Helping Families Affected by Depression: Incorporating Prosocial and Caregiving Literature

In this study, we use prosocial and caregiving literature to strengthen the family section of anti-depression campaigns. We suggest that the addition of the prosocial and caregiving insights bring a new perspective on depression caregiving of family members that goes beyond a mere description of the family‘s reactions and coping abilities. Built on essential components such as empathy, knowledge and skills instead of fear or anxiety, the development of a specific theoretical framework for designers of anti-depression campaigns targeting people caring for family members suffering from depression increases our understanding of family member behavior as caregivers. It provides families with a comprehensive tool that includes motivational and determining factors in one‘s will and ability to deliver appropriate help in the face of family illness. Specific recommendations for designers of social marketing campaigns are provided. In addition, we exemplify how an anti-depression campaign targeting family members of depressed people is consistent with the prosocial and caregiving literature, while waiting for a formal evaluation of the effectiveness of the model presented in this article.


Introduction
Depression is a prevailing mental illness affecting more than 350 million people worldwide (World Health Organization, 2015).It is a serious illness because it may impair one's functioning in daily tasks, productivity, relationships, and health and may even lead to suicide (Health Canada, 2009).Although depression is treatable, less than 40% of people affected by depression seek care from a specialist (Centers for Disease Control and Prevention, 2015) due to societal barriers such as stigma and self-stigma (Jorm et al., 2003) or preferences for self-help or action-oriented/user-driven strategies (Berger, Wagner, & Baker, 2005;Ellis et al., 2013;Rochlen, Whilde, & Hoyer, 2005).In the absence of a specialist's help, the family may play a key role in the recovery of depressed loved ones.Indeed, the depressed person needs help and a family member may become a caregiver by providing protection, guidance, and support and therefore assist in the loved one's recovery.The term -caregiving" refers to a broad array of behaviors designed to reduce suffering and promote recovery in a family member (Canterberry & Gillath, 2012).
Anti-depression social marketing campaigns are common (Dumesnil & Verger, 2009) and effective in raising awareness of depression and mental illness and in changing attitudes in the general population (Hui, Wong, & Fu, 2015;Livingston et al., 2013;Nousgroup, 2014;Quinn et al., 2014).These campaigns, however, generally focus on the depressed person and the general public, and seldom address the needs of family members.Only a few national campaigns (i.e., Australian beyondblue, Canadian Depression Hurts, UK Depression Alliance, New Zealand's depression.org, and US Men Get Depression) provide a section for family which includes information on how to care for a person affected by depression.Nevertheless, to our knowledge, no theoretical framework has been proposed to help design or to evaluate websites targeting family members of depressed people.Developing resources geared towards family caregivers may potentially assist in reducing the stress that family caregivers experience while caring for their loved one (Möller-Leimkühler, 2005).
There is thus a need to develop a theoretical basis for this particular targeted audience (Kelly, Jorm, & Wright, 2007;Noar, 2006).In this study, we thus focus on the person helping the family member suffering from depression and choose to use the prosocial behavior (PB) (Penner, Dovidio, Piliavin, & Schroeder, 2005) literature and the caregiving behavioral system (CBS) literature (Brown, Brown, & Preston, 2011;Canterberry & Gillath, 2012;Swain et al., 2012) to understand the process and difficulties a family member experiences while caring for a loved one in need.We choose to incorporate PB and CBS because both build upon attachment theories, explaining human motivation in first becoming, then staying involved in the caring for a loved one.We feel that this critical positive component (not based on fear or a negative emotion) was missing from the literature addressing campaign design and evaluation of campaigns targeting family members of depressed people.Through understanding the caregiving process, we can suggest effective messaging and evaluation guidelines for depression campaign components targeting family members of depressed people with the ultimate purpose of helping families better cope with this illness.

