Is befriending by trained volunteers of value to people suffering from long-term mental illness?

Exploring the use of social network interventions for adults with mental health difficulties: a systematic review and narrative synthesis

BACKGROUND

People with mental health difficulties often experience social isolation. The importance of interventions to enhance social networks and reduce this isolation is increasingly being recognised. However, the literature has not yet been systematically reviewed with regards to how these are best used. This narrative synthesis aimed to investigate the role of social network interventions for people with mental health difficulties and identify barriers and facilitators to effective delivery. This was undertaken with a view to understanding how social network interventions might work best in the mental health field.

METHODS

Systematic searches using combinations of synonyms for mental health difficulties and social network interventions were undertaken across 7 databases (MEDLINE, Embase, PsycINFO, CINAHL, Cochrane Library, Web of Science) and 2 grey literature databases (EThoS and OpenGrey) from their inception to October 2021. We included studies reporting primary qualitative and quantitative data from all study types relating to the use of social network interventions for people with mental health difficulties. The quality of included studies was assessed using the Mixed Methods Appraisal Tool. Data were extracted and synthesised narratively.

RESULTS

The review included 54 studies, reporting data from 6,249 participants. Social network interventions were generally beneficial for people with mental health difficulties but heterogeneity in intervention type, implementation and evaluation made it difficult to draw definitive conclusions. Interventions worked best when they (1) were personalised to individual needs, interests and health, (2) were delivered outside formal health services and (3) provided the opportunity to engage in authentic valued activities. Several barriers to access were identified which, without careful consideration could exacerbate existing health inequalities. Further research is required to fully understand condition-specific barriers which may limit access to, and efficacy of, interventions.

CONCLUSIONS

Strategies for improving social networks for people with mental health difficulties should focus on supporting engagement with personalised and supported social activities outside of formal mental health services. To optimise access and uptake, accessibility barriers should be carefully considered within implementation contexts and equality, diversity and inclusion should be prioritised in intervention design, delivery and evaluation and in future research.

Patients' and volunteer coaches' experiences with an informal social network intervention in forensic psychiatric care: a qualitative analysis

BACKGROUND

Improving supportive social networks in forensic psychiatric patients is deemed important due to the protective effects of such networks on both mental health problems and criminal recidivism. Informal interventions targeted at social network enhancement by community volunteers showed positive effects in various patient and offender populations. However, these interventions have not specifically been studied in forensic psychiatric populations. Therefore, forensic psychiatric outpatients' and volunteer coaches' experiences with an informal social network intervention were explored in this study.

METHODS

This qualitative study was based on semi-structured interviews conducted alongside an RCT. Forensic outpatients allocated to the additive informal social network intervention, and volunteer coaches, were interviewed 12 months after baseline assessment. Interviews were audio-recorded and transcribed verbatim. Reflexive thematic analysis was used to identify and report patterns in the data.

RESULTS

We included 22 patients and 14 coaches in the study. The analysis of interviews revealed five main themes reflecting patients' and coaches' experiences: (1) dealing with patient receptivity, (2) developing social bonds, (3) receiving social support, (4) achieving meaningful change, and (5) using a personalized approach. Patient receptivity, including willingness, attitudes, and timing, was a common reported barrier affecting patients' engagement in the intervention. Both patients' and coaches' experiences confirmed that the intervention can be meaningful in developing new social bonds between them, in which patients received social support. Despite, experiences of meaningful and sustainable changes in patients' social situations were not clearly demonstrated. Coaches' experiences revealed broadened worldviews and an enhanced sense of fulfillment and purpose. Finally, a personalized, relationship-oriented rather than goal-oriented approach was feasible and preferable.

CONCLUSION

This qualitative study showed positive experiences of both forensic psychiatric outpatients and volunteer coaches with an informal social network intervention in addition to forensic psychiatric care. Notwithstanding the limitations, the study suggests that these additive interventions provide an opportunity for forensic outpatients to experience new positive social interactions with individuals in the community, which can initiate personal development. Barriers and facilitators to engagement are discussed to improve further development and implementation of the intervention.

