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Principles of Social Psychiatry

Published by andiny.clock, 2014-07-25 10:34:04

Description: This second edition ofPrinciples of Social Psychiatry
appears more than 15 years after the first one, and even
a cursory comparison between the contents of the two
editions clearly documents that the scope and the
impact of the social component of our discipline and
profession have remarkably increased during the past
few years.
There is now a more widespread awareness of
the role of social risk factors even in the aetiology of
mental disorders that had been traditionally perceived
to be mostly biological in their causation. Schizophrenia is a good example. The research evidence concerning the association between some social factors – such
as urbanicity and a history of migration – and the
likelihood of developing a psychotic condition is now
quite robust, and there is also some evidence of a
synergy between these factors and familial liability in
the causation of the disorder.
Also increasing is awareness of the impact of social
factors on the identification and the diagnosis of
menta

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SOCIAL INTERVENTIONS FOR PSYCHOSIS 433 with mental health problems, in spite of symptoms or leads to improved not worse mental health and that the diagnosis, should be able tomake avaluedcontribution longer people remain out of work the worse the prog- to their communities. In one study, 40% of people with nosis. This is because work provides a sense of worth, mental health problems who had been in open employ- identityandﬁnancialsecurity.Psychiatristscanredress ment had been told by a mental health professional that assumptions by occupational health, social and they would never work again. This erodes hope and employment (‘Jobcentre Plus’ in the UK) staff who diminishes opportunity. On the other hand, those may have low expectations of patients’ ability to work. employed have fewer relapses, regardless of severity Interventions for promotion of social inclusion for of diagnosis [69]. While alleviation of symptoms does mental disorders (such as psychosis) thus include not necessarily result in reinstatement offormer valued targeting key areas (see Table 32.2). roles and relationships [63], it does require a different There is also a growing recognition of the need for approach and can mean returning to work despite not socially inclusive services that address a host of sub- having fully recovered (see Table 32.1) [70]. groups of service users. These include young people In terms of knowledge and training, mental health with early psychosis, the homeless and marginalized, practitioners need to be aware of the rights of patients and those with complex needs. Bertolotte and under the Disability Discrimination Act [71] in the UK McGorry [73] noted that despite available interven- or other countries’ equivalents. In the UK, this Act tions that could reduce relapses by more than 50%, not outlaws discrimination against disabled people in edu- allpatients have access to them, and ‘when they do,itis cation, employment and public transport and includes not always in a timely and sustained way’ (p. 116). A a duty on employers and education providers to make vision was drawn up including: ‘respect of the right to ‘reasonable adjustments’ to facilitate access to ser- recovery and social inclusion... respect of the strengths vices. Psychiatrists can write letters to employers and and qualities of young people with a psychosis, their can address patient fears that looking for employment, families and communities, encouraging expectations including unpaid work, will trigger a beneﬁts review or ...’ and, ﬁnally, ‘services that actively partner young loss. They need tobe awarethat medicationside effects people and their families ...’ [73]. A campaign was like drowsiness can rule out certain jobs, that work launched by a coalition of government and NHS representatives, mental health, drug and homeless Table 32.1 Implications of a social inclusion agenda for charities to address the complex needs group of mental health services patients who do not easily fall into one or other service (see www.homeless.org.uk for weblink). Areas to be Past emphases and goals New social inclusion agenda addressed include: reconnecting clients with families, making service care plans more personal, addressing To ‘cure’ people by To help people with mental rights and responsibilities, increasing service user treating illnesses, health problems do the reducing symptoms things they want to do, live involvement, addressing stigma and discrimination. (cognitive and emo- the lives they want to lead Finally, the ‘choice agenda’ may also be seen as part tional problems), and access opportunities of the initiative for greater social inclusion. In mental skills deﬁcits and that nondisabled citizens health it may be a means of understanding life and dysfunctions take for granted treatment choices rather than health service location/ To identify problems Identify strengths and convenience, which are features of the ‘choice possibilities agenda’ amongst nonpsychiatric patients [74]. There Care for the patient Opportunity for the individual is evidence to suggest that encouraging people to Change the individual Change the environment to consider how they should be supported during to ﬁt in support the person; adjust- relapses results in fewer compulsory admissions [75]. ments to facilitate access Limits to choice in psychosis include the use of Prescribe what is good Enable people to control their compulsory treatment in high-risk cases, where illness for people own lives and the support severity impairs the capacity to exercise choice [76]. they receive Furthermore, there are problems with the concept of

434 SOCIAL INTERVENTIONS Table 32.2 Interventions for the promotion of social inclusion Individual service user needs . Work in partnership and convey hope through exploring goals, strengths, unrealized potential, psychosocial situation, opportunities for community participation, promotion of autonomy and well-being . Support access to general medical services, including health promotion . Provide choice over patients’ care to reduce the misconception that having a mental health problem means one is incompetent Medication reviews . Optimizing drugs to reduce stigma. Excessive doses can have major effects on patients’ quality of life and on how they present themselves with increased weight, tremor and movement disorders interfering with their own, and others’, perception of themselves. Lethargy reduces involvement in leisure and employment activities Psychological approaches . Psychological interventions should be more actively promoted by psychiatrists . Unduly negative perceptions of schizophrenia can impair recovery yet many patients can make substantial recoveries [50]. ‘Normalizing’ schizophrenia can again be crucial to hope of recovery Management and leadership . Redesigning mental health day services to promote community participation . Changing the impersonal, passive atmosphere of the mental health service environment itself; most pressingly, acute admission wards . Actively support safe alternatives to hospitalization (which fosters chronicity and stigma) including early intervention services, culturally sensitive interventions and promotion of access to services in schools, colleges and primary care Social inclusion in training . The General Medical Council (GMC) UK, has been: training medical students to consider social factors and encouraging curricula to reﬂect community medicine . The evidence base for this should be included at every level (psychiatric, continuing professional development) of training and they should receive training from people who experience mental health problems and their carers Other social interventions by practitioners include: . Promoting participation via social networks, training/education, beneﬁts, advocacy [72], leisure activities in mainstream settings; linking people with vocational/disability employment advisors; referring people to guides on stigma, employment, social networks . Early intervention services can prevent patients losing their jobs after their ﬁrst psychotic episode . Working closely with the criminal justice system; police training on mental health . Local and national campaigns: including campaigns to promote mental health such as those run by the Royal College of Psychiatrists (‘Changing minds’) choice, where restricted resources offer none (low less well off [74]. Some have also exercised caution in income countries, local inequalities of care) or where presenting patients with an array of choices that can higher advantaged and more vocal patient groups bewilder and lead to high levels of stress and exercise their choice to the opportunity cost of the anxiety [77]. 32.7 SUMMARY In relation to psychosis, and indeed all mental disorders, for help: ﬁnances, accommodation, meaningful activity social interventions are a key and neglected component and relationships. Research into these areas is still of mental health services. They involve work on areas limited, but such as there is suggests that they can be that are central to patients’ expressed wishes and needs highly effective and are welcomed by patients.

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33 Social management of common mental disorders Patricia R. Casey Department of Psychiatry, Mater Misericordiae University Hospital, University College Dublin, Republic of Ireland Writing a chapter on the Social Management of welfare beneﬁts and poverty, and that it falls more Common Mental Disorders (CMDs) is a signiﬁcant within the remit of social work, social policy and challenge since the evidence base referring to social politics than psychiatry. Schizophrenia is the excep- treatments for CMDs is sparse – as a literature search tion. in which social interventions have become asso- will quickly reveal. Within psychiatry, the term ciated with altering the immediate environment in ‘psychosocial’ is used liberally, and while the which the patient lives and so focuses broadly on the ‘psycho-’ component is clear and has been well emotional temperature of the family, known as researched, particularly in the area of psychological Expressed Emotion (EE). So, while it seems that therapies, the ‘social’ element has remained largely as social treatment is concerned with the changing mere lip-service to an appealing aphorism. When aspects of the patient’s environment rather than symp- asked what the social element of treatment involves, toms or functioning speciﬁcally, a clear deﬁnition of the common answer is that it relates to housing, ‘social treatment’ as applied to CMDs is lacking. 33.1 WHAT IS SOCIAL MANAGEMENT? Heretofore psychiatric treatments have focused exclu- since this can inﬂuence the aetiology, severity and sively on the individual receiving an intervention from duration of the disorder. a mental health professional with the goal of reducing Social interventions by deﬁnition have a public distress or functional impairment using either phar- healthdimensiondevelopedatnationalpolicylevel[1] macological or psychological techniques alone or in that relate to prevention. Included here are public combination. However, it has become increasingly education and antistigma campaigns as well as the recognized that this is a narrow view and that the social training of general practitioners in the recognition and contextof symptoms should also be taken into account management of CMDs. Measures to enhance social Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

440 SOCIAL INTERVENTIONS capital are now part of government policy [2] aimed at milieu without recourse to secondary psychiatric ser- improving the mental health of the population, while vices. The latter might include cognitive therapy, the provision of therapists who will deliver brief ordinarily regarded as a standard psychological inter- interventions at community or primary care level to vention; yet when delivered, for instance, via the the large numbers of the general population is another internet, its reach will be much more extensive. facet of this preventive drive. Workplace interventions A further question is, what is meant by environ- to identify those at risk from or with psychiatric ment? Clearly a number of people living in proximity disorders have also been developed. to another, be it a rural neighbourhood or a town, Since these relate to prevention they are beyond the constitute an environment, but what of two people scope of this chapter and are considered in Chapter 30. living together? Can this be said to be a social envir- For the purpose of this chapter social treatments are onment? According to some inﬂuential ﬁgures, deﬁned as those interventions that aim to alter the such dyads are legitimate subjects for the study of patient’s social environment when it has contributed environmental inﬂuences on illness [3] and so bring in some speciﬁc way to the psychiatric disorder or can family interventions within the ambit of social be delivered easily to largenumbers in their own social interventions. 33.2 WHAT ARE COMMON MENTAL DISORDERS? Common mental disorders (CMDs) include unipolar/ (ODIN) [8] found a one-month period prevalence of major depression, anxiety disorders and stress disor- 8.5% with a range from 2.6 to 17.1% depending on the ders (adjustment disorder) but for obvious reasons site. Turning to panic attacks, a lifetime prevalence of exclude psychotic disorders. CMDs will be the subject 22.7% and for panic disorder with and without agor- of this chapter, in so far as there is evidence to support aphobia of 1.1 and 3.7%, respectively, has been social interventions in their management. reported [9], while for generalized anxiety disorder Thesix-monthprevalenceofmajordepressioninthe ratesofslightlyover3%werefoundintheECA[4]and EpidemiologicalCatchmentAreastudy(ECA)[4]was NationalComorbiditySurvey[5].Ratesforadjustment 2.2% across ﬁve sites and the later National Comor- disorder have not been measured in most of the large- bidity Survey (NCS) [5], a replication study, found a scale epidemiological surveys.IntheODIN study[8]a 12-monthprevalenceof6.6%andalifetimeprevalence prevalence of 1% was found, although higher rates of of 16.2%. In Edmonton, Canada, the one-month pre- 2.3% have been found in the elderly [10]. valence was 3.2% and in Christchurch, New Zealand Being the fourth most common cause of health- 5.3%[6].TheNationalHouseholdSurveyofBritain[7] related disability and projected to rise to second place identiﬁed a one-week prevalence of 2.1% and the in coming decades, depression is the disorder that has Outcome of Depression International Network attracted the most attention. 33.3 FAMILY THERAPY The use of family therapy in treating common mental directly on symptoms and more on changing destruc- disorders is based on the theory that the system in tive communication and behaviour between and which the person lives has a role in generating and/or within family members and through that route redu- in maintaining symptoms – in this respect it represents cing symptoms. In particular, family therapy has a social intervention par excellance. Therefore, been used in the treatment of depression. This issue, family therapy aims to improve the interactions however, is complicated by the variety of family between or among family members so that family therapies that exist. These include psychoeducational, functioning improves. The goal is thus focused less behavioural and psychoanalytical models as well as

SOCIAL MANAGEMENT OF COMMON MENTAL DISORDERS 441 systemic, structural, solution-focused, narrative and Expressed emotion, with its three components of post-Milan models. This diversity makes studies about emotional overinvolvement, criticism and hostility, is the beneﬁts of family therapy difﬁcult to interpret. generally associated with severe and enduring mental The use of family therapy speciﬁcally in treating illnesses such as schizophrenia [12]. There is also a depressive illness was the subject of a systematic literatureonitsimportanceontheoutcomeofdepressive review [11] in which the authors included not just illness,althoughthishasreceivedmuchlessattention.If major depression but also those with depressive symp- EE is a variable inﬂuencing outcome, it follows that toms not meeting speciﬁc criteria for a formal diag- familytherapymight havearoleinreducingsomeorall nosis of this condition. The primary outcome exam- of its three components and that ultimately this would ined was reduction in total symptom score using a inﬂuence outcome. An early study [13] found that range of rating scales; secondary outcomes included coupletherapywasmoreacceptablethanpharmacother- family functioning, other symptom changes (e.g. apytoagroupofdepressedpatientslivingwithacritical hopelessness, suicidal ideation, anxiety), general partner and that the reduction in symptoms was main- functioning, quality of life and a range other possible tained at 2 years post-treatment. outcomes. Four levels of evidence from 1 (good) to 4 However, the relationship between EE and relapse is (none) were identiﬁed. Of the 43 studies identiﬁed complex, as was shown in a study [14] of older adults only six met the criteria for inclusion, and the hetero- with depression. While high EE overall was not asso- geneity between these did not allow pooling of data so ciated with relapse, there was an interaction with the as to calculate an effect size, nor did it allow any relationshiptothepatients.Amongadultchildrencaring judgement as to the preferred form of family therapy. for older patients, high EE status was signiﬁcantly While there were some good studies, the authors associated with relapse at one year and fewer achieving concluded that the evidence overall was at level 3 completeorsustainedrecovery,whilespouseswithhigh (limited or conﬂicting) but it rose to level 2 (moderate) EE showed a trend towards lower relapse rates and when reduction in depressive symptoms was consid- higher rates of complete and sustained recovery. How- ered and when improvement in family functioning ever, another study [15] found that the direction of the was the outcome. Family therapy also reached level 2 associationwasthereverseofwhattheearliertheoryhad in comparison to no treatment or waiting list controls. suggested. Patients and their partners were interviewed Compared with pharmacotherapy, there was limited separately at three-monthly intervals over one year, and evidence (level 3) of equal efﬁcacy for combined whilethenatureoftheassociationcouldnotdeﬁnitively family therapy and pharmacotherapy when compared beestablished,itappearedthatcontinuingcriticismwas to pharmacotherapy alone. The authors concluded the result of continuing depression, while the relation- that the use of other psychological interventions for ship between these was mediated by the relative’s which there is a better evidence base is preferable to understanding of the illness. This view was reinforced family therapy, notwithstanding its widespread use. byarecent10-yearfollow-up[16],whichquestionedthe This study demonstrates the value of systematic signiﬁcance of EE and perceived criticism since neither reviews in challenging received wisdoms, but it also was associated with outcome. At this point it is not demonstrates the limitations imposed on those work- possible to conﬁrm the early ﬁndings of the prognostic ing in an evidence-based environment. For example, signiﬁcanceofhighEEontheoutcomeofdepression.If questions that arise are whether pharmacotherapy on furtherstudiesdemonstrateacausallinkwithdepression its own compares favourably with family therapy outcome then family therapy will once again have alone, a question that is often asked in clinical settings. therapeutic potential. 33.4 BIBLIOTHERAPY The demand for psychological treatments is high and services that are available. An attempt to overcome cannot be met by the current level of psychological this deﬁcit was the creation of a new grade of

