During mental health rotation I came across the scenario, which forced me to reflect on it. A 30 years old male patient diagnosed with schizophrenia since four to five years and has multiple admissions during past years. During examination and history taking I came to know that he is being admitted since two year back in Civil Hospital with the complaint of aggression, hallucination and suspiciousness. He was admitted by his sister who wanted to get rid of the responsibility of taking care of him. Furthermore he belongs to low socioeconomic background from the outskirts of Karachi. He is married and has 4 children, his elder brother and all other relatives are supporting him menially. According to his sister he should be restrained with “Zanjeer”. They think that he is putting up an act. His elder brother has left him because of his disease. He has left taking his medications since six months and with nobody realizing it. After six month when he became very aggressive and his family was unable to control him, he was brought for admission in Civil Hospital.
Looking at my patient’s scenario I believe that there were multiple factors which led him to mental illness. Most severe of these were poverty, illiteracy, low socio-economic status, stigmatization and eventually all of they evolved family support from him. If we just see what family is: according to Shomaker (2006 )
“…A group of individuals who are bound by strong emotional ties, a sense of belonging and a passion for being involved in another’s lives.” (pp.163)
Therefore it could be said with substance that families live in different compositions including nuclear, extended, multigenerational, single-parent and same gender families. According to B.A.Marry(2005): “…so either they are connected emotionally or by blood or in both ways”. Hence family is composite institution where every member is mentally and emotionally affected by the existence of other members. Also that, the presence of family members in healthy state influences the metal health of rest of the family members. In Pakistan, the extended family system is most common family system. In such family systems, individual autonomy is equivalent to group autonomy and the group is the complete family unit. People in Pakistan dearly follow the joint family system and live their life along with their folks. (Naeem, 2005).In other words, it can be said that extended family system has many advantages, it is also of harm in some cases to the members. Due to the sheer size of the family, the members are denied individual attention and care that is so required for any patient. The same happened to my patient who was left alone by his extended family.
According to De Sousa(2009):
“The family is both a system and a unit in society, a primary multifunctional institution into which all human beings are born, brought up and nurtured by various interpersonal relationships. Thus family serves as the basic architect of the individual’s personality. The relationship between the individual and the family members determines the disposition to illness and health in every stage of life right from infancy to old age. He further says that the family is strategic centre to understand human emotions and relationships that play pivotal roles in both positive health and disease. It is the major support system for the patient that is mentally ill but at times the patient is often deprived of psychiatric treatment due to family burdens that exist”.
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Family support and role of each member starts since the time of birth as parents as brother as sister and many other different roles which shows their care and affection through bodily gestures, verbal and nonverbal communication and provides a sense of security to the infant and it go on throughout the life. De Sousa(2009) share that the individuals who receive a lack of support early in life remain at an increased risk of experiencing poor health later in life”. If one has lack of family support than he/she might be not able to withstand of normal stressors and ultimately the person will end up in mental illness. It would thus be apt to say that our lives are closely in need of support from other people, without which our existence may not be possible.
Family members of person with mental disability can play a critical role in enhancing the care and treatment of their ill family members; however the ability of family to fulfill their caregivers’ role- is negatively affected by numbers of barriers alike. Lack of family support it can be due to social stigma and this is the main reason that mentally ill people’s social network becomes narrow. Gotlib and Feely (2000) supports that the notion by saying that “over time, due to social stigma associated with serious mental illness, developing and maintaining relationships can be difficult”. A support system is vital for people living with mental illness yet at the same time the illness places relationship at risk. The negative effects are at risk of being exacerbated in case of family not being present and poor prognosis and relapse may be the result.
According to Naeem (2005)”While the attitudes people hold towards mental illnesses has been studied to some extent in Europe. Nothing is known about what people think about mental health problems in Pakistan. Still we are far behind to know the role of family in mental health.” as we did not have enough literature to support and, thinking ahead for the roles of family to contribute will take time.
In our society mental illness is taken as a stigma and still people are not clear about the causative factors of the disease, rather they are connecting it with supernatural forces as cited by Karim.S. et al(2004) “it is widely perceived that mental illness is caused by supernatural forces such as spirit possession, punishments for one’s sins. “if we connect these believes with literacy status of our country then it is quite evident that the lower the literacy rate the greater the force of these believes will be . He further says “the literacy rate was 47.1% in 1997-2000” not only low literacy rate but low socio economic status which is letting people to strive for their basic needs. Though in Pakistan living together family is our culture but the trend lacks definitive approaches. For example, the family members do not realize the roles they are expected to play. This breeds in confidence among the family members preventing them from leading mentally healthy lives.
Family support is required at every age of life, family support and social network shows positive effect on health and well being. Mustafa (2005) suggests that support of family is important to maintain the mental health of individuals. As he mentioned in his work that “Social net work communicates love and affection to them who are in their network’ though patient has a social network (family) despite of them he is left alone. There is a process of social support which includes; (family, friends, neighbors etc) and social climate. In this process first” need” is identified than emotional and instrumental support is delivered through family network and when all parties combine together than a social climate is made for each other’s need. After each type of support is provided outcome appears in a form of mental health promotion. Need is about identification of need of family support, willingness of receiving support, and willingness of giving support in different circumstances.:
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If I relate this stage need with my patient then his need was attention, caring attitude from his family however he was fail to receive it. No positive supports identified and if it was identified than it was the only physical part of his care, they were taking care of his physical need however nobody was realizing what actually his need was? This deficit of supportive family role leads to ending patient in the withdrawal of all his medication. So the effects of family presence and mental health problems play a major positive role during the treatment like increase chances of early rehabilitation and prevent relapse.
