Social network transactions of psychiatric patients

Sot Scr M-d Vol 34, No 4, pp 433-445. 1992 02179S36/92 $5 00 + 0 W Pnntcd m Great Bntam All nghts reserved Copyright 0 1992 Pergamon Press plc

SOCIAL NETWORK TRANSACTIONS OF PSYCHIATRIC PATIENTS

GEOFFREY NELSON,’ G BRENT HALL,~ DENDE SQUIRE’ and RICHARD T WALSH-B• WERS~ ‘Department of Psychology, Wilfnd Launer University, Waterloo, ON N2L3C5, Canada, ‘School of Urban and Regtonal Planmng, Umverstty of Waterloo, Waterloo, ON N2L 3G1, Canada and

‘Department of Psychology, Wtlfnd Launer Untverstty, Waterloo, ON N2L 3C5, Canada

Abstract-In thrs research we examme self-reported soctal network transacttons of former psychtatnc mpattents restdmg m dtfferent types of housmg m the commumty Unhke earlrer research, we found constderable rectproctty m network transacttons with famrly and friends Only professtonals provtded more support than they recetved from patients Provtdmg emotronal support to others was postttvely correlated wtth postttve affect, commumty mtegratton, and mastery Respondents reported more supportrve than unsupporttve transacttons with network members and more supporttve transacttons wtth fnends than wtth famtly or professtonals Fmally, residents of supportrve apartments and group homes provrded and recetved support more frequently than restdents of board-and-care homes We drscuss the results In terms of thetr imphcattons for pohcy and future research

Key words-housmg, networks, adaptatton, rectproctty

INTRODUCrION

The last several years have Seen unprecedented growth m the number of supporttve housmg programs m Ontario, Canada and elsewhere for former psychtatnc inpatients [l]. Geographers, planners, psychologtsts, and soctal workers have begun to examme the phtlosophy, context, process, and outcome of supportive housmg for this population [2+. In contrast to pnvately-owned and operated housing (e g nursmg homes, board-and-care homes [BCH], angle-room occupancy [SRO] hotels), “supportive” housing is not for profit Staff members in supportive housing encourage residents to support one another and to become mvolved in hfe m the community. The purpose of this paper is to examine social network transactions m the context of supportive housing and BCH To this end, we diverge from the traditional emphasis on the structural aspects of patients’ networks (e g size, density) and concentrate, instead, on the functional charactensttcs of soctal network transactions We focus on the actual nature of supporttve and unsupporttve transactions (as reported by patients), because they have been neglected m pre- vtous research and because we believe that these transacttons are likely very important for patients’ adaptatton to community life [5-6]

Socral network size and cotnposrtion

Research on the soctal networks for psych&c Inpatients has found that they tend to be relatively small (5-10 close network members) with a high proportton of family members [7-IO] One aspect of patients’ networks whtch has not been closely exammed IS the gender of network members. It has been suggested that women are soctahzed both to seek and

to give mttmate support more than men [l 1, 121 In the study of family stress related to caregtvmg to adult children wtth psychtatnc problems, the vast maJority of pnmary caregivers are women, usually mothers or sisters [13-15)

Functional aspects of network transactions

Supportive and unsupportlve transactlons There have been many attempts to classify the types of transactions between network members. Four types of supportive transacttons have emerged fairly consistently from theoretical and empirical attempts at classification (1) emotional support, (2) sociahzing support, (3) tangrble support and (4) problem-solvmg support [l&18]. Emotional support, whtch has also been referred to as mttmate mteraction, esteem support, or non-drrecttve support, refers to the ex- pression of warmth and approval and is important for meeting a person’s need for care, love, esteem, and value [19]. Soctahzmg support 1s concerned with social-recreational interactions which can help meet a person’s need for belonging, sense of commumty, and fun [19,20]. Tangible assistance refers to practical asststance with dally hvmg tasks and chores Finally, problem-solvmg support means advice, m- strumental support, or dtrecttve guidance which can help a person to cope with and solve problems m living [21].

The very term “soctal support” mdicates that the posttive aspects of soctal network transacttons have received pnmary emphasis. More recently, empirical [22,23] and theoretical papers [20,24,25] have pointed to the need to examine negative, unsupportive, and upsetting transacttons Potenttally negative aspects of the four types of social network transacttons can be delineated [26] Emottonally

433

434 GEOFFREY NELSX el a/

unsupporttve transacttons refer to cntrclsm, ndrcule, or relection Socially unsupportive transactions refer to excluston from soctal-recreational actlvrttes, while tangible unsupportrve transactions refer to refusal to provide practical help Fmally, unsupporttve problem-solvmg transacttons refer to encouraging a person to avotd or deny a problem