TRIAL REGISTRATION

This study is registered at the Netherlands Trial Register (NTR7163, registration date: 16/04/2018).

Epidemiology of loneliness in a cohort of UK mental health community crisis service users

PURPOSE

Loneliness is an important issue for mental health service users. However, it has not been a particularly prominent focus of recent mental health research. This paper aimed to explore the severity of loneliness among people leaving mental health community crisis services, and to identify factors associated with loneliness.

METHODS

A total of 399 participants experiencing mental health crises recruited for a research trial from community crisis services were included in this cross-sectional study. They completed the eight-item measure of the University of California at Los Angeles Loneliness Scale and a set of instruments assessing socio-demographic, psychosocial, and psychiatric variables.

RESULTS

Severity of loneliness was high among people leaving community crisis services. Longer years since first contact with mental health services (2-10 years, coefficient = 1.83, 95% CI 0.49-3.16; more than 10 years, coefficient = 1.91, 95% CI 0.46-3.36) and more severe affective symptoms (coefficient = 0.32, 95% CI 0.23-0.40) were associated with greater loneliness, whereas bigger social network size (coefficient = - 0.56, 95% CI - 0.76 to - 0.36) and greater social capital (coefficient = - 0.16, 95% CI - 0.31 to - 0.003) were associated with less severe loneliness.

CONCLUSIONS

This paper supports a view that people experiencing mental health crises often report relatively severe loneliness, and that loneliness tends to become more severe during the course of illness. A greater awareness of loneliness among mental health professionals may be beneficial. Loneliness is a potential focus of the development of interventions to improve the lives and outcomes of people with significant mental health problems.

Befriending Services for Culturally Diverse Older People

Befriending services may address loneliness and social isolation amongst older people. However social diversity is rarely reported in investigations of befriending services. The views of non-users are also rarely explored. In this research, we explored older adults' experiences of, and attitudes towards, a befriending service, among service users and non-service users, drawing on interviews and focus groups with 76 older adults, 10 volunteer visitors, and 20 service providers. Participants agreed that the befriending service helped alleviate social isolation and loneliness and that supportive services to foster connection are needed. Barriers to engagement included lack of knowledge, appropriateness of services and feeling undeserving. The befriending service was most successful when a match went beyond a transactional 'professional-client' relationship to resemble genuine friendship, underpinned by mutual interests and norms of reciprocity and reliability. We also identified five clear ideas about what characterizes an ideal supportive service; supported opportunities for getting out, genuine and reciprocal relationships, reliability, visitor characteristics, and connecting people to their culture. Befriending adds to social networks, and enhances connectedness to the community. Loneliness is alleviated when mutually beneficial and genuinely reciprocal relationships develop. However, group interventions or connections to community groups may be more appropriate for some.

Measuring Group Process in Nurse-Facilitated Support Groups for Psychosocial Club Members

Nearly half of patients with serious mental illness (SMI) lack friends and social connectedness-building blocks of recovery. While support groups have been found to promote friendship-building, there is little information about the process. This study examined the use of nurse-facilitated support groups by Psychosocial club members with SMI. Participation, core members, therapeutic factors, content discussed, and satisfaction with the intervention were measured. Perception of unmet need for a friend and membership in a group was measured before and after the intervention. Participation increased over time. Core members emerged. Yalom's therapeutic factors evolved. Discussion included sexually transmitted diseases, safety, making friends, health problems, problems with landlords, and adverse events such as victimization. The unmet need for a friend decreased. Two-thirds were satisfied with the groups. Support groups are low-cost psychosocial interventions that can be used to help patients with SMI move toward recovery.

Motivations and experiences of volunteers and patients in mental health befriending: a thematic analysis

BACKGROUND

Volunteers frequently participate in befriending schemes with people with mental illness. This study aimed to explore the motivations and experiences of volunteer befrienders engaging in these schemes in addition to the experiences of befriending recipients.

