Impact of social network among caregivers of individual with alcohol dependence syndrome

1Department of Psychiatric Social Work, Ranchi Institute of Neuro-Psychiatry & Allied Sciences, Ranchi, Jharkhand, India, 2Psychiatric Social Worker, Child Development Centre, Department of Paediatrics, Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi, India, 3Department of Psychiatric Social Work, Ranchi Institute of Neuro-Psychiatry & Allied Sciences, Ranchi, Jharkhand, India, 4Professor and Head, Department of Clinical Psychology, Ranchi Institute of Neuro-Psychiatry & Allied Sciences, Ranchi, Jharkhand, India, 5Associate Professor and Head, Department of Psychiatric Social Work, Ranchi Institute of Neuro-Psychiatry & Allied Sciences, Ranchi, Jharkhand, India


Introduction
Alcohol dependence is a major problem worldwide; India being no exception. Alcohol which was once used as part of rituals and medicaments now has become a worldwide problem that attracts high attention of mental health professionals. Alcohol is an addictive phenomenon, is not yet fully conceptualised by the society; therefore, the patients are not worried about their addiction and majority of the referral are not seriously to identify the situation. Ethyl alcohol is the ten most dangerous drugs for human health. It's marked ability to induce physical dependence [1] and abuse affect the whole organism, particularly serious damage to the digestive, central nervous and cardiovascular system. Alcoholism is the third largest healthcare problem in India today. [2] It hampers socioeconomic-political arena of human being. Alcohol dependence does not create problem for physical and mental health of patient only, but it also jeopardy the life of the caregivers also. It also hampers the social support system of caregivers. On seeing any family member plunge deeply into alcohol and becoming its slave, the near and dear one starts maintaining distance from that family. This weakens the family support system. The caregivers start thinking that they are alone in this battle and struggle. That lessen their motivation and the enthusiasm they have to go through deep stress and trauma situation. Social support is being delivered to a particular person by his social networking system and by people with whom he feels to have the comfort during the interaction. [3] Social support is provided by one's social network including family, friends, and co-workers.
Garrison and Howe, [4] an individual's social network is aptly defined by the sum of those human relationships that have a significant effect on his or her life. Members of an individual's network may represent both affective (i.e. psychosocial support and supplies, such as personal interest and emotional support) and instrumental (i.e. money, housing, etc) resources, and include relatives, friends, neighbours, associates, employers, and so on.
Social network therapy is further defined by Garrison and Howe [4] as the clinical technique of involving a person's social network with the goals of modifying the network of emotional influence or affective resources in order to facilitate active reality-based coping and problem-solving, and articulation of the instrumental resources available. His underlying assumption is that the solution to a variety of 'human dilemmas' lies within the expectations and collective resources of an individual's social network.
Rueveni [5] describes the process as "a time limited, goal oriented approach that will help family members in a crisis to assemble and mobilise their own social network of relatives, friends and neighbors; this network will become collectively involved in developing new options and solutions for dealing with a difficult crisis". Some related approaches, all hall marked by their mobilisation or resources in an individual's relational field, have been variously referred to as social system psychotherapy, ecological therapy, and kinship therapy. These approaches share similar goals, designate the social network as the therapeutic unit of intervention, and employ similar techniques for achieving their goals and can therefore be considered synonymous with social network therapy or 'networking' . Given the systems oriented nature of networking, as a reference point, a brief sketch of the historical development is in order.
According to House et al., [6] social support is believed to help in reducing stress in three important ways. First, family members, friends, and acquaintances can provide direct tangible support in the form of physical resources (e.g., lending money, doing the grocery shopping, and taking care of children). Second, members of one social network can provide informational support by suggesting alternative actions that may help to solve the stress-producing problem. These suggestions may help the person to look at his problem in a new way and thus help to solve it, or to minimise its impact. Third, those in the social network can provide emotional support by reassuring the individual that he is cared for, valued, and esteemed. These supportive individuals can provide nurturance, acceptance, and love. It is in man's nature to form communities and it is also in his nature to communicate. Researchers believe that man is propelled by instincts and desires which can only find full gratification by living in community and through interaction. Social networking (or network theory) is not an exact science and may reasonably be termed a social catalyst in discovering the method in which problems are solved; organisations are run to the degree in which individuals succeed in achieving goals. [7]

Materials and methods
Aim: To study the influence of social network among caregivers of individual with alcohol dependence syndrome.

To establish the social network among caregivers in
individual with alcohol dependence syndrome. 2. To study the social support among caregivers in individuals with alcohol dependence syndrome with and without social network.
Research design: In this study, a pre and post with control group design was used.
Sampling method: Samples were selected by using the purposive sampling method, from the Ranchi Institute of Neuro-Psychiatry & Allied Sciences (RINPAS). Sample size and procedure: Initially 30 patients and their caregivers were selected and assessed on the basis of General health Questionnaire-12 (GHQ-12). [9] Out of which, only 24 caregivers who fulfilled the inclusion and exclusion criterion constituted the sample. Two caregivers from experimental group and two from control group showed their reluctance in attending the session. Hence, finally ten caregivers in experimental and ten in control group were recruited.

