Life is given once, when a child comes to this world she/ he has many dreams in her eyes. None of them has thought about the stressors, but they are faced towards many stressors in life. There dreams break when they realizes that the social support which was their coping is no more with them. This is happening in the below mentioned scenario.
My patient was 59 years old female with schizophrenia. Patient had this disease from last 17 years. The symptoms patient had on admission was: ghabrahat, and crying spells. Patient her self dont know the reason of crying spells, patient said when ever she is alone some where she feels like crying and she is unable to rule out the reason. Patient lives in an extended family with her son, daughter in law, and grand daughter. She is a widow her husband died when she was 26 years old; patient had a supporting relationship with him. After her husbands death she was all alone to raise her children. Patient faced plenty of difficulties in rearing them, and at that time no in laws helped her. Before marriage patient was living in a poor family with her parents, 4 sisters and one brother. Patient has studied up till metric. After this she was working in home and helping her mother. Patient said there was no support provided in childhood because every body was busy to earn in order to fulfill living needs. Patient had only one best friend with whom she shared every thing but now she is married and living in other country. Now patient is not sharing her feelings to any one as she said she do not feel like sharing to any one.
Looking at my patient scenario I feel she had multiple factors which led her to mental illness these were; poverty, lack of parental attention in childhood and teenage, unavailability of supportive person, loss of husband, suppression of own feelings due to role transition, and social stigma. These all factors have evolved lack of social support in patients life. According to Perese & Wolf Social support is the subjective measure of the emotional values that a person receives from his or her social network- the individual or group with whom the person is in contact (p. 593). Social net work communicates love and affection to them who are in their network. Though patient has a social network (family) despite of them she feels alone. Weiss says as cited by Perese and Wolf (2005) Loneliness is caused by not being alone but by being without some definite needed relationship or set of relationship. This quotation explains that only presence of social network is not valued, it should be supportive one other wise one might feel lonely inspite of presence of many people around.
In addition, lack of social support can be due to social stigma and this is the main reason that mentally ill peoples social network becomes narrow. Chernomas and Clarke (ND) supports 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 schizophrenia yet at the same time the illness places relationship at risk. Social support starts from the time of birth as parents shows bodily gestures, verbal and nonverbal communication provides a sense of security to the infant and it goes on through out the life. Chatters, Krause and Shaw shares that Individuals who receive a lack of support early in life remain at an increased risk of experiencing poor health later in life. In our daily lives we all have social network which helps us in resolving our problems. If one has lack of social support than he/she might feel lonely. Perese and Wolf shares some causes of loneliness he says among the general population, loneliness is often related to loss or disruption of relationships, lack of partner or a social network, poverty, lack of transportation, problematic living situations, and lack of opportunity for social interaction (p. 593). These factors shared are present in my patients life. and its impact was that she felt she is all alone. It would best conclude if I would say that every point of an individuals life is closely interrelated to one an other, and outcomes of lack of social support will decrease mental health promotion.
Significance of the issue in Pakistani context:
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. Research done by Dr. Gadith in 1994-1996 about shamanic concepts and mental illness, supports that people who visited shamans were actually falling under mental illness according to DSM IV criteria however shamans said that these people were affected by jinn, aseb, and evil magic. This research shows that People living in our country do not believe in existence of mental illness. If people are not aware of mental illness than how they will support their family members who are mentally ill.
In a seminar titled Mental Health across the Life Span organized by Aga Khan Universitys Mental Health Research and Development Forum, Dr. Syed Haroon emphasized that family support plays an important role in mentally ill patients health promotion. Yet there are live examples of patients who are left alone in Karwan-E-Hayat and in asylums by their family members because they are unable to deal with it and in addition, mental illness seems as a social stigma to them.
An other study done by Dr. Niaz in (2001) on Overview of womens mental health in Pakistan, she shares, isolation and lack of social support are the main psychological problems in older ages. She further stated that At government level there are no community social support centers or day care centers for children of working mothers. Psychiatrists have identified that mental illnesses requires a great social support but unfortunately not the population nor government is interested in doing some thing to increase support to people.
All these researches show that how mental illness is seen in our society and how much support is required, not only in illness but support is needed by every one to be healthy.
Critical analysis of the issue:
There is a process of social support (refer appendix A) which includes; antecedents, types of social support and out comes. Antecedents include a need (of social support), social network (family, friends, neighbors etc) and social climate. In this process first need is identified than emotional and instrumental support is delivered through social network and when all parties combine together than a social climate is made for each others need. After support is provided outcome appears in a form of mental health promotion. Need is about identification of need of social support, willingness of receiving support, and willingness of giving support in different circumstances (context specific).
