Help-Seeking Determinants and Instrumental Barriers
The Social Network
The social network has been referred to as a network of potential consultants (Angermeyer, Matschinger, & Riedel-Heller, 2001). It consists of multiple spheres of influence, each defined by its proximity to the individual, from the intimate and informal confines of the nuclear family through successively more select, distant, and authoritative laymen until the professional is possibly reached (Cauce et al., 2002; Rogler & Cortes, 1993). The intervention of the social network is a critical factor in helpseeking behaviour, especially in traditionalist communitarian systems (Barksdale & Molock, 2008). It influences the conceptualisation and interpretation of psychopathological symptoms, stereotypes regarding the effectiveness of given care pathways, coping mechanisms and the ultimate decision on which caregiver to consult (Sorketti, Zuraida, & Habil, 2013).
Cauce and colleagues (2002) illustrate the dynamics of the social network with the example of an African American mother of a seemingly depressed child who may consult her own mother, her sister, her best friend, and the family priest to get their opinions on whether her child’s problem is serious or worthy of attention. Each conversation may alternately increase or decrease her level of worry and a corresponding commitment to seek help. If this round of consultation leads to a conviction to seek help, another round of consultation might ensue regarding what type of help that should be sought. In another example, a study that explored the perceived norms of mental health help-seeking among African American College Students found that family norms made a unique significant prediction of help-seeking intentions (Barksdale & Molock, 2008).
In communitarian cultures such as the Igbo of south-eastern Nigeria, the family forms the basic unit of the social network and is the customary starting point of the help-seeking pathway. The decision to seek help for mental or psychological problems, and the pathway to be explored, is a collaborative family effort which usually crystallises from a deliberative decision of the adult family members, with possible input from close associates including extended family members and friends. Relatives equally take it as their responsibility to prompt a member who demonstrates the need for help to seek help urgently.
While studies conducted in Western cultures cautiously noted that an attitude towards mental health services is 'partially' transmitted by family and friends (Angermeyer et al., 2001: Rickwood & Braithwaite, 1994), the decisive influence of the social network in collectivist cultures was exemplified in the finding that relatives initiated contact for the first treatment option in nearly 91% of cases in a study of an Igbo sample whereas only 9% was initiated by the patients themselves (Aniebue & Ekwueme, 2009). A study that investigated care-seeking of psychiatric patients in northern Nigeria found that for over four in five of patients, contact with the first healer was initiated by the patients’ relatives with only 3% of first contacts being initiated by the patients themselves (Aghukwa, 2012).
Another study which investigated pathways to mental healthcare in northern Nigeria noted that sources of information about available mental health facilities came mostly from community members and neighbours (65%) ahead of the mass media (15%) (Abdulmalik & Sale, 2012). Hence, while social networking is only beginning to be encouraged in the West, for example, encouraging spouses to come to an initial appointment (Cusack, Deane, Wilson, & Ciarrochi, 2004), and calls are made for the creation of social advocacy groups that include partners, friends, family, and individuals from the community (Byrne, 2000), such practices are normative in collectivist cultures.
Cameron and colleagues (1993) found that 50% of those who sought medical services in the US were prompted to go by a significant other. They also found that 92% of those who sought medical care (as opposed to 61% of those who did not) talked to at least one person about their problem before seeking professional medical help. These corroborate the suggestion by Cauce and colleagues (2002) that social networks may have their greatest impact at the point of service selection in the help-seeking process because of their strong influence on real decisions about treatment.
It has been noted that, if the need to go for mental health assessment and treatment is strongly supported by the family, it does often work (Thornicroft, 2008), while living alone at the time of onset, and experiencing a lack of family involvement on the pathway to care increased the likelihood of a negative care pathway being taken (Anderson, Führer, & Malla, 2010; Morgan et al., 2005). In developing collectivist cultures, the family cares for both the majority of clients who are outpatients due to a lack of admission facilities and those who are admitted in care. The latter is reinforced in Nigeria by a care policy whereby one close relative must stay with a patient on admission (Aniebue & Ekwueme, 2009).
Donnelly (1992) observed that a family-oriented psycho-educational approach was more effective in treating immigrants from collectivist cultures in an individualistic Western environment than an individual
Help-Seeking Determinants and Instrumental Barriers 83 modality alone. Family collaboration is likely to increase the psychiatric clients’ treatment adherence and follow-up in the community in these cultures. Hsu (2003) had indicated that a family-oriented psycho-educational approach could enlighten family caregivers in such areas as medication regimens, especially monitoring medication in order to prevent relapses.
Social networks can influence the help-seeking behaviour of people suffering from mental disorder, as a communication system by providing information and links, as a reference system by formulating normative expectations, and as a support system by providing care, reporting symptoms and helping patients cope with psychosocial stressors especially where the healthcare system is less developed (Angermeyer et al., 2001; Bergner et al., 2008; Wong, 2007a,b).
