Perception of family members regarding the support group conducted in a psychiatric intervention ward

Abstract

OBJECTIVE  To analyze the perception of relatives of patients with mental disorders about the support group in a psychiatric hospitalization ward.

METHOD  This is a research with a qualitative, exploratory an descriptive approach, performed at a General Hospital in Rio Grande do Sul with ten relatives of patients who had been participating in a weekly support group. Data collection took place in October 2016, through semi-structured interviews. A thematic content analysis was used for the treatment of data, whence emerged the category: Perception of family members about the support group.

RESULTS  The relatives perceive the group as a space that gives them strength and support, allowing for listening and experience exchange among its members, giving information on the disease and treatment, safety, and inserting the family in the treatment.

FINAL CONSIDERATIONS  The support group can be understood as a strategic action of caring for the family, affecting their lives and the treatment of those who are hospitalized.

Keywords: Nursing; Mental health; Health services; Self-help groups

Resumo

OBJETIVO  Objetiva analisar a percepção de familiares de pacientes com sofrimento psíquico acerca do grupo de apoio em uma internação psiquiátrica.

MÉTODO  Pesquisa com abordagem qualitativa, exploratória, descritiva, realizada em hospital geral do Rio Grande do Sul com dez familiares que participavam de grupo de apoio semanal. A coleta de dados ocorreu no mês de outubro de 2016 através de entrevistas semiestruturadas. Empregou-se a análise de conteúdo temática para tratamento dos dados, na qual emergiu a categoria: Percepção dos familiares sobre o grupo de apoio.

RESULTADOS  Os familiares percebiam o grupo como um espaço de apoio e fortalecimento, de escuta e trocas entre os integrantes, de informação sobre a doença e tratamento e de segurança e inserção da família no tratamento.

CONSIDERAÇÕES FINAIS  Portanto, o grupo de apoio pode ser entendido como uma ação estratégica de cuidado ao familiar, repercutindo na sua vida e no tratamento de quem está internado.

Palavras-chave: Enfermagem; Saúde mental; Serviços de saúde; Grupos de autoajuda

Resumen

OBJETIVO  Analizar la percepción de familiares de pacientes con trastorno mental acerca del grupo de apoyo en una internación psiquiátrica.

MÉTODO  Investigación con abordaje cualitativo, exploratorio y descriptivo, realizada en el hospital General de Rio Grande do Sul, con diez familiares que participaban en un grupo de apoyo semanal. La recolección de datos ocurrió en el mes de octubre de 2016 por medio de entrevistas semiestructuradas. Se empleó al análisis temático de contenido para tratar a los datos, y emergió la categoría: Percepción de los familiares sobre el grupo de apoyo.

RESULTADOS  Los familiares perciben al grupo como un espacio de apoyo y fortalecimiento, de escucha e intercambios entre los integrantes, de información sobre la enfermedad y tratamiento, y de seguridad e inserción de la familia en el tratamiento.

CONSIDERACIONES Finales  El grupo de apoyo puede ser entendido como una acción estratégica de cuidado al familiar, repercutiendo en su vida y en el tratamiento de quien está internado.

Palabras clave: Enfermería; Salud mental; Servicios de salud; Grupos de autoayuda

INTRODUCTION

The Psychiatric Reform was a long and complex process of redirection of the mental health assistance model. It questioned the asylum model, which was based on psychiatric hospitals, and advocated for care within the territory, social reinsertion and the maintenance of family ties^1-2.

In this context, families, nowadays, considering the Brazilian public policies on mental health, that prioritize dehospitalization and the deinstitutionalization of assistance, are very important for the treatment³. A disease cannot be separated from the family context and, since it is an essential element, the family must be understood as an ally of the health team, acting as a resource to promote comfort, so that the patient can acquire confidence, and, consequently, invest in the treatment⁴.

However, in addition to seeing the family as a great ally, it is necessary to see them as a unit that needs care from the health professionals⁵. Health services must consider the family as potential users, keeping in mind their day-to-day hardships, overload as they follow-up with the therapeutic process, and, at the same time, giving them instruments so they can also provide care for the family member that needs care⁶.

From this perspective, working with support groups destined to family members becomes something essential in the path to deinstitutionalization, as well as an important strategy to care for the needs of the family members which will certainly reflect on the care offered at home to the person with some type of mental ailment⁷. Thus, the treatment in which the family is also cared for shows the positive influence that the family environment can have on the course of the treatment of many psychiatric disorders⁸.

