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© Borgis - New Medicine 1/2009, s. 19-23
*Ewa Wilczek-Rużyczka
Social support for people suffering from depression and their families
Vice Head of the Institute of Nursing and Midwifery, Faculty of Health Sciences, Medical College, Jagiellonian University, Cracow
Katarzyna Wojtas, MSc Junior Assistant, Institute of Nursing and Midwifery
Head: Prof. Antoni Czupryna, PhD
Summary
The experience of mental illness is a difficult situation not only for the patient but also his or her family. Natural consequences of this morbid state include changes of past lifestyle and social functioning of patients after they went through a mental crisis. Mental illness often leads to a situation where patients are isolated from society and experience social discrimination and stigma. It results in loneliness, a sense of isolation and not being understood, which may exacerbate patients´ illness. That is why support received from close relatives and friends becomes so important, for it complements the help and support provided by clinicians and the whole therapeutic team during the course of treatment.
The objective of this work was to try to define the role of social support and its influence on the well-being of the mentally ill. In order to achieve this purpose, the literature regarding this topic and personal experiences obtained while working in the psychiatric unit were reviewed. This paper describes depressive symptoms classified according to ICD-10. It also discusses their consequences for social functioning of a suffering person and analyses social support and its sources in the light of interpersonal relations and interactions.
Introduction
The experience of mental illness is a difficult situation not only for the patient but also his or her family. Natural consequences of this morbid state include changes of past lifestyle and social functioning of patients after they went through a mental crisis. Mental illness often leads to a situation where patients are isolated from society and experience social discrimination and stigma. It results in loneliness, a sense of isolation and not being understood, which may exacerbate patients´ illness. That is why support received from close family and friends becomes so important, as it complements the help and support provided by clinicians and the whole therapeutic team during the course of treatment.
The objective of this work was to try to define the role of social support and its influence on the well-being of the mentally ill. In order to achieve this purpose, the literature regarding this topic and personal experiences obtained while working in the psychiatric unit were reviewed.
Social support is an important element enhancing the process of recovery. It stimulates mechanisms for coping with difficult situations. Therefore, it may limit the consequences of mental illness regarding social roles of patients. However, the efficacy of social support will depend on the form and ways of providing this support and also on the patient´s ability to see and accept it. Moreover, social support efficiency also depends on various factors including interpersonal relations between subjects receiving and providing support. The patient should define the character of a difficult situation such as depression, and express his/her individual needs for social support.
Depression, colloquially understood as feeling sad, blue or in a low mood, is defined in psychiatry as „a special kind of disorders regarding mood and emotions, which may be classified as a morbid state, and therefore require medical help”. In order to distinguish depression from normal mood changes, clinical evaluation including the following elements should be taken into account: the intensity of disorders, their duration, the efficacy of pharmacotherapy, and severity of experienced symptoms [1].
Depression is a mental disorder comprising psychological, social and biological conditions. Nosological classification recognizes three groups of depression: reactive, endogenous, and somatogenic depression [2]. From the symptomatological point of view depressive symptoms are diagnosed on the basis of disease symptoms. According to the ICD-10 classification of Mental and Behavioural Disorders, the major depressive symptoms include: lowered mood, loss of interests, decreased energy, and additional symptoms, e.g. sense of guilt, lower self-esteem, sleep disorders, decreased concentration, memory loss, and suicidal thoughts and tendencies. Depression may be diagnosed when a specific number of symptoms is observed on a daily basis for a period of at least two weeks. The above classification defines the following morbid syndromes: depressive episode, recurrent depressive disorders, bipolar affective disorders, and chronic mood disorders – dysthymia. Depressive symptoms may also be diagnosed in patients suffering from schizophrenia, neurosis or organic mood disorders [3].