METHODS

Semi-structured interviews were conducted with 38 volunteers and 23 befriending recipients, across 12 mental health befriending schemes in the UK, and analysed using Thematic Analysis. Volunteers highlighted their motivations for wanting to befriend. Individuals discussed their experiences, including the benefits and any challenges.

RESULTS

Analysis of interviews revealed the motivations for individuals to volunteer in mental health care, the experiences of both volunteers and recipients of befriending, as well as how complex the role of befriender is. The three overarching themes were (1) Personal growth & altruism as motivations for volunteering, (2) Impact of "doing things" versus "being there" and (3) Negotiating between professional role and friendship.

CONCLUSIONS

A number of personal and altruistic factors motivate individuals to volunteer in mental health care. The experiences of both volunteers and befriendees convey important factors affecting these relationships. In particular, the nuance of the befriending role and the ways in which it can impact the lives of recipients. Indeed, such factors need to be considered when formulating these befriending schemes.

Friendship and money: A qualitative study of service users' experiences of participating in a supported socialisation programme

BACKGROUND

Social opportunities can be limited in the lives of people with enduring mental illness (EMI) due to psychiatric stigma, restricted home environments and employment barriers. Supported socialisation programmes have the potential to redress the impact of social isolation.

AIM

To explore the experiences of service users with EMI taking part in a supported socialisation programme, using written diary entries.

METHODS

This article reports on the qualitative component of a randomised controlled trial of supported socialisation for people with EMI (published previously in this journal). Trial participation involved (1) being matched with a volunteer partner and engaging in social/leisure activities while receiving a stipend of €20 or (2) receiving this stipend only and engaging in self-driven socialisation. Participants completed written diaries documenting their perspectives on their experiences of supported socialisation. Data were analysed using Thematic Analysis.

RESULTS

Experiences of participation were characterised by involvement 'normalising' life, fostering a sense of connectedness, improving physical health, and facilitating engagement with culture. Taking part helped participants integrate socialising into their identity, enhanced their perceived capacity to be social, and cemented/expanded social networks. Participants also experienced significant obstacles to socialisation.

CONCLUSION

Supported socialisation can increase confidence, social competence and self-agency; buffer against psychiatric stigma; build social capital; and afford opportunities to enhance social integration, inclusion and belonging.

Effectiveness of befriending interventions: a systematic review and meta-analysis

OBJECTIVE

Befriending is an emotional supportive relationship in which one-to-one companionship is provided on a regular basis by a volunteer. It is commonly and increasingly offered by the voluntary sector for individuals with distressing physical and mental conditions. However, the effectiveness of this intervention on health outcomes is largely unknown. We aim to conduct a systematic review of the benefits of befriending.

DESIGN

Systematic review.

METHODS

A systematic search of electronic databases was conducted to identify randomised controlled trials and quasi-experimental trials of befriending for a range of physical and mental health indications including depression, anxiety, mental illness, cancer, physical illness and dementia. Main outcomes included patient-relevant and disease-specific outcomes, such as depression, loneliness, quality of life, self-esteem, social support and well-being.

RESULTS

A total of 14 trials (2411 participants) were included; 7 were judged at low risk of bias. Most trials showed improvement in symptoms associated with befriending but these associations did not reach statistical significance in all trials. Befriending was significantly associated with better patient-reported outcomes across primary measures (standardised mean difference 0.18 (95% CI, -0.002 to 0.36, I²=26%, seven trials)). However, there was no significant benefit on single outcomes, including depression, quality of life, loneliness ratings, self-esteem measures, social support structures and well-being.

CONCLUSIONS

There was moderate quality evidence to support the use of befriending for the treatment of individuals with different physical and mental health conditions. This evidence refers to an overall improvement benefit in patient-reported primary outcomes, although with a rather small effect size. The current evidence base does not allow for firm conclusions on more specific outcomes. Future trials should hypothesise a model for the precise effects of befriending and use specified inclusion and outcome criteria.

Community families: A qualitative study of families who volunteer to support persons with severe mental illness

BACKGROUND

Social interventions targeted at people with severe mental illness (SMI) often include volunteers. Volunteers' perspectives are important for these interventions to work. This article investigates the experiences of volunteer families who befriend a person with SMI.