Regarding this type of family care, support groups for relatives of patients emerge as spaces that allow not only for the acquisition of knowledge and know-how related to the ways in which family members live with psychiatric suffering, but, especially, as a space for permanent construction of new possible meanings regarding the health/sickness process and of new social support networks^9-10.

The interest to develop the theme came from the work in a multiprofessional health residency, in which the importance of the support group conducted for relatives of the patients of a psychiatric hospitalization ward for people with mental disorders could be observed. That instigated the idea of analyzing the perception of these family members about the support group, considering the position established by the Psychiatric Reform.

Thus, considering the family as essential in the treatment of the person victimized by psychiatric suffering, and the support groups as powerful strategies to care for these families, the following question is raised: What is the perception of the family members of people with mental disorders about the support group developed in a psychiatric hospitalization unit?

The objective is to analyze the perception of relatives of patients who are undergoing psychiatric suffering, regarding the support group developed in the psychiatric hospitalization ward of a general hospital.

This work can contribute to the process of constituting support groups for family members and getting to know the new reality of health services, especially the psychiatric hospitalization ward, from the perspective of the new mental health legislation. In addition, it aims to offer subsidies for the construction of knowledge about the theme, stimulating the formulation of new methods to insert family members in the treatment, having as a starting point their own needs for care in mental health institutions.

METHOD

This study is an exploratory, descriptive and qualitative research¹¹. It was developed in a psychiatric hospitalization ward (PHW) of a general hospital in the south of Brazil, a ward that has 36 beds, 26 of which for SUS (Unified Health System) patients and 10 for insurance ones, and cares for serious acute psychiatric situations. The unit has a multidisciplinary team made up of physicians, nurses, nursing technicians, residents, psychologists, nutritionits, a social assistance and an occupational therapist.

The support group developed at the PHW is open to the relatives and companions of the hospitalized patients. There is not a predetermined number of participants, and all relatives of the patients are invited. The meetings take place every week, in a room in the psychiatric ward itself. The group is coordinated by a nurse and a psychologist, and there are from eight to ten participants, on average, every meeting.

This group aims at the promotion of a space for conversation and support for confronting the disease and understanding the emotional factors involved with it, in addition to promoting considerations on the theme and discussions about previous experiences among people who have a relative under psychiatric suffering.

The participants of the research were relatives of the patients hospitalized at the PHW. The inclusion criteria of the research comprised people who: were participating in the support group during the period of data collection, had been in a group meeting at least once, were over 18 years of age, had good communication skills and did not have any cognitive deficits.

Since this was a qualitative research, the final number of interviewed subjects was defined by the criteria of data saturation, which is a broadly used concept in qualitative researches in the health field¹². Considering all this, ten family members were interviewed.

Data were collected in June 2016, through a semistructured interview about the perception of family members regarding the support group, made up of the following questions: "What is your perception of the Support Group?", "Does the group contribte in any aspect when it comes to your relative? Which aspect?" , "How do you feel after participating in the group?".

Family members were invited to participate in the study after the group meeting was over, moment in which a day and time were scheduled for data collection, according to the availability of the participants. The interviews lasted, on average, 15 minutes, and were conducted in a PHW office, recorded, and later transcribed for analysis.

The thematic data analysis was carried out according to Minayo¹¹, whose technique is divided in three stages: pre-analysis, a literal transcription of the interviews is conducted and the register units elaborated; content exploration, where data was codified and grouped together according to their similarities and differences, generating categories and sub-categories; and treatment and interpretation of the results, stage in which the more meaningful statements were selected. They were discussed considering the contributions of scholars of the field, and generated the category: "The perception of family members on support groups".

This research was approved by the Ethics Committee of the aforementioned hospital, according to Protocol 1,424,320, and all ethical aspects of researches with human involvement were taken into account¹³. All participants signed the Free and Informed Consent Form after being briefed on the objectives of the research. To maintain the anonimity of participants, interviews were codifified using the letter E followed by a number which indicated their chronological order. E1, for instance, indicated the first person interviewed.

RESULTS

The perception of family members on the support group

From the interviewed family members, four were mothers, three were wives, two were children, and one, a sister. Only one participant was male. Their age varied from 35 to 63 years old, with a higher concentration around 50 years of age. In the moment of data collection, four interviewees had informal jobs, two were unemployed, two were housekeepers, and one was on leave at her job. Regarding their relatives in PHW, four had been committed due to depression, four due to schizophrenia, and two due to drug abuse.