Depression is characterized by a very wide spectrum of symptoms [2, 1, 4]. The major symptom of depression is worsened mood, described by patients as gloom, resignation and sadness, while feelings of joy and satisfaction are not experienced despite objective reasons for them. Relations with close family and friends also suffer; the contacts become colder and even indifference may be observed, regardless of earlier strong and positively expressed emotions. Family members may often feel guilty and accuse each other of inefficient relations with the sick person. Depressive mood is characterized by a tone of despair, suffering and helplessness.
People with depression often exhibit disordered thinking. They also have low self-esteem, low self-confidence and decreased sense of dignity. They forget about all their achievements in both professional and family life. Instead, they focus on failures, which, in their opinion, prove their incompetence. Negative assessment of the past, present and future often leads to suicidal attempts. Kepinski described this situation perfectly with the following words: „Depression is a kind of darkness. It seems like the depths, a black wall separating a person from the world. The past, present and future are black.” [5]. Moreover, pointing to positive aspects of life, the presence of happy, smiling people, or attempts to cheer up individuals with depression, causes additional irritation [6].
Decreased motor activity, as one of the depressive disorders, manifests with slowed locomotor movements, which seem to be ponderous, requiring enormous effort from the patient. However, one must be aware that drive disorders may also take the form of stupor or motor anxiety/arousal. Everyday activities, which used to be performed before depression occurred, become neglected or significantly limited. They are frequently accompanied by aversion, which is misunderstood by other people and leads to unjustified remarks about the patient´s laziness. Patients lack the strength to challenge such assumptions; therefore they accept this label though they do not agree with it.
Slowed functioning of a patient with depression can also be observed in the aspect of mental processes. The pace of thinking slows down; statements are short, laconic and proceeded with moments of reflection. Depressive patients are tired by conversation. That is why information for them should be simple and short; „deep depression excludes long conversations with the patient (...) very often he/she is unable to say a word” [6]. Attention must be paid to the following complaints given by patients: concentration difficulties, problems with focusing and worsened ability to remember things. Specific features of depression are present in biological functioning. They manifest with hypo- and hypersomnia accompanied by 24-hour changes of mood and activity (morning hours are the most difficult). Apart from the above-mentioned problems patients also complain of poor physical well-being. This symptom should never be underestimated, taken lightly or trivialized with the words „you´ll feel better in a minute” because it may signal serious somatic disorders. These include: dyspnoea, headaches and dizziness, brachycardia, decreased arterial blood pressure, constipation, and dryness of mucosa. ICD-10 does not include one symptom of depression, i.e. slowly drifting anxiety, whose intensity changes in time, with the sense of threat, and internal tension.
The experience of various bothersome symptoms in the physical and mental spheres of the patient´s life affects his/her social functioning. „Recent years have brought a significant increase of interest in psychosocial effects of depression. It especially concerns family life disorders and disease influencing the patient´s social environment ”[7]. Depressive patients tend to become isolated from their surroundings. The circle of their friends becomes tighter; sometimes relations are even broken. They are overwhelmed by their own negative emotions and are unable to maintain social relationships. The situation gets much worse when no psychotic symptoms are observed in the course of depression. Then the patient´s criticism makes the experience of disease a lot more severe. People in the patient´s social sphere start to notice that someone who previously was known to be full of life has become dull, grey and quiet. Facial mimics are very poor and express only sadness, while the eyes show tension and suffering. Slower pace of thinking and difficulties with making decisions make the whole process of communication hard and may even lead to frustration of the interlocutor, annoyed by the long periods of silence.
Mentally ill patients overwhelmed by personal suffering and the burden of experienced sadness show no interest in the surrounding world. Patients are convinced that other people do not understand them and feel lonely. And other people, unaware of depression or its course, avoid contacts with the patient. It seems safer not to get in touch and protect one´s own emotional life from others´ problems. That is how the phenomenon of indifference and social alienation is born.
