PRACA ORYGINALNA / ORIGINAL ARTICLE

Wprowadzenie systemu interwencji psychoterapeutycznych dla opiekunów pacjentów z endogennymi zaburzeniami psychicznymi

Nataliia G. Pshuk, Liudmila V. Stukan, Anna O. Kaminska

National Pirogov Memorial Medical University, Vinnytsya, UKRAINE

Abstract

Introduction:Providing care for patients with endogenous mental disorders is associated with significant psychosocial burden.

The aim of this study was to introduce a system of psychotherapeutic interventions for family caregivers of patients with paranoid schizophrenia and bipolar disorder based on understanding their prevalent coping behavior patterns and communicative coping resources evaluation.

Materials and methods: A total of 273 family caregivers of patients with paranoid schizophrenia and bipolar disorder were involved into this survey under informed consent conditions. Control group included 55 mentally healthy respondents, in whose families there is no mentally sick family member. Test for psychological diagnostics of coping mechanisms (E. Heim) and emotional empathy test (А. Mehrabian) were chosen as psychological testing research tools. Values of p <0.05 were considered significant.

Results: The study revealed prevalence of certain maladaptive coping strategies and lack of communicative coping resources in family caregivers of patients with paranoid schizophrenia and bipolar disorder. These data might be among significant predictors of communicative dysfunctions in families where one of the family members has endogenous mental disorder, and must be considered while developing appropriate psychotherapeutic programs.

Conclusions: On the basis of revealed data, we have introduced an integrative system of psychotherapeutic interventions, aimed to develop adaptive forms of coping behavior in family caregivers, increase their empathetic and affiliative resources, create favorable conditions for activation of personal resources and adaptive potential of both family caregivers and patients with paranoid schizophrenia and bipolar disorder.

Key words:

Wiad Lek 2018, 71, 5, -985

 

INTRODUCTION

Providing care for mentally sick patients is associated with significant psychosocial burden [1]. There are nearly 450 million people in the world who are diagnosed as having a psychiatric illness throughout their lifetime. Among these disorders, schizophrenia and affective disorders comprise 55% of hospital admissions and 65% of inpatient care [2]. The WHO statistics indicates that more than 25% of population world-wide is affected by some sort of psychiatric disorders. This shows that globally one family in every four is involved in care-giving for a patient with psychiatric illness.

The stigma surrounding mental disorders is a concern. Patients with bipolar disorder and schizophrenia face discrimination, misunderstanding and stigma, and too often, family caregivers are blamed for mental disease [3]. At the beginning of the disease, psychopathological symptoms may be challenging for family members to cope with. In the early days, relatives of patient may be in denial, believing that illness is something that the patient just needs to “get over”. Symptoms of bipolar disorder and schizophrenia are also challenging to deal with [4]. Symptoms like hallucinations and delusions might be confusing and frightening, while depressed mood, suicidal thoughts and attempts, fatigue, anxiety, cognitive deficits can dramatically change personalities, leaving family members to grieve for the loss of the person they knew. Symptoms of schizophrenia and bipolar disorder affect emotional, cognitive and behavioral responses of care-giving relatives, and these emotional, cognitive and behavioral responses affect reactions of mentally sick family member and ultimately the course of the illness [1, 2, 3].

There is an obvious need to provide psychotherapeutic help for family caregivers who deal with various stressful situations due to having mentally sick patient in their family. The mode of interaction and coping strategies determine the course of illness in these patients, and hence positive interaction can improve quality of life of both the caregivers and the patients [5].

THE AIM

The aim of present study was to introduce a system of psychotherapeutic interventions for family caregivers of patients with paranoid schizophrenia and bipolar disorder based on understanding their prevalent coping behavior patterns and communicative coping resources evaluation.

MATERIALS AND METHODS

A total of 243 family caregivers of patients with paranoid schizophrenia (PSch) and bipolar disorder (BD) were involved into this survey including either wife/husband or one of the parents. Control group (CG) included 55 mentally healthy respondents, in whose families there is no mentally sick person.