Intervention module:
The intervention package was developed on the analysis of concerned literature, discussion with experts, and observation of conduct of few support group intervention programmes. The intervention package consisted of 14 sessions. The focus was to help caregivers who live a very stressful and traumatic life while living with alcoholic patients through forming and joining network support group. They used to see themselves sharing a common platform; where group member's problem resembles to them, they learn how to counter these problems. Hence the module included inputs to improve communication; information related to network, relapse, and recovery; role functioning; and information related to alcohol. A brief overview of the intervention package is given below.
The following tools were used for this study-Socio-demographic and clinical datasheet of the respondents: It is a semi-structured and self-prepared proforma. It contains information about socio-demographic variables like age, sex, religion, education, marital status, domicile, and occupation, and clinical details like diagnosis, age of onset, total duration of illness, any history of mental illness, any history of significant head injury, seizures, and any other significant physical, or psychiatric illness.

GHQ-12:
Goldberg and Williams [9] developed GHQ-12. It is used to screen any psychiatric morbidity in healthy persons. GHQ-12 is the short version of the original GHQ containing 60 items for the detection of the psychiatric illness. Internal consistency of GHQ -12 has been excellent. A high degree of internal consistency was observed for each of the 12 items with Cronbach's alpha value of 0.37-0.79, while total score was 0.79 in the population study. Test-retest correlation coefficients for the 12 items score were highly significant.
Social Support Questionnaire: [10] This scale measures perceived social support, i.e. social support as perceived by the subject. It had total 18 items and four possible responses may be, four=agree a lot, three=agree quite a bit, two=agree somewhat, one=disagree. Some items were positively worded and scoring remaining same one, two, three, four; some negatively worded, so the scoring is to be reversed for these items, i.e. four, three, two, one. Score indicates the amount of perceived social support. Higher score indicates more perceived social support and vice versa. It was a reliable and valid questionnaire. Testretest reliability after two Weeks interval on 50 subjects was found to be 0.59, significant at 0.01 levels. Table 1 shows the comparison of two groups, i.e. experimental group and control group, in relation to socio-demographic parameters in patients; there was no significant difference. Table 2 shows the comparison of two groups, i.e. experimental group and control group, in relation to socio-demographic parameters in caregivers; there was no significant difference. Table 3 shows comparison of social support between experimental and control group at baseline. Social support mean was 41.40±3.86 and 40.80±3.65 in experimental and control group respectively. Mann-Whitney U test was performed to compare the difference between experimental and control group on social support. Result revealed that there was no significant difference between the two groups on social support (Z=.802, p>0.05).    Table 4 shows comparison of scores obtained after intervention in experimental and control group. Social support mean was 45.60±4.14 and 41.60±3.56 in experimental and control group respectively. Results show there was significant difference between both groups in social support (z=2.05, p<0.05).

Discussion
With the establishment of social network among caregivers, they got bonded and integrated together. The bond helps in enhancing caregiver's physical and psychological health directly and indirectly by reducing the negative effects of stressors and health. Present study findings are also consistent with the findings of Chuang and Yang, [11] who concluded that online support communities help to connect with each other and expand their social resources. It increases the amount of support for coping with health issues. Tracy and Martin [12] concluded that children played pivotal role in recovering their mother from the clutches of substance, as child form network with her mother and gave her emotional support. Raj et al. [13] and Hazarika and Bhagabati [14] studied children of alcoholics. Laudet et al. [15] concluded that persons with greater participation in mutual aid reported less mental health stress and higher level of wellbeing. Participation in mutual aid was indirectly associated with recovery through perceived levels of support. Acier et al. [16] found that mutual help network helps in emotions management, especially in controlling negative feelings, and improves their communicative and expressive ability.

Limitations
The sample size was small which limits the generalisation of the finding. It was a time bound study. Long-term effects of social network among caregivers could not be assessed. Thus, it cannot be commented whether the beneficial effect of social network are maintained. The study only included alcoholic patients. Only male caregivers were taken in study.

Future direction
For effective generalisation, the present study needs more attention to include large sample. Longer follow-up studies are needed to see whether the results obtained are maintained in long-term. As the study was based on clinical sample, its impact and fruitfulness can be seen in other area also.

Conclusion
The present study is indicating that the caregivers of individual with alcohol dependence syndrome go through tough life. Every day of their life is full with challenges and difficulties due to individual with alcohol dependence syndrome. In those unfavourable conditions, they have to run their life; they have problems in coping, decision making, wants to have less contact, and burden. Social network among caregivers of individual with alcohol dependence syndrome works as a protective shield that salvage them from stress, trauma, and difficulty they face being caregivers of individual with alcohol   dependence syndrome. It creates a platform where they can share their feelings, knowledge, and information, related with it as the group member's problem resembles. Therefore, they share it without any kind of shyness and fear.