If I relate this stage (need) with my patient than in childhood, she needed her parents support but they were not willing to give because they were busy in earning for food which was an optimal need for living at that time. In adolescent age, patient developed a coping skill by being busy in house hold and at this time she and her parents both were unwilling to give and receive support. In addition she had a supportive friend but unfortunately she left her after marriage. In her adulthood when she got married, she highly needed her husbands support because she was passing through a role transition but again this support fade away by her husband death and she was left alone with the responsibility of two young children. Some times there was a need but there was no positive supports identified and if it was identified than they were unwilling to provide support, this leaded to absence of supportive social net work.
Social support is required at every age of life, social support and social network shows positive effect on health and well being (Taylor, Seeman & Gurung, 2003. If I see my patient scenario through life span I see that:
In childhood and teenage:
At this stage children are looking forward to their parents for support, the support which is provided in childhood develops self esteem, confidence and sense of belonging. My patient belonged to a poor family where their priority was food so, parents were busy in earning and no support was provided to children. According to Chatters, Krause and Shaw (2004) early parental support is believe to be linked to the development of current supportive social relationship, a sense of personal control, and a sense of self-worth .early parental support is strongly related to both mental and physical health outcomes.
In adolescent age, my patient only had a friend whom she was considering supportive because she was always there to listen her. Patients friend got married and she was alone in this world despite of having a family. Friend had an important place in my patients life. According to a research conducted by Perese and Wolf (2005) friend provides a sense of security and belonging that buffers the stressors of life lack of friends was reported in one-third of the general population.
In young adulthood:
A time came when my patient got married. It was a change in her life and she was highly needing a support to get adjusted in new life, she got support from her husband and she got 2 kid and she entered into a new role transition a mother .Unfortunately her husband died and she never received that support which was needed by her husband. Gurung, Taylor and Seeman (2003) shares a functional-specific model, it suggests that individual requirement for specific forms of support can be met only within certain relationship. Even the same type of support is provided by different sources, its impact may not be the same. Still patient is lacking her husbands support and no one can cover it.
In middle adulthood:
In this stage she was unable to cope with stressors alone but her role did not allowed her to share her feelings with others and she suppressed it. Now patient is mentally ill, she still needs her familys support but no body is here for her support. Her children are busy in their own life and patient personality is not allowing her to explore social network. Gurung, Taylor and Seeman (2003) say, Personal characteristics may be critical determinant of whether support transaction increases or decreases over time.
This analysis make it clear that through out the life span there were multiple factors patient was going through and it lead to lack of support.
Integration of Newmans model:
Her model is showing the relation between stress and coping and the impact. I have chosen this model because in my patient scenario she was unable to cope with the stressors alone and that is why she got mentally ill. Betty Neuman is talking about three lines of defense which varies with age and development. These lines of defense prevent us from any life stressors; these could be loss, cultural change, stress and pain. The stressors could be multiple; it could be of more intensity and when a person is unable to cope with the life stressors and if the coping is not appropriate than the lines of defense could be break and person can get physically or psychologically ill.
Strategies to deal with the issue:
At individual level I actively listened to the patient, I helped patient in identifying the supportive person, I involved patient in different activities to improve her social network, I educated patient regarding need and importance of social support and I tried my best to explore patient feelings. I planned education session after assessing my patient. I planned my teaching according to my patients strength and weaknesses. In this teaching firstly I acknowledge patients feelings and I made her self to explore the reason of her illness, she was able to identify the lack of support system. I taught her to involve in social gathering and to talk with other patients and to share her feelings with others. After giving this teaching I observed that my patient was involving in social activities.
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. Support groups will also give a sense of friendship. Moreover counseling sessions could be done to explore patients feelings and to help them. In addition, school plate forms can be utilize to deliver teaching there for awareness To make a support group I will plan this strategy with the help of psychotherapist in identifying the same patients who are suffering form lack of social support. In implementation I will make them share their life experiences; this will help them learn through each others experiences. To evaluate a mini survey could be done to compare the social support system before and after the involvement with support group.
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 NGOs to conduct different seminars for mental health promotion, this will enhance education level of the population and they them selves will take step to overcome factors responsible for 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 the seminar.
Analysis of own thinking / Learning:
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 one 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 patients scenario. After analysis my patients life with the present condition I felt that I am blessed by God by having the supportive family, friends, and the community. I feel my patient was innocent but still she got the disease. I feel