Friendship: The forgotten relationship in the rehabilitation environment

You are a 19-year-old male who works as an apprentice carpenter and shares a house in a regional town with a couple of friends. You go to work during the week and spend time with your friends after work and on weekends. You have a strong group of friends that share sporting pursuits, go to the football and share the odd drink or two. One day you are involved in a serious car accident. You have been transported by air ambulance to intensive care at a major metropolitan hospital. The doctors tell you that you have a complete C6 spinal cord injury and an acquired brain injury. From intensive care you are moved to a rehabilitation unit where you live for the next eight months of your life as you try to recover the best you can from your injuries. Your parents have taken extended leave from their work and have rented a house in the city so that they can be with you every day and participate in your rehabilitation. But what about your friends? Your friends are the people who you spent most of your spare time with but how often can they see you when they are 200 kilometres away? What happens to those friendships? Are they invited to be a part of your rehabilitation? How will they react to you when you return home? Can things return

to the way they were? How are your friends dealing with your injury? Who is providing support to them? Do they even understand your injury?
There is an increasing awareness that traumatic injury has ramifications beyond the individual who is injured. Physical, social and psychological consequences exist for the injured person, their family, friends and the communities in which they live yet there remains a paucity of research investigating the changes that occur in relationships, the implications of injury for relationships and the post-injury processes associated with relationships [1].
Friendships, in particular, remain largely unexplored by all health and welfare professionals [2], including rehabilitation providers in clinical settings and rehabilitation researchers. Little is known about how people with traumatic injury and associated disability perceive the changes that occur over time in their social network and how these changes affect their ability to participate in their communities [3].

fRIenDShIP IS UnIQUe
In the context of social support, friendship offers something unique because, unlike other relationships, it is not task-specific or based on formal attachments [4]. Rather, it exists solely on its own merits and for its own purpose [5]. Friendship has been viewed as one of the most important of all relationships because friends help us understand the purpose of life [6]. Indeed, having friends is considered to be a normal and desirable part of life [7].
Despite the multiple and varied definitions of friend, the voluntary nature of the friendship bond appears to be a common component [5,7,8]. Indeed, psychologists and sociologists have identified a number of qualities that characterize friendships and differentiate them from other types of social relationships. These include interaction over time, reciprocity, exchange of positive affective behaviors, and well-developed negotiation and conflict resolution strategies [9]. Friendships are differentiated from family and other formal relationships because friendship implies equality and voluntary association. Close supportive friendships are more likely to cause individuals to feel valued as a person whereas support from family members may be viewed as obligatory and taken for granted. Friendship, thus, is an informal and voluntary relationship [10]. Having a friend or friends, therefore, says something about the individual as a person because that person has been chosen from amongst others as special.
The current body of evidence about friendships suggests that friendship patterns and the needs of people vary across the life cycle [11,12]. While significant literature exists on friendships during childhood and adolescence and there is an emerging literature on friendships during later life, Adams et al. [13] concluded that we know relatively little about the nature of adult friendships. While there is a lack of stability in friendships over the course of an entire life, it is likely that friendships show significant change over the short-term, particularly following significant life change (e.g., illness, disability or divorce). It is reasonable to hypothesize that any significant life event may present potential challenges to the friendship because there is no filial or cultural obligation associated with the bonds in that relationship.

fRIenDShIP followIng InJURY
Although easily taken for granted, the importance of friendship is clearest to those who lack friendships in their lives [14]. Stable and rewarding interpersonal relationships are potentially the single most important factor influencing a person's quality of life [15,16] yet these significant relationships are rare or absent for many people with disability [17]. Kozloff followed 14 adult patients with acquired brain injury, finding decreased social relationships and increased feelings of isolation over time [18]. She suggested a decrease in the number of friends and the frequency of contact with those friends inevitably leads to social isolation [18].
Changes, both positive and negative, in friendships and relationships have been reported consequences of spinal cord injury (SCI) [19]. As a result of sustaining a SCI, most individuals reported a substantial decrease in social interactions with friends [20]. Chan [21] reported that often persons with SCI experienced dissatisfaction with and declines in social role functioning and activities. There was a change in the structure of their friendship network from people without disability to mostly people with disability. Chan proposed several potential explanations for these changes in friendship, namely a lack of motivation from the person with SCI, isolation from the general public, exclusion from social gatherings, and rejection from friends. They were 'isolated from the 'real' world or forced into the 'disabled' population'. Furthermore, involvement in activities where friendships are typically fostered has also been shown to significantly decrease following SCI [22].
The focus on supporting existing interpersonal relationships such as friendships has received much less attention in the published literature than that of peer support following injury. Anecdotally, Gill [23] described how changes emerged between friends who had interests and activities they enjoyed together prior to the injury. After injury, they often struggled to identify anything in common. This phenomenon within interpersonal relationships can take on different forms: 1) the injured person's acceptance or rejection of such relationships, or 2) the friend's acceptance or rejection [23]. Friendships are voluntary and it is unknown, especially in the context of hospitalization, whether the expectations that are held of friends are lower. There is a paucity of research that informs this topic.
Friendship patterns have been found to be strongly influenced by a range of structural and contextual contexts including the sociopolitical, interpersonal and geographical environment [24,25]. Perceived equity in friendship maintenance behaviors as well as factors such as positivity, supportiveness, openness and interaction have been identified as key considerations [24,26]. Deterioration of the relationship between friends is likely to occur in situations where there are changes in personality, distracting life events, conflicting expectations of friendship, variable life circumstances and perceived betrayal [27]. Furthermore, Sias et al. [28] proposed that avoidance of discussion about important topics is characteristic of the friendship deterioration process. When considering this literature and extrapolating to the contexts of people hospitalized following injury, it becomes clear that these factors involved in friendship maintenance and deterioration may be particularly relevant. Extended periods of separation from friends and dramatic personal changes for the injured person may mean that the injured individual has difficulty exhibiting reciprocal maintenance behaviors and is contextually exposed to factors that may heighten the risk of friendship deterioration.
Indeed the rehabilitation and service system may perhaps be the most important context to consider in its impact on friendships as it is usually unfamiliar to both individuals and has not previously been encountered within their friendship. Friendships and relationships are affected by the ways in which the health, rehabilitation and human services systems interact with their dayto-day functioning. Subsequently, the entire context of the rehabilitation process and the person's unique environment must be taken into account. Although the impact of the service system has often been discussed and researched at a macro level (e.g., policy implications for empowerment, philosophical underpinnings on outcomes), closer examination of the various day to day www.edoriumjournals.com/ej/dr Kendall 14 routines of these contexts have been less forthcoming but will be integral to any examination of friendship following disability.
Despite the important role of families in the rehabilitation process for individuals with disabilities, it is argued that friends play a different but equally important role, yet are rarely included in the rehabilitation process. Friendship may be one of the most challenging frontiers remaining in rehabilitation confronting healthcare professionals. Healthcare and rehabilitation professionals are mandated to achieve person-centredness in service provision, addressing the person's specific and holistic situations including their friendships. Clearly, a greater understanding is needed of the challenges facing friendships and the ways in which we can, as rehabilitation professionals, enhance the maintenance and growth of friendships through and beyond rehabilitation after injury.