Interviewed family members saw the group as a space where they give strength and support for one another, where they learned there that they were not the only ones who experienced having a family member hospitalized in the PHW. The experience of the others gave them strength, as the statements below indicate:

[...] I was in a pit I couldn't climb out of, and then, with the group, I came to see it was not like that. I started to understand that I'm not the first one who's going through this, and that she'll have these ups and downs, and I'll have to stay always strong to manage to pick her up (E4).

It's hard, the entire family suffers. But the group helps a lot, it helps you to find strength, because sometimes we don't have the strength, I think it's very important, it helped me a lot, because it's not easy(E10).

Family members that take care of patients under psychiatric suffering need help, since oftentimes their health can also be prejudiced, as they are affected by changes in their daily lives. In addition to their lack of training and knowledge to deal with this situation, these family members live daily with the stigma of social discrimination, a meaningful burden in their lives.

Considering that, the group can contribute to change their behavior, allowing for improvements in their coexistence and to the reduction of conflict.

The members of the group resignify their perception of family members, showing that they are not alone, as they recognize that the problems they lived through with the person who undergoes psychiatric suffering are common to everyone, which opens up space for listening and sharing experiences among group members.

It helps a lot, which is good because we hear what the group is saying, there's always a different opinion, someone says something, another one says something else [...], each gives their opinion, the mediator accepts everyone's opinion and each one helps the other (E1).

I think the group is very good because people have the chance to help and expose their problems and each one helps the others (E2).

The group helped because we share experiences, people share how they act, what they feel. You start listening to what the people say, the problems each one has, and then you learn what to do, how to act, to be more patient and understanding (E6).

The importance of the exchange of daily experiences with family members is conducive to group cohesion, allowing for the expression of themes of common interest. This feeling can be intensified through an emphasis on the similarities between experiences. Thus, when group members interact with one another, they can offer support, understanding, advice and encouragement.

Interviewed family members reported to feel the need to receive further guidance when it comes to the crisis, to get to know the pathology (diagnosis, causes, treatment and prognosis), and to learn how to approach their relative during crises. Therefore, they identified that the group helps in recognizing the difficulties that take place in their daily lives with the person under psychiatric suffering, offering group members a space where helpful information about the disease and the treatment can be found.

I found it important because it makes many things clear to us. And by the way I had a lot of questions for when R. came back home. I even told the others in the group that it was my first time, and I really needed some clarification because I didn't know, I was totally lost. But the professional and the other family members there told me kind of how it could play out, so the group was very important (E4).

Well, for me it was really important, it helped me a lot, I started to get better even to be able to help, to understand better the disease (E5).

Oh, it helped me a lot, it helped me to understand a lot of what W. does, even though I had dealt with him for years, there were a lot of things I didn't get. Then I'd ask, and they'd explain, and they supported me with many things that W. does, that I have to understand to deal with him better. It helped to help me to deal better with him (E10).

The support group studied allowed for a collaborative work between family members and professionals, sharing information on the disease and discussing together the doubts and difficulties on the treatment. Therefore, the burden originated from the first acute episodes of the disease tend to subside, as the family member receives more information and experience to deal with the problems.

The group mediator has the responsibility to create situations that are conducive to a collective learning process about the disease and the ways to deal with the difficulties these families face in their daily lives.

Through the statements of the interviewees, it can be noted that the way they relate to their relatives is an important challenge to them. They can have a hard time understanding how to act, which results in difficulties to accept or even self-blaming. The support group was seen by the interviewees as a space to aid in their process of accepting the disease.

I didn't feel so alone, and I saw that there are other people that understand you, even if it's not the same situation. That helped me. I felt safer, and I saw he's receiving good care here, so I got calmer and learned to accept the disease better and to accept him as he is (E3).

In the beginning we don't accept. Actually, we'll never accept it, we always want there to be an improvement, we hope, but, in the case of some diseases, that's not what happens [...] but I learned to accept that better, to deal with that better. The group helped me a lot, not that I accept it today, we never accept it, but we learn to deal with it (E5).

Through participation in the group, family members' acceptance of the disease was greater as they understood it better, leading to better ways to deal with the person who lives under psychiatric suffering. Therefore, the participants valued their opportunities to talk about their fears and difficulties in the group, making the acceptance process easier as they learned more about the disease and the treatment.

Insecurity and fear also were frequent feelings among the family members interviewed. They highlighted the benefits of having a space to relieve tensions, where they could be listened and cared for, feeling safer and calmer with regards to the hospitalization and the disease process of their family member.

I felt safer, to make her [the patient] feel safe. I think that me talking to her alone, telling her that she's not the only one, that other people have been committed to many hospitals, and here she is, as the others mentioned, in the best place, I think that helped her a lot too. Because she was very depressed and now she's much more cheerful. I went home much calmer, when I saw that her problem was not the end of the world (E4).