Methods: clinic-anamnestic, social-demographic, clinical-psychopathological, psychological testing, statistical analysis. Test for psychological diagnostics of coping mechanisms (E. Heim) [6, 7] was chosen as a psychological testing research tool to measure leading coping-strategies of family caregivers of patients with PSch and BD. Personal communicative coping resources (empathy, affiliation, sensitivity towards neglection) were estimated by emotional empathy test by А. Mehrabian.

RESULTS

In psychology, coping is generally understood as a process of managing challenging circumstances, expending effort to solve personal and interpersonal problems, and seeking to master, minimize, reduce or tolerate stress or conflict [8, 9, 10]. A coping strategy may be defined as personality’s actions in dealing with complex situations and adaptation to existing circumstances [11, 12]. There are different classifications of coping behavior and coping strategies in modern psychology. E. Heim suggested considering emotional, cognitive and behavioral coping strategies, which involve behavior that can be adaptive, relatively adaptive or non-adaptive [6, 7]. Adaptive behavioral options in different spheres include search for social support, problem analysis, installation of self-worth, self-esteem and self-control increase, deep awareness of self, protest against difficulties and optimism. Maladaptive variants of coping behavior are associated with active avoidance, retreat, refusal to solve problems, humility, confusion, dissimulation, ignoring, suppression of emotions, self-blame, aggression, hopelessness, resignation, laying the blame on others. Relatively adaptive variants of coping behavior concern compensation, diversion, constructive activity, behavior, characterized by desire to move away from solving the problems by alcohol or drugs abuse. In cognitive sphere, relatively adaptive options are associated with relativity, making sense, religious forms of thinking, aimed for devaluating difficulties in comparison with other life difficulties, giving special meaning to overcome, faith in God and perseverance in the faith (“God is with me”) when confronted with complicated situations. In emotional sphere variants of behavior refer emotional discharge, passive cooperation – behavior aimed to removal of stress associated with problems, emotional discharge, or transfer of responsibility to resolve the difficulties by the others [6].

The study revealed that family caregivers of patients with schizophrenia and BD exhibit relatively adaptive and maladaptive coping-strategies more often compared to control group individuals, which might create significant obstacles for successful social and psychological adaptation of individual family members and thus, harmonious functioning of a family as a whole. The research suggests, that family caregivers of patients with PSch and BD compared to control group, tend to use coping strategies of humility, confusion, emotional suppression, self-accusation, ignoring and escape (tab. I).

Decreased tendency to perceive social support was revealed in relatives of patients with PSch while family caregivers of patients with BD tend to have higher ability to perceive help and emotional support from significant others compared to family caregivers of patients with PSch and CG respondents.

Coping behavior features revealed by this study should be understood as an important predictor of communicative dysfunctions in families where one of the family members has paranoid schizophrenia or bipolar disorder, and taken into consideration while creating appropriate psychoeducational and psychotherapeutic programs.

Results of study of “empathetic” and “affiliative” tendencies, “sensitivity towards neglection” in family caregivers of patients with PSch and BD and healthy respondents are given in table II.

Statistically significant differences between coping resources scores of family caregivers of patients with PSch and BD and the CG respondents were detected in all the subscales, where the data on empathy and affiliation tendencies were significantly lower in both family caregivers’ groups, and on the scale of “sensitivity towards neglection” are significantly higher compared to the CG scores (p <0.001).

Revealed indicators of communicative coping resources in FC of patients with PSch and BD reflect predicted by the situation (presence of a relative’s illness) emotional state.

Adequate level of affiliative-empathic tendencies contributes to the involvement of constructive behavioral coping strategies while dealing with stressful life situations.

Communicative coping resources are a basis not only for overcoming problem situations, but also for effective adaptation to social demands. It is through psychological resources that an adaptive or non-adaptive behavioral style is formed, based, first of all, on processes of empathy, affiliation, psychological protection, locus of control, self-esteem of the individual. In a situation where disease, on the one hand, completely changes personality structure and leads to suppression of emotional sphere, and on the other hand, complicates process of adequate interpersonal communication in family as well as in society in general, understanding main communicative resources of family caregivers becomes significant.

