspirations & Quality of Life
Expectations, aspirations and Quality of Life.
Ph.Corten[1]
I.Bergeret[2]
R.Hachey[3]
C.Mercier4
I. Pelc[1]
Expectations, aspirations and Quality of Life.
Summary
Authors have observed that the expressed Quality of Life by patients included in rehabilitation programs may decrease in the course of the treatment. After a brief review of the international literature, they hypothesize that aspirations and expectations are correlated with the Quality of the Life and analyze the direction of these correlations. Authors demonstrate that, there is a positive correlation between assessment of the actual life and levels of expectations and aspirations, but negative correlations between the gap, the ratio of aspiration or expectation, and the Subjective Quality of Life. They conclude on a warning on the risk to do with the Quality of Life a direct indicator of therapeutic program success.
Key words: Quality-of-Life; Adult; Mental-Disorders; Psychiatric-Rehabilitation; General-Population; Aspiration; Expectation; Assessment
Expectations, Aspirations and Quality of Life.
Introduction.
The Quality of Life appears to be a very current topic. However, it appears that this label hides several meanings (Mercier 1994):
1)The Environmental Quality of Life based on objective indicators (standard of living, comfort, pollution, criminality...).
2)The Health Related Quality of Life focused on functional abilities, Well-Being, years in good health added to life (QALY), adverse effects and patients' compliance.
3)The Quality of Life as a Whole or Subjective Quality of Life based on the satisfaction of the proband in regard to several Life Domains.
In the context of mental disorders, it seems more relevant to refer to this last definition especially with patients included in therapeutic rehabilitation process (Mercier & Filion 1987, Corten & al 1994). However, Hachey (Hachey & al 1992, Hachey & Mercier 1993) enlightened that psychiatric patients included in rehabilitation programs may have a less good Quality of Life than not included ones. Furthermore, clinically, it is unexceptional to observe that scores on Quality of Life may decrease while these patients get better for the therapist.
One can wonder if the referentials were not modified by the therapeutic program. If the patient increases his life aspirations, in the same time the gap between this goal and the present life increases too (Bearon 1989, Mercier 1994). Consequently, in an Osgood's differential where the maximum and the minimum are the referentials, the proband will be led to put the present life further away the optimal point.
Aspirations and Quality of Life: brief review of the literature
The topic of aspirations emerges first in the framework of the achievement theories: the success of an action being associated to a feeling of satisfaction. Nevertheless since 1957, Robaye (Robaye 1957) differentiated aspirations, expectations and predictions. For this author, aspiration would be the goal that one plans to reach while expectations would be the goal that one waits to reach considering personality (and affects) and the difficulty of the task. The prediction would be in relationship with the analysis of the present abilities. For achievers, expectations are superior to the present performances but inferior to long-term aspirations. In case of success a modification of goals can be observed, the individual updating its predictions, then its expectations and, finally, its aspirations. It would be, thus, a psychic mechanism of adaptation that would aim at maintaining constant the gap between the present performances and the expectations or the aspirations. Furthermore, expectations should be nearer the predictions than the aspirations
In the field of the Quality of Life as a whole, which concerns us, aspirations and expectations were introduced in the concept since Campbell (Campbell & Converse 1972, Campbell 1976, Campbell & al. 1976, Campbell 1981) and Andrews (Andrews & Withey 1974 & 1976, Andrews & Crandall 1976, Abbey & Andrews 1985, Andrews & Robinson 1991). Campbell & al. in 1976, hypothesized that Quality of Life was based on a double referential: the others’ situation (social comparison theory) and self-aspirations or expectations. The greater the gap between the present situation and the aspirations or expectations, the more the Quality of Life would be altered. They insisted furthermore on the interest of evaluating this gap in terms of ratio rather than in terms of score differences. Indeed, a ratio is a proportional measure taking into account the starting point; however differences (gap) as well as ratio allow few comparisons in test-retests measures by lack of standard comparisons. Andrews (Andrews & Withey 1976, Andrews & Robinson 1991), introduced a more complex hypothesis including the notion of congruence level with needs, environment and aspirations in the Quality of Life model.
