Strategies for coping with family members of patients with mental disorders

ABSTRACT Objective: to identify the coping strategies of family members of patients with mental disorders and relate them to family member sociodemographic variables and to the patient's clinical variables. Method: this was a descriptive study conducted at a psychiatric hospital in the interior of the state of São Paulo, with 40 family members of hospitalized patients over the age of 18, and who followed the patient before and during hospitalization. We used tools to characterize the subjects and the Folkman and Lazarus Inventory of Coping Strategies. Results: the coping strategies most often used by family members were social support and problem solving. Mothers and fathers used more functional strategies (self-control p=0.037, positive reappraisal p=0.037, and social support p=0,021). We found no significant differences between the strategies and other variables examined. Conclusion: despite the suffering resulting from the illness of a dear one, family members make more use of functional strategies, allowing them to cope with adversities in a more well-adjusted way.


Method
A descriptive, exploratory cross-sectional study performed at a 250-bed psychiatric hospital in the interior of São Paulo working with SUS, healthcare plan and private patients, thus serving a heterogeneous group of people in terms of socioeconomic and cultural level.
The study population was made up of the family members of patients hospitalized in said hospital due to mental disorders between October and December 2013.
The inclusion criteria were: 18 years or older, be related to the hospitalized patient in some way, and have followed the patient before and during hospitalization.

The Folkman and Lazarus Inventory of Coping
Strategies includes the thoughts and actions people used to handle the internal or external demands of a specific stressful event. It is a list of 66 items answered using a Likert-type scale, with four possible answers (0: never used this strategy; 1: used it a bit; 2: used it a lot; 3: used it extensively). This scale is not associated with a total score as a sum for assessment, as the items should be assessed using average scores within each factor (4) .

This tool was translated and validated for Brazilian
Portuguese, demonstrating correspondence between the original English language version and the translated one, allowing it to be applied to other studies. In the original study, Cronbach's alpha ranged from 0.56 to 0.85 across the factors. The items that make up this tool are split into eight factors: comfort, distance, self-control, social support, acceptance of responsibilities, escapeavoidance, problem solving and positive reappraisal (11) .
The elements of FLICS are split into two categories: (1) functional strategies, made up of self-control, social support, problem solving, positive reappraisal and acceptance of responsibilities, and (2) dysfunctional Pompeo DA, Carvalho A, Olive AM, Souza MGG, Galera SAF.
strategies, corresponding to confrontation, distancing and escape and avoidance (12) .
We ran a pre-test with five subjects to test, adjust, fine-tune and measure duration of application of the proposed data collection tools, which did not result in any changes. Data was collected during verbal interviews conducted during visiting hours.
The data was processed and analyzed using To assess the coping strategies we calculated the mean, median and average deviation of the score obtained for each factor. Mean scores were calculated based on the number of items in each factor. The internal consistency of FLICS data was checked using Cronbach's alpha.
To analyze the mean scores of the association between coping strategies and sociodemographic variables, we used Mann-Whitney's non-parametric test to compare the two groups, and the Kruskal-Wallis test and Dunn's post-hoc test to compare more than two groups. We used a significance level of 0.05.
This study complies with Brazilian and international standards of ethics for research involving human beings, and received a favorable opinion from the local Ethics Committee (Document # 300,424). All of the patients signed the Free and Informed Consent Form.

Results
Of the 40 family members of patients with mental disorders, 20 were male and 20 female, with ages ranging from 18 to 67, with an average of 39 and SD of 14.7 years. Regarding the family relationship, seven (17.5%) were a parents (father or mother), 10 (25%) were the children, nine (22.5%) a sibling, and 14 (35.0%) were a nice/nephew, grandchild, in-law or cousin. 24 (60%) of the participants had ten or more years of schooling, and half (50%) of the sample claimed to be Roman Catholic.
The coping strategy most often used by family members was social support, and the least used was confrontation. Functional strategies were the ones used most often. The internal consistency of FLICS factors measured using Cronbach's alpha ranged from 0.44 to 0.79 (Table 1). There was a significant association between family relationship and self-control strategies (p=0.037), social support (p=0.021) and positive reappraisal (p=0.037), indicating that parents (mother and father) use this strategy more often than children, siblings or other family members (Table 2).
Rev. Latino-Am. Enfermagem 2016;24:e2799 Women tend to escape and avoidance and problem solving more than men. Family members earning between four and seven minimum salaries are more prone to using positive reappraisal.
We did not find significant differences in coping strategies in terms of age, years of schooling or religion, but did find a trend towards a significant difference for the variable "has partner'. Family members reporting no partner are more likely to use escape and avoidance for coping with their problems, while those who claim to have a partner score more highly in problem solving.
The only clinical variable with marginally significant results was the presence of psychotic symptoms, showing that problem solving tends to be more used by family members of patients who do not display psychotic symptoms (Table 3).
Pompeo DA, Carvalho A, Olive AM, Souza MGG, Galera SAF. Family member coping strategies differ by disease type and duration. However, we found no significant differences between coping strategies and patient clinical variables (Table 3).

Discussion
The results of this study show that the family Adopting these strategies may contribute to reducing the stress and overload of caregivers (13) .
According to the Lazarus and Folkman perspective of coping with stress, social support is based on the person's effort to seek support within his/her social, professional and emotional spheres (14) . Studies in the United States (13) , India (3,15) and China (16)(17) found that the search for social support is an important strategy for caring for a mentally ill family member. Family, friends, religions, doctor visits and other resources provided by the healthcare system and the community were the forms of social support Individuals with fewer years of schooling often use dysfunctional strategies, as it is hard for them to find the source of the problems and options to solve or address it (19) . In this survey, family members with fewer years of schooling had higher scores in confrontation compared to those with more years of schooling.
Confrontation is an aggressive manner chosen to change a situation, such as anger and inflexibility (14) .

This may be the result of constant periods of crisis and
instability resulting from the disease, as well of moments of suffering and uncertainty regarding the future and social and financial concerns and difficulties (2) .
Individuals reporting that they have partners were more likely to use problem solving, and those without were more likely to use escape and avoidance. Ideally, a partner is associated with affection, daily living, the exchange of experiences and mutual support, which may explain the choice of functional strategy.
The trend to using the functional strategy problem

Conclusion
The coping strategies most often used by the family members of people with mental and psychiatric disorders are social support and problem solving. Parents use more functional strategies for caring with a child with a mental disorder.
There are few studies to date, either in Brazil or abroad, on the experience of family members of people with mental or psychiatric disorders, and how they cope with the stressors, in particular using a specific theoretical reverence such as the Inventory of Coping Strategies.
The results of this study are limited because it used a small, non-probabilistic sample, leading to a possible bias and being less representative of the population.
We also highlight the fact that we did not look at other variables that may have interfered in the coping strategies and provide better subsidies for our results, such as the persons' personality, overload, social support and stress levels.
However, the results obtained enable understanding how family members face the presence of mental disorder in a dear one, and allows nurses to reinforce the concept that the family is an important care group, thus expanding their scope of action, with interventions designed to manage caregiver overload so that he or she may be able to better deal with the patient's disease, and maintain his/her balance and positive outlook, ultimately impacting the care of the person with mental illness.