While there has not been any research with psychratnc patients which examines these types of supportive and unsupporttve transactions, there has been research on such transactions with other populations, mcludmg people whose spouses have Alzhetmer’s disease [26] and cancer patients [27] This research has found that while unsupporttve transactions occur far

less frequently than supportive transactions [26-281, unsupporttve transactions are more strongly related to people’s emottonal well-being than supportive transactions [26-281

Sources of soual network transactions Few studies have examined the types of transactions psychtatnc pattents have with people from different parts of their network. In a study of ex-patients restdmg m BCH, Parks and Prhsuk [29] found that supportive emottonal, soctal, and tangible transactions occurred most often with hvmg companions and friends as opposed to family members However, the malortty of patients reported that they would turn to family or the BCH operator first tf they needed emottonal or tangible help

With regard to unsupporttve transactrons, Vaughn and Leff [30] have reported that the level of expressed emotion m famrhes IS a stgmficant predictor of relapse for former psychtatnc inpatients Expressed emotion has been defined as crttrcrsm, hostrhty, and overm- volvement Crtttcs of this concept have argued that It has been used by professronals to “blame the vrctrms” [31], and that It reinforces family members’ doubts and tendencies toward self-blame [32] Like the “schrzophrenogemc mother” concept before it, the concept of expressed emotion could be a new form of “mother blammg” [33] While the ongmal research on expressed emotion dtd consider both supportive and unsupportrve transactrons, research needs to consider the sources (family, friends, and professtonals) of such transactions for a more thorough understanding of these phenomena

Reclprocrty of social network transactions

While socral network transactions have been con- ceptualized as an exchange process [20,25], very little research has focused on the participant as the provider of supportive or unsupporttve transactions Instead, most studies and most social support scales that have been developed focus on the pafiictpant as the recipient of various types of social support However, Rressman [34] has argued for some time that provrdmg support to others IS very important for one’s well-bemg Moreover, recent mvestrgattons of the elderly [35] and church group members (361 have found that rectprocrty of supportive exchanges 1s

related to well-being, thus supporting Rressman’s hypothesis Constantly bemg on the recetvmg end of social support wrthout opportumtres to reciprocate (as m the case of being a client m some type of therapy program) may foster dependency and lower self-esteem [25, 341

Research on current and former psychratnc patients has consistently found a lack of rectprocrty m network transactions, patients have been found to receive support more often than they provide support to others Tolsdorf [IO] found that psychtatnc patients reported providing less support and receiving more support from network members than did medr- cal patients Moreover, the psychratnc patients reported having more asymmetnc (I e non-rectprocal) relationships with network members than did the medtcal patients In a study of people hvmg m SRO hotels, Cohen and Sokolovsky [7] found that level of symptomatology m schtzophrema was dtrectly assoct- ated with asymmetric relatronshrps with others Fmally, m the previously mentioned study of psychtatnc patients residing m BCH, Parks and Pthsuk [29] found little evidence of recrprocrty m the network transactions of residents Almost no rectprocrty was reported m relattonshtp with BCH operators, while there was some reclproctty m transactions wtth fellow resrdents

One could take these findings at face value and suggest that the patients and their symptomatology are solely responsible for the observed lack of recrproctty However, rt 1s possible that hospitals, SRO hotels, and BCH can be oriented towards promotmg mstttutronal dependency rather than mdependence m residents [37,38] Thus, there may be a norm m such settings that the role of the resident 1s to be the passive recipient of caregrvmg, not an active agent who IS expected to be responsible, self- sufficient, and helpful to other residents Therefore, rt may be important to examine the context of network transactions to understand the finding of

non-reciprocity

Context of social network transactions

Several researchers have argued that tt IS important to consider the social context of social network transactions [12,20, 391 In then review of the htera- ture, Nelson and Smith Fowler [4] reported that housmg charactenstrcs, such as size and physrcal- architectural features, are related to social mter- actions Nelson and Earls [40] found that psychratnc patients hvmg m their own home, their parents’ home, or a group home reported more people in the residence who provided soctal and tangrble support than patients hvmg m a pnvate apartment or room- mg srtuatron In a study of psychratrtc patients who were diagnosed as having schrzophrema, Goldstem and Caton [41] found that patients who hved wtth family members reported higher levels of both supportive and unsupportrve network transactions than patients hvmg alone or m SRO hotels Thus, the

Social network transactlons 435

type of housmg may be related to social network related to patients’ adaptation, mcludmg transactlons measures of

Socrat network transactlons and adaptation to commu- mry hfe

Several studies have exammed the relatIonshIp between social network transactlons and vanous mdlcators of patients’ adaptation. Rates of rehospl- tahzatlon have been found to be Inversely related to frequency of supportive transactlons (41,421 and directly related to the frequency of unsupportlve transactlons [41]. It has been reported that commumty integration IS posltlvely correlated with both provldmg and recelvmg emotional support [43,44] Frnally, frequency of supportive network transactlons has been found to be related to emotlonal well-bemg [43,45]

(a) posltlve affect, (b) negative affect, (c) sense of mastery (d) commumty mtegratlon, and (e) Independent functioning?