David.T(2006)” distinguishes between two facets of family involvement-family involvement with the client (apart from treatment) and family involvement specific to the client’s treatment because they may have different antecedents and consequences and because families may be involved in one way, but not the other. For example, a family member may provide financial assistance to the client but not be involved in the client’s treatment. Both types of involvement are operational zed in terms of the quantity, nature, and perceived quality of the involvement. Like although his mother was present with him but most of the time she was worried about his physical need
Calgary Family Intervention Model (CFIM): One way to think about change.CFIM is an organizing framework conceptualizing the intersect between a particular domain (i.e., cognitive, affective, or behavioral) of family functioning and a specific intervention offered by a health professional (Wright, Lorraine & Leahey, 1994). This model emphasis on early involvement of family in patient’s cares where positive and negative feedback can be given to encourage and improve dealing. Families are required to be involved in every level of interventions. As family education and awareness about disease, its management and prognosis is very important. In keeping above scenario in mind for group level interventions one can refer to Gravois, Paulsson and Fridlund (2006) grounded theory model of mental health professional support (MHP). It is based on the needs of families with a member suffering from severe mental illnesses. In this model researcher give four category of MHP support that being present, listening, sharing and empowerment.
In this model ‘Being present’ refers to the early contact, early identification o f role changing and giving early information about coping and disease management. Listening plays very important role in mental illness management. In this model assessment is based on active listening of patient and family experiences. After assessing the burden and worries of family and patient .Health care professional can do intervention that can help family to understand patient needs and learn effective coping skills to deal with the patient. They can also form support groups for family so that they can share their feeling and motivate each other to take better care of patient and relieve pain of stigma. Sharing in this model means maintaining coordination with family and as team could take decisions for the patient. Interaction with shared responsibility will create sense of security in family that will lead to open communication between MHP and family .Thus leading to good prognosis of patients.
Lastly, the empowerment which implies that when the family members cope with the situation and obtain a deeper understanding of mental health/illness, they seem to have gained empowerment. Thus, MHP counseling about mental health/illness, in a group or individually, empowered the family” (Gravois,Paulsson & Fridlund(, 2006.)
At individual level, I actively listened to the patient After through assessment of patient, data were organized and those areas were highlighted which need change .This is the very important step as in the scenario the main problem with the patient was disease process which was aggravated due to lack of support .As with good family support patients can live better life. So I focused the family as well as the individual to deal with the problem. Firstly I planned to give patient education about disease process, developing insight and dealing with delusion, as due to withdrawal of psychiatric medication since six months he was very aggressive and his grandiose delusion were very strong indeed, so I tried to give awareness about himself so the co-operation from his side could make family support easier for him. Secondly I involved patient in different activities to improve her social network and beside this I have planned patient teaching for the family that include awareness about mental illness and discharge teaching. “To improve the quality of life, psychosocial intervention with the family and the mentally ill person e.g. family problem solving, drug compliance, crisis management, training of social skills and cognitive behavioral strategies are suggested”. (Gravois & Fridlund, 2006). But unfortunately I was not able to interact with client’s family. Interventions were carefully planned in keeping culture and educational level of client in mind .
Support groups can be made for better coping. Perese and Wolf (2005) say, “The primary goal of a support is to increase members’ coping ability in the face of stress, to strengthen ‘the central core’ of individuals” beside this supporting family functioning and cohesiveness via acknowledging their values, and advocating for maintaining sense of self worth. Support groups will also give a sense of friendship. Moreover psycho education sessions could be done to help the families. In addition, school plat forms could be utilized to deliver health education to increase awareness and to build support groups. Moreover, I will plan this strategy with the help of psychotherapist in identifying the same patients who are suffering from lack of family support. In implementation I will make them share their life experiences; this will help them learn through each other’s experiences. To evaluate a mini survey could be done to compare the social support system before and after the involvement with support group and beside this I have planned patient teaching for the family that include awareness about mental illness and discharge teaching. “To improve the quality of life, psychosocial intervention with the family and the mentally ill person e.g. family problem solving, drug compliance, crisis management, training of social skills and cognitive behavioral strategies are suggested”. (Gravois & Fridlund, 2006). As cited by Gotlib &Feely (2000)” an approach to developing strengths is to help families develop knowledge or competencies that can enable them to cope and develop. Families can be assisted to locate and access experiences or materials to augment their knowledge.” But unfortunately I was not able to interact with clients. Institutionally health awareness sessions can be done to make people aware of life needs and importance of mental health promotion. Media can be utilized for Speeches to convey our messages to the government to resolve some psychosocial factors: poverty, lack of parental support. Some steps should be done to improve poverty as this is the common factor for mental illnesses. Could work with NGO’s to conduct different seminars for mental health promotion, this will enhance education level of the population and they themselves will take step to overcome factors contributing to mental illness. To plan a seminar at institution level I would make a plan of what need to be discussed in this seminar, I will discuss the target population with directorial level. In this seminar psychiatrists can be included for broadening the horizon of knowledge. After this I will make sure that on implementation media coverage is there. To evaluate this, small research could be done to see the prevalence of mental illness in the community. In addition, small questionnaires can be used to compare the knowledge level before and after seminar.
When I visited the psychiatric hospital I was upset by looking at patients’ condition. I was amazed that how this disease has took hold of patient and how this is done all of a sudden. It was my prejudice that genetic and biochemical factors are the most prominent ones, to cause any disease however it is not true psychosocial factors can be the most influencing one to have a disease as it is in my patient’s scenario. I assumed that the lack of family support only exists in Pakistan however through literature search I came to know that it is global issue. It is also very important to keep this fact in mind that family members and mental health care professional frame the role of family members in the care process. After analysis my patient’s life with the present condition I felt that I am blessed by God by having the supportive family, friends, and the community.
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