During my clinical rotation I was assigned to a 32 years old female with diagnosis of Schizophrenia and sub diagnosis of Schizoaffective Disorder. She had a known case of psychiatric illness for last 2 years. She had divorced after 6 months of marriage. During this period she had experienced multiple episodes of depression as well as mania. This time she has presented with sever psychotic symptoms. The patient was very depressed. Initially it was difficult to converse with patient but as I tried to get involved in her personal hygiene care, and took vital sign on going bases. However, I built rapport with her and started the interview. During the interview she was not responding to my questions rather she was talking about her family members. She was saying that she did not have any problem and told me that she was brought here forcefully by some unknown persons. Now she wants to go home and see her family. It was very difficult to take the history because no family member was around to verify the data and there was not enough data in the patient file to cross check. However with the help of my faculty we approach a nursing supervisor he call her family and told them to visit her/call her. Next week patient seemed very settled, because her mother has called her. When I talked to her she was sharing her personal history with me. I concluded that she has multiple stressors e.g. family was ignoring her and her needs, she does not share her problems with her family members because they do not listen to her and consider her mental. The theme extracted from this scenario is that her family is not accepting her disease. They are not supporting her and she is being ignored.
Family plays a significant role in building a person. Family is just like a planting a tree, where our roots take place and we grow. We are shape within a unit, which prepare us for what we will experience in the real world and how we react to those experiences. Family is all about providing support and encouragement in every step of life. One needs more support and help of the family in times of difficulties and illness. One of the most useful ways to help the mentally ill patient is to provide “Family support”.
According to Weine & Siddique (2009) “family support is the assistance given to family to cope with the extra stresses that accompanies caring for a person with emotional disabilities. And it is also regarded as encompassing tangible and emotional assistance that family provides to their member. Tangible family support is composed of tasks focusing and pragmatic assistance. Emotional support is garnered when family members provide assistance by showing and expressing concerns, care and reassurance.” Whenever a loved one is label with any mental illness, every member of the family feels pain and shares the suffering. The illness disrupts the family associations and functioning. Therefore, a support for families having a family member with mental illness should be provided in order to increase their coping skills, improve communication, and enhance their knowledge regarding the disease process and treatment options. “Family therapy is recommended when the nurse determines that the family system is impaired because of a psychosocial problem or mental disorder in one or more family members.” (Fortinash & Worret 2004). Family support is very important component of the treatment for psychiatric disorders. The family support improves medication compliance, decreases chance of relapse, and it also improves interactions between patient and family.
The word “Schizophrenia” comes from Greek terms meaning “splitting of the mind.” People with schizophrenia, however, do not have a split personality. They have a disorder that affects thinking and judgment, sensory perception, and their ability to interpret and respond to situations appropriately”. (Stuart & Laraia 2005). Family member can play an important role in helping to keep their schizophrenic relatives supported and oriented. In order to be supportive, family must understand and accept that mental illness as a disorder of the brain just like diabetes is a disorder of the body; not anyone’s fault; and not an indication of moral or spiritual failure. Family members need to know this so that they do not blame their schizophrenic relatives for being mental, or think of them as willfully lazy. Patients are often incapacitated, and a drain on family energy and resources, but this is not intentional on the part of patients, who are in many ways victims more than anything else. The single most important thing family members can do to support their ill relatives is to help them remain oriented and on task with their therapeutic routines; helping them stay on medications, and attend scheduled psychotherapy sessions and doctor visits, hence family members can also benefit their ill relatives by helping them with personal care, eating a well-balanced diet, and getting regular exercise, even if it’s just a walk.
Many a times, patient’s behavior becomes very embarrassed and not manageable for the family member. This is a difficult time for families. Many families who do not have any knowledge regarding mental health and illness view these patients as mental and used to yell at them instead of supporting them. My patient was also having similar condition. In the beginning her family thought that she is acting to gain attention. Instead of helping her and making her realize that she is having behavioral and judgment problem, they side line her.