442 SOCIAL INTERVENTIONS therapist – the primary care graduate mental health Table 33.1 Types of bibliotherapy worker (PCGMHW). These are psychology gradu- Stand-alone self-help Used without any other ates with 1 year’s training in delivering brief thera- therapy pies. The expectation is that psychological therapies Adjunctive self-help Used in combination with will thus become more accessible for larger numbers pharmaco- or psychotherapy of people. This approach within primary care was Pure self-help Exclusively self-administered trumped by proposals put forward by Professor (check this deﬁnition) Predominantly self-help Minimum of professional Leyard, a health economist with the London School assistance but initial of Economics, who in 2005 recommended increasing evaluation to develop a the numbers of therapists trained in delivering brief rationale for the reading therapies by 10 000 and working from treatment recommended centres rather than from primary or secondary Minimal-contact self-help Occasional professional care. He envisaged that these would train under the contact tutelage of clinical psychologists and that they would Guided self-help (a form Professional help from a have suitable background training in social work, of minimal-contact PCGMHW along with psychiatric nursing and so on. Each centre, he envi- self-help) bibliotherapy saged, would serve a population of 250 000, with about 20 therapists in each. However, if these ambi- tious developments do not materialize or do not live common disorders like depression and anxiety, but up to expectations, there will continue to be a role for these are limited in number and some have methodo- various forms of self-help and guided self-help. logical problems. The majority are based on cognitive One form of self-help that is widely and readily approaches and the focus has been on the short-term accessible and available to anybody who wants it is clinical effectiveness rather than on the long-term bibliotherapy. This self-help intervention has been in impact, and none have considered cost effectiveness. use since the 1990s when a study of 500 American A systematic review [18] of eight studies of self-help mental health professionals found that 70% for anxiety and depressive disorder in primary care ‘prescribed’ a book between the face-to-face sessions found that, while most identiﬁed some beneﬁts from and that 86% reported this to be beneﬁcial to their self-help, the studies were methodologically limited patients. It is deﬁned as the reading of self-help or and recommended further research. related material so as to speed up recovery. The involvement of PCGMHWs in guided self-help However, a bewildering plethora of terminologies received a boost when the National Institute for have developed around bibliotherapy that includes Clinical Excellence (NICE) Guidelines [19] on the standalone, adjunctive, minimal contact, guided, pre- management of depression recommended their use as dominantly self-help and self-administered self-help part of a ‘stepped care’ model. Stepped care is a form (see Table 33.1). These seemingly trivial distinctions of health care delivery that has two components, the are important when examining the beneﬁts or other- ﬁrst being that it is least restrictive in terms of incon- wise of various studies, since there are likely to be venience, cost to the patient and therapist time. The differences between the various categories, just as second element is that it is self-correcting [20]; in there are differences between antidepressant thera- other words, if the basic intervention is unsuccessful pies. Being mindful of these distinctions is important then the therapist will identify this and recommend because, unsurprisingly, there is a suggestion that more complex traditional treatments. therapies involving some professional contact are How well does guided self-help work? Such a model superior to pure self-help [17]. has intuitive appeal and some meta-analyses have The vast array of self-help books available for a found a large effect size [21]. However, many of these range of psychiatric conditions presents a challenge studies were carried out on nonclinical popula- for doctors, especially general practitioners. Studies tions [22], often recruited through newspaper adver- of self-help approaches have been carried out for the tisements, so the populations towhom the interventions

SOCIAL MANAGEMENT OF COMMON MENTAL DISORDERS 443 were delivered may bevery different from those seen in receiving the intervention showed satisfactory adher- clinical practice. A recent study [23] attempted to ence to, and reported satisfaction with, the treatment. address this by selecting a population referred from However, at three-month post-treatment follow-up primary care with a diagnosis of depression and/or there was no beneﬁt from the intervention in terms of anxiety. The aim was to explore whether guided self- the outcome measures such as anxiety or depression help delivered by a paraprofessional similar to the scores. Social function did improve although the PCGMHW provided additional beneﬁts for those who authors were unable to interpret this ﬁnding since were randomized to this intervention over and above it did not come about through symptom reduction. being on a waiting list for a psychological intervention. Overall the results were reported as demonstrating no In total, 114 individuals were randomized, and those beneﬁt from guided self-help. 33.5 PSYCHOEDUCATION Considering our deﬁnition of social interventions it mation. The workshops, using cognitive techniques, can be argued that casting a net widely into the general were run by two clinical psychologists and two assis- population so as to ‘catch’ the few (or many, depend- tants. Those wishing to participate were assigned to ing our one’s perspective) who have common mental the intervention group or to the waiting list control disorders is also a form of social intervention. An group. Even allowing for an attrition rate of 33%, the example of this is the development of easily accessible results were positive and at three-month follow-up psychoeducational workshops that would provide indicated a signiﬁcant reduction in General Health psychological interventions for those who previously Questionnaire (GHQ) and Beck Depression Inventory might not have consulted their primary care physi- (BDI) scores and an increase in self-esteem scores cians or, if they had, might not have been offered compared with the waiting list controls. Overall, 45% psychological interventions due to service limitations. of the experimental group, compared with 8% of the These have been outlined in a number of studies control group, improved. described below. Typically, these workshops focused However, several questions are raised by popula- on ‘stress’ and on ‘depression’. The former were tion-based psychoeducation interventions such as successful [24] and well attended, appearing to reach those described above: a group who had not consulted their doctors with these problems previously. They were also associated with a 1. Do these interventions capture thosewho needtreat- reduction in symptoms and so were deemed, overall, ment in the ﬁrst instance, that is thosewhose distress to be effective. On the other hand, the workshops on is excessive or whose functioning is impaired? depression [25] were poorly attended and many of those who participated had already been referred to 2. If these interventions reach those needing treat- specialist services. Accordingly the focus changed ment, does it reach those who otherwise would and a workshop entitled ‘How to improve your self- remain untreated? conﬁdence’ was initiated [26]. These typically lasted one day and thosewith stress- 3. Among those receiving treatment, is the impact related problems were invited to attend free of charge. sustained beyond three months so that additional They were widely advertised in leisure centres, treatment from general practitioners or from sec- libraries, community centres and so on, and catered ondary services are unnecessary? for up to 25 people. So as to avoid stigmatization and overcome the reluctance of many to seek help, they The ﬁrst question is difﬁcult to answer since diag- were held in a public facility such as a leisure centre. noses were not made and all who wished were invited No exclusion criteria were applied and a telephone to attend. In addition, the instruments used, i.e. the number was provided for those wanting further infor- BDI and GHQ, are not diagnostic, but screens and

444 SOCIAL INTERVENTIONS measures of severity, so it is possible that the group A more modest variant of this was a study [27] was a diagnostically heterogenous one of varying that compared group psychoeducation with one-to- symptom severity, ranging from those with distress one problem-solving therapy and with treatment as due to acute or long-standing life stressors to those usual using a sample identiﬁed as depressed from with major depression and generalized anxiety. That the general population. Diagnosis was made using a said, three-quarters of the participants scored as prob- two-stage screening method. Since participants were able cases on the GHQ, suggesting that at least a identiﬁed in a structured manner, the population proportion may have needed treatment. The second is offered the intervention was more diagnostically partly answered by the data from this study in that it homogeneous than in the studies cited above. The showed that 39% had not attended their general results showed that group psychoeducation and one- practitioners with these symptoms, but no data on the to-one intervention reduced the proportion who were level of intervention offered to those who did consult depressed by 14 and 17%, respectively, compared were presented, so the real level of need may be with treatment as usual. These differences, observed underestimated. Finally, the follow-up period of only at six months, were not maintained at one-year follow- three months meant that whether the improvement up. Moreover, the one-to-one intervention was more was sustained and therefore reduced the need for acceptable than the group intervention with 63 and treatment from other sources could not be measured. 44%, respectively, completing treatment. 33.6 INTERNET-BASED INTERVENTIONS While computer-based interventions have been avail- cognitive-behavioural principles. Structured inter- able for some years, the use of the internet as a views often accompany the trial. A concern is the resource is relatively recent, and although widely level of control over the websites, and obviously those available, is still not universal, particularly for some that are fully open have little control applied and so groups of patients such as the elderly or those who can be used for pure self-help, although in trials, sites have ﬁnancial or other social problems. However, the are generally password-protected, allowing some con- growing interest in internet-based treatments and their trol of the material that is used. In addition, concerns potential for reaching large numbers warrants their about side effects have been voiced, which include inclusion in this chapter. So far, studies are few in fears that internet interventions may increase nonre- number and have small sample sizes. Four therapeutic sponse rates to subsequent live treatments. strategies have been identiﬁed as follows: Studies have been carried out on those with panic disorder, social anxiety disorder and post-traumatic . Pure self-help. symptoms, and while they are few in number and have small sample sizes, results were most promising . Predominantly self-help – a therapist explains the in the treatment of panic disorder. At the time of rationale and teaches how to use the tool. writing two studies of internet interventions for the treatment of depression were identiﬁed and the . Minimal-contact therapy – active involvement of a results of both were positive, with high completion therapist but less than in traditional therapy, e.g. by rates. The reader is referred to recent comprehensive email. reviews [28,29] on this topic, with both sounding notes of cautious optimism and calling for further . Predominantly therapist-administered but in con- research in efﬁcacy, effectiveness and cost effective- junction with self-help material. ness. A recent initiative has been the development of web-based problem-solving techniques for those with Most of the studies have utilized minimal-contact depressive, anxiety or work stress symptoms. The therapy, and the approach is invariably based on study [30] included 213 subjects recruited through

SOCIAL MANAGEMENT OF COMMON MENTAL DISORDERS 445 the mass media who were randomized to the four- less pronounced in those with work-related stress and week minimal-contact therapy or to a waiting list more pronounced in those with greater severity of control group. Anxiety, depression and quality of life symptoms at baseline. Clearly studies such as this improved in all active treatment groups, but this was need to be replicated. 33.7 RESILIENCE ENHANCING AS TREATMENT It is manifestly true that life’s stressors cannot be esteem, positive affect and self-leadership, and lower predicted, and for this reason there is little optimism scores on depression and stress scores. The ﬁndings that psychiatric illnesses induced by these, such as suggest that resilience-enhancing techniques may be adjustment disorder and depressive illness, can be useful as part of stress management and/or stress prevented. An alternative perspective is that the man- prevention programmes. ner of dealing with these stressors is what determines Social supports are among the most widely studied the appropriateness or pathology of the response. elements of resilience, and their presence has been Hence there is a growing interest in resilience and on linked to protection against depression and to reduced ways in which this can be harnessed so as to prevent or functional impairment, as well as to improved out- reduce the impact of adversity on the individual. come with treatment. On the other hand, social iso- Resilience is deﬁned as the ability to bounce back to lation and low levels of social support have been one’s original level of emotional well-being after linked to an increased risk of a multiplicity of dis- encountering difﬁculties, negative events, hard times orders, in particular depression, stress, post-traumatic or adversity [31]. Several psychosocial factors have stress disorder, dysthymia and adverse emotional been identiﬁed as facilitating resilience, including a reactions to physical illness. sense of self-esteem, patience and cognitive ﬂexibil- While there is a signiﬁcant volume of research on ity, curiosity, humour in the face of difﬁculties, reli- the relationship between social supports and distress gious (or spiritual and altruistic) activities, social or depression, these studies have mainly been carried supports (including role models and mentors), active out on selected populations, such as those with serious coping (exercise and training) and a belief that pro- physical illness or who have been diagnosed with blems can be solved [32]. Some of these, such as active depression. Most are cross-sectional in design, thus coping and religious practice, lie in the domain of only allowing for the evaluation of associations rather prevention and will not be considered further here. than for examination of potential causal relationships. Enhancing resilience is increasingly seen as having More recent studies that have addressed these potential among those at risk for or experiencing methodological concerns have conﬁrmed the stress- common mental disorders. Therefore, approaches that buffering effects of social support and social net- improve coping strategies, social supports and self- works, but have moved from the broad assessment esteem might reduce the likelihood of developing of social support/networks to examining the place of psychiatric disorder. One study [33] examined the speciﬁc types of support in buffering (modifying the effect on stress-related symptoms of resilience train- impact of) speciﬁc stressors. One such study [34] ing in two four-hour sessions of resilience enhance- found that work-related stress was buffered speciﬁ- ment. The target population was university students, cally by the number of neighbours with whom the randomly assigned to either the intervention group or respondants had frequent contact, while the effects waiting list control. The results, comparing the pre- of chronic stress, indicated by receiving disability and post- intervention scores on a number of mea- allowance, were buffered by having a high number sures, indicated that the intervention group had higher of neighbours and receiving instrumental support. resilience scores, enhanced coping skills in areas such Linked to social supports is the question of volun- as problem solving and reduced avoidance behaviour, teer befriending of those with depression. There are higher scores on protective factors such as self- several reasons why this, rather than other forms of