MATERIAL

Qualitative interviews with members of volunteer families.

DISCUSSION

The families were motivated by helping a vulnerable person and by engaging in a rewarding relationship. However, the families often doubted their personal judgement and relied on mental health workers to act as safety net.

CONCLUSION

The volunteer involvement is meaningful but also challenging. The families value professional support.

Effectiveness of one-to-one volunteer support for patients with psychosis: protocol of a randomised controlled trial

INTRODUCTION

Social isolation is common in patients with psychosis and associated with a number of negative outcomes. Programmes in which volunteers provide one-to-one support-often referred to as befriending-have been reputed to achieve favourable outcomes. However, trial-based evidence for their effectiveness is limited.

METHODS AND ANALYSIS

This is a randomised controlled trial comparing the effects of one-to-one volunteer support with an active control condition for patients with psychosis over a 1-year period. Patients in the intervention group will receive the support of a volunteer for 1 year, who will meet them weekly and engage them in social and recreational activities. Patients in the control group will not receive support from a volunteer. In both groups, patients will be given a booklet detailing locally available social activities and otherwise receive treatment as usual. Patients, volunteers, clinicians and researchers involved in the delivery of the intervention will not be blinded to group assignment, while researchers carrying out data collection will be blinded. Data collection will be conducted at baseline, at 6 and 12 months. The primary outcome is the amount of time spent engaging in social activities per day. Secondary outcomes include symptoms, quality of life, self-esteem and costs of care. Attitudes of volunteers towards mentally ill people will be assessed. Finally, in-depth interviews will be conducted with patients and volunteers.

ETHICS AND DISSEMINATION

The study has been approved by the National Research Ethics Service (NRES) Committee London-Camden & Kings Cross (reference 15/LO/0674). The findings of the trial will be published in open access peer-reviewed journals and in the National Institute for Health Research (NIHR) journals library, and presented at scientific conferences. In addition, findings will be summarised for a lay audience and circulated to all relevant National Health Service (NHS) and voluntary organisations.

TRIAL REGISTRATION NUMBER

ISRCTN14021839; Pre-results.

Motivational interviewing to enhance adolescent mental health treatment engagement: a randomized clinical trial

BACKGROUND

The prevalence of anxiety and mood disorders in adolescents is a growing public health concern worldwide. Given the high rates of drop-out and limited resources available in psychiatric settings, the importance of engaging adolescents in evidence-based treatments cannot be understated. The aim of the study was to determine the efficacy of motivational interviewing (MI), as a brief pre-treatment intervention, to enhance treatment engagement in a standard therapy setting (group cognitive behavioral therapy; gCBT) for adolescents with anxiety and mood disorders.

METHOD

Ninety-six adolescents (13-18 years) with a principal diagnosis of an anxiety or mood disorder participated in a trial conducted at two publicly funded outpatient services. Participants were randomly assigned to individual MI for treatment engagement prior to gCBT (MI + gCBT), or to an individually administered active control (befriending) prior to gCBT (befriending + gCBT). Eight pairs of gCBT were run in parallel. Outcome measures were the mean number of gCBT sessions attended, treatment initiation, and ratings of readiness for treatment.

RESULTS

Participants randomized to MI as a pretreatment intervention attended significantly more group therapy sessions compared to those in the active control condition. The MI group also demonstrated greater treatment initiation, and ratings of treatment readiness were significantly higher for those randomized to MI.

CONCLUSIONS

MI, used as a pre-treatment intervention, enhanced group treatment engagement in adolescents diagnosed with anxiety and mood disorders compared to the active control condition. MI is a promising intervention to facilitate engagement in adolescent mental health settings.

Social contacts and loneliness in people with psychotic and mood disorders

BACKGROUND

Social relations can be measured through: a) objective indicators, i.e. the number of social contacts in a given time interval or b) subjective indicators, i.e. feelings of loneliness. Comparing subjective and objective indicators in patients with psychotic and mood disorders may help to understand whether diagnosis-specific interventions should be designed for increasing their social relations. In this study we assessed social contacts outside home, work environments and mental health services, which may be increased by these interventions. We also explored feelings of loneliness which could influence readiness of patients to participate in interventions.