DISCUSSION

On the basis of analysis of the obtained data, we identified main targets and proposed an algorithm of psychotherapeutic interventions for family caregivers of patients with endogenous mental disorders, aimed to develop constructive forms of coping behavior and to improve quality of interpersonal communication in families of patients with PSch and BD.

We involved integrative approaches including following methods:

– cognitive-behavioral psychotherapy;

– mindfulness-oriented cognitive therapy;

– psychological training;

– art-therapy.

Choice of psychotherapeutic methods and specific content of psychotherapeutic sessions were determined by actual targets.

The introduced system of interventions aims to form an adequate attitude of relatives towards mental disease of a family member, increase communicative competence by forming the skills of emotional and predicative empathy, skills of effective communication and adaptive coping behavior, creating favorable conditions for activating communicative resources and increasing adaptive capacity of the family in general.

System tasks:

1) development of realistic notions about causes, pathogenesis, peculiarities and consequences of disease in family caregivers of patients with PSch and BD, understanding possibilities of its treatment, prognosis, and also the importance of social and therapeutic environment for social adaptation of patient and prevention of stigmatization;

2) formation of ability to predict consequences of their behavior, to understand manifestations of verbal and non-verbal communication, to navigate in general system of interpersonal interactions;

3) mastering skills of constructive coping behavior under stressful life circumstances;

4) creation of conditions for the formation of adequate interpersonal interaction in a family with a mentally sick family member;

5) formation of value systems aimed at preserving health and enhancing personal adaptation potential in family caregivers.

In the content plan, the proposed algorithm of psychotherapeutic interventions for family caregivers of patients with PSch and BD is a three-component structure (fig. 2):

1. theoretical block (psychoeducation and motivation for next interventions), aimed at providing information for relatives of patients with PSch and BD, concerning causes, mechanisms of formation, approaches to treatment and consequences of disease;

2. practical-oriented block (psychological training, group and individual psychotherapeutic work in cognitive-behavioral approach, mindfulness, art therapy), aimed to provide self-awareness, self-understanding, activation of personal communicative coping resources, activation of adaptive personality potential in general; stress-resistance development;

3. developing block, based on psychological training as a special form of work with the person and the group, aimed at acquiring knowledge, skills and abilities, assimilation of effective ways of coping, working out intrapersonal and interpersonal conflicts connected with a family member’s illness through such methods as group discussion, modeling of family situations, art-therapeutic technologies.

The proposed system of psychotherapeutic interventions for family caregivers of patients with PSch and BD involves combination of group and individual forms of psychotherapy using appropriate techniques and methods (table III).

As part of comprehensive care for correction of negative emotional states, the use of mindfulness-based cognitive therapy by Zindal Sigal, John Tisdal and Mark Wilson on the basis of the mindfulness-focused practices of reducing stress by John’s Kabat Zina, was proposed.

First and foremost, the very concept of mindfulness implies the notion of awareness, that is, the unconscious awareness that arises when focusing on the present moment [13,14]. And “absence of estimation” is the most important part, as in our life we give an estimation to practically everything that we encounter. Our consciousness is almost always busy with feelings “like” – “do not like”, “want” – do not want”, “good” – “bad” [15].

In mindfulness state attention is focused on instant experience, without filtering, without evaluation, without waiting.

Mindfulness is a state of consciousness that arises when we specifically direct our minds on what is happening now. This is the ability to draw attention to thoughts, physical sensations, images, sounds, smells – all that happens to us at the moment of life. Actual skills can be very simple, but because they differ from the usual behavior of our mind (thinking), it takes some time to form these skills. The ability to evaluate, substantially and literally realize your life experience (the completeness and variety of content of the experienced events and phenomena) and the simultaneous awareness of the internal representation of experience, some subjective stroke of reality, and not the objective reality itself [13, 14].

In addition, mindfulness-cognitive therapy also includes general knowledge about anxiety, depression, fear, emotional states and skills in understanding emotions, feelings, thoughts, their interactions and their consequences [13]. Within this approach, we can teach people the ability to take care of themselves, because in a situation of a sick family member, as a rule, family caregivers forget about themselves, their own desires, their needs and their lives in general, neglecting themselves, which, in turn – has extremely negative consequences.