446 SOCIAL INTERVENTIONS social support, might have a superior impact on out- considered. Positive events and ‘difﬁculty reducing’ come. There is the knowledge that somebody strategies have been termed ‘fresh start experiences’, cares enough to visit voluntarily and without being and these putative contributors to remission in chronic paid. There is also the ﬂexibility of visiting times depression along with befrienders have been incorpo- and locations; ﬁnally, the mutual disclosure of friend- rated into a more substantial investigation of their ship and even the sharing of difﬁculties might enhance roles relative to each other. This study [36], an exten- self-worth and self-conﬁdence. This was examined sion of the earlier one [35], clearly identiﬁed fresh in a randomized controlled trial of chronically start experiences as the key predictors of remission depressed women [35] and while longer duration of (odds ratio 6.92) and while befriending continued to befriending was associated with greater remission play a role (odds ratio 4.09) it was less prominent than rates (up to 76%) those who only saw a social worker other variables such as attachment type and the but not the volunteer also did well, with a 70% absence of any further negative events. Whether remission rate compared with a 39% remission rate depressive symptoms in this context are always indi- in the control group. However, the sample size was cative of depressive episodes or whether they are best small, with 43 in each group, and there was no control regarded as adjustment disorders [37] is an interesting for possible confounders or for the effects of other and important question that is outside the scope of this simultaneous interventions as the analysis of data was chapter, although there is a case for including adjust- bivariate. ment disorders among the common mental disorders, If life events have the capacity to trigger depressive particularly in the context of social interventions, episodes, then the possibility that subsequent events notwithstanding the paucity of research in this area. that are positive or aids that assist in coping with For a more detailed exposition on social support the negative events will reduce symptom severity must be reader is referred to Chapter 35. 33.8 CONCLUSION The evidence base for social therapies on their own 4. Myers, J. K., Weissman, M. M., Tischler, G. L. et al. is limited and could be described as ‘soft’. While (1984) Six-month prevalence of psychiatric disorders in various interventions such as family therapy, internet three communities. Archives of General Psychiatry, 41, treatments and bibliotherapy, as well as aspects 971–982. of resilience-enhancing interventions, provide some 5. Kessler, R., Berglund, P., Demler, O. et al. (2003) The evidence of efﬁcacy and effectiveness, further epidemiology of major depressive disorder: results from thenationalcomorbiditysurveyreplicationstudy.Journal studies and where possible systematic reviews are of the American Medical Association, 289, 3094–3105. required. 6. Weissman, M. M., Bland, R. C., Canino, G. J. et al. (1996) Cross-national epidemiology of major depres- sion and bipolar disorder. Journal of the American REFERENCES Medical Association, 276 (4), 293–299. 7. Jenkins, R., Lweis, G., Bebbington, P. et al. (1997) 1. Paton, J., Jenkins, R. and Scott, J. (2001) Collective The National Psychiatric Morbidity surveys of Great approaches for the control of depression in England. Britain – initial ﬁndings from the household survey. Social Psychiatry and Psychiatric Epidemiology, 36, Psychological Medicine, 27, 775–789. 423–428. 8. Ayuso-Matoes, J. L., Vazquez-Barquero, J. L., Dow- 2. Department of Health (2001) Making It Happen: rick, C. et al. (2001) Depressive disorders in Europe: A Guide to Mental Health Promotion, TSO, London, prevalence ﬁgures from the ODIN study. British Jour- pp. 46–50. nal of Psychiatry, 179, 308–316. 3. Leff, J. P. (1993) Principles of Social Psychiatry, Black- 9. Kessler, R., Chiu, W. T., Jin, R. et al. (2006) well Scientiﬁc Publications, Oxford, pp. 3–11. The epidemiology of panic attacks, panic disorder

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34 Problem-solving therapy for people with personality disorders 1 1 Mary McMurran, Christine Maguth Nezu and Arthur M. Nezu 2 1 Department of Psychiatry, Institute of Mental Health, University of Nottingham, Nottingham, UK 2 Department of Psychology, Drexel University, Philadelphia, Pennsylvania, USA 34.1 INTRODUCTION Personality disorder is deﬁned in the Diagnostic and opment of effective treatments for people with per- Statistical Manual of Mental Disorders [1,2] as ‘an sonality disorders has the potential to reduce distress, enduring pattern of inner experience and behaviour social problems and health care costs. The impor- that deviates markedly from the expectations of the tance of this has been recognized by the UK Depart- individual’s culture, is pervasive and inﬂexible, has an ment of Health in their document, Personality Dis- onset in adolescence or early adulthood, is stable over order: No Longer a Diagnosis of Exclusion [5]. time, and leads to distress or impairment’ (p. 629). The While the existence of provision for people with personality disorders and their key characteristics are personality disorder in intensive inpatient services listed in Table 34.1. The prevalence of personality and in forensic services was acknowledged, what was disorder identiﬁed in a recent study of a representative identiﬁed as missing in many areas was a commu- sample of the UK general population, using a struc- nity-based service for people with personality dis- tured clinical interview, was 4.4% overall, with men orders. The guidance was that all Health Service more likely to have a personality disorder (5.4%) than Trusts should develop multidisciplinary, specialist women (3.4%) [3]. The prevalence of each personality personality disorder treatment teams, whose func- disorder type identiﬁed in Coid et al.’s study is pre- tions would be to develop ways of working with sented in Table 34.1. patients with personality disorder and to support People with personality disorder suffer high levels health service staff whose caseload includes people of distress, suicide, self-harm, addiction, family with personality disorder. Clearly, these specialist breakdown and social exclusion. They place a high teams require a repertoire of effective treatments for burden of cost on primary care, costing almost twice working with people with personality disorder. The as much as people without [4]. Therefore, the devel- purpose of this chapter is to describe in detail one Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

450 SOCIAL INTERVENTIONS Table 34.1 Prevalence of DSM-IV personality disorder in a UK sample [3] Personality disorder Key characteristics Prevalence (%) Cluster A 1.60 Paranoid Distrust, suspiciousness 0.70 Schizoid Socially and emotionally detached 0.80 Schizotypal Unusual perceptions, odd beliefs, socially anxious 0.06 Cluster B 1.20 Antisocial Disregards the rights of others 0.60 Borderline Unstable mood, relationships and self-image 0.70 Histrionic Excessively emotional, attention-seeking 0.00 Narcissistic Grandiose, lacks empathy, needs admiration 0.00 Cluster C 2.60 Avoidant Socially inhibited, feels inadequate, oversensitive 0.80 Dependent Clinging, submissive 0.10 Obsessive–compulsive Perfectionist, inﬂexible 1.90 Any personality disorder 4.40 Personality disorder unspeciﬁed a 5.70 a Unspeciﬁed personality disorder was where the individual met 10 or more criteria for personality disorder overall but did not meet the criteria for any speciﬁc diagnosis. particular therapy – problem-solving therapy. Before of psychosocial treatments for people with person- focusing on this therapy, however, a broader picture ality disorder will be given. 34.2 TREATMENTS FOR PEOPLE WITH PERSONALITY DISORDER In the opinion of service users, clinicians and aca- services promoted informed choice from a range of demics, treatment services for people with personality options. These multicomponent services illustrate the disorder should aim to reduce the stigma associated different levels of intervention and support that com- with the diagnosis and improve the individual’s qual- prise a holistic, supportive and client-centred service: ity of life [6]. The preferred service is one that is psychological, social and occupational interventions community-based and offers psychological interven- are all important. Psychological interventions were tions. Treatment and support may need to be offered observed to prepare people to make the best use of long-term and so it is likely that a range of therapeutic social and occupational opportunities. Speciﬁc psy- activities will be required to meet the needs of service chological interventions will be described more fully users. This is illustrated in a recent Department of next, but with due recognition of the wider provision Health project, which supported and evaluated a required for people with personality disorders. number of pilot community-based services for people with personality disorder [7]. These pilot projects provided a range of psychological and psychosocial 34.2.1 Psychological treatments interventions to help people with personality disorder improve their coping skills, social functioning and A recent systematic review of randomized controlled quality of life, and also provided assistance for service trials of psychological treatments for people with users to access a wide range of community-based personality disorders found both cognitive-beha- activities, education and employment. Rather than vioural and psychodynamic therapies to be effective impose interventions upon the client, these new for people with personality disorders [8]. This accords

PROBLEM-SOLVING THERAPY FOR PEOPLE WITH PERSONALITY DISORDERS 451 with earlier meta-analyses of treatment outcomes 18 months duration with general psychiatric treatment for personality disorders which showed a strong for people with borderline personality disorder. They 1 positive effect of treatment (Cohen’s d 0.80 to found that the treatment group became less depressed, 1.39), with both cognitive-behavioural and psycho- decreasedself-harmingbehaviours,reducedtheirdays dynamic approaches showing good effects [9,10]. in hospital and improved their social functioning, Dialectical behaviour therapy (DBT) is the most whereas the control group did not change or even widely evaluated treatment, primarily with women deteriorated. The treatment group maintained these with borderline personality disorder. DBT is based on gainsandshowedsomefurtherimprovementatfollow- the premise that the borderline personality disorder is up 18 months after treatment. typiﬁed by a failure to regulate emotions. Emotional Cognitive-behavioural treatments, which modify dysregulation is understood to have developed as a maladaptive core beliefs and teach emotional and result of a biologically based emotional vulnerability interpersonal coping skills, have proven effective in in combination with an invalidating environment, reducing obsessive and avoidant beliefs in those with which is one where the child’s private experiences avoidant personality disorder [20], improving emo- are denied, contradicted or punished by signiﬁcant tion control in those with borderline personality dis- others [11,12]. A combination of group and individual order [21] and improving social functioning [22]. therapies, over a period of around a year, focus on Contingency management has enabled the transfer of enhancing motivation to engage, building self-accep- drug abusers with antisocial personality disorder into tance, developing distress tolerance, teaching skills routine care [23]. Psychoeducation, along with phar- for emotion regulation and improving interpersonal macological interventions, reduced relapse rates in effectiveness. Positive effects in randomized con- groups of people with any personality disorder [24]. trolled trials have been to reduce self-harming beha- One randomized controlled trial that appeared in viours, reduce substance use and improve global the literature too late to appear in Duggan et al.’s [8] adjustment [13–15]. Furthermore, those in DBT are systematic review was combined psychoeducation signiﬁcantly more likely to remain in treatment com- plus a brief problem-solving therapy called Stop & pared with those in treatment as usual [15]. One Think! This intervention was effective in improving important aspect of DBT concerns its focus on social functioning and anger control in community ongoing peer supervision and support for DBT thera- adults with any personality disorder [25]. Since there pists [11]. For therapists working with persons diag- is evidence that problem-solving therapy is effective nosed with personality disorder, it can be frustrating for people with personality disorder, our focus will and disappointing frequently to confront patterns of now turn to describing this intervention in more depth extreme emotional instability, suicidal and aggressive and describing its adaptation for this particular client therapy-interfering behaviours, and volatile reactions group. This is not to imply that problem-solving to the therapist [11]. therapy is superior to any other therapy – it is simply In groups of people with any personality disorder, one evidence-based therapy that clinicians may psychodynamicinterventionshaveeffectivelyreduced choose to offer and clients may choose to receive. depression and improved quality of life [16], and also However, problem-solving therapy does have the reduced symptoms and target complaints [17]. Bate- potential to be offered widely in community mental manandFonagy[18,19]comparedpsychoanalytically health services, and thus it is of high relevance to oriented psychotherapy with partial hospitalization of readers of this book. 1 Cohen’s d is an effect size statistic calculated by subtracting the post-treatment mean from the pre-treatment mean and dividing by the pooled standard deviations. An effect size of .20 is considered small, .50 medium, and .80 large.

452 SOCIAL INTERVENTIONS 34.3 PROBLEM-SOLVING THERAPY Problem-solving therapy is a cognitive-affective- nication skills, goals and values of all the persons behavioural intervention that promotes the applica- involved. Difﬁculties can arise when there are tem- tion of effective problem-solving skills to solving perament clashes, goal conﬂicts or skills deﬁcits. problems in everyday living [26]. The theory and There is abundant evidence of an association practice of problem-solving therapy was originally between social problem-solving deﬁcits and psycho- outlined by D’Zurilla and Goldfried [27] and has since logical distress, physical ill-health, substance misuse, been reﬁned and revised by Thomas J. D’Zurilla, hostility and aggression, and mental health pro- Arthur M. Nezu and Christine Maguth Nezu [28–30]. blems [34–37]. Assisting people to develop better Recent meta-analyses of problem-solving therapy social problem-solving skills can protect against these outcome studies document its effectiveness for people adverse outcomes by increasing the likelihood of with a wide range of mental and physical health achieving an effective solution to life’s problems. An problems [31–33]. effective solution is: ‘one that achieves the problem- Our own research indicates that problem-solving solving goal (i.e. changes the situation for the better therapy is an effective intervention for people with and/or reduces the distress that it produces), while at personality disorders [25]. To set the scene, we will the same time maximizing other positive conse- begin by describing the conceptual underpinnings of quences and minimizing negative consequences ... the problem-solving therapy. We will then outline the to others as well as oneself’ ([28], p. 13). Thus, a relevance of problem-solving therapy to people with solution that disregards the welfare of other people is personality disorders. Finally, we will present evi- not an effective solution. As an example, consider a dence suggesting that problem-solving therapy can situation where, in an intimate relationship, a person help people with personality disorders to function feels jealous of his or her partner’s friendships with better. others. One solution that may reduce the unpleasant feelings of jealousy is to control the partner’s social activities through intimidation. While this may reduce 34.3.1 Social problem solving feelings of jealousy, there are obvious negative con- sequences for the partner; hence the solution cannot be Social problem solving is ‘the self-directed cognitive- deﬁned as effective. Effective solutions might include affective-behavioral process by which an individual more equitable relationship contracting and a closer attempts to identify or discover solutions to speciﬁc examination of the causes of jealous feelings. problems encountered in everyday living’ ([28], p. Empirical studies of problem-solving processes 11). The use of the descriptor ‘social’ identiﬁes this have identiﬁed two dimensions that determine pro- type of problem solving as that which is applied to the blem-solving outcomes: problem orientation and pro- wide variety of stressful problems encountered in the blem-solving style [28]. Problem orientation refers to course of everyday living [28]. Problems may be acute the individual’s personal beliefs, attitudes, emotional or chronic; they may be small daily hassles or large reactions and efﬁcacy expectations with regard to complex life problems; and they may manifest as problems in living. A positive problem orientation internal distress or conﬂict with others. While the is the tendency to appraise problems as a challenge, wider political and economic context is an important show optimism about the likelihood of solving pro- framework for understanding an individual’s pro- blems, believe that one has the ability to solve pro- blems, the focus here is on problems in living that blems, acknowledge that problem solving requires originate from the individual in interaction with his or time and effort, and attempt to cope with the problem her social environment. All interpersonal situations rather than avoid it. A negative problem orientation is are inﬂuenced by individual characteristics, such as the tendency to view problems as a threat, believe that the temperament, emotion regulation skills, commu- problems cannot be solved, doubt one’s own ability to