Background
Several theories have been utilized to describe the stress and coping mechanisms of caregivers notably Kreps's (1988) relational health communication competence model (Weathers, Query, & Kreps, 2010), Pearlin's model of family caregiving (Cameron et al., 2011), and several personality models (e.g., Löckenhoff et al., 2011).Behavioral and stage step theories used in caregiving contexts include the theory of planned behavior (Schuster, Kubacki, & Rundle-Thiele, 2016), the theory of reasoned action (Corcoran, 2011), and the Caregiver Behavioral System model (CBS) (Canterberry & Gillath, 2012;Swain et al., 2012).Theories used in depression contexts, including the theory of planned behavior (Hui, Wong, & Fu, 2014) and transtheoretical model of change (Levesque et al., 2011;Tsoh & Hall, 2004), describe intentions and behaviors of the depressed person.Most recently, Levit, Cismaru, & Zederayko (2016) combine transtheoretical model of change and social marketing principles in a mental e-health context and create a set of 25 detailed criteria to guide the development of anti-depression campaigns with a focus on the depressed person; the information targeting family and friends was not considered.That said, there is a dearth of studies using behavioral theories explaining caregiver motivation in caring for depressed people.For example, Jeglic et al. (2005) are among the few authors who have used the CBS model to characterize partner coping abilities to manage another's depression.Additionally, Egbert, Miraldi and Murniadi (2014) proposed the extended parallel process model, usually used in fear appeals, to understand the behavior of college students in the intervention in a friend's depression and to design health depression campaigns.The authors suggest that empathy, emotional contagion, and perceived knowledge may influence the decision-making process of intervention.They also emphasize the persuasive role of family in convincing the depressed loved one to seek professional help.

Prosocial and Caregiving Behavior
The Caregiver Behavior System (CBS) is comprised of three stages: (a) the perception of a need in another, (b) a caring motivational or feeling state, and (c) the delivery of a helping response to the individual in need (Swain, 2010;Swain, Kim, & Ho, 2011;Swain et al., 2012).From the CBS perspective, one can identify the fundamental reasons that encourage family members to help others in need of care, their initial response to the need that they have identified or perceived from their loved one, and their motivational conflicts during the entire process that includes the actual active care.

The Perception of a Need in Another
The PB literature (Latane & Darley, 1970;Penner et al., 2005) and the CBS literature (Brown, Brown, & Preston, 2011) stipulate that whether or not a person renders aid at the individual level depends upon the outcomes of a series of prior decisions that involve as a first step recognizing the situation as one requires assistance.The CBS literature further stipulates that significant individual differences exist in terms of a person's tendencies to perceive distress cues, and to understand, interpret and act upon them (Canterberry & Gillath, 2012).For example, adults who experienced quality parenting as children may express stronger compassion and altruistic behaviors toward others, being therefore more likely to help a family member in need (Swain et al., 2012).Compassion, defined as -the feeling that arises in witnessing another's suffering that motivates a subsequent desire to help‖ (Goetz, Keltner, & Simon-Thomas, 2010, pg. 2), is a psychological construct encompassing feelings of empathy (social cognitive ability), loving kindness (caring feelings), and generosity (helping actions) toward others regardless of kinship (Brown & Brown, 2006;Swain et al., 2012).Compassion therefore is a motivation to promote the well-being of others and is subserved by a general caregiving system that may operate at the family level (Brown, Brown, & Preston, 2011).
Because feeling compassion can act as a motivator for caregiving, campaign designers could use messages that encourage developing compassion for family members.There are several ways to increase compassion through training (Weng et al., 2013).Since greater altruistic behavior may emerge from understanding the suffering of other people (Weng et al., 2013), messages may increase empathy by explaining the suffering of the depressed person, stating that depression is an illness, and emphasizing that the family member's behavior is a behavior of a person who suffers.To increase loving kindness and generosity, the other two facets of compassion, the messaging should include themes that increase attachment to the person in need (Penner et al., 2005) through methods such as encouragement to retrieve positive memories with their loved one, as this may induce a sense of security and positive mood, and make the caregiver become more sensitive and responsive to the depressed person's needs (Canterberry & Gillath, 2012).This can be done through the presentation of pictures implying attachment-figure availability (e.g., a couple holding hands and gazing into each other's eyes), the presentation of the names of security-providing attachment figures or words associated with a sense of security provided by an attachment figure (e.g., love, hug, comfort), and guided imagery concerning either the availability and supportiveness of attachment figures or security-enhancing interactions (e.g., describing a time when one received comfort and support from a loved one) (Canterberry & Gillath, 2012;Mikulincer & Shaver, 2007).
Consistent with the above recommendations, beyondblue, a national Australian anti-depression campaign (www.beyondblue.org.au/) has a 44-page guide titled -The beyondblue Guide for carers -Supporting and caring for a person with anxiety and depression‖ (Beyondblue, 2016).The guide contains a multitude of useful advice on how to take care of a loved one dealing with depression while at the same time taking care of oneself.The first section titled -Caring for others‖ is consistent with some of the suggestions from the PB and CBS literature.For example, numerous pictures of happy couples or loving people as well as people talking to each other are shown in the guide, posited by CBS to encourage emotional attachment and to make people more likely to render help.As well, quotes of carers' thoughts and feelings during the process of caring for a loved one are provided everywhere, and may be likely to increase the feeling of attachment toward the person in need of care (e.g., I would not put up with it, if I did not love him, p.27).