While attending psychotherapeutic sessions, people acquire the skills to treat their thoughts as just thoughts, and not as an ontological reflection of reality. Such an attitude suggests a higher efficiency of coping with negative experiences, namely, the ease of updating alternative aspects of experience, refraining from negative evaluation of neutral events, breadth of range and adaptability of responses to negative incentives [14]. The ability to realize the subjectivity of the internal picture of reality is seen, thus, as an effective way of overcoming various forms of psychological stress – anxiety, fear, irritation, anger, rumination.

The dysfunctional nature of these forms of stress is often associated with highly destructive strategies: avoidance, suppression, or excessive anxiety by negative feelings and thoughts. The counterproductivity of these strategies, in turn, is aggravated by the fact that these methods are rapidly automated and paradoxically perceived by the subject as effective and necessary, despite the obvious evidence of the opposite.

For better understanding of own thoughts, negative thinking style and its influence on emotions, sensations, and human behavior, cognitive techniques are used. At the same time, at the beginning, people are taught to understand their own manifestations of mental life, and reveal the essence of such concepts as cognitive distortions, intermediate and deep beliefs. As for cognitive distortions, or mistakes in thinking, the skills of understanding, recognizing and changing on more adaptive and realistic views on the situation and life in general are developed. Thus, the most typical cognitive disturbances that are common for family caregivers of patients with PSch and BD are, for example, focus on the negative (when a person notices only negative things and aspects of the interaction and does not see all that is positive), exaggeration or reduction of information, catastrophic thinking (human propensity to build negative predictions and see catastrophic consequences in everything), generalization (the tendency to make general conclusions from individual facts), personalization of guilt, reading of thoughts etc.

CONCLUSIONS

Thus, on the basis of in-depth study of the identified socio-psychological features of the functioning of the family as a social and therapeutic environment, we have introduced an integrative system of psychotherapeutic interventions, aimed to normalize the psycho-emotional state, develop adaptive forms of coping behavior of family caregivers, increase their empathetic and affiliative resources, create favorable conditions for activation of personal resources and adaptive potential of patients with paranoid schizophrenia and bipolar disorder.

References

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2. Narasipuram S, Kasimahanti S. Quality of life and perception of burden among caregivers of persons with mental illness. AP J Psychol Med Am J Nurs. 2012;13(2):99–103.

3. Pompili M, Harnic D, Gonda X et al. Impact of living with bipolar patients: Making sense of caregivers’ burden. World Journal of Psychiatry. 2014; 4(1):1–12.

4. Nadkarni RB, Fristad MA. Stress and Support for Parents of Youth with Bipolar Disorder. The Israel Journal of Psychiatry and Related Sciences. 2012;49(2):104–110.

5. Geriani D, Savithry KSB, Shivakumar S et al. Burden of Care on Caregivers of Schizophrenia Patients: A Correlation to Personality and Coping. Journal of Clinical and Diagnostic Research. 2015;9(3):VC01-VC04. doi:10.7860/JCDR/2015/11342.5654.

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7. Rayhorodskyy D. Praktychna psykhodiahnostyka. Metodyky ta testy [Practical psychodiagnostics. Methods and tests]. Samara: Bakhrakh-M; 2008, p. 357–413

8. Ababkov V. Adaptatsiya do stresu. Osnovy teoryy, diahnostyky, terapiyi [Adaptation towards stress. Basics of theory, diagnostics, therapy]. SPb.: Rechʹ; 2004, p. 30–78

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10. Lazarus R. Coping theory and research: Past, present and future. Psychosomatic Medizine. 1993;55:234–247.

11. Antonovsky A. Health, Stress and Coping. San Francisco: Jossey–Bass; 1979, p. 155–165.

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Conflict of interest:

The Authors declare no conflict of interest.