PROBLEM-SOLVING THERAPY FOR PEOPLE WITH PERSONALITY DISORDERS 453 solve problems and, when problems arise, to experi- appeals to common sense), supporting people in the ence frustration and signiﬁcant upset rather thanview- experience of successful problem solving (i.e. increas- ing negative emotions as a source of information. A ing the likelihood of reinforcement of the developing positive problem orientation facilitates adaptive pro- skills) and encouraging independence rather than blem-solving efforts and a negative orientation inhi- reliance on therapy (i.e. promoting self-efﬁcacy). bits problem-solving attempts. Problem-solving therapy is suited to people with Problem-solving style refers to the activities that personality disorder because the focus is on reducing people engage in when attempting to cope with pro- personal distress and improving social functioning. blems in living. Three styles have been identiﬁed, one These outcomes are considered to be of paramount being adaptive and two maladaptive. Rational pro- importance in personality treatment [6]. Furthermore, blem solving is the constructive problem-solving style social dysfunction has been empirically identiﬁed in that involves the systematic application of those skills several studies as an integral component of personality that enhance the likelihood of discovering an effective disorder [39–41]; hence the emphasis on social func- solution or coping response. These skills are deﬁning tioning that underpins problem-solving therapy is the problem accurately, setting speciﬁc, desirable and highly relevant to the treatment of personality dis- attainable goals, generating a range of options for goal order. The aim in therapy is to help people recognize attainment, weighing up the costs and beneﬁts of each their strengths and limitations and work with these to option, developing a promising solution plan and learn new skills that will enable them to cope more evaluating the plan after it is implemented. By con- effectively with life’s problems. Problem-solving trast, an impulsivity/carelessness style is character- therapy helps clients to adopt a more realistically ized by impulsive, hurried and careless attempts at positive orientation to problem solving, cope better problem resolution, and an avoidance style is char- with the negative emotions that hinder effective pro- acterized by procrastination, passivity and overdepen- blem solving and adopt a rational problem-solving dence on others to provide solutions. Both such styles style that will lead to outcomes that improve social are dysfunctional, usually leading to unsuccessful functioning and reduce distress. problem resolution. Good social problem-solving skills consist of the ability to recognize problems when they arise and be 34.3.2 Social problem solving and realistic about their impact upon oneself, deﬁne the personality disorder problem clearly and accurately, set goals for change, produce a diversity of possible solutions, anticipate In our research, the assessment we have used is the outcomes, devise effective action plans that have Social Problem-Solving Inventory – Revised (SPSI- stepwise stages and carry out those action plans to R) [42]. The SPSI-R measures problem-solving orien- solve problems effectively. These are the skills taught tations and styles: Positive Problem Orientation in problem-solving therapy. However, problem-sol- (PPO), Negative Problem Orientation (NPO), ving skills may be learned but not applied successfully Rational Problem Solving (RPS), Impulsivity/Care- unless the individual feels optimistic about ﬁnding lessness Style (ICS) and Avoidance Style (AS). A total solutions to problems and conﬁdent in his or her Social Problem Solving (SPS) score may be calcu- ability to work towards realizing these solutions. lated from these scales. Effective social problem Therapy must work to decrease the person’s negative solving is indicated by higher scores on PPO, RPS problem orientation and develop a positive orienta- and SPS, and lower scores on NPO, ICS and AS. tion; without attention to these cognitive-emotional Using the SPSI-R, we have found that people with matters, therapy is unlikely to be effective [31,33]. personality disorders, both community adults present- Engaging peoplewith personality disorders in treat- ing for treatment and detained personality disordered ment is a major challenge [38]. The social problem- offenders, reported less desirable scores on all SPSI-R solving approach enhances engagement by offering an scales compared with a functional sample of mature accessible framework for change (i.e. the approach students (see Table 34.2). Overall, women community

454 SOCIAL INTERVENTIONS Table 34.2 Mean scores and standard deviations on the Social Problem-Solving Inventory – Revised for UK samples Personality disordered Personality Male personality community women disordered community disordered offenders Male mature SPSI-R (N ¼ 93) a men (N ¼ 80) a (N ¼ 72) b students (N ¼ 70) c Positive problem orientation 4.37 (3.69) 6.36 (4.38) 9.29 (4.63) 12.82 (4.14) Negative problem orientation 29.15 (8.16) 25.35 (8.34) 22.33 (8.65) 10.95 (6.79) Rational problem solving 19.52 (17.16) 24.20 (17.53) 29.19 (18.08) 44.78 (12.60) Impulsivity/carelessness style 21.14 (9.58) 19.64 (9.00) 23.32 (8.88) 10.97 (5.84) Avoidant style 15.38 (7.14) 14.56 (6.31) 15.25 (6.48) 8.25 (5.42) Social problem solving 6.64 (3.40) 7.92 (3.41) 8.52 (3.57) 13.39 (2.51) a Unpublished data from Huband et al.’s [25] sample. b Unpublished data from the Personality Disorder Treatment Unit, Arnold Lodge, Leicester. c Data from McMurran et al. [43]. personality disorder clients show more dysfunction Further work is necessary in examining the speciﬁc than any other group. social problem-solving strengths and weaknesses We have also examined the relationship between associated with each personality disorder type, parti- the SPSI-R social problem-solving scales and speciﬁc cularly those types that were rarely represented in the personality disorder characteristics, assessed using sample under study. However, these preliminary data dimensional scores on the International Personality tell us two things. First, people with Cluster B Disorders Examination (IPDE) [44] in 179 commu- disorders, and particularly people with borderline nity adults in treatment for personality disorder [45]. traits, are likely to beneﬁt from a focus on an impul- The prevalence of speciﬁc personality disorders in this sivity/carelessness style of problem solving. Chang sample is presented in Table 34.3, showing that those et al. [46] investigated the relationship between social presenting for treatment in the community had difﬁ- culties associated primarily with borderline and avoi- Table 34.3 Frequencies of presence and absence of dant personality disorders. diagnoses for each personality disorder (N ¼ 173; 73 men, 100 women) [45] None of the SPSI-R scales predicted Cluster A personality disorder characteristics. In Cluster B, the Present Absent Cluster/diagnosis impulsivity/carelessness style was the common Men Women Total Men Women Total thread, consistent with the dramatic, emotional or Cluster A erratic description of these disorders. Borderline per- Paranoid 8 11 19 51 71 122 sonality disorder scores were predicted by high ICS Schizoid 1 2 3 70 89 159 and low AS; histrionic personality disorder scores Schizotypal 1 0 1 70 97 167 were predicted by high ICS; and narcissistic person- Cluster B ality disorder scores were predicted by high ICS and Antisocial 10 9 19 59 83 142 high PPO. We expected antisocial personality disorder Borderline 23 59 82 33 27 60 scores to be associated with an impulsivity/careless- Histrionic 0 3 3 73 91 164 ness style, but this was not evident in our data. In Narcissistic 2 1 3 69 99 168 Cluster C, negative problem orientation was a com- Cluster C mon predictor of avoidant and dependent personality Avoidant 32 42 74 33 38 71 disorder scores, consistent with the anxious nature of Dependent 2 6 8 65 84 149 Obsessive– 9 10 19 46 71 117 these disorders. Avoidant personality disorder scores compulsive were also predicted by low ICS. Obsessive-compul- Not otherwise 18 17 35 55 83 138 sive personality disorder characteristics were not pre- speciﬁed dicted by any SPSI-R scale.

PROBLEM-SOLVING THERAPY FOR PEOPLE WITH PERSONALITY DISORDERS 455 problem solving and positive psychological function- actions most likely to lead to an effective solution; and ing in a student sample using the Ryff [47] measure of (6) evaluation – learning to review the degree of psychological well-being. High ICS scores were sig- success of the action plan, so that the problem-solving niﬁcantly and negatively related to several domains: process is reinforced by success and so that corrective personal growth, purpose in life, positive relations action may be taken where necessary. In Stop & with others, autonomy and self-acceptance. An impul- Think! these steps are translated into six key questions sivity/carelessness style of social problem solving is, that guide the problem-solving process in clinical therefore, important to address in therapy for people practice: (1) Feeling bad? (2) What’s my problem? with Cluster B disorders and improvements in self- (3) What do I want? (4) What are my options? (5) concept and interpersonal functioning would be What is my plan? (6) How am I doing? In Stop & expected outcomes. Second, people in Cluster C, and Think! sessions the focus is on each participant’s particularly those with avoidant traits, are likely to current concerns, aiming not only to solve existing beneﬁt from a focus on a negativeproblem orientation. problems but also to teach people the problem-solving This relates to feelings of fear, pessimism and inade- strategy. quacy when faced with life’s problems. The impor- Stop & Think! was piloted ﬁrst with personality tance of dispelling this negative cognitive-emotional disordered offenders detained in a UK regional secure orientation was evident from evaluation of our treat- unit, with consequent improvements in patients’ ment outcome data: reducing a negative problem SPSI-R scores [51,52]. In a survey of patients’ opi- orientation was the best predictor of good out- nions, Stop & Think! was viewed overall as a helpful come [48]. It is to a description of this treatment that intervention [53]. More recently, the effectiveness of we will now turn. Stop & Think! with community adults with person- ality disorder has been evaluated in a randomized controlled trial [25]. In this trial, Stop & Think! was 34.3.3 ‘Stop & think!’ a problem-solving preceded by up to four individual psychoeducation sessions. In psychoeducation, the client’s personality approach to working with people disorder diagnosis is clariﬁed and linked with the with personality disorder problems in functioning experienced by the indivi- dual [54]. This component developed from informa- One therapeutic approach to developing the skills of tion that people in treatment for personality disorder social problem solving that has been evaluated with may not have been informed of their diagnosis or have peoplewith personality disorder isStop & Think! [49]. been helped to understand how their diagnosis related Based ﬁrmly on research into social problem solving to their emotional and behavioural problems [55]. and upon soundly evaluated therapies [28,30,50], this Psychoeducation is an educative and motivational group intervention aims to teach the skills of good component that precedes problem-solving therapy social problem solving. These are: (1) problem recog- and together these components are called PEPS ther- nition – learning to recognize that negative emotions apy – psychoeducation and problem-solving therapy. are signals that a problem exists and responding to The value of PEPS therapy was then examined by negative emotions by using them to inform and pro- allocating 176 men and women with any personality ceed with a rational, problem-solving approach; (2) disorder in the community to either treatment or a problem deﬁnition – learning to deﬁne a problem waiting list control. The treated group received, on clearly and accurately; (3) goal setting – learning to average, nine Stop & Think! group sessions and a specify the desired outcomes; (4) generation of further three individual sessions, the purpose of which alternatives – learning to be creative and generate a was to support the implementation of action plans. range of possible ways to achieve the set goals; (5) Using an intention-to-treat analysis, at 6-month fol- decision-making – learning to examine the likely low-up post-treatment the treated group showed sig- positive and negative consequences to both self and niﬁcantly better functioning on the primary outcome others of each potential solution and to select those measure – the Social Functioning Questionnaire

456 SOCIAL INTERVENTIONS Table 34.4 Mean scores on psychometric tests for treatment and control groups (standard deviations in parentheses) Endpoint Measure Range Intervention N Control N Difference d SFQ 0–24 a 12.09 (4.54) 74 13.74 (3.78) 72 1.05 0.25 SPSI-R 0–20 9.62 (4.05) 75 7.12 (3.42) 70 2.09 0.56 STAXI 0–96 a 45.1 (16.5) 76 51.2 (16.5) 55 6.1 0.37 a Higher scores represent greater dysfunction. (SFQ) [56], which measures functioning in the important in four ways [58,59]. First, the intervention domains of home, work, leisure and relationships. was brief, this being more acceptable to many patients Improvement in social functioning is of key impor- than lengthier interventions, with the likelihood of tance in that this has been identiﬁed in several studies reducing drop-out and also being more acceptable to as an integral component of personality disorder (e.g. services with limited resources. Second, the interven- see Reference [39]). Treated participants also showed tion was delivered in real clinical settings; hence its better status on two secondary outcome measures –the likely effectiveness in everyday practice was indi- SPSI-R total social problem-solving score and anger cated. Third, it was offered to people with any person- expression, as measured by the State-Trait Anger ality disorder or combination of personality disorders, Expression Inventory (STAXI-2) [57]. More detail is so it was inclusive rather than exclusive. Fourth, it was presented in Table 34.4. Further analysis showed that, delivered by nonspecialist staff; hence it would be after controlling for baseline social functioning, the possible to deliver it relatively cheaply. These advan- best predictor of improvement was a positive change tages notwithstanding, there is a need for further in the SPSI-R scale, NPO [48]. investigation into the respective contributions of psy- This research shows that a relatively brief interven- choeducation and social problem-solving therapy in tion based on psychoeducation and social problem- achieving good outcomes and an examination of the solving therapy is a promising intervention for people maintenance of gains over a longer-term follow-up with personality disorders. Commentators on the ran- period. A larger, multisite randomized controlled trial domized controlled trial have identiﬁed the study as of Stop & Think! is now under way. 34.4 CONCLUSION Problem-solving therapy is one apparently effective a treatment plan that will help the client achieve the treatment approach that has potential value as one of desired treatment outcomes. The problem-solving the components within the broader range of services process leads the clinician through activities to assist that people with personality disorder require. Improv- with understanding the problem, identifying inter- ing the capability of staff to work with people with mediate and ultimate treatment goals, and evaluating personality disorders is a national priority [60]. Train- progress towards goals. This approach may have value ing, based on a Stop & Think! therapy manual [61], is for staff who feel in need of training to work with well developed. Additionally, the problem-solving people with personality disorders [62]. process can be used by clinicians as a conceptual Through future research, we hope to identify framework to assist in case formulation and the devel- speciﬁc deﬁcits in social problem solving that opment of treatment strategies [29]. Using the pro- relate to particular personality disorders, so that blem-solving approach in this way, the clinician or we can adjust our intervention better to meet the therapist has a ‘problem’, namely the difﬁculties needs of clients. This will require attention to issues presented by the client, and the ‘solution’ is to devise associated with reluctance to access and engage in