Answers to these questlons will be used to make recommendations for pohcy, practice, and future research

METHOD

Settmgs

Research questions

This mvestlgatlon attempts to provide answers to several research questions

Partlclpants for this research project were “re- crusted” with the assistance of the mental health workers who have regular contact with residents of houstng programs for mdlvlduals with a psychlatnc hlstory Residents of supportive housmg were contacted prlmanly na housmg directors and staff, and partlclpants hvmg m BCH were contacted through mental health workers who vIsIted these homes on a regular (usually weekly) basis Members of the research team mltlally met with housing directors, housmg staff, and mental health workers to explam the nature of this study

What ts the size and composltlon of psychlatnc patients’ social networks with respect to the type of network member (family, fnend, professlonal) and the gender of network members?

(4

(b)

(4

(4

(b)

Are there differences in the proportIon of network members with respect to supportive vs unsupportlve transactlons? Are there differences m the proportlon of network members with respect to type of network member (family, fnend, professional) provldmg or recelvmg support? Are there differences m the proportlon of network members with respect to provlding vs recelvmg support? Are there differences m the frequency of network transactlons with respect to sup- portlve vs unsupportive transactIons Are there differences m the frequency of network transactlons with respect to proved- mg vs receiving support?

Are there slgmficant correlations between the number of people to whom supportive or unsupportive transactlons are provided and the number of people from whom supportrve or unsupportlve transactlons are received, thus m- dlcatmg reclproclty of exchange? Are there slgmficant correlations between the frequency of provldmg supportive and unsupportlve transactlons and the frequency of recelvmg supportive and unsupportlve transactions, thus mdlcatmg reclproclty of exchange? Do residents of supportive group homes (GH) and supportive apartments (SA) differ frdm residents of BCH with respect to mdlces of supportive and unsupportlve transactlons pro- vlded and received and measures of adaptatlony Which measures of frequency of provldmg and recelvmg various types of supporttve and unsupportlve transactIons are most strongly

A total of seven housmg programs operated by five mental health orgamzatlons tn southwestern Ontano was mvolved tn the research five SA programs and two GH In addltlon, four BCH, which are operated by pnvate owners but which have regular contact with one mental health organization, have taken part m the research All of the programs provide permanent housing for psychlatnc patients Indlvtduals who are consldered to have long-term and serious mental health problems are ehglble for residency Most residents have had repeated hospltahzatlons and have been diagnosed as havmg schlzophrema, chrome depresslon, or mamc-depresslon. Indlvlduals who are violent or who have a recent hlstory of drug or alcohol abuse are not ehglble to enter any of the programs

The residences vary with respect to physical en- vn-onment and level of support for residents All the GH studled provide 12-24 hr of staff support per day, while all of the SA programs studied provtde dally contact to “on call” support Some BCH are quite structured with many rules Imposed on residents by operators, while others are quite unstructured and lax Slmllarly, some operators are quite concerned about and supportive towards residents, while others appear dlsmterested and unsupportlve

In general, the SA programs endeavour to provide flexible support that meets the needs of mdlvldual residents and faclhtates Independent hvmg. These residences are m urban and suburban nerghbour- hoods and most are located m newly constructed bulldrngs or townhouse complexes The GH aim to

436 GEOFFREY NELSB et al

provtde more structured support than the SA, they too are located m urban and suburban netghbour- hoods and tend to be quote “home-like” Wtth one or two exceptions, the BCH have no mandate other than to provide accommodatton and meals for thetr restdents Restdents of some BCH have the opportunity to participate m social and recreattonal activttles conducted by mental health workers from outside

their restdence, but these acttvittes are avatlable only on a weekly basts Most residents of BCH live m the central business area of thetr cities, and these rest- dences, with one or two excepttons, tend to be crowded, accommodatmg 12 to 22 residents, noisy, and occasionally run-down

Snmple

There were 66 participants m the study, 40 men and 26 women Parttcrpants resided m SA (n = 43), GH (n = lo), and BCH (n = 13) at the ttme of the study The malortty (73%) of participants received social assistance, while 27% were employed either part-time or full-time The modal mcome was %750-$1000 per month More than half of the participants (56%) had obtained their high school dtploma, and most (92%) were smgle, separated, divorced, or widowed All of the parttcipants were receiving at least one type of psychotroptc medlcatton to control the symptoms of their disorders The participants ranged m age from 20 to 66 (average age = 34 4 years)