In Pakistani societies there is a significant value of family in one’s life. Family members provide continuous support for each other in every step of life. On the other hand due to lack of awareness make them limited and they are not approaching for treatment. Therefore if proper education and awareness will provided to the families regarding mental illness of their family member, they will take better care of the patient. It will also reduce the cost of treatment, increase the medication compliance and decrease the relapse. According to Sousa, (2009), “in countries like Pakistan family 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.” So in this regard we can say that family’s role will be very effective for patients in Pakistan. “The family plays multiple roles in the treatment process, course of the illness and in relapse prevention. It is therefore of utmost importance than in our routine practice we develop into family dynamics and work on this aspect of psychiatric illness. Psycho-education and family therapy must be included in routine psychiatric treatment programs and shall go a long way to reduce family burden and relapse-prevention in schizophrenia and other mental disorders.” (Sousa, 2009)
Family psychosocial education is especially useful with patients who lack insight into their own illness (schizophrenia and bipolar disorder), or patients who are not able to reasonably communicate their recent behaviors. Family will help orient the client to reality. “Family members hold a huge wealth of information about the client’s behaviors, their moods, and the stability of these things. When it’s a psychotic illness, perception of reality is impaired, so family members who often live with or near the client can help peace together what’s been going on.” (Frisch & Frisch, 2005)
In order to make the support system strong, family psychosocial education seems to be very useful in a number of different conditions for both patients and their families. If the focus of care will be the involvement of family and interventions carry out for family, therefore it will reduce relapse, and lessen the hospital admission, help with medication management and compliance. “People with schizophrenia live better lives if they enjoy the support of family and friends. Some cultures are more accepting of people with disease.”(McGlynn, 2009).It is becoming increasingly clear that a supportive family plays a vital role in helping schizophrenics. “No matter how good their medical treatment may be, if a patient with schizophrenia is sent out of the hospital to be alone, they are never going to do as well as with a family that’s concerned, that will look after them, that will make sure the doctors do what they’re supposed to do” (Gorman, 2009). In our Pakistani cultural families better tolerate the condition, because the fundamental difference in our cultural is the size of families, religious beliefs about family , and extended families play an important role to care for a schizophrenic relative, it also help ease the burden carried by immediate family members.
A patient with severe mental illness has proven to be effective in reducing the relapse rate and the distress level with family support. Mental health professionals use different models and frameworks for different therapies in their every day practice. However, there is no ideal framework available for adult mental health professionals on incorporating family work in their everyday practice. “The Pyramid of Family Care” given by Mottaghipour & Bickerton, (2005) is based on the same conceptual work as Maslow’s Hierarchy of Needs. The bottom level includes the family’s basic needs about the illness, orientation and connection to the mental health service and assessment of family. The second level focuses on general education on different things. Third level is the level in which psycho-education is given. It gradually becomes more specific and at fourth level consultation of family is done. The top level represents complex needs for interventions such as family therapy to be supportive to ill family member. In my patient scenario, this Pyramid would be very useful in planning and implementing the family support with the help of family education. The interventions carried out for my patient and her family was very limited. I was unable to get the opportunity to meet with my patient’s family. However I was able to build trust with the patient and explore her personal information. I was involved in her care, but I was unable to assess the family and connect them with the mental health service, assessment of the family could have obtain through direct interviewing of family members to explore the issues and problems, coping styles and support systems and observing various features of family relationships, which was not possible due to families unavailability. Second step is to provide general awareness to family regarding mental health. I developed a teaching plan for my patient to provide education regarding schizophrenia, its symptoms, treatment options and the importance of medication compliance. Due to time limitation I was unable to evaluate my patient.
The Pyramid of Family Care provides is a framework which can be used by adult mental health workers to practice their everyday work with families. This is a very useful framework which can be applied in any setting. Family support can be best practiced by using this model at individual level as I was able to make my patient socialize and I also developed teaching for my patient in order to develop her insight about her disease therapy, this can be use at a group, and institutional level. At group level I tried to make my patient involved in daily activities, and I was successful at some point that my patient stared going to occupational therapy and was able to work with other patient there. This hierarchical model assumes that significant clinical gain can be made by broad application of simple interventions and techniques with a large number of families, and conversely that applying specialized techniques within a service will fail to produce broad benefits without a foundation of basic skills and approaches. Specific tasks are outlined and categorized in a hierarchical way. A minimum level of care is clearly defined to guide the worker and ensure the basic tasks are fulfilled before undertaking, more specialized interventions. By defining and breaking down the tasks, workers are empowered to involve families as an achievable part of their everyday practice. It is necessary to clear here that a worker could be anybody a nurse, a physician or any person could be trained to carry out this therapy. At the top of the Pyramid, specialized interventions are acknowledged as being built upon the basic levels and required by fewer families. The main focus is on collaboration with families. If the basic levels in the pyramid are fulfilled effectively, there will be less need of more specialized interventions. Therefore this can be applied at any level.
My feelings and thoughts regarding family support remains in the fact that the family is a unit which means a lot to me, because I have been away from my family since I was in school. I know how it feels when you are sick and your family is not around. I cannot forget my childhood days when me and my siblings use to sleep together and my mother and father use to tell us stories at bed time, and many thing which I cannot express in words. The rituals and traditions, of family not only create memories and leave a family legacy, but creates our first pathway in life, I think that family support is beneficial not only for psychiatric patients but all patients who are hospitalized due to any reason. I learned many things after writing paper. I reviewed a lot of literature including benefits of family support as well as different researches, Such as the attitude of different societies towards mental illness. This will help me in my future work and practice.
In conclusion, family support is an important part of treatment. It helps in remake the family structure. Family support plays a vital role for families who are having difficulties in maintaining family integrity and functioning. Benefits of family support are more therefore I will recommend that family support should be a part of the treatment. I think holistic approach will not be holistic if the family is not supportive to the mental ill individual. It is very important to consider the impact of families, communities, religion, spirituality, living situations and medication. All these factors affect an individual’s experience of mental illness and the way that society reacts to the individual