Michalos would establish the first global theory: 'the Multiple Discrepancy Theory' (MTD) (Michalos 1985 & 1986). He would demonstrate that the comparison between on the one hand what one has and what one wants to have had the greatest impact on the Quality of Life (goal-achievement theory) (Lewin K 1944, Campbell & al 1976, Andrews & Withey 1976, Michalos 1983), and on the other hand between what one has and what significant other persons have (social comparison theory) (Duncan 1975, Campbell & al 1976, Andrews & Withey 1976, Wills 1981, Michalos 1983), then, between what one has and what one has for needs (person environment theory) (Harrison 1978, Caplan 1983), and finally between what one has presently and either the best that one has had in the past (Campbell & al 1976, Michalos 1983) either what one thought to be able to reach 3 years ago (Festinger 1957, Campbell & al 1976). The only theory that seems to have little impact on the present Quality of Life would be, for Michalos, the gap between what one has and what one expects to have within 5 years. Nevertheless, it is important to mention that for all the other theories, Michalos associates a small gap with a good Quality of Life but that for this last theory he uses the reverse hypothesis (large gap). Furthermore this author chooses a long period of time (5 years) to measure expectations while generally the literature, since Campbell & al (1976) limits this to one year. Finally it must be emphasized that this theory is essentially based on what one has and not on what one is.
In the field of Health Related Quality of Life, the first authors to introduce the concepts of aspirations and expectations seem to be Najman & Levine (1981) whith the purpose of evaluating the impact of new medical technologies on the Quality of the Life. Nevertheless, these authors only quote the hypothesis of Mason & Faulkenberry (1978), ascertaining them as direct evidences. Indeed, Mason & Faulkenberry, hypothesized that the greater the gap between the present life and the aspirations and/or performances, the lower the level of satisfaction. But, contrarily to what relates to international literature their results are not as univoque as they appear.
The most quoted author (Schipper & al 1990, Häyri 1991, Parmenter 1994, WHOQOLGroup 1995, Testa & Simonson 1996) in the medical literature is Calman (1984), defining the Quality of the Life as a gap between patient’s expectations and successes. He notes that this gap varies in the course of the sickness; he distinguishes the potentiality from the current ability and underlines the importance of having realistic goals. Häyri (1991) points how much this assertion could be harmful with a radical interventionist surgeon, telling that it is always possible to restore Quality of Life afterwards!
“It is perfectly possible that a paralyzed ballet dancer would rather not live at all if the only alternative is to live to be ‘rehabilitated’ to an entire different life. ‘Growing in other ways’ is certainly commendable, as long it is reasonabily voluntary, but forcing the dancer to, say, enjoy and appreciate drawing with the teeth may come closer to torture than appropriate medical care”
Häyri M. 1991
In the context of mental disorders, de Leval in 1995, clearly distinguished the concept of Ill-Being which refers to the present, the concept of Quality of Life which tends from the present to the future and the concept of depression which is only experienced in the past and in the present. In a phenomenological approach of the depression focused on the temporality, the author underlines that on one hand, the past is remote from the present and ceases to nourish it; and that on the other hand, the future is reduced to the only wish to recover the lost past (called the intrinsic future). At the heaviest of the depression the gap between the present and the intrinsic future would be maximal but along with the recovery this gap reduces. It is called the intrinsic Quality of Life. Simultaneously to the recovery, the past is unified with the present, involving the subject in a true future (called extrinsic future). A seesaw effect would appear at this moment. The gap being maximal with this new future, the evaluation of the Quality of Life (Extrinsic Quality of Life) decreases, while undoubtedly the patient is clinically improved and expresses the feeling that his Quality of Life is better than some time ago!
Hypothesis.
The aim of this paper is to demonstrate that aspirations and expectations have direct correlations with the Quality of Life and to analyze if these correlations are positive or negative. We hypothesize that the greater the gap between the present life and the expectations and/or aspirations is, the lower the Quality of Life will be.
Materials & Methods .
A) Tools.