IntervIew procedure

Imttal contact with potential parttctpants was made by program staff, who gave restdents a cover letter from the mvesttgators descrtbmg the research, what was involved for them, and their nghts as participants Whtle we do not have precise figures on response rates, staff of SA and GH reported that most new residents agreed to participate On the other hand, staff contacts for the BCH reported that a mmonty of BCH restdents agreed to participate Thus, while we have a fairly representative sample of SA and GH, we have, at best, a convemence sample of BCH restdents Restdents who were interested m being interviewed then met with one of the research asststants The six research asststants all have a background m psychology or social work, and all but one are women Interviewers explamed that the mterviews were confidential, that nothmg restdents said would be conveyed to program staff or would Jeopar- dize their residence m the program, and that they had the right to refuse to answer questions The mtervlew procedure was quite flextble Residents were free to choose the date, ttme, and locatton of the mterviews (1 e at their restdence, at a coffee shop, or 3ome other place), as well as thetr preferred mtervtew procedure The latter could mvolve havmg the interviewer ask the questions and record the answers, readmg and wntmg responses themselves, or some other agreeable combmation Our rationale m provldmg a flexible data collection procedure IS that maximtzmg the

comfort level of the partictpants would enhance the quality of the data obtained We also recognize that this procedure may have influenced the partictpants m other ways None of the restdents appeared to be actively delustonal or hallucmatmg durmg any of the mtervtews Residents were asked to respond to two mtervlew schedules a Soctal Network Transaction schedule and an Adaptation to Community Life schedule Nmety percent of the residents of SA and GH completed both of these schedules wtthm three months of moving mto thetr residence After these mtervtews were conducted and the data analyzed, wntten feedback reports were prepared for each of the agenctes and for the residents who parttctpated In the research

Soual network transaction measures

Data on four general aspects of restdents’ social networks were obtained First, residents were asked to name the people who were important to them, whether they liked them or not, and with whom they had contact m the past rune months This network list provtded basic mformatlon on network stze catego- nzed mto three network segments, namely, family, friends, and professtonals Two-week test-retest re- habihty coefficients for a sample of 39 university students are as follows family (0 94), friends (0 83), professionals (0 73), and total (0 89) Second, restdents were asked to describe qualitatively how their relattonshlps had “changed durmg the past few months” m terms of both positive and negative changes

Third, restdents were asked to provtde mformatton on the nature of contacts with network members, specifically the number of network members who provtded or recetved supportive and unsupportive transactions Residents identified those members on their network hst to whom they had provided the four

types of supporttve and unsupportive transactions (emottonal, soctal, tangible, and problem-solvmg) For example, the question “Who on the list have you provided expresstons of care, love, esteem, or value to m the past month?” was used to assess emottonal support provided On the other hand, the question “Who on the hst have you provided expressions of cntictsm, ndicule, or rgectlon to m the past month”” was used to assess emotionally unsupportive transactions provtded For each item, scores were obtamed by sum- ming the number of people named m the three network segments The same questtons and scoring were used to assess supportive and unsupportive transactions recetved from network members

The fourth measure was the frequency of supporttve and unsupporttve transacttons provrded to and received from network members For each of the four types of supportive transactions given and received, restdents were asked to rate, on a five-point scale, how frequently that transaction had occurred m the past month (1 = “not at all” to 5 = “almost every day”) The average frequency scores are for all

Socral network transactrons 437

network members (I e they dtd not dtfferenttate between types of network members).

The latter two measures are new scales constructed for thts study Smce we wanted to examme the rectproctty of supportrve and unsupporttve transactrons, tt was necessary to develop these new scales None of the extstmg social network or soctal support scales examme both support or non-support provtded and recetved

We obtamed some rehabrhty and vahdtty data on these new scales To estimate rehabthty, we computed Cronbach’s alpha on the four items of each of the etght subscales These values, which are presented m Table 1, mdtcate reasonable Internal conststency for SIX of the subscales To estrmate convergent vahdtty, we correlated the erght subscales wtth the well-estab- hshed measure of total network stze (see Table 1) Not only do all of the subscales correlate stgmficantly wtth total network stze, but they all correlate stgmficantly and m the expected direction with one another

Adaptation to commumty h/e measures

The first dtmenston of adaptatton to commumty life measures postttve and negattve effect Five Items were used to assess posittve affect (happy, Joyful, pleased, glad, and dehghted) and negattve affect (angry, depressed, worned, frustrated, and sad) These Items, measured on a five-pomt scale, were extracted from Drener and Emmons [46] and Folk- man, Lazarus, Gruen and De Longts [47] Scale end-pomts ranged from “not at all” to “every day” Cronbach’s alpha was 0.89 for posmve affect and 0.84 for negattve affect Addttronally, posmve affect IS directly correlated wtth our measure of commumty mtegratton (r = 0 43) and negatrve affect IS mversely correlated with a measure of mastery (r = 0 42) Postttve affect and negative affect were stgmficantly mversely correlated (r = - 0 35)