Boerner (2009) exemplified the importance of the traditional support of family friends with the story of Nancy Sharby, a mother of two children suffering from bipolar disorder in the US. She could not have her children treated because their insurance plan did not cover mental health since, as she lamented, "... the brain is the only organ in the body that requires its own insurance policy.” Nancy had to fall back on a friends and family network support system. She confessed: “If I didn’t know the people 1 know, I never would have gotten the services I did for my kids .... Both my kids have told me that if 1 didn't do what I did for them, they'd be dead or psychotic by now, because they were very, very sick. You can’t advocate for yourself when you’re psychotic. But even if you’re not psychotic, you still can’t fight for yourself if you don’t know the system .... I have friends who are psychiatric nurses, social workers, insurance brokers, and if 1 didn’t have all those pieces, 1 couldn’t have gotten the services I did for my kids.”
In a study by Dow and Woolley (2012), Albanian respondents described the close-knit nature of the family as the most important thing in life, and the main source of help and support for coping with various problems, including mental health issues. Family bonds and obligations were described as so strong that family members were reportedly willing to make sacrifices such as deciding not to get married or to quit jobs in order to care for sick loved ones. The family was described as the first, and sometimes the only place, for seeking help, especially with mental health problems. Family members would neglect their own mental health as they carried the burden of caring for one of their own with mental health problems.
In collectivist cultures, people do not distinguish their own interests from those of the group, and they perceive the self as intertwined and bound to others. While Western cultural values emphasise individualism, success, competition, and intellectualism - values that may inhibit Westerners from turning to the informal network for help for fear that it may be interpreted as a sign of weakness (Tzahr-Rubin, 2003), family andprimary group relations are central and highly valued in collectivist cultures with their emphasis on the collective over the individual. This enables mutual aid and reliance on informal help over professional mental health facilities, which, from the perspective of the communitarian settings, have the potential to isolate the patient.
However, while the social network can provide care, and report symptoms, and could be an important source of advice and information for health-related issues, the complex dynamics of the social network could also mean that it might inhibit prompt seeking of mental healthcare. For instance, help from the social network (family, extended family, friends, and community members) in the communitarian societies is normally unsolicited - the goodwill of every community member in volunteering assistance is presumed, and every suggestion at the time of crisis, whether potentially helpful, harmful, or even contradictory is open to consideration and often favourably so. At times, rivalry can arise between the different arms of the network regarding whose opinion should hold sway, and this could add to the stress of the situation while also hampering decisive intervention.
The quality of the social network is also a factor; a social network with less mental health literacy could keep recycling ignorance to the detriment of the patient. It is noted that social networks delay in their recognition of the first signs of mental illness hence impeding prompt intervention and that families and friends most often suggest seeking care mostly when socially disturbing symptoms become prominent (Gater, Jordanova, Marie, & Alikaj, 2005; Mkize & Uys, 2004). Furthermore, as Mkize and Uys observed, with the structure of the family in the communitarian African system whereby there is usually the adult (male) head that takes the final decision on issues, there could be a delay in the decisive intervention in the event of a sudden crisis, in the absence of a family head in distant employment.
While limited social networks predicted restricted utilisation of mental health resources in one study (Bonin, Fournier, & Blais, 2007), research also hints at the irony of the inhibitive influence of tightly meshed social networks that could lead to delay in contacting health facilities (Rogler & Cortes, 1993; Lin, Inui, Kleinman, & Womack, 1982). When networks are open, and the individuals are not too involved with each other, they are more exposed to information about the environment, including where to go for professional treatment. People may be pressured towards the acceptance of normative beliefs that could run contrary to formal helpseeking in close-knit networks. The impact of the normative expectations could be felt in the finding that networks afraid of stigmatisation delay contact with psychiatric services (Angermeyer et al., 2001).
Moreover, collectivist cultures with strong community support systems and interlocking community and familial networks could also feel able to meet their needs from within: hence they will be reluctant to seek external
Help-Seeking Determinants and Instrumental Barriers 85 help (Gilbert et al., 2007; Tata & Leong, 1994). Social conflicts arising from the closely knit and communal lifestyles of most African societies have also been associated with the emanation of distress (Asuni, Schoenberg, & Swift, 1994). Stigma and discrimination are particularly significant in collectivist societies where communities are smaller, social networks are closely enmeshed, and privacy is lacking (Barney, Griffiths, Jorm, & Christensen, 2006). Thus, social proximity can be a double-edged sword in the sense that, while the stronger sense of community may be a protective factor which offers higher social capital, the experience of social stigma may be more pronounced in such closely enmeshed communities.