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35 Social support Traolach S. Brugha Department of Health Sciences, University of Leicester and New Academic Unit, Leicester General Hospital, Leicester, UK 35.1 INTRODUCTION There is evidence that social support is important for social support networks will be referred to, including physical and psychological health as well as for survi- environmental, social, interpersonal and cognitive val[1,2].Therehavebeenfewclinicaltrialstoevaluate techniques. More detailed background information the effects on health of enhancing personal social and guidance can be found elsewhere [3]. support networks. The need for an experimental and It is likely that deﬁciencies in social support net- evaluative approach to the topic needs to be empha- works are the result of a combination of environmen- sized.InthischapterIsetoutsomeoftherecommended tal, interpersonal and intrapersonal causes, operating principles of psychosocial management to be consid- over long periods of time [4]. Intervention is therefore, ered by practitioners and others concerned speciﬁcally perhaps, more likely to succeed where both the person with the health problems of those who suffer from and his or her social network can be considered the psychiatric disorder. Methods relevant to the topic of targets of intervention. 35.2 BROAD AND NARROW DEFINITIONS OF SUPPORT AND SUPPORT NETWORKS Social support can be deﬁned as ‘those aspects of jective components, for example conﬁding, intensity, social relationships thought to confer a beneﬁcial and reciprocity of interaction and reassurance of effect on physical and psychological health’ [5]. To worth’ that particularly merit study [5]. Thus the this must be added that it is not so much the ‘wide deﬁnition has a hypothetical status. variety of material needs that reach individuals Social support is a heterogeneous concept [6,7]; through the action of others’ that may be important, therefore speciﬁc deﬁnitions of support must be used but it is rather the ‘speciﬁc “personal” provisions of in research and in clinical practice to facilitate mea- social relationships and particularly their more sub- surement reliability [8]. Among the psychologically Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

462 SOCIAL INTERVENTIONS or psychiatrically unwell, measurement may well be these disorders although the case for this was probably contaminated by symptoms [9,10]. Social networks overstated in earlier studies [18]. Recovery from and social support appear to be inﬂuenced by a variety symptoms of anxiety and depression [19] and from of environmental and constitutional factors including, psychiatric disorder such as clinical depression is perhaps, genetically inherited temperamental charac- signiﬁcantly predicted by levels of social support teristics such as sociability [11], developmental fac- assessed prospectively [20]. It is also quite possible tors such as extreme and early social disruption and that different aspects of support are important at deprivation [12], as well as by such environmental different times and for different groups of peo- factors as ‘where you work’ [13] and who you end up ple [19,21]. For example, onset factors may differ with as your ‘life partner’, family and friends [14]. from factors that inﬂuence recovery [22]. While per- Deﬁcits in social support are associated with ceived deﬁcits in social support are particularly asso- an increased risk of developing symptoms that ciated with a negative course, it appears that other can be described as psychological dysfunction or aspects of social relationships that are not necessarily ‘neurotic’ [15]. Personality factors [16,17] are also perceived as deﬁcient have a signiﬁcant inﬂuence on likely to play a signiﬁcant part in the development of future levels of clinically signiﬁcant symptoms [21]. 35.3 THE PRINCIPLES OF PSYCHOSOCIAL MANAGEMENT Although the overall role of social factors in the their extensive social network, the therapist refusing aetiology of psychiatric disorder remains ‘unproven’, to see the patient on their own. However, both the it is now clear that deﬁcits in social support [20] person and their social environment may require and stressful life events [23] play a signiﬁcant role in exploration and modiﬁcation at the same time [25]. the aetiology and pathogenesis of clinical depression. It could be argued that giving the patient too many Their aetiological importance does not seem to be different kinds of experiences and instructions might signiﬁcantly affected by whether or not a particular lead to confusion. For example, giving a patient a episode of depression includes ‘biological social skills training package at the same time as symptoms’ [20,24]. Perhaps the most important prin- conducting an intervention at the level of that patient’s ciple to bring home to patients and their relatives is that family may leave the patient confused as to where conditions like depression are probably inﬂuenced by a exactly the problem exists. On the other hand, there is a multiplicity offactors, both physical and psychosocial, surprising lack of evidence that different treatment which when added together may lead to illness. There- methods produce detectable differences in their effects fore successful treatment will frequently depend on a in relation to depressive disorders [27,28]. This may combined physical (biological) and psychosocial well beduetocommoncomponentsofallpsychothera- approach [25]. In this regard, psychiatrists who follow pies, including the experience of a warm, positive and a social orientation often make use of a combination of supportive personal relationship [29], clearly pertinent drug treatments, psychotherapy and socioenvironmen- to the present topic. Thus there is no reason why tal ‘manipulation’ in dealing with a case that might not helping a patient to improve their sources of support otherwise yield to just one of these approaches [26]. cannot be combined with a stress management pack- Difﬁculties may arise in trying to apply both a social age. Equally, in order to ‘win over’ the patient to the and a personal approach. A traditional counselling or valueofsupportfrompeoplewhohavepreviouslybeen psychotherapeutic approach may well require that the perceived to be disinterested, a cognitive strategy that therapist and patient deal only with what the patient or challenges such negative beliefs and results in a posi- client brings to the therapy setting, never meeting tiveperception of thevalue of such an attitude may also outside it. Similarly, a strict social approach might be effective. require that the therapist meet only with the patient/ Thetreatmentstrategymustofcoursebewiththefull client and their partner, family or (very rarely indeed) consent of the patient, whose conﬁdentiality must

SOCIAL SUPPORT 463 always be fully respected. In their network therapy, werenotallowedandthatconﬁdenceswouldbebroken SpeckandRuevni[30]madeitclearfromthebeginning routinely. Whichever policy is chosen, it must be clear of sessions that secrets, conﬁdences and collusions what the policy is before sessions begin. 35.4 WHICH SOCIAL SUPPORT VARIABLES SHOULD BE CHANGED? When beginning any intervention, it helps to be clear freedom to maintain a number of supportive relation- about the problems to be worked on and the objectives ships with close relatives and good friends [19]. to be aimed for. The importance of perceived satisfac- Just being in the presence of people can be as tion with social support is common to most observa- important as sharing speciﬁc conﬁdences and other tional studies [1,19]. Thus people who complain of personal transactions. Certain individuals may not being unsupported are more likely to be psychologi- welcome a more personal interest being taken in them cally unwell concurrently and in the short-term future. by others. We do not yet know enough to be able to say Satisfaction or dissatisfaction with support presup- whether it is best to accept such people as they are or to poses a recognition that one needs support. It may well encourage more active social participation. Growing be that seeking support is in itself a bad prognostic recognition and knowledge of the autism spectrum is indicator, irrespective of whether or not it is obtained. adding to our understanding [33] of the importance of Equally, it may be argued that not being aware of its such individual differences. It would be a mistake to possible value may ‘turn off’ the supporters. think that such ‘silent company’ represents an indica- However, feeling that others are not helpful [31] tion that a minimal degree of social contact is not may well go along with being socially isolated. welcome. Indeed, there is a danger in getting con- Social integration – not relying too heavily on just cerned about silence, and in the training of social care one or two individuals at a high level of intensity – workers it is important to point out that silence is not also appears to be important. Social ties are rela- necessarily a sign of hostility or anger. Clearly, how- tively easy to ask about and would seem to be a ever, an introverted style is bound to work against much more straightforward topic for a patient to greater social integration and adaptation. Such indi- focus on. However, as we have already seen, viduals may be harbouring increasingly irrational patients with small social networks are not only concerns and fears about their role in their social less likely to recover from depression but may also world. In order to help them to develop better support be unaware of their afﬁliative needs [21]. Patients from others, such people probably should be encour- who may perhaps have found close social ties aged to make particular efforts to show others their unsatisfactory in the past may resent the suggestion appreciation for the company they are offered. that amends need to be made. Practical or instrumental support may be impor- The needs of men and of women may differ, tant but so too is equity – an equal exchange of and possibly on quite traditional, even ‘sexist’, favours [34] – and so too is the symbolic importance lines [19,21]. For example, it may be more important of ‘what giving or receiving really tells me about what to men to have ‘informal’ social contact with other the other person feels about me’. One should distin- men towhom they can relate easily, preferably outside guish between rescuing someonewho is ‘helpless’ and the competitive setting of theworkplace (or indeed the in genuine hardship, on the one hand, and, on the other home). However, some men may ﬁnd it difﬁcult to hand, doing something for someone who has the seek and make use of such opportunities for informal means to obtain what is being offered, and thus contact. Men may suffer more than women when an running the danger of fostering dependence. This can intimate social relationship such as marriage breaks be an issue for carers, including those of us with down [32]. Some women may be better off when professional responsibility for others. retaining independence in their social lives, beyond The needs of natural supporters or carers (tradition- a speciﬁcintimate relationship, thus allowing them the ally female members of the family) are increasingly

464 SOCIAL INTERVENTIONS recognized in law if not often provided for [35,36]. should not be overlooked. There are implications Often the unmet needs of carers are material, e.g. for for growth through a psychotherapeutic relation- welfare assistance, for respite care (a break from ship as much as for wider social issues of control in a chronically ill or dependent patient) or for infor- society, the workplace and the home [37]. Compe- mation and advice. However, contact with staff titiveness and dominance will often be apparent in and emotional burden are also important targets of group settings, but the competitive person may be assistance [36]. unaware of the danger of isolating himself or Issues of power and control should be monitored; herself from the support of others. Issues of control both for the patient and for the natural supporter, may also be important in high expressed emotion cooperation and freedom to choose what is wanted (EE) families. 35.5 THE NEED FOR EXPERIMENTAL STUDIES The somewhat unpredictable nature of any attempts to highly anxious primiparous mothers identiﬁed during help people by enhancing or in some way modifying a survey. The experimental treatment consisted of their support systems must be acknowledged. At least either lay or professional assistance, in the expectation two arguments can be made for conducting interven- that improvement in the treated mothers would be tion development and randomized intervention trials attributable to the therapeutic ingredient of social in which interpersonal functioning and social support support. Social support was assessed by means of the (or factors thought to buffer the effects of uncontrol- Interview Schedule for Social Interaction (ISSI), a lable adverse life events) are modiﬁed experimentally. standardized interview. The intervention cases did First, there are the difﬁculties in population-level show a signiﬁcant improvement on state and trait accurate measurement of exposure and outcome. anxiety, in contrast to the controls, but there was no Second, analysis of the effects of interventions in evidence that this was due to a change in the reported populations and communities could lead on more levels of social support. In another pioneering pre- rapidly to improvements in public health following vention intervention study, only those subjects (mid- widespread implementation. Although there con- dle aged and working class women in the community) tinues to be optimism about the future potential of who responded to ‘network stimulation’ seemed to observational research to help us better understand the beneﬁt [43,44]. interplay of environmental, genetic and developmen- Social support interventions may not work when tal inﬂuences on complex mental disorders [38], as in evaluated in clinical trials because pre-trial interven- the rest of medicine, there can be little doubt that more tion development was inadequate. Evidence of this reliable and potentially useful ﬁndings are unlikely to comes from examining unsuccessful programmes: a follow unless research efforts are also directed with at community intervention that failed to get elderly least equal determination to the use of ethically persons to improve their social support systems [45] acceptable experimental research designs. and shortcomings in developing effective postnatal Both laboratory experiments and ﬁeld trials have depression prevention interventions. To reduce risk been described. Laboratory experimental studies on factors for postnatal depression previously veriﬁed in normal volunteers have shown reduced anxiety [39] a cohort survey of 507 women in their ﬁrst preg- and enhanced performance at a problem-solving nancy [46], an existing parental-support-enhancing task [40] following a series of supportive statements manualized intervention programme was adapted for and reduced perceived stressfulness of a laboratory pregnant women at increased risk of postnatal depres- task [41] when completed in the presence of a friend. sion. Then 209 pregnant women were randomized to In the ﬁrst reported study designed to use social receive the adapted intervention ‘preparing for support to improve mental health [42] a controlled parenthood’ (PFP) antenatally [47] delivered by men- experimental intervention study was conducted on tal health professionals in secondary care. With the

SOCIAL SUPPORT 465 intention to treat analyses, assignment to PFP had no the interventions there was a signiﬁcant beneﬁcial signiﬁcant impact on the score levels of the main effect at one, four and 28 months post-intervention risk factors, including a measure of social support on depression. Explicit social support aspects of the networks [48], nor on depression at 3 months training package were described as supportive beha- postnatally [47]. A similar larger trial in the same viours by trainers, such as expressions of empathy, population provided by research therapists also failed validation of participants concerns and feelings, to beneﬁt mothers [49]. However, results [50] of a new encouragement of coping. Group exercises were also larger cluster randomized controlled trial in mothers designed to ‘provide opportunities and reinforcement following childbirth does suggest that retraining of participants’ supportive behaviours towards each health visitors in psychological approaches to post- other’ [52]. However, as the intervention contained natal symptoms of depression may enhance their many different components, this rendered less certain ability to support women and prevent later postnatal a ﬁnal inference about the treatment speciﬁcity of a depression [51]. social support effect (the other ingredients being a job A randomized controlled experiment conducted on search skill-training component and an emphasis 928 unemployed respondents in Michigan, who within the group on the anticipation of possible set- agreed to be randomized either to receive an informa- backs or barriers to job seeking, termed ‘inoculation tion pack (control group) or to participate in eight against setbacks’). It is of public health signiﬁcance 3-hour group training sessions over a two-week that a similar programme has been implemented period, was designed to prevent the development of nationally in Finland to combat the catastrophic depression and to increase reemployment levels [52]. increase in unemployment in the early 1990s that Analyses were based on ‘intention to treat’, and followed the collapse of the previously dominant although many respondents declined to participate in Soviet economy. 35.6 PERSONAL INTERVENTIONS: THE PSYCHOTHERAPEUTIC APPROACH Psychotherapeutic approaches, i.e. interventions others. IPT was developed by workers who had pre- directed at the patient rather than at supporters, can viously found that exitlife events were associated with be of several kinds. A cognitive psychotherapeutic an increased risk of depression [55]. IPT is conducted approach may be designed to alter dysfunctional in a one-to-one, psychotherapeutic setting, with timet- attitudes and beliefs about the value of close personal abled sessions, in which exploratory and interpretative relationships with others. A social skills training rather than prescriptive (as in cognitive and beha- package may be designed to overcome skills deﬁcits vioural therapies) techniques are employed. Thus it that may be restricting a patient from developing or is closely based on traditional psychotherapy, which making effective use of more supportive relationships. emphasizes the importance of the client–therapist Interpersonal psychotherapy (IPT) for depression, by relationship, or transference. The subject matter of providing the patient with a social relationship that is IPT is of particular relevance. The initial assessment safe to learn within, may also lead to enhanced skills in focuses on frequency and quality of social interaction, obtaining additional sources of support from others. personal expectations of key social relationships, These three kinds of strategies have also been dis- areas of dissatisfaction and ﬁnally on what the patient cussed in relation to helping the lonely and socially wants from each social relationship. Many of these isolated [53]. variables are covered in standard social network The example of IPT merits closer consideration. A inventories [48]. Grief and loss, disputes, changes in detailed training manual has been published [54]. By roles and deﬁcits such as loneliness are also examined. providing the patient with a social relationship that is The IPT process has been shown to overlap very safe to learn within, IPT may also lead to enhanced little in its content with cognitive psychotherapeutic skills in obtaining additional sources of support from methods [56], but there do not appear to be signiﬁcant