A Caring Motivational State -Motivational Conflict
If the person feels compassionate toward the other family member and considers caring for the family in need, he/she will start evaluating his/her own ability to alleviate the suffering (Canterberry & Gillath, 2012).At this point, the question is how and if effective active help can be provided.The CBS has yet to be activated: a decision must occur before the system is activated even though a need and health threat to the family has been perceived.One may care emotionally for the well-being of another person, but because of personal reasons and/or situational reasons, proper care cannot be given, hence these motivational conflicts create a decision-making process (Brown, Brown, & Preston, 2011).Certain criteria may enter into play such as:  the closeness of the relationship, the level of attachment, the attachment style (controlling, responsive, compulsive),  the interdependence of happiness of the family members (c.f. the fitness interdependence concept as per Brown, Brown, & Preston, 2011), the feeling of reciprocal threat to health to the carer and the depressed person and the benefits for the family functioning,  the affect (such as sympathy and anger),  social support outcome expectations and controllability (Siegel et al., 2012),  the usefulness of the intervention, the type of caregiving required, and the type of response required,  the belief and attitude towards the illness (depression) and the severity of the depression,  the sense of competence and personal attributes of the family members (social connections, personal health, education, personality traits, etc.),  situational attributes (e.g., problems at work),  and other sources of motivations (such as cultural norms, obligations, compassion, and empathy) (Canterberry & Gillath, 2012;Egbert, Miraldi, & Murniadi, 2014;Guttman & Ressler, 2001).
According to the PB literature, the delivery of a helping response will only occur if the perceived pros overcome the perceived cons (costs) of caregiving for the depressed loved one (Penner et al., 2010;Prochaska, 2008).The family member may decide to either actively help (and move on to start planning the rehabilitation of the person and to look for solutions) or to not become a caregiver if he/she considers he/she does not have the required skills or resources needed to render help.If a family member has assurance and confidence that he/she can alleviate the other person's illness, then he/she will decide to become a caregiver (Canterberry & Gillath, 2012).The CBS is then activated and the caregiver starts thinking about specific ways to improve the well-being of the family member in need.If the family member perceives that the cons are overwhelming, he/she may distance himself/herself from the depressive person and may bring the depressed person into the hands of someone else (e.g., a professional, a hospital, a parent).It is noteworthy that in depression cases, the provision of help can be simultaneously provided by both the family and health professionals (psychologists, physicians, social workers, etc.).
In terms of advice for designers of campaigns targeting family members of depressed people, several suggestions can be made based on the PB literature.The message should emphasize norms such as family responsibility and reciprocity to encourage the caregiver to help (Dovidio, 1984).It should use arousal and affect, in particular emphatic arousal to encourage feelings of emphatic concern, such as sympathy and compassion that are likely to arouse altruistic motivation with the primary goal of improving the welfare of the person in need (Batson, 1991).The message should encourage the caregiver to commit to help and express this commitment in public (Kerr, 1995;1999).Public commitment has been found to trigger behavioral change (Mckenzie-Mohr & Smith, 2008).