Authors used a set of computerized tools: the Quavisub (Corten & al 1994, 1998) including, among others, the following instruments:
- The satisfaction scale with life domains (SLDS) of Baker and Intagliata (1982) modified by Corten and Mercier (Caron & al 1997) (49). In this scale, probands have to relate 16 life domains with small pictures of faces from the most smiling one to the sadest one on a scale from 1 to 8. As compared to the original scale, 4 items were cancelled by lack of validity between European and North American populations (stepwize analysis method) and 4 items, related to the self-esteem and self-actualization, were added. The reliability ( of Cronbach) of the original scale, tested by Baker & Intagliata in 1982 on an American population was 0.84. Caron & al. in 1997 tested the original scale increased by the new items on a Canadian population with healthy subjects and psychiatric patients in Abitibi and found an of Cronbach equal to 0.90, Corten & Mercier tested also in 1997 the modified scale on a Belgian population and found an of Cronbach equal to 0.91. In our study, we will use the crude score (from 1 to 8) of a single item concerning the ‘satisfaction with life in general’, and a computed index (from 1 to 5) - mean of the 16 items of the SLDS - that we will call 'global satisfaction'.
- The Life Scale of Cantril (1965) used by Campbell & al (1976) This scale analyzes the position of the subject in a Osgood's differential represented by a ladder graduated from 1 to 100 whose extremities are, on one hand, the best that one can imagine and, on the other hand, the worst that one can imagine. In this scale, the subject has to place on the ‘ladder’ his present life, the worst situation in the past, the best situation in the past, his life last year, the level where he perceives his peers, his life the next year, that we will call expectations, and the best to which he believes to be able to aspire, that we will call aspirations.
B) Samples.
The population of this study included 399 patients with mental disorders according to the DSM IV and 399 healthy people having no psychiatric background, not taking currently psychotropic drugs (except sleep inductors) and not unemployed. Each patient was matched with a healthy person according to the age category, the gender and the level of education.
Patients were symptomatically stabilized at the time of the interview (BPRS> 35 and< 80) (Lukoff 1986) and had a global functioning superior to a severe incapacity (GAFS> 30). The patients were either hospitalized in psychiatric facilities (N= 115) or included in rehabilitation programs (N= 210) or followed in an outpatient clinic (N= 74).
C) Statistics.
Next analyses were computed with SPSS software. A first part will present a brief descriptive analysis of samples (means and standard deviation). In a second part conformity analysis will be computed on aspirations and expectation of the Life Scale of Cantril, and on the Satisfaction Scale with Life Domains (SLDS), for healthy subjects and psychiatric patients (t-test of student p= 0.01). Finally correlations analysis between scores in the Satisfaction Scale with Life Domains (SLDS) and, on one hand, the expectations and, on the other, aspirations in the Life Scale of Cantril will be computed (p= 0.01).
Furthermore, two indices will be used in this paper: on the one hand, gaps between aspirations or expectations and the present life[2] and on the other hand, ratio[3] to take into account objections of Campbell & al (1976) and of Mason & Faulkenberry (1978).
Résults.
A) Descriptive statistics
By construct, the mean of age of the two samples is similar: 41.2 years + 15.1 years, and the sex ratio distributes the two samples similarly in 44% of women for 56% of men.
The patient mean GAFS was 57.4 + 16.3 (it is-to-tell that they had symptoms or difficulties with average intensity in the social, professional or educational functioning) and the intensity level of symptoms (BPRS) gives a mean score of 39.2 + 10.8. (minimum = 24 maximum= 120, pathological threshold= 35, severe= 54). On the average, they were since 10.9 years +10.1 in psychiatric process. Half of them were not hospitalized these 12 last months; 88% took psychotropic drugs and the heaviness of their medication was considered as medium (3 +1.3 in a graduated scale from 1 to 5).
