THE SOCIAL SUPPORT NETWORK FOR BLACK PSYCHIATRIC INPATIENTS

A survey was carried out o f almost 50% o f Black inpatients in a state psychiatric hospital to evaluate the level o f accessibility o f the family network o f the patients. Staff were interviewed on the problem s they ha\>e witJj contacting families. The sun'ey shows the extent o f inadequate access and identifies reasons for the problem. OPSOMMING ’n Opname is gedoen van 50% van die S w a r t b in n e p a s ie n te in ’n staatspsigiatriese hospitaal om die vlak van toeganklikheid van die familie-netwerk van hierdie pasiente te evalueer. Onderhoude is ook met personeel gevoer in verband met die problem e wat hulle ondervind om families te kontak. D ie opname toon d ie om van g van o n v o ld o e n d e (berukbaarheid) en identifiseer redes vir dieprobleem.


INTRODUCTION
Social support netw orks are an im portant aspect in the care, treatm ent and rehabilitation o f psychiatric inpatients (Liberman, 1988).The overriding goal o f practice is to keep the client in the comm unity and in contact with his or her existing netw ork as much as possible because o f the eroding effects o f frequent separations.
If and when hospitalisation is necessary, the c lie n t and n e tw o rk m em b ers sh o u ld be encouraged to keep in con tac t w ith one another.The psychiatric nurse should be there to ensure that the client's progress is enhanced by im proving netw ork building skills, and improving connections between the cHent's personal and p ro fe ssio n a l n e tw o rk by in v o lv in g th e fa m ily d u rin g tre a tm e n t (Ellison, 1983).

*
In this .study,a social network refers to all the people known by a person w ith whom interaction occurs.Social support network refers to all these people in the network who offer psychological support and tangible assistance.

PROBLEM STA TEM EN T
In Natal, making contact w ith the fam ily o f a b lack h o sp italized p sy c h ia tric p a tie n t is difficult in many w ays for the follow ing reasons:-1.From admission the patient may have no traceable family.Patients found w andering the streets, or those presenting them selves to the hospital or brought by escorts or police are som etimes not able to give im portant personal information due to the degree o f mental illness.
2. Patients do not receive regular visits from their next o f kin and som etim es may be discharged w ithout the staff ever meeting their next o f kin.H omes are som etimes far and the difficulties o f getting to hospital many.
3. Contacting the family by correspondence can be complex as there is often no proper address.Patients from the rural areas do not use a street name or house number when giving their addresses.If contact w ith the fam ily is so m inim al, the team can n o t a n sw er q u e stio n s about the background, prem orbid personality or cause o f illness.

SIG N IFIC AN C E OF SO C IAL SU PPO R T
A reasonable am ount o f tested evidence points to the positive relationship betw een social support and mental health (M ullis and Beyers, 1987).This relationship is explained by three schools o f thought.
The first school explains support as having a direct effect on mental health.W ell-being is seen to be the result o f strong social support in flu e n c in g a n d e n h a n c in g g ro w th and developm ent and reducing social isolation (Litwin and A uslander, 1990).The strength of this view is in the preventative aspect.Stress has been found to have a harmful effect on people and social support networks seem to protect them, im prove on w ell-being and their level o f adjustm ent to stressful situations such as illness (Prim om o, 1990). T

S lU D Y DESIGN
A survey w as done in a psychiatric hospital situated in an urban area in the Natal M idlands.
The study w as carried out by the researcher alone over 5 days in September 1991.

Patients
The research sample w as drawn from the total hospital population o f 381 patients cared for in 13 wards.O f this population 48,5% were stra tifie d a c c o rd in g to g e n d e r and then ra n d o m ly se le c te d and th u s the sa m p le consisted o f 128 males and 57 females.In one ward w here the numbers were very low, all patients were included despite the gender ratio not being correct.

STAFF
All the psychiatric professional nurses in charge of the thi rteen wards, the psychiatric community professional nurses and the three hospital social workers were included in the survey.

Patients
A study of hospi tal records was used to col lect data on age, sex, marital status, next of kin, address, telephone number and any 'leave of absence' record.Patient interviews w ere held to obtain inform ation not available in the records.T his included information on any visits received from fam ily or significant others but such information depended on the patients' mental state.

Staff
Sem i-structured interviews w ere carried out with staff mem bers.These were used to obtain in f o r m a t io n o n a n y d i f f i c u l t i e s th e y experienced in contacting the support network and w hether attem pts have been m ade to overcom e these difficulties.The influence o f g e n d e r on accessibility o f the family is sum marised in Table 4, show ing that for 43.6% w omen o f opposed to 36,7% men, there were no obvious w ays o f comm unicati ng with patients' fam ilies.On the other hand, more women than men had the m aximum score o f 3. On testing, it w as found that access is significantly different for men than w omen (t value 7,36; significant at 5% level).