466 SOCIAL INTERVENTIONS differences in their relative effects on outcome [27]. In signiﬁcantly associated with time-to-index episode a report on the efﬁcacy of IPT as a maintenance onset, there was little evidence of an association treatment for recurrent depression, the process of between events experienced during maintenance therapy was studied also through ratings of audio treatment and the time to recurrence. These results taped sessions with the guidance of a Therapy Rating provide evidence that IPT may decrease the potency of Scale, which rated, for example, the therapist’s life events in provoking recurrence. exploration of the patient’s social network with The content of cognitive behavioural psychother- respect to a particular problem experienced by the apy (CBT) for depression does focus frequently on patient (such as depression) [57]. The study showed cognitions about the self, in relation to other key that when the patient and therapist were successful in persons. Classic examples of faulty cognitions are maintaining a high level of interpersonal focus, rating oneself as less able than others in the absence monthly maintenance sessions of IPT had a substan- of conﬁrmatory evidence, and, for example, thinking tial prophylactic beneﬁt. Prior analyses from the that ‘they wouldn’t be interested in me or they National Institute of Mental Health Treatment of wouldn’t like me anyway’. In an open process study Depression Collaborative Research Program also of 17 depressed and anxious patients undergoing indicated that patients’ expectancies of treatment CBT that was designed to disaggregate the interper- effectiveness and the quality of the therapeutic rela- sonal and technical effects of cognitive therapy (coun- tionship predicted clinical improvement. These data tering negative cognitions), Persons and Burns [62] were reanalysed to examine the hypothesis that the found that both changes in automatic thoughts and in link between treatment expectancies and outcome the patent’s relationship with his therapist made sig- would be mediated by patients’ contribution to the niﬁcant contributions to mood changes. Burns and alliance [58]. Among 151 patients who completed Nolen-Hoeksema [63] found that therapeutic empathy treatment, this hypothesis was supported, suggesting has a moderate-to-large causal effect on recovery from that patients who expect treatment to be effective tend depression in a group of 185 patients treated with to engage more constructively in sessions,which helps CBT. Patients of therapists who were the warmest and bring about symptom reduction [58]. most empathic improved signiﬁcantly more than the A 16-week bilingual controlled clinical trial com- patients of therapists with the lowest empathy ratings, pared a group receiving interpersonal psychotherapy when controlling for initial depression severity, home- for antepartum depression to a parenting education work compliance and other factors. An exposition of control programme [59,60]. Fifty outpatient antepar- the possible use of cognitive behavioural therapy tum women who met DSM-IV criteria for major (CBT) in addressing problems in social support has depressive disorder were randomly assigned to inter- been provided by Parry [31]. In addition to identifying personal psychotherapy or a didactic parenting educa- and challenging cognitions that may lead to support tion programme. Recovery criteriawere met in 60% of from others being devalued, unused or abused, this the women treated with interpersonal psychotherapy, form of CBT focuses speciﬁcally on teaching new according to a global clinical impression (CGI) score skills in eliciting and making use of support from of < or ¼ 2, and in 15.4% of control women. others. Interpersonal psychotherapy may also protect There is also growing evidence that assigning a one- against the risk of recurrence due to stressful life to-one depression care manager signiﬁcantly contri- events [61]. A study compared the role of life events butestoeffectiveprimarycaretreatmentofdepression. in predicting time to index episode onset under con- For example, in a notable randomized controlled trial ditions of no or variable treatment versus the role of of collaborative care management of late-life depres- life events in predicting the time to recurrence during sion intervention patients had access for up to 12 maintenance interpersonal psychotherapy. Eighty- months to a depression care manager who was super- three women with recurrent major depression parti- vised by a psychiatrist and a primary care expert and cipated in acute IPT treatment followed by 2 years of who offered education, care management and support maintenance IPT. Although severe life events were ofantidepressantmanagementbythepatient’sprimary

SOCIAL SUPPORT 467 care physician or a brief psychotherapy for depression tion patients had a 50% or greater reduction in depres- – Problem-Solving Treatment in Primary Care [64]. A sive symptoms from baseline compared with 19% of total of1801 patients aged 60years or older with major usual care participants. Intervention patients also depression (17%), dysthymic disorder (30%), or both experienced greater rates of depression treatment and (53%), were studied. At 12 months, 45% of interven- more satisfaction with depression care. 35.7 ENVIRONMENTAL INTERVENTIONS The implication of the term ‘environmental inter- system was a normal source of help and support to vention’ is that intervention should be targeted on families facing stress and challenge. He then provided others (the partner, family, wider social network, the a more elaborated formulation of social system ther- community). apy taking into account the structure of the psycho- In marital therapy, a range of interpretive and social kinship system, with different kinds of inter- prescriptive methods have been described and eval- vention depending on the level or type of system at uated [65–67]. The frequency and quality of interac- which intervention seemed to be needed. The aim of tion and attention are central issues in counselling a any therapy was to ‘achieve communication and couple with sexual dysfunction. In family therapy, congruence of goals amongst all the people with issues of control and the freedom to engage in age- whom the patient may have contact’. Thus the patient appropriate social relationships outside the family can would be better able to utilize the resources available also be key matters for discussion, acceptance and for in the system. Halevy-Martini et al. [72] emphasized change within the maturing family. that an important ﬁnal stage in network therapy is the Social network intervention has been des- shifting of the locus of control from the therapeutic cribed [30,68]. Erickson’s paper [68] is a useful source team to the network itself. of additional reference material, helpfully discussed. Group psychotherapy [73] represents an interesting The paper by Speck and Rueveni [30] is essentially a bridge between personal and environmental appro- detailed description of the problems and the thera- aches. Closed groups, in which interaction outside peutic sessions that took place with a ‘schizophrenic therapy sessions is strongly disapproved of, clearly family’. A particularly positive aspect of this approach belong in the former category and yet are partly based may lie in the more positive expectations and under- on the premise that insight and learning comes best standing of the network towards the disabled indivi- through an open sharing with others and the support, dual: a truly supportive community. understanding and listening that they provide in the Others have also discussed therapy beyond the dyad groupsetting.Ontheotherhand,inopengroupsthereis or family [53,69–71]. Pattison et al. [69] argued that little or no reason to discourage the development of family therapy should extend beyond the nuclear social relationships that may have begun within the family because the extended psychosocial kinship group, provided conﬁdentiality is respected. 35.8 COMMUNITY SUPPORT SYSTEMS The use of the term ‘community’ may be misleading legislation based on developments in social policy) because the objective of such ‘support systems’, or is discussed brieﬂy in the next section. services, is to identify and solve medical, psycholo- The PCMH [74] in the United Stated promoted a gical and social problems, which are then managed at policy to foster natural support systems in the wider an individual or family level. In contrast to this, community. The topic takes us into a much more intervention with problem communities at a commu- general aspect of community and social psychiatry, nity or macro-social level (e.g. through welfare discussed elsewhere [5]. This topic is also covered in

468 SOCIAL INTERVENTIONS other chapters in this book (in particular see Chapters can bring the user into contact with a wider range of 29and 31) andwillbereferred toonly brieﬂy here.The potential companionship and mutual support. term ‘system’ is intended to denote the principle that According to Holloway (in Reference [84]), users the provision of physical, social and psychological of day care services mentioned social contact as the needs to individuals who are ill or disabled, and there- most important and valued aspect of such services for fore at risk of being unable to fend for themselves, is them. Recognizing the social dimension from the well organized, managed and coordinated. point of view of individual service users is important In order that such services or systems function but difﬁcult. Staff may identify social relationships effectively the speciﬁc medical, psychological, social that do not exist (in the view of the patient). Therefore and welfare (material) needs of patients and their patients’ own perceptions and views should be sought. carers in the community must be assessed [76–82] This is a particularly important issue where the trans- and any identiﬁed needs met. In the presence of fer of one or a group of patients to a different service clinically signiﬁcant mental illness, problems in func- facility is being decided upon. tioning that could contribute to social isolation, such More work is needed on the effectiveness of self- as an inability to initiate, form and maintain social help groups, particularly in view of their widespread interaction, lack of use of public and recreational use and popularity [85]. A number of descriptions of amenities, and observed slowness and underactivity, informal and voluntary support systems for the chroni- should be identiﬁed. Such disabilities may be reme- cally mentally ill living in the community have been died and a variety of interventions may be helpful. described by Mitchell and Birley [86], Cutler and Such interventions include social stimulation, training Beigel [87] and Shannon and Morrison [88]. in social interaction skills, guided practice in the use Support for the supporters (or carers) will include of public and recreational amenities, befriending advice, education about the illness and practical schemes [83] or a sheltered environment with appro- assistance with material and welfare problems, priate social contact (particularly where training or which may greatly relieve the burden on a carer prompting to exercise skills has failed). Support and and thus indirectly beneﬁt the patient. The interven- advice for relatives and carers is also an important tions that have been developed for the families of additional ingredient of such a support system. high EE patients with schizophrenia incorporate a The provision of services should be based on the number of these methods and have been shown to be promotion and maintenance of independence (and the of consistent beneﬁt to the patients of these families discouragement of dependence) in service users, with in clinical trials [89] (see also Chapters 9, 31 the additional advantage that attendance at a service and 32). 35.9 COMMUNITY-BASED INTERVENTIONS An attempt to appraise the effectiveness of case-level work techniques for use by social workers has been (client-centred) and community-level social care has produced by Seed [91]. been provided in a review of the social work literature Rook [53] discussed ways in which the community by Matilda Goldberg [90]. While it was possible to environment and the structure of the working envir- identify an example of a case-level evaluation that onment could be modiﬁed so as to enhance and showed measurable improvements in outcome for facilitate more social interaction for the lonely. Simi- identiﬁable individuals (community survival), it larly, ‘unintentional network building’ can follow proved more difﬁcult to ﬁnd such evidence in from projects that give people who are isolated in the community-oriented practice, although the latter may community a task that can only be carried out by have the advantage of inﬂuencing earlier referral of cooperation, sharing and thus meeting in the form of individuals at risk (presumably an analogue of popu- new social groups, as in groups with charitable and lation screening). A guide to the application of net- voluntary tasks.

SOCIAL SUPPORT 469 The role of the ‘community worker’ acting in a implemented in the present decade in some govern- speciﬁc neighbourhood (or a cluster of physically ment-funded Sure Start programmes [96]. related residential units) is discussed by Parry [92], Heller [71] argued that certain social contexts and who also contrasts such formal interventions with the community structures may enhance support, giving potential contribution to community functioning of as an example providing the unemployed paid work, ‘natural helpers’ such as bartenders and hairdressers. which may be viewed as far more ‘supportive’ than Milne and Mullin [93] reported on a successful struc- providing a ‘support group’. Enhancing individual tured training programme in which hairdressers were skills and competencies may not be of value because trained in the provision of social support to their cultural norms and adverse social conditions serve customers. The programme was evaluated experimen- to maintain undesirable behaviour. This particularly tally and its success was indicated by enhanced seems to apply to those who, because of their experimental group customers’ ratings of the per- gender, ethnic status, age or low socioeconomic ceived helpfulness of their hairdressers. Mother-to- group status, are prevented from using what would mother befriender schemes in Leicester (Homestart) otherwise be more effective interpersonal strategies. and in South London (Newpin) were described by Van This then leads to the need for research and in der Eyken and Pound et al. (in Reference [94]) and by due course social policies at the macro-community Cox et al. [95]. Aspects of this approach have been level. 35.10 THE CLINICAL APPROACH Clinical and psychosocial assessment can and should nature of his or her psychopathology may contraindi- be conducted together. Within psychiatry, our knowl- cate any signiﬁcant attempts to increase social stimu- edge of the biological, developmental and psychoso- lation (with its inevitable demands) from others. Some cial basis of psychopathological disorders makes it examples of this might include patients suffering from easier for us to adapt our style of social assessment to acute exacerbations of symptoms with a persecutory individuals who, for any of these underlying reasons, content or those with fundamental social handicaps may respond in extremely unusual ways to enquiries that greatly limit their capacity to interact with others, about their social support systems. For example, as, for example, occurs in cases of Asperger syn- symptoms such as pathological guilt, subjective retar- drome [97]. Outlined here is a procedure for eliciting dation, irritability, simple ideas of self-reference and the psychosocial variables that indicate lack of social magical thinking, which may be elements of the support during the clinical assessment of each patient. clinical picture, may signiﬁcantly affect the quality It is based on research interviewing experience with and quantity of social interaction between a patient patients and with symptom-free subjects together with and his or her social network, as well as signiﬁcantly experience gained in clinical practice. distorting the record of these events that the patient A description of the social support system can can provide. Equally, this principle may also extend to begin by adding to information already gathered other members of the network who are distressed or about the family – focusing on the location of have problems in psychological functioning. Al- members, their frequency of contact and the kinds though such clinical problems may distort the quality of transactions that occur, and then moving on to a of information obtainable concerning a patient’s sup- consideration of the strength of social relationships in port system, this in no way reduces the importance of terms of ‘felt attachment’, the ability and tendency to pursuing such information with care and attempting to conﬁde and the degree to which these qualities appear act on it in a positive way. to be reciprocated. Where the patient is married or A second important issue that must be considered, has a close sexual relationship, particular attention is in relation to possible intervention strategies, is the given to the social relationship with this partner extent to which a patient’s vulnerability to stress or the under these headings. (It may also be worthwhile to

