Social Support Needs Among the Institutionalized Elderly with Schizophrenia

There is now substantial empirical evidence demonstrating that social ties and social support play an influential role in health maintenance and differential vulnerability to illness. Research repeatedly finds that those reporting higher levels of emotional support and social integration are associated with lower rates of both mortality and morbidity than the more isolated and/or those receiving little social support (House, Landis and Umberson, 1988).

Since social support appears to matter importantly for health promotion and well-being in general populations, it may be both especially important and especially problematic among the institutionalized and communitydwelling with serious and persistent mental illness.

In particular, individuals with a history of schizophrenia are especially vulnerable to fewer supportive resources. In fact, there is a paucity of research documenting the psychosocial needs of older adults with schizophrenia (Cohen, et al., 2000; Rodriguez-Ferrera and Vassilas, 1998).

It is therefore important for care planners and service providers to monitor the supportive milieu of their clients. This paper briefly reports upon the supportive needs of three patient groups residing in psychogeriatric settings: organic, mood and schizophrenic disorders.

Research indicates that those diagnosed with a psychiatric disorder tend to have access to fewer social ties and consequently fewer potentially supportive resources (Hammer, 1981; Nelson et al., 1992). Regardless of how such support associations are measured - by network indicators, number of friends, or by marital status - the social resources of the chronic mentally ill tend to be both fewer and less diverse than those never requiring mental health services.

For example, individuals diagnosed with schizophrenia are between three to four times more likely to be single than those never suffering with a major mental illness (Turner, Dopkeen and Labreche, 1970). Besides marital status, other studies have compared and contrasted the social networks of the mentally ill to both general (nonclinical) populations and other clinical groups receiving medical attention. In general, the networks of the mentally ill are smaller in size and less heterogeneous in membership composition. In particular they are more likely to be kin dominated, and involve higher degrees of patient dependency upon others with a lack of reciprocity in exchanges. Overall, these network structures characteristic to the mentally ill have been found to be less conducive to supportive exchanges and interactions.

A number of factors may contribute to the overall paucity of support resources that is characteristic of psychiatric patients. Sporadic periods of hospitalization, poor social skills and a general reduction in social competence, the occurrence of symptoms which often produce bizarre and/or paranoid behaviour and the resulting stigma associated with mental illness, all may erode the patient's ability to secure and maintain social ties.

Many patients find themselves in a situation requiring social support, yet, at the same time, tend to lack the personal and social resources which facilitate the support process. Having fewer social ties to draw upon in times of need would seem to reduce the opportunities for supportive exchanges. In a very real sense, long term patients frequently find themselves living in a situation aptly described as a "network crisis" (Lipton, 1981). This "crisis" stems from the disparity between supportive needs and supportive resources.

Study Sample

These analyses report upon a convenience sample collected from three inpatient, psychogeriatric facilities located in Western Canada. The study sample (N=129) was composed of 57% males and the mean age was 77 years old (age range 53-97). The analyses reported here were restricted to patients with a primary diagnosis of either organic disorder (52%), schizophrenia (26%), or mood disorder (22%). Data collection was based upon the Resident Assessment Instrument-Mental Health (RAI-MH) version (Hirdes, et al., 1999). The RAI-MH is a patient focused, multidisciplinary assessment instrument designed to be an essential component of an RAI-based integrated health information system linking mental health with home care, long term care, acute care and rehabilitation.

The primary application of the RAI-MH is to gather and organize information that may be used to support the development of personspecific, multidisciplinary care-plans. Besides care-planning, the RAI-MH may also be used to assist with quality assessment, outcomes evaluation, and case-mix funding. The RAI-MH includes a number of items indexing social support and social integration. Several of these items are incorporated in the findings discussed below.

Indicators of Social Support and Social Integration

A review of Tables One through Three indicates that patients with a primary diagnosis of schizophrenia were associated with lower levels of informal support resources and lower levels of received support compared to patients with a primary diagnosis of either organic or mood disorder. [Table One] reports the bivariate relationship between current marital status and psychiatric diagnosis. Consistent with previous research, patients diagnosed with schizophrenia were more likely to be never married (59%) with only 5% being currently married. In comparison, research subjects with a diagnosis of either organic or mood disorder were more likely to be currently married (37% and 21% respectively).

[Table Two] compares psychiatric diagnosis by contact with family and/or friends over the prior 30 day period (from assessment date). Approximately 38% of patients with an organic diagnosis were in contact with family and/or friends over the last 7 days while 35% had contact within the last 30 days. Of those with a mood disorder, over 50% had contact with informal supports within the last 7 days. Of those diagnosed with schizophrenia, only 12% had contact with the last 7 days. [Table Three] shows provision of emotional support from informal sources by the three diagnostic groups. Over 70% of the patients diagnosed with schizophrenia were coded as not receiving any emotional support from informal sources over the prior 30 day period. Patients with a primary diagnosis of organic or mood disorder were more similar with respect to received emotional support.

Implications for Formal Care Providers

These findings demonstrate the paucity of informal supports for those older patients with long term schizophrenia. In the analyses reported here, individuals with a primary diagnosis of schizophrenia were associated with lower levels on all three indicators of informal social supports. Since social supports and social resources are important determinants of health and well-being, it is important for formal care providers to monitor the supportive milieu of their patients / clients.

By definition, the process of social support requires not only a recipient but also a potential provider. Whether this "other" is a specific person (a spouse, son/daughter, friend, or social worker) or a social group of some form (a self-help group, coffee club) supportive exchanges assume at least a dyadic relationship.

Logically then, not only are patients themselves candidates for interventions aimed at increasing the overall supportive experience but so too are other participants within the client's social network. Ideally, support interventions should attempt to target as many (potential) participants as possible. Gottlieb and Selby (1989:64) recapitulate the need to broaden social support interventions beyond a strictly patient level. Within their work these researchers provide a typology listing examples of various level-specific support interventions. For example, through family educational and therapy programs family members can receive specific instructions on how to be more efficient support providers while avoiding the hazards of care-provider burn-out. Another example of a dyadic intervention is the facilitation of hospital visitor programs.

Volunteer programs may be ideal sources of social support and companionship for many of the more isolated as such programs provide the opportunity for clients to interact with others in a casual, non-intrusive manner. Volunteers represent the potential addition of "a loose tie" into the patient's social network. Volunteers do not live with the client and both participants can mutually agree where, when and how frequently to meet. In this way the client is provided with some sense of control over the interaction process.

Besides the facilitation of dyadic (or one-toone) interventions, Gottlieb and Selby (1989) also list a number of group level interventions within their typology. Many such social groups can be based either upon an informal (coffee, hobby and/or recreation clubs) or semistructured, educationally-based structure (weekly living skills programs).

An additional benefit of these groups is that they provide the opportunity for meaningful social interaction among the local client base. For example, recreation and hobby-based groups can facilitate an atmosphere conducive for shared leisure and simple enjoyment of interests with others. Alternatively, social groups based upon a self-help format can provide the opportunity for individuals to share problems and experiences with fellow members. Self-help groups also may provide the opportunity for members to help one another, thereby gaining a sense of at least some reciprocity in the social support exchange process.