The message should help the potential caregiver identify and appreciate pros of helping and at the same time reduce the costs associated with the actual provision of help.Indeed, the caregivers can be helped to develop beliefs about how their care can benefit the depressed person and the entire family (Grusec et al., 2002).More importantly, the messages may attempt to reduce the perceived costs of helping and increase the perceived benefits, so a person may realize the positive impact rendering help may bring and the negative consequences a lack of help may not be able to prevent.For example, it can be pointed out that engaging in relaxing, fun activities on a regular basis as a family would benefit not only the depressed member but the family as a whole.
Most important, the message should increase the confidence of the potential caregiver that he/she can actually alleviate the other person's illness.The message should encourage insecure caregivers to acquire the helping skills needed to provide care (Grusec et al., 2002).This can be done by applying general principles from learning theories, particularly operant conditioning and social learning.For example, messages can include methods to make a career feel rewarded for rendering care, therefore reinforcing the particular behavior.Increasing confidence can also be achieved by using simple encouragement slogans such as -Many families are successful in controlling depression.You can do it, too!‖ and providing individuals with reasons to believe that they can follow the recommendations.Presenting success stories from people who were able to keep the illness under control is also another way to encourage caregivers (Cismaru, 2014;Cismaru et al., 2011;Pike, Doppelt, & Herr, 2010).
Consistent with the suggestions provided above, beyondblue (https://www.beyondblue.org.au/supporting-someone/supporting-someone-with-depression-or-anxiety)likely increases carers confidence that they can provide the appropriate help by pointing out things one can do to help someone with depression as follows:  let the person know if you've noticed a change in their behavior  spend time talking with the person about their experiences and let them know that you're there to listen without being judgmental  suggest the person see a doctor or health professional and/or help them make an appointment  offer to go with the person to the doctor or health professional  help the person to find information about depression and anxiety from a website or library  encourage the person to try to get enough sleep, exercise and eat healthy food  discourage the person from using alcohol or other drugs to feel better  encourage friends and family members to invite the person out and keep in touch, but don't pressure the person to participate in activities  encourage the person to face their fears with support from their doctor/psychologist.
Beyondblue also provides advice of what can be unhelpful to do while caring for a family member suffering from depression:  put pressure on the person by telling them to 'snap out of it' or 'get their act together'  stay away or avoid them  tell them they just need to stay busy or get out more  pressure them to party more or wipe out how they're feeling with drugs and alcohol.
In addition, beyondblue has an on-line chat option available 24 hours that can provide specific advice about what is helpful or not for the person suffering from depression and the caregiver in their particular situation.This on-line chat may considerably increase confidence in carers that they provide the appropriate help, since all family are probably willing to help a loved one in need, but are not sure if their good intentions are translating in helpful aid.