METHODS

100 patients in outpatient mental health care were asked to: a) list their social contacts; b) report their feelings of loneliness on a validated five point Likert scale. Multiple logistic regression models were used to test associations of diagnostic categories with: a) having more than one social contact in the previous week; b) reporting at least moderate feelings of loneliness.

RESULTS

Patients had on average 1.7 (SD=1.7) social contacts in the previous week (median=1.0); 77 patients reported at least moderate feelings of loneliness. Patients with psychotic disorders (n=30) showed a statistical trend towards having just one or no contacts in the week before the assessment (Odds ratio, OR=2.246, p=.087). Patients with mood disorders were more likely to report at least moderate feelings of loneliness (OR=2.798; p<.05).

CONCLUSIONS

Patients with psychotic disorders, compared to those with mood disorders, may be less likely to report feeling lonely although they tend to have less social contacts. Strategies to enhance social relations of people with psychotic disorders may include approaches to increase patients' drive to establish new social contacts and to emotionally support them in this process.

Strategies used by older women with intellectual disability to create and maintain their social networks: An exploratory qualitative study

Introduction

Social networks are important to health and wellbeing, and enhancing social networks are key occupations for older people. This is relevant for older people with intellectual disability, particularly older women, who face challenges in building social networks, and their social networks are vulnerable to loss as they age. This study aimed to investigate how older women with intellectual disability create and maintain their social networks.

Method

This exploratory qualitative study involved conducting in-depth interviews with five women with mild to moderate intellectual disability (as defined by their service organisation) aged over 50 years and living in the community, using the Support Interview Guide, that has previously been used with younger adults with intellectual disability. Participants could communicate in spoken English. Data were coded line by line and analysed using a thematic analysis.

Results

Participants created social networks independently and through others. Strategies used included communicating, sharing activities, celebrating special occasions, organising activities, supporting each other, having a routine, being out and about and using formal assistance. Barriers and facilitators were also identified.

Conclusion

As older women with intellectual disability age, occupational therapists and support organisations need to focus on assisting this group to build and maintain their social networks.

Personalised support delivered by support workers for people with severe and persistent mental illness: a systematic review of patient outcomes

AIMS

Personalised support services assist patients with severe and persistent mental illness (SPMI) to live with functional deficits by providing living skills, emotional support, community access and advocacy. This paper aims to systematically review the evidence for personalised support.

METHODS

Systematic searches of Medline, PsycINFO and Google Scholar (inception to March 2011) identified studies investigating patient outcomes for personalised support services. The quality of the selected studies was assessed. The strength of evidence for the three categories of patient outcomes (illness acuity, personal functioning and patient satisfaction) was graded.

RESULTS

Fifteen studies met inclusion criteria with most rated as having moderate or weak study designs. The selected studies evaluated programs for outpatients with SPMI. There was moderate strength of evidence for reducing illness acuity and improving patient satisfaction with services, and weak strength of evidence for improving personal functioning in studies published to date. Most programs delivered multiple service types, and no clear pattern of service types leading to specific patient outcomes could be discerned.

CONCLUSIONS

Although evidence published to date for personalised support is of variable quality, it suggests that services may be effective. More research on the effects of personalised support subtypes on patient outcomes is required.

Improving life satisfaction for the elderly living independently in the community: care recipients' perspective of volunteers

With an aging population who wish to remain living in the community, this article explores the experiences and benefits of receiving volunteer services from a home support program established to assist people with increasing needs to remain living independently. Face to face interviews explored how the services of informal carers (volunteers) provided through the program made a difference to the daily lives of 16 recipients. Improved life satisfaction was identified through the themes of being helped with daily activities, positive human contact, and fear of a poorer quality of life. It was found that addressing recipients' social, emotional, and mobility needs supported them to remain living at home.