Unfortunately, despite social information programmes in the mass media, mentally ill people are still treated as second-class citizens, of the worse category. „ From both the historical and present point of view the concepts of mental illness and the mentally ill person are present in the social consciousness in the form of broad negative connotations and stereotypes. ” [8] Kepinski´s opinion about people surrounding mentally ill patients seems to be particularly relevant when taking into account these types of social attitudes and behaviours. „ No other environment is as dangerous as the human one. It hides evil, cruelty, a tendency toward taking away freedom, etc. Therefore, a man cannot be sure what to expect from others. No other environment is so insecure, ” says Kempinski [5].
Society does not like distinctness and non-conformity, especially when it concerns mental health. It is much easier to understand somatic disease, physical suffering caused by injuries or surgical interventions. It is easier because it is justified and tangible. Mental suffering cannot be touched, seen or measured. This phenomenon cannot be evaluated by any scales or measures. „As far as mental illness is concerned, finding the cause of suffering is the major problem. Furthermore, the analysis of those causes does not make much sense, for the patient´s fears, sadness, hostility, terror and strange behaviours seem unfounded ” [3].
Mental suffering is a highly subjective experience and it requires multiple skills from people accompanying the patient so they can understand the patient´s inner discomfort and provide adequate support.
Interest in social support issues has its origins in the nineteen sixties, when evaluation of social support efficacy and its active role in treatment during the course of depression was attempted for the first time [9].
Social support in the aspect of interpersonal relations is seen as helpful relations of protective character. Through such relations a person´s interpersonal needs may be fulfilled. It makes the process of adaptation to difficult situations easier. Contact with others becomes accessible and it preserves the patient´s health status on the highest possible level [10].
Siegel´s definition of social support from 1993 describes it as „information received from other people saying that they love you, that you deserve to be taken care of, that you are worthy and dear, and you are also a part of the network of interrelations in relationships with your parents, spouse, partner, other relatives, friends, society, church, club and even your favourite pet ” [11].
The model of social support given as a category of interpersonal interactions:
– Its purpose is to bring one or both participants closer to the solution of a problem, overcome difficulties, reorganize disturbed relations with the patient´s social environment and support the patient emotionally;
– During the course of this interaction, emotions, information, instruments and material goods are exchanged;
– Aptness between what is expected and what is provided is the key element making this social exchange effective;
– Exchange taking place during this interaction may be one-sided or mutual while the direction of the relation between the supported and supporting is constant or changes;
– Interaction and exchange take place in problematic and difficult situations [12].
An important point of reference for social support analysis is its consideration in the context of support perceived vs. received. The analysis of perceived support allows the patient to point to people and places which might be used in difficult situations. Received support includes subjective and objective assessment of the patient regarding the amount and quality of actually received support. The analysis of the concept of support cannot omit the aspect of its outcome as a major or buffering effect. The major (direct) effect describes beneficial influence of support on the patient´s health status because it gives strength and a sense of adherence. Lakey´s research proved that social support correlates with health and it determines well-being and comfort. The second type of direct interventions includes the presence of those closest to the patient, which in the case of stressful situations protects supported individuals from the effects of stress. The buffering hypothesis, emphasized by many researchers (Cieslak, Cobb, House), recognizes perceived and received support as a buffer decreasing the tension and helping overcome difficult situations. This attitude toward support allows the patient to change his/her self-evaluation, see his/her competencies from a different perspective and increase the sense of resourcefulness [9].
Social support includes, under its definition, positive interventions, motivating patients to take an active effort in order to solve problems. It may confirm the patient´s adherence to a group, make people feel safe and indicate the correct direction of activities in both a material and emotional way. Of course effective support means support provided by individuals competent in given fields, especially when instrumental and informational support is concerned. If the patient is not ready to receive support, the objective, which is to help the patient, cannot be achieved. Therefore, it is fundamental to get to know the person we want to help well. The one who wants to support the other must learn his/her expectations and mechanisms of coping with difficult situations.
