Alleviating Psychiatric Illness – The Integral Role of Family
During our clinical rotation to psychiatric department at Civil Hospital, Pakistan, I had a 28 years old patient who was tentatively diagnosed with schizoaffective disorder and was accompanied by his father who was there with him at all times; furthermore his father told me that he can’t leave his child even for a minute because he never knew what he can do the next moment, “As he is not in his senses that’s why I have to keep an eye on him”. In the hospital, it was also suggested that one family member should be present at all times in the psychiatric department. Afterwards, we as a group of three students decided to conduct a teaching, based on our need assessment we came to know the topic which was in the best interest of patients’ family members and especially to my patient’s father that is “caregiver role strain” but unfortunately he denied to come to the room where we were conducting the teaching because he did not want to leave his son alone. We conducted the teaching session with those who voluntarily came to the room and gave separate teaching to my patient’s relative because according to my assessment he was experiencing care giver role strain and this teaching would help him to get some relief from the strain.
Our motive behind that teaching was; once the caregivers are able to take care of themselves and when they are both physically and mentally healthy then they will be able to care for the diseased one so, our ultimate goal was to directly promote the health of psychiatric patients. Although role of family is crucial in physical illness as well but in mental illness it is considered as an essential part of treatment regimen and it is actually one of the mental health promoting practice. Family is an integral aspect for an individual and its presence gives us a psychological support and strength to effectively deal with all the hurdles. Without their support it seems difficult to promote mental health because medical interventions alone are not effective but in fact families play a significant role in alleviating mental illnesses.
Umaporn (2006) states that “family is the most important context of an individual. The primary function of a family unit is to provide a setting for the development and maintenance of family members on the social, psychological, and biological levels” (p. 1946). Patients diagnosed with psychiatric illnesses are the most vulnerable group of people as they are least understood by their families and society. If family considers them as a burden then society will never make an effort to accept an individual with psychiatric illness.
The support of family for an individual with mental illness is crucial in Asian Indian culture. The involvement of the family is so imperative, that often it becomes a prerequisite of seeking help for psychiatric illness (Stanhope, 2002 as cited in Cook & Tarnovetskaia, 2008). Studies have concluded that the rate of recovery from schizophrenia is greater and mortality of people with schizophrenia is lower in the developing world than in the developed countries and the key positive factor that bring that change is the involvement of families in the course of treatment (Warner, 2009). Let’s view this aspect in a sense that what difference it will make if family is not involved in the treatment of psychiatric illnesses in cases where people living alone without any family support or those who are orphaned and did not have any family to support during the course of their illness.
Studies have found that homelessness is associated with poor quality of life due to lack of family and social relationships (Pinikahana, Happell, Hope &Keks, 2002). A family must fulfill six basic functioning dimensions that are problem solving, communication, affective responsiveness, affective involvement, roles and behavior control according to McMaster model of family functioning (Trangkasombat, 2006). Studies have suggested that if there is a disruption in family functioning then the ability of the family to deal with the psychiatric illness would be affected. In accordance to above presented scenario, family functioning was disrupted in the areas of problem solving, and communication. Further, it has been found that family functioning influences the severity and the course of many psychiatric disorders.
Most often family functions are more interrupted in patients with psychiatric illness as compared to non clinical group (Trangkasombat, 2006). During my articles search, I came across with several studies that talk about family playing a significant role in promoting mental health; lorenza (2008) states “family involvement is a fundamental ingredient of the management of severe mental disorders” (p. 5). Avinash in context to Pakistan (2009) state that The family plays multiple roles in the treatment process, course of the illness and in relapse prevention. It is therefore of utmost importance that in our routine practice we delve into family dynamics and work on this aspect of psychiatric illness (p. 42).
But at the same time families’ face multiple challenges when their loved ones are diagnosed with psychiatric illnesses, this aspect needs to be understood thoroughly because interventions performed by health care professionals would only be effective once family member don’t considered the diseased person as a burden on themselves. Hitoshi and Narumi (2009) state that: Awareness of the sense of burden felt by family caregivers and the level of acceptance by the patients with mental illness of care provided by family members can have a significant impact on the care of such patients. If caregivers feel a strong sense of burden, home care may not be worthwhile. Because of this, it is essential to clarify the sense of burden felt by caregivers and to identify factors that affect this feeling, with the goal of promoting smooth continuation of home care (p. 128).
Specifically, it is important to discuss some of the factors that lead to the feeling of burden. Some factors identified from literature are: demographics characteristics of the families, the severity of the psychiatric symptoms and the patients’ ability for social adaptation (including problematic behaviors), psychosocial factors (including the family’s ability to cope with the needs of the patient), the time spent providing care, the duration of care, and economic problems, and awareness of family members about psychiatric illnesses (Fujino & Okamura, 2009). In case of my patient, I have identified certain factors for instance, family belonged to a low socio-economic status which bring financial constraints (In that government hospital they provide medications free of cost and other expenditures were very minimal; this has somehow decreased the burden of treatment), deficit of knowledge regarding the psychiatric illness of his child, child’s father was the only bread earner of the family and at present he was jobless because no one else can stay with the son and other members of the family are engaged in taking care of other children; all these factors contribute to bring frustrations, and burden to family. In practice, I found that family members are given least importance in providing knowledge regarding the illness and treatment course which is also one of the factors to feel frustrated and furthermore the patient as well as the family have to face stigmatization from the society. Thus, family members are not able to care for the diseased person effectively and therefore, mental illnesses are prevailing in our society.