B) Conformity analysis
- Expectations and Aspirations (table 1)
For all the results in the Life Scale of Cantril (min= 1 max= 100), patients have significant lower scores than healthy people (t- test p=0.01). The present life for healthy people is estimated at 71% while for patients at 49%.
table 1: Life Scale of Cantril (min= 1 max =100)
VariablesTotal Pop.ControlsPatientsSign
m s.d. m s.d. m s.d. t-test
Worst in the past 25.04 +19.56 29.07 +18.86 17.85 +22.28 0.000
Best in the past 81.29 +14.18 82.06 +12.43 77.80 +18.07 0.001
Last Year 59.57 +23.06 63.38 +19.48 47.45 +28.160.000
Present Life 63.76 +21.63 71.31 +12.81 48.95 +27.10 0.000
Others 62.56 +16.09 64.44 +13.50 57.16 +20.410.000
Next Year (Expectation) 72.02 +18.49 74.88 +14.04 64.73+25.28 0.000
Best in future (Aspiration) 82.41 +15.80 84.30 +14.77 70.45+20.69 0.000
Figure 1
- present and past
The first evidence that appears is that for patients as well as for controls the present life is evaluated as less good than the best in the past, but the loss between the best in the past and the present life is more important for the patients (Controls gap= -10.75, Patients gap= -28.85)
The second evidence is that controls assessed the present life better than their life last year (Controls: gap= +7.93 and ratio %= 113%), but the patients assess the present life quite similarly to their life last year (Patients gap= +1.2 points and ratio %= 103%)
- present and future
For controls, the expectation gap is 3.57 (ratio %= 105%) while the aspiration gap is 12.99 (ratio %= 118%). For patients, the expectation gap is 15.78 (ratio %= 132%) while the aspiration gap is 21.50 (ratio in%= 144%).
Healthy people imagine therefore the next year (expectations) a little better as compared to their present situation while patients imagine it clearly better. Patients put their expectations, proportionally, closer to the best to which they can aspire (ratio: aspiration/expectation in%= 109%) than to their present life (ratio expextation/present = 132%), while healthy probands, dissociate them more (ratio: aspiration/expectation in%= 113%, ratio expectation/present= 105%).
- past and future
For the past compared to the future, healthy people as well as patients consider their close future less enviable than the best in the past (ratio: controls= 91%, patients= 83%). As for their far future, healthy people estimate it at the same level as the best in the past (ratio controls = 103%), while patients no longer have such an ambition (ratio patients= 91%).
- present and others
Finally, healthy people estimate the situation of their peers less enviable than their present life (Controls gap= +6.87 and ratio %= 90%) while for patients it is the reverse: they see the present situation of others as more enviable than their present life (Patients gap= -7.35 and ratio %= 117%).
A typological analysis, (Bergeret & al 2002), demonstrated that these attitudes are not uniform for controls and for patients, some patient groups having the same behaviour as controls and some control groups having the same behaviour as patients.
- Quality of Life. (table 2)
Analyzes satisfaction scores concerning life domains, emphasizes same differences aspreviously described for healthy people and for patients: the Quality of Life for the healthycontrols is significantly better than for the patients as well for the Global satisfaction as well as for the single item 'the life in general' of the SLDS (Table 2).
table 2:Quality of Life Scores of the Satisfaction Scale with Life Domains
VariablesTotal Pop.ControlsPatientsSign
m s.d. m s.d. m s.d. T test
Global Satisfaction 3.54 +0.81 3.99 +0.53 306 +0.770.000
(min = 1 max = 5)
'life in general' 5.43 +2.04 6.42 +1.21 4.36 +2.160.000
(min = 1 max = 8)
If the Global Satisfaction is transformed from a 1 to 5 scale, to a 1 to 100 scale, in order to compare this score to the ‘present life’ score of the Life Scale of Cantril, results are respectively 74.5% for healthy people, and 52.2% for patients. These scores are similar to those obtained with the Present Life Score in the Life Scale of Cantril (see table 1).
C) Correlation analysis
- Are there correlations between the Quality of Life and the Life Scale of Cantril?
If yes are these positive or negative correlations?
- Present life (table 3)
For patients as well as for healthy people, an extremely significant positive correlation exists between the manner in wich the two samples estimate their present life in the Life Scale of Cantril and the global satisfaction or the single item 'the life in general' in the Satisfaction Scale with Life Domains (SLDS). It means that there is a good probability that the measures of the two scales are indicators of the same phenomenon.