Individuals suffering from depressive disorders, which are often of recurrent character, require support, understood widely, and awareness of its accessibility. The sources of support include family, friends and colleagues, but also religious groups and professionals. The following paragraphs attempt to define and describe those sources of support in the context of depression.
The patient´s therapeutic team is the basic support group, which is the first to form the right attitude towards the patient, delivers support and educates the patient´s family. The therapeutic team sees support as a fact, which is not to be modified but comprises an important element in the process of coping with stress caused by disease [13]. In order to make support effective it must be built on an authentic attitude to the patient, be engaged in his/her situation and be willing to provide help.
People providing support are expected to be considerate and patient but most of all they should be able to understand the helplessness overwhelming the patient. Patients should feel warmth, kindness and benevolence, which constitute obligatory behaviour of the therapeutic team. It influences faster recovery of the patient, and builds one´s faith and hope in his/her ability to play social roles in the future. It also convinces the patient about his/her value and dignity. When mentally ill people feel accepted by those surrounding them they start to accept themselves, which might become the turning point in the process of restoring their emotional life. Individuals able to show their acceptance towards the patient are characterized by inner harmony and serenity. The attitude of tolerance and positive feelings toward the patient lacks egoism and reluctance. It is due to the fact that the balance between the personal „I” and the patient´s „I” is preserved. Nurses, doctors, therapists and psychologists must be aware of all conditions of therapeutic relations which are necessary for successful treatment. They must face and answer some questions asking if they are ready to provide help and support.
– Is my manner and attitude going to be recognized by others as trustworthy?
– Am I an expressive person sending clear information?
– Am I able to show positive attitudes toward other people, be warm, caring and show interest?
– Am I strong enough to protect my autonomy?
– Am I able to enter the world of emotions, to see and feel as the other person does?
– Am I able to accept every person coming to me for help and is this acceptance unconditional?
– Am I able to be sensitive in my actions so no one sees my behaviour as a threat towards them?
– Am I certain that the person I am talking to can be granted autonomy?
– Am I free from expressing opinions about the subject of the relation? [14].
Specialists make patients realize their problems. Then together they define therapeutic objectives so the patient recovers as soon as possible. At this stage support means being present, talking and explaining what can be improved in relations with the patient´s family and how to prevent isolation and rejection. The mentally ill patient needs the presence of another person, kindness, acceptance, stability and safety. Patients want to be understood by others. However, at the same time they expect others to be calm and self-controlled. This results from the fact that positive emotions and mood experienced by those delivering support affect the supported and improve their well-being.
Awareness of real kindness and silent company are important elements of the therapy [6]. As far as relations with the patient is concerned, the first place is taken by emotional contact emphasized by nonverbal communication. Gestures and looks tell the patient he/she is not alone and has allies and helpers in this fight against depression.
The question why one´s family and friends are not always a source of support should be answered. It seems there are several reasons:
– Lack of strength and energy to support mentally ill people,
– Complicated interpersonal relations before one fell ill,
– Fear and uncertainty how to behave,
– Lack of knowledge about the nature of the disease,
– Dominating depressing mood transmissible to people surrounding the patient,
– The opinion of family members that the patient does not need their support,
– negative emotions caused by the disease of a close person,
– showing those who deliver support some unrealistic attitudes, which makes them feel guilty and aware of their incompetence,
– poor coping with difficult situations of those who are expected to provide support may cause patients requiring support to withdraw in order to protect themselves from additional stress.
The above analysis leads to the question of whether those who are to receive support also introduce some factors which prevent them from taking full advantage of provided support. Unfortunately, the answer is positive. These factors include personal resources of the patient, patient´s self-evaluation and self-esteem, which determine social functioning, and also the mechanism of being in control. It seems that the need for social support presented by the patient is also important. This need may be a feature of dependent personality. People with depression demonstrate this kind of personality. It is characterized by many features including passive subordination to others, low self-esteem and low self-evaluation. It is additionally accompanied by indecision regarding started activities and the fear of loneliness and isolation. Such people are also oversensitive to mental and somatic stress; they quickly become tired and are unable to experience pleasure [9, 15].