FACTORS INFLUENCING FAM ILY ACCMSS
A t-te s t o f 9 .5 3 s h o w e d a s ig n if ic a n t relatio n sh ip betw een m a r it a l s t a tu s and accessibility o f the fam ily (on a 5% level).The number o f divorced and w idow ed people is so small that it might not be an im portant finding.
The difference between single and married is mainly on levels 2 and 3 (Table 5).
The influence o f the type o f adm ission is sum m arised in

STAFF INTERVIEW RESULTS
The following factors w ere seen by nursing a n d s o c ia l w o rk s t a f f a s in f lu e n c in g accessibility o f the family.

ENVIRONM ENTAL FACTORS:
• The p atien ts' hom es w ere inaccessible because o f poor infrastructure, no proper roads o r addresses.N o house num ber, e s p e c ia lly in the rural and in fo rm a l settlement areas, was m entioned by 63% of staff interviewed.• Patients are at tim es picked up in the streets and certified by police with no information about the fam ilies available.
• T h e p e o p le e sc o rtin g p a tie n ts to the psychiatric hospital are not necessarily the relatives.T hey may be hired by the local m agistrate in the relevant residential area.

PER SO N A L FACTORS
• The degree o f mental illness o f the patient is such that he cannot give a clear history o f his illness.
• III i teracy is sti II a problem with patients not a b le to d e s c r ib e c le a r ly a p la c e o f em ploym ent or give telephone num bers of relatives.
• Social w orkers have found that patients w ithhold addresses because the hospital seem s better than home.Som e patients admitted for observation do not w ant their fam ilies to know w here they are.

S O C L \L FACTORS
• The fam ily reacts negatively to patients because o f the stigm a o f mental illness.

A C C E S S
M %  • The family gels relief when the patient is removed from home.
• Family m em bers may not be at home or away w orking when the home is visited.

OTIIER FACTORS
• Comm unity services are centered in urban areas with few facilities available in rural areas.
• There are few mental health societies.This w as specifically mentioned by the social workers.
• Hospital social workers depend on field social w orkers who usually have their own case loads w hich take precedence.
• S o c ia l w o rk e rs fall u n d e r d if fe re n t ad m in istrativ e au th o rities su ch as the province and the various homelands so liaising and coordination is difficult.

CONCLUSION AND RECOM M ENDATIONS
Poor access to patients' homes w as evident with only 32.4% of patients havinga reachable home address, only 59% o f hom es being reachable by transport and only 24.3% having telephones.
Variables such as age, sex, marital status and type o f adm ission play a role in netw ork accessibility.A higher percentage o f fem ales than males had no access, but on the other hand more fem ales scored high for accessibility than males.
More support w as given to ages bel ow 18 and above 66 years.For ages between 25 and 39 years the mean score was 0. On the w hole these adults formed a neglected group.
Single people had less support and on level 3 there w ere more married than single patients.Certified and state patients had poor support an d th e re w a s a la c k o f d e c e n tra lis e d psychiatric services.This means that patients from rural areas have to travel to urban areas for treatment.
If there is no clinic near the patients' homes, psychiatric illness may not be detected early and unnecessary hospitalisation may result.
The other finding w as the fragmentation of services w hereby it is difficult for social w orkers to refer cases to other social w orkers in the rural areas.Likewise, liaison between th e D e p a rtm e n t o f Ju s tic e , c o rre ctio n al s e rv ic e s and h ea lth se rv ic e s sh o u ld be im proved so that patients know w here and when to go.
A dm ission procedures could be bettered so that the fam ily accom panies the patient to hospital or gives full particulars to w hoever brings the patient to hospital.
Psychiatric care should be available at various health care levels with extension to the rural com m unities.Less hospitalization can be envisaged because both the patient and family have accessible health care facilities.Health education on mental health/illness should be aimed at families, so that they are able to u n d erstan d and accept their m entally ill m em ber.H ealth education is essential in forensic psychiatry so that patients and their fam ilies know their rights or w hat to do.
Comm unity psychiatric nurses and primary health care w orkers should be involved with comm unity development.The introduction o f available resources such as postal systems and clinics to the rural areas and even some urban areas will augm ent the delivery of appropriate services.

A
c c e s s ib ility o f th e fa m ily w a s ra te d according to a score o f 0-3.The patient received one mark for each o f the follow ing;--rcachable hom e address -telephone num ber -visitors from home Where none of the above factors were present the score w as 0. T his accessibility score was then correlated with different dem ographic fa c to rs to e s ta b lis h th e ir in f lu e n c e on accessibility.

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In u n d e rd e v e lo p e d a re a s , s h o p s and schools are far from homes.If shops and schools are used as residential addresses, post may be checked very seldom.• Few houses had telephones • C om m unity sta ff are afraid o f leaving govem m ent vehicles alone and w alking too far, for fear o f the vehicle being stolen • The psychiatric institution itself is far from patients' homes A D M ISSIO N PR O C ED U R E

1994 Age in Years Table 1 Patient Sample According to Age and Gender
h is takes us to the seco n d view w hich suggests that social support acts as a buffering agent by m ediating and m oderating stress.
A nother group v iew s support as m eeting certain needs.It is in the presence of social su p p o rt that req u irem en ts are m et w hen certain tasks are perform ed.Support is thus given and gained in the process o f carrying out tasks(M ullis and Byers, 1987).The sam e sources o f support can affect people with different needs in a varied way.Curationis, Vol.17, No. 2,