Befriending for mental health problems: processes of helping

BACKGROUND

One avenue for addressing the social consequences of mental health problems is through befriending, a supportive relationship in which one-to-one companionship is provided on a regular basis. Although there is some evidence that befriending can improve psychological and social functioning, little is known about how it works.

OBJECTIVE

This qualitative study aimed to understand the helping processes occurring in befriending relationships, from the perspectives of both befriendees and befrienders.

METHOD

Semi-structured interviews were conducted individually and jointly with eight befriendees and their corresponding befrienders. Thematic analysis was carried out on the data set of 23 interviews.

RESULTS

The analysis generated nine themes concerning qualities of the relationship valued by befriendees and befrienders (e.g., empathy and mutuality), processes of making meaning (e.g., considering alternative perspectives), and how change was effected in befriendees' lives (e.g., learning how to have healthier relationships with others). The accounts emphasized the importance of the quality of the relationship itself, and highlighted aspects of the relationship that were sometimes difficult to negotiate.

CONCLUSIONS

The findings suggest that befriending shares commonalities with other types of psychological help. However, it is also characterized by some particular challenges, such as establishing an empathic relationship and managing boundaries and endings.

Compeer friends: a qualitative study of a volunteer friendship programme for people with serious mental illness

BACKGROUND

People with serious mental illness (SMI) experience numerous barriers to developing and maintaining friendships.

AIMS

To explore the benefits and drawbacks of an intentional friendship programme (Compeer, Inc), which develops new social relationships for people with SMI by matching them in one-to-one relationships with community volunteers for weekly social activities.

METHODS

Twenty clients and volunteers, in Compeer friendships for different lengths of time, participated in individual semi-structured qualitative interviews. Several volunteers were themselves current or former consumers of mental health services.

RESULTS

Participants reported numerous benefits to participating in Compeer. Clients and volunteers spoke enthusiastically about the benefits of gaining a friend. Many intentional relationships deepened over several years into mutually beneficial friendships. Most clients became more outgoing, sociable and active, with increased self-esteem, self-worth and self-confidence. Volunteers who had experienced mental illness themselves provided unique added benefits to the relationship. Drawbacks were minimal and financial and other costs to volunteers were low.

CONCLUSIONS

Intentional friendships can be a potent yet cost-effective way to help people with SMI develop social skills, expand their social networks, and improve their quality of life. However, because relationships take several years to develop, quantitative evaluations using short follow-up periods may underestimate programme effectiveness.

Developing Pilot Befriending Schemes for People with Autism Spectrum Disorders in a Region of Greece: Lessons from Practice

Befriending represents an expanding resource for the social support of vulnerable people in the community. This article discusses the development of two pilot befriending schemes for individuals with Autism Spectrum Disorders (ASDs) in the central region of Greece. In the first part, the context, the aims and participants of the schemes are described and in the next part, the positive aspects and obstacles encountered in both schemes are discussed.

Knowledge about social networks and integration: a co-operative research project

AIM

This paper is a report of a study investigating how knowledge of social network and integration influenced mental health professionals' understanding and practice.

BACKGROUND

Community mental health work focuses on people suffering from mental health problems as well as the consequences for the person involved and their family or network. There is a need to expand community mental health workers' knowledge about social networks and their functions.

METHOD

A qualitative study using a co-operative research approach was used to develop participants' knowledge of social network and social integration theory. Action research has the potential to facilitate changes in the field. Data were collected using focus groups. Qualitative content analysis was employed to develop the theme and categories. The data were collected in 2004-2005.

FINDINGS

The main theme identified was the potential of experiential knowledge-based competence, which was characterized by the following categories: (1) increased knowledge, (2) awareness of social interactions, (3) cross-disciplinary professionalism and (4) potential for changes in practice. Participants' knowledge and awareness of the potential of social integration as a tool for social network interventions were considerably strengthened. However, this knowledge needs to be implemented in practice.