When no support is observed the priority of the therapeutic team should focus on starting cooperation with the patient´s family and obtaining it in the process of treatment. This goal might be achieved through the introduction of psycho-educational programmes, organizing a support group for patients´ families and willingness to explain any doubts. The therapeutic team should educate the patient´s family and friends that they should not display in front of the patient any perspectives of a better life, or analyse the causes of sadness, fears and lack of patient´s self-confidence though patients do not see these objective reasons. The patient´s family must remember that the consequences and awareness of depression are not necessarily understood by the patient. Therefore, they should not demonstrate surprise, indignation and impatience related to patient´s difficulties with verbalizing his/her feelings and accompanying emotions.
When depression is diagnosed it is important to help the patient´s family accept the situation. The family prepared for difficulties concerning care and aware of the course of depressive symptoms has a chance to create a stable basis for social support. Then the patient´s self-esteem may be reinforced with special emphasis on the concept that one should not be ashamed of the disease because anyone might suffer from it. „As patients feel kindness and taken care of, they start to believe that it is possible to rely on somebody in any difficult situation. Their self-confidence is restored, and therefore they feel less blue” [6].
Religious groups are also believed to be a source of support. The results of multiple studies confirm relations between religion and human behaviours when ill. Religion may help to cope with problems and overcome barriers in interpersonal relations. It also makes people feel a part of a group and a community. „ Religion is also a factor reducing depression. Results of numerous studies have shown that people who totally accept God´s will in their life experience gloom in difficult situations less frequently. The experience of negation, injustice, being disrespected or lack of understanding by other people becomes meaningful when interpreted as a means of spiritual education allowed by God. The decision to identify with God´s will brings peace, rest and safety” [16].
Conclusion
As far as patients with diagnosed mental disease are concerned, one must be aware that this type of disease and its prognosis pose a great challenge to an individual in the bio-psycho-social aspect. Feeling supported may result in improved well-being when remission is achieved for a long period of time. The awareness of being someone important to the family and other people gives strength and motivation to start the therapy. Moreover, it gives strength to accept oneself as an ill person but still worthy, and with high self-esteem [17]. As a result of received support, people suffering from depression and experiencing a crisis may learn the mechanisms of releasing negative emotions and how to verbalize emotions. It seems that this kind of support is expected by ill people for it allows them to find hope for each coming day [10].
Depression, like every other mental disorder, is hard to treat. Therefore, in order to provide real help for suffering persons it must be well understood. One must be aware of feelings and emotions experienced by patients. The attitude of understanding and acceptance is welcomed. Then patients have a chance to receive real, authentic and effective support giving strength to fight their disease and develop mechanisms of coping with difficult situations. However, those who provide support, i.e. the patient´s family and his/her social environment, must be free from negative emotions. Furthermore, they also need access to professional help.
Conclusions
– support offered to ill people allows one to understand them, show empathy, acceptance and tolerance,
– support manifests as being interested in the patient´s situation and proves the presence of those offering help,
– received support prevents isolation and the sense of loneliness,
– support given to patients is also a method of inviting the patient´s family to cooperate in the process of treatment and allows psychoeducation,
– offered support triggers the mechanism of coping with stress through the modification of negative influence of stressors,
– aptness and the range of support depend on people offering support and those who need it,
– provided support decreases the prevalence of depression, and it is an element of treatment for mood disorders. It also has a preventive function.
Piśmiennictwo
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Adres do korespondencji:
*Ewa Wilczek-Rużyczka
Instytut Pielęgniarstwa i Położnictwa CM UJ
Str. Kopernika 25, 31-501 Kraków
tel.: (12) 421-41-60, 424-72-82
e-mail: ewaroz0@poczta.onet.pl

New Medicine 1/2009
Strona internetowa czasopisma New Medicine