I think it was very productive I mean, the meetings, in my case I could come to all of them, but all the ones I came to helped me a lot, I got out of here calmer, relaxed, I externalized what I was feeling about her disease (E5).

The participants found that in the space of the group they felt that they were not alone, that they had a team they could turn to when necessary, that there were other people with family members in the same situation. This condition gives feelings of safety and calm to them, reverberating in their relationship with their relative undergoing psychiatric suffering.

The family that understands itself to be the protagonist in the treatment of the family member hospitalized in the PHW should be considered by the professionals in all its specificities, opinions and actions. In this perspective, the care to the family becomes paramount for the treatment, and the group emerges as a powerful support strategy, in the perspective of the interviewees themselves.

For me the support group for families is very important because the family is the foundation. The patient is sick and, the family, it ends up sick too, so it's not enough to treat the patient and not the family, because the family will stay sick, and this sick family won't be able to help them to get better (E5).

I learned, here, that family help is important. Very important, because you find out that the family is helped here and then it helps the patient on the outside (E6).

The support group is an important strategy to care for the relatives of people with mental disorders in the PHW. It changes the blaming logic that was pervasive in mental health for many years, leading to a logic according to which the family is the protagonist in the process of rehabilitation of its member. Therefore, the perception of family members reveals that preoccupations originated from the patient's care can have a negative impact on the rehabilitation of the person who is hospitalized in the PHW, and that the support group is a powerful space for families to find their own care, which have positive reverberations on the treatment.

DISCUSSIONS

The Brazilian Psychiatric Reform opened space for new ways to consider and think about the knowledge and practices of health professionals who act in the mental health network services. These considerations allowed for professionals to see other ways to care for people with mental disorders, understanding family as something essential in this process¹.

Therefore, spaces such as support groups have been important in the context of health services that act from a Psychosocial Attention perspective. Family members of hospitalized patients, regarding the rehabilitation of their relative, feel that such spaces give them strength, and make them feel calmer and safer².

Families see the group as a space that offers them the possibility of expressing their anguish and fears, which they would not do in other contexts of their lives; that is also made easier by the mutual identification established among the participants of the group. Thus, the preventive potential of these groups emerges from the fact that they make it possible for people who undergo similar situations to expose their knowledge and experiences through testimonials and the sharing of experiences⁵.

The participation in groups favors the exchange of experiences, the confrontation of problems, and provides mutual support and solidarity, as well as it promotes feelings of belonging and trust, which strengthens and favors the recovery of self-esteem. Listening the problems of others and feel that you are not the only one generates a feeling of universality¹⁴.

The task of caring for and living with someone under psychic suffering can be very demanding, especially in moments of crisis, which makes it necessary to train family members and caretakers to manage these critical moments. Therefore, support groups can act as spaces for health education or be psychoeducational, teaching these families ways to manage, while also being a space for them to externalize their feelings about subjective and objective burdens that living with the ill patient entails¹.

Family members, thus, seek information on the disease and the treatment, and that collaborates to improve their emotional stability within the family nucleus, allowing for the family to improve their ability and capability to care. However, the lack of guidance can generate conflicts between the patient and its family members, negatively impacting the therapeutic process and leading to an increase of the family burden^15-16.

The contact with people undergoing similar situations helps to alleviate suffering, diminish isolation, and allows for the sharing of experiences, resulting in greater support and comfort¹. Through the groups, family members understand better the disease and the treatment, and there is a meaningful improvement in the relationship between the patient and the family. Aggression and anxiety decrease while tolerance and willpower increase^17-18.

When a family member gets mentally ill, the family faces social prejudices and stigmas that they help to maintain themselves, since many of them, when facing that reality, believe that the best solution is isolation. All changes and situations undergone by the family due to the disease bring them suffering, especially in the beginning and for those who are experiencing the crisis of their relative for the first time¹⁹. In the adaptation stage, the family changes its daily routine, and with that change, the lack of preparation to deal with the new situations can be noticed. With that, the support group shows itself to be very important in this process⁸.

It should be highlighted, considering especially the issues indicated on the difficulties to care for the patient and the suffering that comes from it, how necessary are therapeutic interventions targeted at the health of the caretaker, so that they can diminish their suffering and rethink their occupational lives, in addition to learning adequate strategies for family care²⁰.

In this study, this was found to mean the need for a new logic of attention for the person with psychiatric suffering, according to which the family should not only be included in the assistance plans, but also be treated as the central part of the care. This, however, implicates in an assistance to be implemented according to the needs of each family, considering their uniqueness and context. The health service professionals must be aware of the demands and particularities of each care unit, developing strategies and creating spaces that contemplate the variety of needs that might present themselves ²⁰.