Community Integration was measured by a seven- item scale denved from Segal and Avtram [48] Restdents were asked whether or not they had parttctpated m seven acttvittes m the past week, mcludmg eatmg m a restaurant/coffee shop, gomg shoppmg, partictpatmg m a commumty group or acttvtty, vistt- mg wtth others, partrctpating m a recreational event,

domg volunteer work, and gomg to work or school Cronbach’s alpha was 0 62, and thts measure was postttvely correlated wtth posittve affect (r = 0 43) and mastery (r = 0 33)

Mastery was measured usmg a seven-Item scale developed by Pearhn and Schooler [49] Items reflect the extent to whtch tndrvtduals percetve that they have control over thetr hves and are rated on a four-pomt scale from “strongly agree” to “strongly dtsagree” The scale was found to be mternally conststent (x = 0 69) and was correlated m expected dtrecttons with the above measures

Fmally, we mcluded a stx-ttem measure of mdependent functtonmg, revtsed from a scale used by Rappa- port et al [50] The Items measure the degree to which a restdent IS able to functton mdependently m areas such as money management and housekeepmg Res- idents rated each Item on a three-pomt scale “others’ responstbthty”, “shared responstbthty”, and “own responstbthty”. Cronbach’s alpha was 0.67, and thts scale correlated stgmficantly (r = 0.21) wtth Mastery

RESULTS

Socral network sue and cotnposltlon

The average network stze for the sample was 12 76, wtth an average of 4 73 famtly members, 5 02 fnends, and 3 01 professtonals. We exammed the average stzes of pattents’ network segments by then gender and the gender of network members (see Table 2) A 3 x 2 x 2 mrxed ANOVA was performed to examme the assoctatton of network stze with network segment (a repeated factor conststing of three levels), gender of network member (another repeated factor wtth two levels), and gender of parttctpant (a between factor wtth two levels) All three vanables Interacted to Influence network stze, F(2,122) = 17 43, P < 0 001 There was also a stgmficant mteractton between gender of network member and gender of parttctpant, F(1,61) = 22.24, P < 0 001

To determine the nature of the three-way mteractton, the procedure of sample effect comparisons described by Keppel (51, pp 303-3121 was used Rrst, the mteractron between gender of network member and gender of parttctpant was exammed at

Table I Corrclatron matnx for sowal network transactIon measures

Cronbach’s

Aloha 1 2 3 4 5 6 I 8

I Total network we

Functional network we

(number of ocoole~

’ 2 Provtded ,os;tw; transactlon 0 62 0 60

3 Prowdcd negatwe transactIon 0 72 0 52 061

4 Recerved posttlve transaction 0 70 . 062 081 0 34 - 5 Rcccwed ncgatwe transactlon 041 c 041 0 45 038 041

Frequency of &ansacttons -

6 Prowded posltwe transactlon 0 63 038 053 0 36 047 0 28

7 Prowded negattve transactIon 0 40 031 0 50 0 70 0 40 0 55 0 58 8 Reccwed powtve transactlon 0 70 034 050 027 0 61 0 34 0 63 051 - 9 Recetved nenattve transactlon 0 67 0 34 031 0 68 031 0 79 031 0 59 0 36

Note All correlattons are stgmficant at the 005 level Correlations that are undcrhncd mdlcatc the degree of

rectproctty m prowdmg and recewmg supportwe network transactlons

438 GEOFFREY NELKF. er al

Table 2 Average wze of network segments for psychlarrlc pauents by gender of partxlpant. gender of network members, and network

segment

Pdrt~c~pant’s gender

Network segment

Family

Fnends

Professionals

Gender of network members

Me” Women

Me” Women

Me” Women

Men (n = 40) Women (n = 26)

Mean (SD) Mean (SD)

I 77 (0 35) 2 II (2 07) 2 66 (1 33) 3 08 (2 54) 3 32 (2 44) I 46 (1 58) I 60 (1 74) 3 69 (3 21) I 24 (1 03) I 40 (1 44) I 40 (1 46) 2 20 (1 56)

each of the three levels of network segment Only the mteractlon at the level of friend was slgmficant, F( 1,64) = 39 20, P < 0 001 Men reported havmg more men fnends, while women reported having more women fnends

There were also mam effects for gender of network member, F(1,61) = 11 69, P < 0 001, and for network segment, F(2,122) = 8 88, P < 0 001 Partlclpants have more women than men m their networks, and they have more family and friends than professionals