The Delivery of Helping Response to the Individual in Need
According to the CBS, if a person decides to help a family member suffering from depression and feels confident that he/she can actually alleviate the suffering, aid is likely to be provided (Canterberry & Gillath, 2012).Rendering aid may include searches and evaluations of possible programs and activities, consultations with a health professional, and engaging in activities of all sorts to maintain the social network of both the caregiver and the depressed person.If the family member's suffering for depression is alleviated, the caregiving system is deactivated in the helper (Canterberry & Gillath, 2012).On the path to recovery it is possible that the depressed individual lapses or that no improvement in his/her condition is observable after aid is rendered.It is also possible that the caregiver is not capable of resolving motivational barriers to the provision of help and fails to stay motivated.If this occurs, the caregiver may have to re-evaluate his/her position and caring techniques and decide if he/she is still capable of assisting the person in need (Canterberry & Gillath, 2012).Two scenarios are predicted: the first predicts that the carer will re-assess the situation and his/her motivations to providing help.At this point, the relationship may be at stake if the cons of caregiving are becoming increasingly unpleasant.The caregiver's job is then to re-evaluate the situation and the means he/she has to being an active agent in the recovery plans of the depressed person.The caregiving system may deactivate itself if the carer decides to give upor to distance himself/herself if the provision of help is no longer an option in order to not trigger the re-activation of the caregiving system (Canterberry & Gillath, 2012).The second scenario predicts that the carer will still have the motivations behind the provision of help and the caregiving system is still activated.The carer will then work towards developing a new plan of actions and try to actively help once again.There could be several persistent attempts (plans) resulting in more effortful caregiving behaviors.In the second scenario, the family member who has decided to be engaged in this process will hopefully learn from past mistakes and make adjustments to move forward (Canterberry & Gillath, 2012).
For motivational purposes, a plan should be made and benefits for both the caregiver and the person in need should be included in this plan.The plan may also include strategies to modulate the carer's stress response and life during the provision of help.Stress arising from the caregiving duties may come from lost opportunities, personal distress, threats to well-being, energy depletion, loss of status at work or in the family, separation from other friends and family members, etc. Caregivers may have to develop self-awareness of their own responses to the depressive state of the person, realize their role in the familynamely, it is through understanding and non-judgmental help that change may occurand may have to create a sense of security in the depressed person in order to transform negative reactions into positive ones (Canterberry & Gillath, 2012).
During the provision of help, the family member applies the plan that is intended to help the depressed person to recover and to go back to a life free of illness.The plan will include items intended to help the caregiver to go through difficult times.During this stage, carers will likely develop a sense of behavioral control, in addition to their caring duties, and control negative thought, engage in amusing and healthy activities, visit family regularly, manage their stress, exercise, and/or seek professional help when needed and all this while keeping in mind the benefits of the provision of help to the family's health and while constantly regulating motivational conflicts (Canterberry & Gillath, 2012).
In terms of advice for designers of campaigns targeting family members of depressed people, several suggestions can be made based on the CBS literature.The messaging should encourage the caregiver and help the caregiver to create a good plan for the family that includes engaging the family in activities of all sorts to maintain the social network of both the caregiver and the depressed person.Next, the message should help the carer to maintain a positive attitude by teaching him/her ways to deal with stress such as exercising or meditation and encouraging the caregiver to remember the reasons about his/her decision to help.It should emphasize the caregiver's essential role in the family's health.Finally, the message should encourage and help the caregiver to resolve motivational conflicts that would act as barriers to the provision of efficient help to the depressed person.Themes or topics to include could cover relationship issues such as spousal support, forgiveness, and couple conflict may need to be addressed to improve the couple's sense of attachment security, which is expected to improve the quality of their relationship including caregiving and care receiving (Canterberry & Gillath, 2012;Johnson & Whiffen, 2003;Obegi & Berant, 2009).In addition, messages should advice the caregivers to expect setback-relapses as a normal part of the healing process.
The beyondblue Guide for careers (http://resources.beyondblue.org.au/prism/file?token=BL/0445), is somewhat consistent with CBS since it offers helpful advice and tips about caring for others that include: The Guide includes also a section titled -Overcoming setbacks‖ as well as relapse and moving forward.It ends with more information and support available that includes National help lines and websites, support for Carers such as Carers Australia and Mental Health Carers Australia.

Conclusion and Recommendations
Family of people suffering from depression may be able to provide appropriate help and care to the person in need on an ongoing basis.Therefore, their role cannot be underestimated.Helping somebody suffering from depression can be extremely difficult.Carers need a strong motivation to do it, especially on a long term basis as well as specific advice of how to help in an effective way.The present paper incorporates knowledge from the prosocial behavior (PB) and caregiving (CBS) literature and shows how this knowledge may guide communication trying to assists carers of depressed people to render effective help leading to healthier families.In addition to focusing on positive aspects of the vast emotional range of an individual, the provision of a comprehensive tool that includes motivational and determining factors in one's decision to help another in need is adding to the current literature of anti-depression campaigns.This paper also gives examples of messaging from an existing campaign (beyondblue) and proposes more messages for future depression campaigns.To effectively apply the theoretical framework presented in this study to anti-depression campaigns and to increase its effectiveness and relevance, further work may formally evaluate the importance of each component of the CBS and the PB theory.

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how to get through the tough times  what worked and what didn't  how to overcome a range of difficulties  how to support a person with a mental condition, and  how to access support available for carers.