Authors’ contributions:

According to the order of the Authorship

CORRESPONDING AUTHOR

Anna Kaminska

Shevchenka street, 71a, Vinnytsya, Ukraine

tel: +380979719887

e-mail: adonidisvernalis@gmail.com

Received: 12.03.2018

Accepted: 05.06.2018

Table I. Structure of coping strategies among family caregivers of patients with schizophrenia (1MGFC) and bipolar disorder (2MGFC)

Sphere

Adaptive
level

Coping strategy

1MGFC,

n=168

2MGFC,

n=75

CGFC,

n=55

n

%

n

%

n

%

1

2

3

4

5

6

7

8

9

Cognitive

Adaptive

Self-control maintenance

25

14,9

14

27,3

12

21,8

Problem analysis

30

17,9

19

13,9

18

32,7

Self-worth installation

22

13,1

8

15,9

9

16,4

Total:

77

45,9

41

57,1

38

69,1

Relatively adaptive

Relativity

16

9,5

4

8,9

2

3,6

Religiousness

15

8,9

7

8,3

2

3,6

Making sense

13

7,7

3

8,2

5

9,1

Total:

44

26,1

14

25,4

9

16,4

Maladaptive

Ignoring

10

5,6

1

7,6

1

1,8

Resignation

11

6,5

8

1,3

2

3,6

Dissimulation

16

9,5

8

5,0

3

5,5

Confusion

10

5,6

3

3,6

1

1,8

Total:

47

28,0

20

17,5

8

14,5

Emotional

Adaptive

Protest

27

16,1

12

14,1

11

20,0

Optimism

21

12,5

17

22,7

18

32,7

Total:

48

28,6

29

38,7

29

52,7

Relatively adaptive

Emotional discharge

23

13,7

10

13,3

12

21,8

Passive cooperation

21

12,5

11

14,7

7

12,7

Total:

44

26,2

21

28,0

19

34,5

Maladaptive

Emotional suppression

21

12,5

7

9,3

3

5,5

Humility

25

14,9

8

10,7

1

1,8

Self-accusation

19

11,3

7

9,3

1

1,8

Aggression

11

6,5

3

4,0

2

3,6

Total:

76

45,2

25

33,3

7

12,7

Behavioral

Adaptive

Altruism

13

7,7

5

6,7

11

20,0

Cooperation

27

16,1

6

8,0

10

18,2

Search for social support

23

13,7

14

18,7

10

18,2

Total:

63

37,5

26

34,7

31

56,4

Relatively adaptive

Distraction

25

14,9

10

13,3

9

16,4

Compensation

35

20,8

9

12,0

10

18,2

Constructive activity

24

14,3

8

10,7

5

9,1

Total:

84

50,0

28

37,3

23

41,8

Maladaptive

Active avoidance

12

7,1

11

14,7

0

0

Escape

9

5,4

10

13,3

0

0

Total:

21

12,5

21

28,0

1

1,8

Table II. Levels of personal communicative coping-resources in family caregivers of patients with paranoid schizophrenia and bipolar disorder compared to control group individuals (score, M±m)

Coping-resources

Groups

р<AB

1MGFC, n=168

2MGFC, n=75

CGFC, n=55

Empathy

9,2±0,11

12,7±0,16

18,7±0,31

0,001

Affiliation

8,3±0,87

10,2±0,37

13,4±0,12

0,001

Neglection sensitivity

12,6±0,53

11,1±0,34

7,8±0,13

0,001

Fig. 1. Algorithm of psychotherapeutic interventions for family caregivers of patients with paranoid schizophrenia and bipolar disorder.

Table III. Targets and content of integrative system of psychotherapeutic interventions for family caregivers of patients with paranoid schizophrenia and bipolar disorder.

Target

Goal

Methods

– dramatic perception of disease and negative type of attitude towards patient

1. adequate attitude towards patient;

2. realistic, conscious and responsible attitude towards disease,
its treatment and consequences;

3. social adaptation of family in general.

Psychoeducation, group psychotherapy, cognitive-behavioral psychotherapy

– decreased ability to percept social support

1. development of empathetic and affiliative resources;

2. decrease of sensitivity towards neglection;

3. formation of communicative competence;

4. increase of social adaptation level and renewal of social accomplishments satisfaction.

Group psychotherapy, cognitive-behavioral psychotherapy, psychological training, mindfulness and art therapy techniques

– maladaptive behavioral patterns

1. mastering skills of effective coping;

2. stress-resistance increase;

3. activation of adaptive personal resources.

Group psychotherapy, cognitive-behavioral psychotherapy, mindfulness techniques