Functional aspects of network transacflons

The proportions of people In the different network segments who provided and received the different types of supportive and unsupportlve transactlons are presented m Table 3 The proportion scores were obtained by dlvldmg the number of people who either provided or received the specific type of supportive or unsupportlve transaction by the total number of people m the network segment Thus, scores can range from 0 to 1 0 From the bottom half of the table, one can see that the proportions of people m the three network segments who provided or received any of the four types of unsupportlve transactlons are very low On the other hand, the data m the top half

of the table show higher proportions of people who provided or received supportive transactions Almost wlthout exception, there IS a descending proportion of supportive transactions, either provided or received, m the followmg order emotional (highest), social, tangible, and problem-solvmg (lowest) The one clear exception to this pattern IS that the partlcl-

pants received problem-solvmg support more than social or tangible support from professionals

A 3 x 2 x 2 x 2 mixed ANOVA was performed to examine the assoclatlon between the average scores (proportions) and network segment (a repeated factor with three levels), supportive vs unsupportlve transactions (a repeated factor with two levels), provided vs received (a repeated factor with two levels), and gender of participant (a between factor with two levels) Gender of participant dtd not interact with any of the other vanables, nor was there a mam effect for gender Therefore, gender was dropped as a factor m the ANOVA, and a completely wlthm design (3 x 2 x 2) was used There was a significant interaction between all three vanables, F(2,124) = 4 05, P ~0 05 All of the other mter- actions were also significant supportive vs unsupportlve by provided vs received, F(1,62) = 5 23, P < 0 05, supportive vs unsupportlve by segment, F(2,124) = 7 11, P < 0 00 I, and provided vs received by segment, F(2,124) = 3 18, P < 0 05 Finally, there were slgmficant mam effects for segment, F(2,124) = 5 77, P -C 0 01, and supportive vs unsupportlve, F(1,62) = 73 64, P < 0 001, but not for provided vs received

The nature of the mteractlons was probed using the simple effect comparison procedures once again The mteractlon between network segment and provided vs received was examined at each of the two levels of supportive vs unsupportlve The network segment by provided vs received Interaction was not slgmficant at the level of unsupportlve transactions, but was slgmficant at the level of supportive transactions, F(2,128) = 4 29, P < 0 05 To further explore the slgmficant mteractlon, paired t-tests were used to compare support provided with support received at each of the three levels of network segment The only slgmficant difference between support provided and support received was at the level of professlonal, r(64) = 2 31, P < 005 Support received from pro- fesslonals was higher than support provided to professionals

In summary, the proportion of network members involved m unsupportlve transactions IS quite low and does not vary by either segment or provided

Table 3 ProportIon of people m dIKerent network segments to whom supportwe and unsupportwe transaclmns were prowded and from whom supportwe and unsupportwe transactions were rewved

Type of tr‘i”saCtl”” Famllv

Prowded to Received from

Friends Profewonals Fbmlly Friends Professionals

Supportwe EmotIonal Scclal Tangible Problem-solving Average

unsupporwe Emotmndl Social T.inglble Problem-solvrng Average

0 51 0 52 0 26 0 43 0 13 - 028 0 08 =o I3 0 25 0 34

0 IO 0 II 0 IO 0 II 0 05 0 07 0 02 0 03 007 0 OS

0 37 0 I4 0 03 0 05 0 I5

0 09 0 IO 0 IO 0 02 0 ox

0 45 0 46 0 25 0 43 0 I7 0 22 0 13 0 I3 0 25 031

0 IO 0 08 0 05 0 08 0 04 0 02 0 05 0 05 0 06 0 06

0 33 0 IS 0 I6 0 25 0 22

0 05 0 I3 001 0 04 0 06

Social network transactions 439

vs received In contrast, supportive transactlons, whether provided or received, were higher for fnends than for family However, supportive transactions received from professionals was higher than supportive transactlons provided to professionals

The average scores for frequency of supportive and unsupportlve transactions provided and received are presented m Table 4 On the frequency measure, the scores for unsupportlve transactions, provided or received, were quite low. On the other hand, scores for supportive transactions, either supported or re- celved, were higher and showed the followmg descending order of magnitude emotional (highest), social, tangible, and problem-solving (lowest) A 2 x 2 x 2 mixed ANOVA was performed to examme the assoclatlon between the frequency scores and supportive vs unsupportlve (a repeated factor with two levels), provided vs received (a repeated factor with two levels), and gender of participant (a between factor with two levels) Gender did not interact with the other vanables, nor was there a mam effect for gender Therefore, gender was dropped from the analysis, and a 2 x 2 completely wlthm ANOVA was performed The two vanables did not Interact, nor was there a mam effect for provided vs received However, there was a mam effect for supportive vs unsupportlve, F(l,52) = 107.71, P < 0 001 The participants reported more supportive than unsupportlve transactions