470 SOCIAL INTERVENTIONS interview such a conﬁdant and establish whether the are not being acknowledged may also be associated illness has had a negative impact on their own sources with conﬂict. It may be easier to identify negative of support.) interaction by approaching it with questions about the The enquiry then moves out towards the wider ‘listening qualities’ of others, in addition to questions social network of close friends, neighbours and work about the extent to which others try to exert social associates (particularly if they are also regarded as control over oneself. Not surprisingly, conﬂict and a ‘friends’, ‘acquaintances’, ‘mates’, etc.). Again, it tendency for competitiveness may go hand in hand. seems useful to enquire about recent social interac- The nature of the enquiry into current social rela- tion, its nature and context, and in particular whether tionships detailed here differs from traditional social there have been planned social events involving these enquiries and ‘clinical histories’ in one important and others, which are not a necessary part of work, or perhaps obvious way: the absence of a historical and routine events in the community (e.g. church atten- biographical perspective. This emphasis on the ‘here dance). Where, as is often the case, a major signiﬁcant and now’ is not unintentional. The ﬁrst justiﬁcation for life event has occurred recently, the transmission of it is that most of the available evidence concerning information between other members of the network associations between social relationship deﬁcits and concerning such events can also be enquired about. psychiatric disorder are based on this kind of ‘present There are two elements to the enquiry about social state’ enquiry (although contextual information used support: the ﬁrst concerns itself with action taken by in rating the threat of life events would appear to be an the patient (help- and support-eliciting, where this exception, perhaps). Second, this emphasis on the seems to be appropriate) and the second concerns the ‘present state’ of social relationships frees the patient behaviour and action of others. With reference to and therapist to look at new ways of increasing the material aid (tangible support), it can be particularly number and quality of available supportive relation- revealing to enquire about the degree to which ships now and in the near future. In contrast, an transactions of this kind have actually occurred in excessive emphasis on the historical and biographical both directions (sometimes termed ‘equity’ in a background to relationships, which may inevitably dyadic social relationship). In trying to achieve a bring to light painful negative interpersonal experi- judgement about the quality of emotional support, it ences in the past, may serve to emphasize and rein- is important to ask questions that reveal something of force powerful arguments and beliefs in the patient the capacity of those involved to identify sources of that go against the possibility of change. distress, to tolerate unpleasant news and the feelings that go with it, and to empathize with the person who is distressed. A variety of both open and closed 35.10.1 Clarifying targets of intervention questions should be employed, the latter being used to focus, on the one hand, on how easy or difﬁcult it Based on this kind of information about the patient’s is for the patient to listen to someone else who has own current social network and supports and clinical something distressing to discuss and, on the other condition, it should be possible to produce a ‘social hand, to ask whether one felt that the other person formulation’ that summarizes their difﬁculties and was really listening and was interested in something possible routes for action. A clearly listed set of man- important that one wished to discuss. ageable objectives with a realistic time frame in which Examples of interaction should always be asked for. toreviewtheiroutcomeshouldberecordedatthisstage. When the questions focus on what actually happened during a recent crisis, they may reveal a great deal 35.10.2 Developing and implementing about other potentially important elements such as coping style, personality and the degree to which a plan of intervention elements of an individual’s psychopathology directly impinge on social interaction. The belief that one is A set of aims both for the patient’s social functioning not being listened to or that one’s ideas and feelings and for those in the wider social network should be

SOCIAL SUPPORT 471 recorded. Common to all such plans is the aim of sion are to a small extent less socially skilled than bringing about an improvement in the patient’s own normal controls but, interestingly, normals tend to perception of the quality of transactions with overestimate their own personal skills whereas others, particularly with those with whom it is appro- depressives tend to provide a more accurate account priate to share information about feelings, worries and of themselves in this respect [99]. Therefore it may be hopes. In addition, not only does the quality of con- unwise to emphasize the question of social interaction ﬁding social relationships appear to matter but an skills, except perhaps to reassure depressed patients extension of the range of different kinds of social that they have a tendency to be overpessimistic about relationships and their functions (sometimes referred their difﬁculties in this respect. to as multiplex relationships) should be aimed for, as It may be necessary also to intervene directly these also appear to be indicative of a better level of through others by working with a couple, the family functioning. or a primary care or occupational health-based practi- Speciﬁc methods should be set out that are designed tionersuchasa nurse.Socialisolationduetothe stigma to try to achieve these aims (bearing in mind the need of being labelled a psychiatric patient can be overcome to consider both the short-term and long-term effects by making direct links with employers, key ﬁgures in on the course of the psychiatric disturbance). The personnel departments or employee organizations. methods used will be familiar to those working in the Where these strategies are effective, they may lead ﬁeld of rehabilitation: training and skill enhancement, others in the social network to change their ideas (or monitoring of goals and making use of feedback from perhaps more speciﬁcally their own expectations) others. For thosewho do not or cannot respond to these about the patient. The adoption of a more realistic and learning strategies, sheltered social amenities and the also a less negative set of attitudes may well be use of visual and verbal reminders and cues by staff or therapeutic, as shown in the experimental work of Leff relatives should be provided, possibly on a long-term and Vaughan [100] on expressed emotion. basis. The clinician (or social worker, psychologist, occu- pational therapist, nurse) must be open to the potential 35.10.3 Evaluating and maintaining value of changing both the patient’s social perceptions outcomes and behaviour, and also to the value of modifying the behaviour and perceptions of others in the network. Information acquired initially about the social support Examples of the kind of action to be taken can range system should be rechecked regularly, possibly as from a relatively brief set of guidelines to the patient often as each meeting with the patient. This provides on how to make better use of potential social resources important information about achieving targets and in their existing network now to a more detailed series also serves to remind the patient about what they need of counselling sessions, incorporating both insight to be concentrating their own efforts on. Progress building and speciﬁc directions on social behaviour achieved will also be a source of encouragement. In and social interaction with others. Such a series of studies by Parker and Barnett [42,101] an attempt to counselling sessions will also provide the important improve social support did lead to signiﬁcant symp- opportunity both for monitoring the results of direc- tom reduction. tive advice and the possibility of modifying it, in order One should not give up just because the patient does to increase the patient’s effectiveness in transactions not seem to be reaching the psychosocial targets that with others. There may, of course, be some parallels havebeensetatthestartoftherapy.Apositiveoutcome, between this approach and that of social skills and in the absence of consistent evidence of an alteration in problem-solving training [98], although the important the supposed aetiological variable, may also be true of distinction between them lies in the way the approach cognitively based psychotherapies [27]. Perhaps an is tailored speciﬁcally to the particular social relation- intense, supportive relationship with the therapist is, ships that the patient is developing with others in their for many patients, a sufﬁcient remedy in itself, regard- network. There is evidence that patients with depres- less of what technique has been used [102].

472 SOCIAL INTERVENTIONS Clinical outcome must also be monitored. It may be establish some system, perhaps through collaboration that anybeneﬁtsof support enhancement are long term with a primary health care practitioner, for monitoring and for this and other reasons it is important to long-term clinical outcome. 35.11 CONCLUSION The nature of support and the factors that appear to 8. Brugha, T., Sturt, E., MacCarthy, B. et al. (1987) The inﬂuence it make up a complex system that involves interview measure of social relationships: the descrip- environmental as well as personal components. A dis- tion and evaluation of a survey instrumentfor assessing tinctionismadebetweenthevalueofemotionalsupport personal social resources. Social Psychiatry, 22, 123–128. provided by personal social relationships and the prac- tical support that long-term and socially disadvantaged 9. Brugha, T. (1988) Social psychiatry, in The Instru- ments of Psychiatric Research (ed. C. Thompson), psychiatric patients need from formal ‘social support John Wiley & Sons, Ltd, Chichester. systems’, which are typically community based in the 10. Brugha, T. S. (1995) Social support and psychiatric present era. The main aim of this chapter has been to disorder: overview of evidence, in Social Support discussclinicalandpsychosocialmanagement,whichis and Psychiatric Disorder: Research Findings and implicitintheworkandfunctioningofmanyclinicaland Guidelines for Clinical Practice, 1st edn (ed. T. S. social agencies of human care. Thus it aims to provide Brugha), Cambridge University Press, Cambridge, somebackgroundtotheworkofsuchservices.Theneed pp. 1–40. for evaluation of support enhancing interventions has 11. Monroe, S. M. and Steiner, S. C. (1986) Social support been emphasized throughout. and psychopathology: interrelations with pre-existing disorder, stress and personality. Journal of Abnormal Psychology, 95, 29–39. REFERENCES 12. Rutter, M. and Quinton, D. (1984) Long-term follow- up of women institutionalised in childhood: factors 1. Brugha, T. S. (1991) Support and personal relation- promoting good functioning in adult life. British ships, in Community Psychiatry: The Principles (eds Journal of Developmental Psychology, 2, 191–204. D. Bennett and H. Freeman), Churchill Livingston, 13. Repetti, R. (1987) Individual and common compo- London, pp. 115–161. nents of the social environment at work and psycho- 2. House, J. S., Landis, K. R. and Umberson, D. (1988) logical well-being. Journal of Personality and Social Social relationship and health. Science, 241, 540–545. Psychology, 52, 710–720. 3. Brugha, T. S. (1995) Social support and psychiatric 14. Cutrona, C. E. (1989) Ratings of social support by disorder: recommendations for clinical practice and adolescents and adult informants: degree of correspon- research, in Social Support and Psychiatric Disorder: dence and prediction of depressive symptoms. Journal Research Findings and Guidelines for Clinical Prac- of Personality and Social Psychology, 57, 723–730. tice, 1st edn (ed. T. S. Brugha), Cambridge University 15. Henderson, A. S., Byrne, D. G. and Duncan-Jones, P. Press, Cambridge, pp. 295–334. (1981) Neurosis and the Social Environment, Aca- 4. Brugha, T. (ed.) (1995) Social Support and Psychiatric demic Press, Sydney. Disorder: Research Findings and Guidelines for Clini- 16. Brewin, C. R., MacCarthy, B. and Furnham, A. (1989) cal Practice, Cambridge University Press, Cambridge. Social support in the face of adversity: the role 5. Brugha, T. (1988) Social support. Current Opinion in of cognitive appraisal. Journal of Research in Per- Psychiatry, 1, 206–211. sonality, 23, 354–372. 6. Cobb, S. (1976) Social support as a moderator of life 17. Brewin, C. R. (1995) Cognitive aspects of social stress. Psychosomatic Medicine, 38, 300–314. support processes, in Social Support and Psychiatric 7. Cassel, J. (1976) The contribution of the social envir- Disorder: Research Findings and Guidelines for Clin- onment to host resistance. American Journal of ical Practice, 1st edn (ed. T. S. Brugha), Cambridge Epidemiology, 104, 107–123. University Press, Cambridge, pp. 96–116.

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36 Modern social networking and mental health 2 1 Keir Jones, James Woollard and Dinesh Bhugra 3 1 South London and Maudsley NHS Foundation Trust, London, UK 2 Surrey and Borders Partnership NHS Foundation Trust, Leatherhead, UK 3 NIH Biomedical Research Centre and Institute of Psychiatry, King's College London, London, UK 36.1 INTRODUCTION Human beings are social animals, and the extent, network of people. These networks may include indi- nature and quality of interpersonal interactions are viduals known only for short periods of time, and only shaped by a range of factors, including broader social ever via telecommunication links, such as the internet. structures, cultural practices and personality. For a Social relationships can be formed and sustained with- considerable part of human history, social groups outtheneedforface-to-faceinteraction(ortheneedfor tended to be generally small and restricted to local handwritten letters, with delivery times of days and environments, simply because it was difﬁcult to travel weeks). Sustaining such long-distance relationships is long distances and move beyond the relatively narrow now possible due to the development of a range of new conﬁnes of immediate settlements. Social networks technologies, in particular mobile phones and the would, in the main, have been constructed through a internet, which allow extensive and essentially limit- web of family relations, marriage, neighbours and less national and international communication. peers. These interpersonal relationships would often The aim of this brief chapter (set alongside Chapter be long lasting and communication would, no doubt, 35, ‘Social Support’) is to discuss how and why social have been face to face. networks are changing and how this change inﬂuences With globalization (see Chapter 12) and intense our notions of social support. We also look at how migration across the globe, along with the increase in these changes in social networks inﬂuence social and communication electronically and otherwise, an indi- personal expectations, which in turn affect societies in vidual in a modern society has the option of relation- general and, more speciﬁcally, affect the mental ships with a disparate and geographically scattered health of individuals. The effects of these modern Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

