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The increased recognition of the burden placed on family members caring for relatives has led researchers to investigate the factors that are most likely to contribute to a negative experience of care giving. While studies have shown that contributory factors may include the psychiatric diagnosis and quantity of symptoms, duration of illness, length of treatment and treatment setting, and relationship with patient, there has been little consensus about the relative effect of these various features on family burden (Lowyck et al., 2004; Möller-Leimkühler, 2005). This is mainly due to the measurement difficulties presented by the concept of family burden and indeed by informal care in general.

In order to avoid some of these methodological weaknesses, Möller-Leimkühler (2005) examined caregiver burden using a multidimensional model and combined standardised and qualitative data assessment and analysis. The results revealed that caregiver’s stress outcome is statistically not influenced by objective stressors such as the clinical ratings of the severity of illness, type of symptoms and psychosocial functioning at first admission. Instead, the most significant predictors on stress outcome included relatives’ expressed emotions, the extent of their emotion-focused coping, and their generally used negative stress response. The burden of care and perception of stress was influenced more by the carer’s subjective appraisal of

that burden and the coping ability of each individual carer than by the objective stressors themselves. This assertion is supported by Harvey et al. (2001) who discovered that caregivers’ negative appraisal of care was a strong predictor of their psychological distress. These studies suggest that interventions to increase the coping capacity of carers should be developed to enable family carers to deal with the consequences of caring for a family member with a mental health problem more effectively.

A longitudinal study of carers conducted by Hirst (2005) using data from the British Household Panel Survey found that the risk of psychological distress amongst carers increased with the intensity of care, implying that carers who provide long hours of care are more vulnerable to adverse psychological consequences of care, women more so than men. Such negative effects were more pronounced around the start and end of the care giving period and continued even when the care giving episode had concluded. The results emphasise the importance of recognising the heterogeneity of the caring population with respect to circumstances and hours of care when considering the effects of care and evaluating supportive interventions. This point is also supported by Östman and Hansson (2004) who found that caregiver burden was more extensive if the carer and patient lived together, had a longer relationship of care, if care giving was provided on a daily basis, and if care giving was evaluated negatively by the care provider. Wolff et al. (2006) investigated several models used to conceptualize and measure the cost of informal care and examined which of these models of financial burden best correlated with measures of psychological burden. The models ranged from the most conservative which only measured family burden in terms of time spent providing care tasks to a more extensive model that included time, in-kind and monetary contributions of family caregivers as well as costs incurred due to the negative health and stress of care giving. Reciprocity was also explored in this study. Two main conclusions emerged from the study. The first is that the burden imposed on informal care givers is likely to negatively impact on their health and increase their experience of stress which in turn increases the cost of informal care giving. The second is that the ability of recipients of care to give back diminishes the financial and psychological burden imposed on carers. Reciprocal giving appears to counteract the objective and subjective burden experienced by family care givers as well as reducing their financial burden Therefore, people with mental health problems must be encouraged and empowered to reciprocate in ways that are important to the care giver, for example by actively contributing to the household and/or managing his/her own care.

The growing awareness of the detrimental effects that care giving can have on informal carers has led to an increase in the provision of supportive interventions targeted to the specific needs of this vulnerable group. In particular, mutual support groups may be an effective way to reduce family burden (Citron et al., 1999). These groups can assist families by offering role models to help carers cope with the problems they typically encounter and providing an environment in which relatives can express their feelings and share their problems without feeling a sense of shame or stigma. Norton et al. (1993) conducted a cost benefit analysis of membership of one such self-help group in the USA – the Alliance for the Mentally Ill (AMI). The study elicited information from 59 family caregivers who were members of AMI and 40 family caregivers who were non-members using a structured interview. The evidence revealed that while there are costs associated with membership, the benefits of membership outweigh the costs and that these benefits are positively associated with levels of participation. These findings imply that measures might be put in place to assist the establishment and maintenance of peer support groups for relatives and carers of people with a mental health problem and active participation in such groups should be encouraged.