Rectprocrty of soctal network transactrons

The reclproclty of social network transactions was examined m two ways First, the ANOVA analysis reported m the previous section examined the associ- ation between the variable provided vs received and proportion of network members mvolved m transactions and frequency of transactions Neither of these two variables was associated with the variable provided vs recerved This result shows that partla- pants did not receive supportive or unsupportive transactions either more or less than they provided these transactions, thus mdlcatmg reclproclty The second way of assessing reciprocity IS to examme the correlations between supportive and unsupportlve

Table 4 Average scores for frequency of supportwe and unsupportwe transactmns prowdcd to and reccwed from network members

Prowded to Recewed from Type of transaction Mean (SW Mean (SW

supportlvc EmotIonal 2 89 u 32) 3 06 (1 21) Social 2 58 (1 30) 2 73 (1 21) Tangtble 2 35 (1 24) 2 23 (1 13) Problem-solvmg 1 86 (1 09) 2 04 (1 1Q Avcragc 2 42 (0 85) 2 52 (0 82)

Unsupp0rt1vc EmotIonal 171 (0 96) 1 99 (1 11) Soual I 72 u 24) I 48 (0 95) Tangible I 23 (0 68) I 29 (0 90) Problem-solnng I 20 (051) 1 42 (0 88) Average I 47 (0 54) 1 54 (0 67)

Note High score means a high frequency

transactlons provided and received These correlations are presented m Table 1

Correlations between the measures of functional network size are presented m the top part of the table The correlation between the number of people to whom support was provided and from whom support was received IS 0 81, mdlcatmg a substantial degree of reclproclty This correlation 1s also higher than the four correlations that are not underlined (and which do not indicate reciprocity) Usmg Fisher’s r to 2 transformation, It was found that the correlation of 0 81 was slgmficantly higher than these four correlations The correlation between the number of people to whom unsupportlve transactions were provided and from whom unsupportive transactions were received IS 0 68, which again shows considerable reclproclty This correlation IS slgruficantly higher than three (0 34, 0 41 and 0 45) of the four corre- latlons not underlmed Thus, not only are the correlations mdlcatmg reclproclty quite substantial for the functional network size measures, but they are also higher than the correlations m which reciprocity IS not expected

The correlations between the frequency of supportive and unsupportlve measures are presented m the bottom part of the table The correlation between the frequency of support provided and the frequency of support received IS 0 63, again mdlcatmg a high degree of reclproclty Moreover, this correlation 1s slgmficantly higher than two (0 31 and 0 36) of the correlations that are not underlined The correlation between the frequency of unsupportlve transactions provided and received 1s 0 59, showing considerable reciprocity This correlation 1s slgmficantly higher than two (0 31 and 0 36) of the four correlations not underlined While the correlations mdlcatmg re- clprocity for the frequency measures are quite high, they are not consistently higher than those correlations m which reclproclty 1s not expected

Context of soctal network transactlons

To examme the context of social network transactlons, we looked at the average scores on the social network size and transaction vanables and the dependent variables (posltlve affect, negative affect, commumty integration, mastery, and independent functlonmg) by the three types of housing m which the partlclpants resided (see Table 5) For each of these vanables, two orthogonal planned compansons were computed The first compared the average of the residents of GH and SA (1 e those m supportive housmg) with those m BCH, while the second compared the residents of GH and SA The residents of BCH had fewer family members, fnends, or pro- fesslonals m their networks than the residents of either GH or SA, but none of these differences was slgmficant Residents of the three types of housing also did not differ slgntficantly on the number of people to whom supportive or unsupportlve transactions were provided

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Social network transactions

Table 6 Stepwx muluplc regrewon analyses wth frequency of supportwe and unsupportwc transactton measures as the Independent vanables and posrttve affect,

negatwe affect, communtty mtepatmn and mastery as the dependent vanables

Statlstlcs Dependent Independent variable vanable r RZ Fkta ! or F

Posltlve Supporwe 045 0 20 0 45 r(64) = 4 01’ affect emottonal (pronded)

All predtctors 0 20 F( I ,64) = I6 04. Negatwc Unsupportwe 0 27 0 07 0 27 r(64) = 2 22’

affect emottonal (pronded) All predxtors 0 07 F(l,64)=491*

Communtty Unsupporuve 0 47 0 22 0 33 r(64)=3 IlO mtcgatlon social (recewcd)

Supportwe 0 43 0 32 0 33 1(64) = 3 19. emottonal (pronded) Unsupportwc 034 039 0 26 f(64) = 2 59’ emottonal (recewed) All predtctors 0 39 F(3.62) = I3 IS*

Mastery Unsupportwe 0 37 0 I3 0 35 f(64) = 2 92’ soctal (pronded) Supportwe 0 II 0 I9 031 r(64) = 2 67’ tangtblc (recetved) Supportwe 036 024 031 r(64) = 2 62’ cmottonal (provtded) All predictors 0 24 F(3.62) = 7 75.