Therefore, it is vital to reduce the sense of burden felt by care givers. Some strategies that could help in involving families in care in order to promote mental health are discussed briefly. Melamed and Romi (2007) gave a model (given in appendix 1) which is used for assessment in order to involve family in the treatment of mental illness. It is actually an assessment model which takes care of four important steps based on which we can plan our interventions. It includes: Stage 1- In-depth family history: Family as a source of information on the patient and family relations. In this stage the staff acquires in-depth history of client, illness, and family.
The stage provides initial distinction between families as merely a source of information on history or partner in the therapeutic process. Stage 2 – Examining familial, emotional, and functional system regarding the illness. It identifies family patterns of coping and communication regarding the illness and it made a diagnostic distinction between families in crisis due to the illness and families with problematic patterns. Stage 3 – Identifying family ability, willingness, and motivation for intervention.
It examines the family’s ability to undergo a process of change. Assessing whether the focus of therapy is the crisis due to illness or whether there are previous family problems preventing the family from focusing on the patients. Because in certain cases, families are not willing to actively involve in the treatment processes. Stage 4 – End of assessment process and recommendations.
Based on the above mentioned assessment stages this stage deals in setting goals that will focus on an intervention based on client’s needs and an understanding of the family (e.g., psychoeducational, dynamic, behavioral, problem solving, and permission). The model discussed above allow us to explore family need’s-both the visible and the invisible ones, understand family dynamics, and their requirements from the health care professionals. If we can relate this assessment model in the case scenario as mentioned above, we came to know that in-depth conversation with the patient and family gave a perception that father has a strong bounding with his son and he is the active partner in the therapeutic process. I have also identified coping mechanism of patient’s father, through that I analyzed based on above mentioned factors that there is no adaptive coping and father was in the state of distress and actually he didn’t have such knowledge how to deal with the problems effectively; this aspect highlights the feeling of burden due to psychiatric illness of his child.
In addition to that, father was willing to be involved in the treatment process. Thus the model is very effective in conducting a thorough assessment and based on that we can plan and implement the identified practice effectively. The need is to focus on family centered care and certain interventions that are practical to achieve the goal of alleviating mental illnesses are discussed briefly. According to Melamed and Romi (2007) family interventions is part of current mental health therapeutic practice.
Family psychoeducation is found to be meaningful in context to the practice. In a study conducted by Drapalski et al. (2008) found that family psychoeducation (which include information about mental illness, emotional support, problem-solving skills, and crisis interventions) is effective in reducing relapse and rehabilitation for persons with mental illness and improve well-being for their family members. After thorough assessment as discussed above, other colleagues and I have planned to provide teaching to my patient’s father and to other attendants on care giver role strain with the goal that it might help them to relieve their stress so that they would better be able to take care of diseased person. During implementation phase, we as a group of three students have conducted a teaching session keeping in mind the understanding level of attendants, in the session we have discussed mental illness, common manifestations of mental illness, myths and believes regarding mental illnesses; this part was included to clear the concept of mental illness as in our culture; mental illnesses are misunderstood with evil eye and black magic so, it was imperative to clear the view in which mental illnesses are perceived.
Afterwards, we have discussed the role of care giver and stressors faced by care givers; in order to highlight the significance of their roles as a care giver. Lastly, we have discussed some adaptive coping strategies which include: ventilation of feelings, management of time, anger and frustrations, take care of their own health, prioritize the work and pay attention to personal interests as well, try to be focused on things that are controllable and think positive in order to deal with hurdles effectively that might assist in reducing the strain of care givers. Interventions were evaluated by asking patients’ attendants to conclude the coping strategies that they can be used in order to relieve the strain. The attendants verbalized some of the coping strategies that can be performed and my patient’s father mentioned the rationale behind performing the coping strategies that all these interventions would help them to maintain their well-being that would in return be helpful in caring for their loved ones.
In addition to the above mentioned, there could be other strategies as well that promote mental health which includes discussions, debriefing session and family therapy that aids in promoting the practice to involve families in care. Family therapy is a type of psychotherapy through which families and individual members of the family learn ways to resolve the matters effectively that results in better understandings among the family members. Through this paper writing, I have learnt the importance of incorporating families in patients’ care and identified some positive outcomes of this practice in patients’ conditions that are very clearly mentioned in the literature. Also, it has enhanced my learning by providing some relevant strategies that could be apply in our context to promote mental health.
I feel that we nurses as health care professionals can make an effort in reducing the burden of families by just involving them in care. I feel that through family psychoeducation I have made a very small but significant change in the lives of those attendants and that is the most satisfying aspect for me. In conclusion, families play a significant role in promoting mental health at the same time it is important for health care professionals to be aware of some factors that can inhibit family members to care effectively for their loved ones diagnosed with mental illnesses. Through identified model of assessment and some strategies we can make an effort in alleviating the burden of mental illnesses that would indirectly amplify the effectiveness in care provided to the patients’ diagnosed with mental illness. The need is to view patients’ holistically and family as an important ingredient in treatment process, this will lead to mental health promotion.
About the Author: Aqsa Bodhani completed four years undergraduate programme of Bachelors of Science In Nursing (BScN) in the year 2010 from Aga Khan University-School of Nursing and Midwifery, Pakistan. She worked two years in the department of Oncology at AKUH enrolled in the Masters of Bioethics Programme Offered by AKUH in 2012. Aqsa is currently working as a Patient Safety Nurse at AKUH and she can be reached at [email protected]
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