CONCLUSION

Co-operative research is an approach that can be beneficial in the public sector. To achieve the best possible results, the whole team must be involved and play an active part in all areas of the research project. If the groups involved are too large, participants' level of engagement may suffer.

Combating loneliness among persons with severe mental illness: social network interventions' characteristics, effectiveness, and applicability

More than half of people with severe mental illness are lonely, the subjective state associated with social isolation and lack of desired relationships. Their loneliness is related to impaired ability to make and keep friends, lack of opportunities to participate in social activities, and stigma associated with mental illness that creates barriers between them and their communities. Treatment for people with severe mental illness often fails to include social network interventions that have the potential to decrease loneliness. Knowledge of social network interventions-their characteristics, effectiveness, and applicability for specific patients-can guide nurses' use of these treatment modalities.

Social support in the healthcare setting: the role of volunteers

The participation of volunteers in the National Health Service (NHS) has been actively promoted during recent years, particularly within community and primary healthcare services (National Health Service 1996, 1998). As a consequence, volunteers currently make a significant contribution to health and social care within the UK. Concerning this contribution, the literature often portrays the volunteers' role as one of providing social support. In the present paper, the authors attempt to explore this role in more detail, drawing on interview data from studies of two separate volunteer programmes. One of these considered the role of volunteers supporting older hospitalised patients (Davies et al. 2001), and the other was based within general practice (Faulkner 2003, 2004). The social support provided by these programmes is considered from the perspective of four broad support mechanisms described by Langford et al. (1997), namely: emotional support; informational support; appraisal support; and instrumental support. Secondary analysis examines the potential contribution of volunteers to patient well-being.

Peer support within a health care context: a concept analysis

Peer support, and the integration of peer relationships in the provision of health care, is a concept of substantial significance to health scientists and practitioners today, as the focus shifts from the treatment of disease to health promotion. If the nursing profession is to effectively incorporate peer relationships into support-enhancing interventions as a means to improve quality care and health outcomes, it is essential that this growing concept be clearly explicated. This paper explores the concept of peer support through the application of Walker and Avant's (Strategies for Theory Construction in Nursing, 3rd Edition, Prentice-Hall, Toronto, 1995) concept analysis methodology. This analysis will provide the nursing profession with the conceptual basis to effectively develop, implement, evaluate, and compare peer support interventions while also serving as a guide for further conceptual and empirical research.

Community care for people with disability: blurring boundaries between formal and informal caregivers

Health care for individuals with disability is increasingly shifting from institutional settings to the "community," with assistance by those in the formal sector. In this article, the authors examine 5 case studies illustrating interactions and relationships between people with disability and their caregivers, using qualitative data collected as part of a community study of disability conducted in a medium-sized city in the northeastern United States. Employing the task specificity framework, they explore the implications of using either formal care providers to fill needs that are more typically met by family and friends or family caregivers to provide care that is best provided by the formal sector. Although our narratives illustrate the negative implications of mismatched care substitution, we conclude that the framework is less applicable to emerging systems of community care.

Social network and social support characteristics amongst individuals recently discharged from acute psychiatric units

This study compares the social support network of a diagnostically heterogeneous group of community mental health service users recently discharged from acute inpatient units, with that of a mental health service user comparison group with no history of hospital admission. Social data were elicited by a structured interview schedule (the Social Network Schedule). It was observed that the study group was characterized by smaller overall social networks, particularly within the primary network, but conversely the group had a greater proportion of service user peer contact. Few differences in perceived social support between groups were observed, although the study group reported fewer confidants. The implications of the study for nursing staff are discussed.

The dialectic of friendship for people with psychiatric disabilities

In the psychiatric literature, the meaning and importance of friendship has remained largely unexplored, subsumed under the rubric of social support or viewed as a component of community integration. Twenty-one qualitative interviews were conducted with individuals suffering from psychiatric disabilities focusing on the meaning of friendship as they described it. Analysis revealed the contrasts, contradiction and paradox of friendship for this group of people. The ongoing struggles of people with psychiatric disabilities regarding the need to connect with others and have friends, and conversely, the need to be alone and to withdraw from others, was highlighted.