The group mediators need to work on the acceptance of the familiar so that this process takes place with the least suffering possible¹⁵. The treatment of a patient under psychiatric suffering is intimately connected to the involvement of the family, as they are mostly a part of the foundation of an individual. Therefore, the evolution of the treatment depends a great deal on the support and acceptance of the family and on the social inclusion of the patient. Only through a feeling of belonging and autonomy can the human being recover their self-esteem, self-image, and establish themselves as a subject of their own story²⁰.

The non-acceptance of the disease by the family may generate a feeling as of never being really calm, due to many preoccupations, especially on the supervision of behaviors the patient adopts or may adopt, such as escape attempts, suicide, and the realization of daily activities¹⁵.

The support groups show that the implantation of strategies focused at caring for family members that care for people with severe and persistent mental disorders is necessary, so that they have opportunities to share considerations on the possible ways to take care of themselves and of the patient, providing them with safety and calm¹⁰. Therefore, the support group can be seen as a strategy for intervention and care, providing the family with the instruments to take efficient care of themselves and of the family under psychic suffering, as to diminish the overload they experience as they carry out their tasks of caring so that they can resignify their experiences²⁰.

It is in this context that the nurse, whether as a member of the health team or as a mediator of support groups, can contribute for the insertion of the family members in these spaces, using abilities such as listening, empathizing, welcoming, establishing ties, as well as multidisciplinary teamwork as instruments in their daily work. They can, therefore, be able to supply the demands and needs pointed out by family members in addition to diminish unnecessary referrals and the waiting time for specialized consultations¹⁷.

The participants of this study understood the support groups as something essential for an effective care to be consistently offered to the person under psychiatric suffering and their families, on the paradigm of the deinstitutionalization and psychosocial care. Abandoning a curative logic that is based only on signals and symptoms and on clinic care, is to rethink the practices of the health services that constitute the network¹⁷.

Mental health services that constitute the health network must offer people suffering from diseases and their family members the strengthening of their relationships in the social means, and the development of many possibilities of social exchange, going beyond a family or domestic environment and extending to many spaces in society, which can contribute for the process of rehabilitation and social inclusion of subjects under psychiatric suffering^16). A treatment conducted like this would, therefore, be one where the focus is valuing the family, as well as guiding them to effectively participate in all actions promoted by it.

FINAL CONSIDERATIONS

The objective of this study was analyzing the perception of relatives of people with mental disorders on the support group developed in a psychiatric hospitalization ward.

Through an analysis of the results it was possible to understand that the interviewees saw the group as: a space where they could give strength and support to one another; listen and exchange experiences with other participants; find help in the form of information on the disease and its treatment; find help for the process of accepting the disease, leading them to feel safer and calmer; and as a space that was a powerful support strategy under the perspectives of Psychiatric Reform and Psychosocial Attention.

Considering how important are family members for the treatment of the person under psychiatric suffering, we have identified in this study that the support group is a strategic health care action that helps the family member to diminish their emotional overload, allowing for them to offer care to the patient without being so affected by it, which reverberates in their lives and in the treatment of the person who is hospitalized.

Therefore, we highlight the importance of this study, since its results contribute for the strengthening of this strategy of care in the scope of the PHW, and can be used in other mental health services. In addition, the results of this research can encourage professionals of the multidisciplinary team, and among them, the nurse, to coordinate support groups and disseminate these spaces, favoring the concepts that eschew blaming, of a space for the care of family members and on the combat of prejudices and discrimination.

However, it should be pointed out that this study had limitations, such as: there was a small number of participants, and the research was developed in only one support group, within one specific PHW. Therefore, future studies are suggested to approach such aspects more deeply, as they are so important in the mental health field.

It is concluded, thus, that understanding the family as a participant in the therapeutic process can influence the search for new possibilities of care and of mechanisms that allow for the autonomy of the user, the acquisition of their rights, and their exercise of citizenship.

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• ¹⁹ Wesner AC, Gomes J, Silva TD, Blaya C, Manfro GG, Heldt E. Effect of cognitive-behavioral group therapy for panic disorder in changing coping strategies. Compr Psychiatry. 2014; 55(1): 87-92https://doi.org/10.1016/j.comppsych.2013.06.008
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Publication Dates

• Publication in this collection
  02 Aug 2018
• Date of issue
  2018

History

• Received
  14 June 2017
• Accepted
  17 Nov 2017