478 SOCIAL INTERVENTIONS technologies, in particular internet-based social net- also be explored, along with the clinical relevance of works, on the nature of human communication will these technological changes. 36.2 WHAT HAS HAPPENED AND WHY? As social groups developed historically, societies acquaintancesirrespective oftheirlocationandactivity. were based around tight networks of family relations, In addition, the internet developed from a minor aca- friends and colleagues who shared a geographically demic, military and niche technology to a user friendly, restricted area and who lived their lives in a relatively highly prized and increasingly unavoidable communi- public arena. Hofstede (1980) classiﬁed societies cation tool across the globe, giving unprecedented either as sociocentric (also known as collectivist) or access to a variety of activities. As the general public egocentric (also known as individualistic). However, began to ‘surf the net’ in their millions, different and major technological and social advances, particu- easiermethods ofcommunicatingand sharing informa- larly over the past 5–10 years, have resulted in a tion developed, including chat rooms, user groups, web dramatic shift in the construction of society and of forums, virtual reality worlds and sites speciﬁcally social networks, particularly in the West, although no dedicated to ‘social networking’. nation is entirely immune from this change. Other Some of the most important and interesting tools factors, such as gender equality, increasing personal that have developed include: mobility with cheap car and air travel and general prosperity, have contributed to people becoming 1. Web forums, blogs, chat rooms. These are usually increasingly aspirational and mobile. They are no based around a particular theme or topic and often longer physically conﬁned to the community of their bring together users who do not know one another origin. These changes have arguably resulted, simul- but share a common interest. Instant messaging taneously and paradoxically, in more transient, pri- (IM) is a form of online communication where it is vate and atomized local communities and broader possible to talk in real timewith friends or acquain- social networks consisting of complex, diverse and tances and can both form a part of a web or chat international networks of individuals. These net- forum, a social networking site or act as an inde- works can be seen at two levels: ﬁrst at a local level pendent communication tool, such as the Microsoft where the contact may be more physical and solid Network Messenger. and face to face, and then at a cyber level where the contact may be ﬂuid, ephemeral and also anonymous. 2. Social networking sites, e.g. Facebook, MySpace, In short, with the rapid development of computer Bebo. These have grown exponentially in recent technology, a seemingly instinctive demand for new years. Most involve having a ‘proﬁle’ including a and substituting methods of maintaining social net- photograph and then a list of ‘friends’ or contacts, works has developed. with which individual proﬁles are linked. These are Avariety of options for social and cyber networking used to maintain existing friendships by keeping have exploded into the public domain, enthusiastically proﬁles updated with recent personal information adoptedbyyoungergenerations.Asthedevelopmentof and allowing the exchange of messages. Users can rail,roadsandrapidmeansoftransportchangedtheway also make new contacts through special interest people communicated with each other through the groups and use the site to advertise real-life perso- introduction of mass travel and postal contacts changed nal or work events. The recent popularity of patternsofsocialinteractioninthenineteenthcentury,so ‘Twitter’, a social messaging interface allowing the technology of the latter half of the twentieth century brief updates of daily activities in real time, makes has further transformed the structures and functions of it likely that increasingly people will keep in social networks. The development of mobile phone contact with the mundane, in the moment, activ- technologyinstantlyallowedeaseofcontactwithknown ities of friends and others. The nature, extent and

MODERN SOCIAL NETWORKING AND MENTAL HEALTH 479 quality of social support available through these be of any gender, race, age or appearance. sites is almost entirely unknown. They navigate the virtual world and interact with other users in organized social structures. 3. Virtual reality worlds and gaming, e.g. Second As well as business and educational forums, Sec- Life, World of Warcraft (WoW). These domains ond Life is being used increasingly to promote remain more niche in appeal, in that they have not charity activity, user self-help groups (including a crossed into the mainstream consciousness in the range of mental health support groups – e.g. same way that social networking sites have, but see Reference [1]) and even government-spon- they still have a devoted and growing following of sored health services attempting to access an other- millions of people worldwide and may become wise hidden adolescent population (e.g. see increasingly popular as broadband technology Reference [2]). expands. These involve a user navigating a virtual ‘world’ either with the predominant function being a range of social and business (e.g. Second Life) or Together, these three methods of communicating pro- social and gaming (e.g. WoW) opportunities. Users vide an entire new way of interacting, building and create an ‘avatar’ – an animated character that can maintaining global social networks. 36.3 WHY ARE THESE CHANGES RELEVANT TO MENTAL HEALTH? Clearly, as mental health professionals, it is expectations from therapeutic encounters, along with always important to understand the context of our ease of access to knowledge that was previously patients’ lives and difﬁculties. As social networking preciously held by professionals, have meant that the via the internet and mobile phones becomes an inte- quality of therapeutic encounters is changing. On a gral part of modern life, we must understand these more practical level, internet-based social networking structures and the strengths and difﬁculties they sites and virtual realities may provide some exciting pose in order to ensure we can give appropriate opportunities for exchanging ideas internationally, advice and exploit them for patient beneﬁt. Under- coordinating research and special interest groups, and standing the language and etiquette of online social maintaining collaborative relationships with other networking allows a professional to understand how it professionals worldwide. There is growing interest can become a risk or protective factor for mental in a range of forms of internet-based clinical practice health problems. (e.g. see Reference [3]) and, with careful preparation, Speciﬁcally, those with mental health problems it may be possible to manipulate the new media for now seek, in increasing numbers, information and patient beneﬁt. support from online resources and support networks. The discussion that follows aims to present, on the Therefore, rather than see them as a separate and one hand, some of the potential beneﬁts of internet- uncontrollable entity, we must ensure that there based social networks and, on the other, some of the are informative, accurate and safe options readily concerns that have been raised in the research litera- available. Shared experiences of their ill-health and ture and media. 36.4 INTERNET-BASED SOCIAL NETWORKS: SOME ADVANTAGES 1. Ease of staying in touch (increasing cohesion).A rather than making us more distant and disparate, it major motivating factor in the development of brings us closer together. They may allow us to mobile phones and social networking sites on the keep in contact with valued friends and family internet is to make ‘staying in touch’ easier; i.e. members more easily and for longer, at reduced

480 SOCIAL INTERVENTIONS costs. Internet-based community groups have advice [2] and an Australian charity provided become commonplace, and many real-life social chat-room-based sexual and mental health consul- and interest groups conduct their affairs through a tations [6]. The Terence Higgins Trust also website or email list. This means that people often provides anonymous advice regarding HIV and expect an immediate response to queries that in AIDS through some social networking sites. the past could have taken weeks or even months. This of course (and encroaching on discussion of 5. Information and education. Both patients and disadvantages) may be an additional source of mental health professionals have access through stress for the recipient. the internet to limitless information. This can take any form, from formal research papers right 2. Bringing disparate groups together. A further through to ‘blogs’ (a sort of internet diary) to potential advantage of modern social networking alternative or spiritual constructions of disease. methods is the ability to bring disparate groups together. These may be minority groups, patient 6. Transcending prejudice. On the internet, a person groups, special interest groups or just the socially may essentially present themselves how they wish, isolated. Millions of people round the world now usually through written text, and these interactions use the internet as a source of support, friendship, may be freer from prejudices that many may face in information and even romantic relationships. person. At one extreme, an entire ‘second’ or ‘parallel life’ can be created on the internet. The 3. Support networks/user groups. Following on from individual can be who they would wish to be, the previous point, the number of organized sup- rather than who he/she really is, thereby creating port and user groups online has exploded. From a dissonance in their identity. Social class, status, more simple website-based message boards to ethnicity, disability, sexuality may all prove to be virtual reality weekly meetings, the range and less of a barrier in any social interaction. People variety of patient/service user groups is can withhold or disclose personal information, as immense [4]. they wish. 4. Anonymity. The anonymous nature of many inter- 7. Safety. Many people feel much safer and more net interactions can be advantageous, particularly secure carrying a mobile phone. One can also argue for conditions that experience more prejudice, that sometimes being able to conduct meetings, such as mental and sexual health [5]. For example, social interactions and even dating on the internet the Spanish Health Service recently launched a may be safer than attempting to meet unknown virtual-reality-based clinic for sexual health people or possibly using more risky methods. 36.5 INTERNET-BASED SOCIAL NETWORKS: SOME CONCERNS 1. Reduction of face-to-face contact. A major sites risk infantilising the mid-twenty ﬁrst concern with modern social networking raised century mind, leaving it characterised by short repeatedly in the media is that it replaces face- attention spans, sensationalism, inability to to-face interaction. Indeed, the psychological empathise and a shaky sense of identity [8]. There effects of this are still being debated currently in is limited research addressing this point, although the media, with concerns raised that this reduction the risks of excessive use are well documen- of interpersonal time is damaging our physical and ted [1, 9]. However, meanings and implications of mental health (e.g. see Reference [7]). The UK face-to-face contact also change with an increasing Guardian newspaper quoted a ‘leading neu- use of ‘webcams’, allowing users to see one roscientist’ as saying that ‘... social network another.

MODERN SOCIAL NETWORKING AND MENTAL HEALTH 481 2. Lack of quality assurance. A further issue with children and adolescents using mobile phones and modern networking and support groups is the the internet to harass others in what could be more quality of available social support and information. covert or intense than traditional bullying. A recent For example, research has highlighted the inade- large survey of secondary school pupils conducted quacies of much of the available material within in the UK [13] suggested that between 5 and 10% the mental health ﬁeld [10]. Inappropriate advice of pupils reported being cyberbullied during the and information may lead to inadvisable actions, last school term, and that victims were less likely to e.g. stopping medication without full consultation inform others than were victims of more traditional with a specialist health professional. bullying. 3. Ease of access to dangerous or detrimental infor- 6. Addiction. There has been a growing discussion of mation. Following a similar line, it is possible to the addictive nature of virtual media, in particular access an inﬁnite amount of information and peer chat rooms, cybersexual encounters, and virtual advice, but this may include potentially very dama- worlds and interactive gaming such as Second ging advice. Particularly pertinent in mental Life or World of Warcraft (e.g. see References [1] health, this includes the large number of suicide and [14]). Concern has been raised that some sites that discuss effective methods. There have individuals use them compulsively at the expense even been a few cases where young people have of their real-life functioning. There is also grow- taken their own lives while live on a webcam [11]. ing evidence that young people with underlying mental illness are particularly vulnerable to 4. Risks associated with anonymity. The anonymous excessive or compulsive dependence on the and user-controlled internet proﬁles run the risk of internet [9, 15]. deception. The most high-proﬁle cases of this involve adults pretending to be teenagers and 7. The communication underclass. All these new ‘grooming’ other young people for sexual satisfac- computer-based technologies require a degree of tion, to obtain photographs, or even to arrange real- information technology literacy and access to the life meetings, although recent research suggests appropriate equipment. Increasing reliance by cha- this may be a relatively infrequent phenom- rities and support networks on the internet runs the enon [12]. There is also the potential risk of people risk of creating a ‘communication underclass’, i.e. posing as professionals or experts within a given individuals who for whatever reason do not have ﬁeld. the skills or ﬁnances to access such media. Some of the individuals who could most beneﬁt may no 5. Cyberbullying. The term ‘cyberbullying’ has been longer be able, or know how, to access the help they coined to describe the observed phenomena of need. 36.6 CONCLUSION In the last ten years, rapid changes in the way we working sites have important repercussions for communicate with one another have taken place. mental health in the most general sense. It is These have come about partly because of the available increasingly important for mental health profes- technology, but mainly because of a shift in local, sionals to have a basic understanding of the shifts community-based social circles to much more ato- in social networks and the mediums that are mized but global networks. available, and how they may be inﬂuencing the The advent of mobile phone and internet com- health of patients and the population at large. As munications and particularly the growth of inter- the computer-literate generation grow up, the net user forums, virtual reality and social net- importance of internet-based technologies will

482 SOCIAL INTERVENTIONS continue to increase and the effects of social 6. Hallett, J., Brown, G., Maycock, B. and Langdon, P. networks will expand ever further. (2007) Changing communities, changing spaces: the There are both major beneﬁts and challenges pre- challenges of health promotion outreach in cyberspace. sented by the new technologies and some of these have Promotion and Education, 14 (3), 150–154. been discussed in this chapter. There is, then, a whole 7. ITN News (2009) Get Off Facebook and Get a Life, programme of research needed to understand and http://uk.news.yahoo.com/4/20090220/tuk-get-off- respond to these dramatic and inexorable changes in facebook-and-get-a-life-dba1618.html. how we communicate, connect and share information. 8. The Guardian Newspaper (2009) Facebook and Bebo Whilenoonehasthepowertohaltthesedevelopments, Risk ‘Infantilising’ the Human Mind, http://www.guar- dian.co.uk/uk/2009/feb/24/social-networking-site- agreaterunderstandingofthemisvitalifmentalhealth changing-childrens-brains. professionalsaretoinﬂuencethewaytheydevelopinto 9. Yen, J. Y., Ko, C. H., Yen, C. F. et al. (2007) The the future to safeguard the health of patients and to comorbid psychiatric symptoms of internet addiction: utilize these developments in the most advantageous attention deﬁcit and hyperactivity disorder (ADHD), way to achieve clinical and professional goals. As yet depression, social phobia, and hostility. Journal of most of the perceived advantages and disadvantages Adolescent Health, 41 (1), 93–98. arehypothetical;researchinthisareais,atpresent,very 10. Nemoto, K., Tachikawa, H., Sodeyama, N. et al. (2007) thin. The long-term effect of this major population- Quality of internet information referring to mental wide shift in social networking remains to be seen. health and mental disorders in Japan. Psychiatry and Clinical Neurosciences., 61 (3), 243–248. 11. The Times (2008) Horror as Teenager Commits Suicide REFERENCES Live Online, http://www.timesonline.co.uk/tol/news/ world/us_and_americas/article5203176.ece. 1. Gorini, A., Gaggioli, A., Vigna, C. and Riva, G. (2008) 12. Ybarra, M. L. and Mitchell, K. J. (2008) How risky are A second life for eHealth: prospects for the use of 3-D social networking sites? A comparison of places online virtual worlds in clinical psychology. Journal of Med- where youth sexual solicitation and harassment occurs. ical Internet Research, 10 (3), 21. Pediatrics, 121 (2), 350–357. 2. The Guardian Newspaper (2008) Teenagers to take 13. Smith, P., Mahdavi, J., Carvalho, M. et al. (2008) embarrassing ailments to Second Life doctors, http:// Cyberbullying: its nature and impact in secondary www.guardian.co.uk/technology/2008/may/10/secon- school pupils. Journal of Child Psychology and Psy- dlife.spain. chiatry, 49 (4), 376–385. 3. Wootton, R., Yellowlees, P. and McLaren, P. (eds) 14. Southern, S. (2008) Treatment of compulsive cybersex (2003) Telepyschiatry and e-Mental Health, Royal behaviour. Psychiatric Clinics of North America, 31 Society of Medicine Press, London. (4), 697–712. 4. Grohol, J. (2004) The Insider’s Guide to Mental Health 15. Ha, J.H., Kim, S.Y., Bae, S.C. et al. (2007) Depression Resources Online, The Guilford Press, New York. and internet addiction in adolescents. Psychopathol- 5. Leach,L.S.,Christensen,H.,Grifﬁths,K.M.etal.(2007) ogy, 40 (6), 424–430. Websites as a mode of delivering mental health informa- 16. Hofstede, G., (1980) Culture’s Consequences: Inter- tion: perceptions from the Australian public. Social Psy- national Differences in Work Related Value. Newbury chiatry and Psychiatric Epidemiology, 42 (2), 167–172. Park, CA: Sage.

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