441

l P coo5

emotional (provided), and unsupporttve emottonal (received) Together these variables accounted for 39% of the variance in commumty integration There were also three predictors of mastery unsupporttve social (provtded), supportive tangtble (received), and supportive emottonal (provtded) These three vanables accounted for 24% of the vanance m mastery The vanable, supportive tangible (received), 1s not stgmficantly correlated wtth mastery and thus must be m the equation because of a suppressor relatton- ship with the other independent variables There were no stgnificant predictors of Independent functioning In summary, provtdmg emottonal support to others IS significantly related to posmve affect, community mtegratton, and mastery

DISCUSSION

Social network size and composltlon

The results of thus study replicate previous research which has shown that the networks of former psychtatnc mpattents are small [7, IO] In examining the composmon of patients’ networks, we found that residents reported associating more with frtends of their own gender This pattern of same sex fnend- ships 1s consistent wtth a large body of research which has found that people prefer fnends of their own gender from a very early age [52] We also found that residents of both genders tdentified more women than men m their networks, particularly m the family Research on the family stress mvolved in caregiving to adult children with psychiatric problems sh&vs that mothers and sisters overwhelmmgly bear the burden of demstttuttonahzatton [13-151 Femmtst analysts suggests that this result IS an example of how women are treated as second-class ctttzens m society The stressful aspects of thrs caregivmg and the lack of pay and support for this important role contnbute

SSM MN-H

to stress reactions for women caregivers, as the above mentioned studies have demonstrated. The quahtat- ive data suggested that ex-patients who recently moved into supporttve housmg reported less dependency on the family This finding leads us to the proposttton that independent hvmg can dmunish the stress that family members, especially women, expenence Future research 1s needed to test this proposition

Functronal aspects of network transacttons

By comprehensively investigating the types of transactions the residents have-that is, both supportive and unsupporttve, across emottonal, soctal, tangible, and problem-solving dimensions, and with family, friends, and professionals-we denved a more complex and positive picture than prevtously reported m research on psychiatnc patients. The quan- titative data summanzed m Tables 3 and 4 and the quahtattve data show that, for our sample, the networks m general are more supportive than unsupporttve, as has been reported with other populattons [26-281. We also found that emotional transactions are more frequent than the other types, and that proportionally more fnends provide support to or receive support from participants, compared with family and professtonals In fact, given that the residents’ fnends are often other residents, there IS some evidence here that this populatton 1s more capable of mutual aid than researchers and mental health workers might have recognized. Parks and Pthsuk [29] also found that fnends and fellow restdents were most frequently mentioned by patients as the sources of emottonal, soctal, and instrumental support Stmtlarly, research on cancer patients has shown the nurtunng potential of friendships [27] Furthermore, our results show that transacttons with family members tend to be positive First, we found

442 GEOFFREY NELSON et UI

that proportionately more family members provide supportive than unsupportlve transactlons to the partlclpants Second, the proportlon of family members who provide unsupportlve transactions IS very small and does not differ from the proportion of friends or professionals provldmg unsupportlve transactions

Recrprocq of soczaf network transactions

In contrast with previous research on ex- psychlatrlc patients [7, 10,291, we found conslderable evidence of reciprocity m transactions between resl- dents and members of their social networks More- over, evidence of reciprocity was found using both ANOVA and correlational analyses with two different measures, functional network size and frequency of transactions There was only one instance m which reciprocity was not observed Professionals provided more support, particularly problem-solving support, than they received from partlclpants Since the results of this study and others [35,36] have shown reaproc- lty to be associated with well-being, we agree with Rlessman [34] that professional intervention that follows a parentahstlc model denies people opportu- nities for provldmg support Professional and self- help mterventlons which emphasize residents’ strengths are necessary for residents to emancipate themselves from dependency relations [53]

There are several possible reasons why ihe findmgs of this study diverge from previous research First, the way support provided and received has been assessed varies from study to study For example, Parks and Plhsuk [29] asked whether participants might be called on by someone m their network to provide support, while we asked who residents had actually provided support to Varlatlons m the way such questions are asked may yield different results Second, sample differences may be Important Cohen and Sokolovsky [7] found that lack of reciprocity m social relations was most pronounced for psychlatnc patients with residual symptoms Patients without such symptoms differed very little m reciprocity from residents without a psychlatrlc history Reciprocity may occur m patients who are relatively asymp- tomatlc and high functlonmg, such as the participants m our sample, whereas non-reaprocrty only becomes apparent in more low functioning, symptomatic ex- patients Third, It IS possible that context affects reclproclty Parks and Plhsuk [29] found some reclproclty between BCH residents and fellow residents, but not between residents and the operators of the homes Previous research demonstrating a lack of reciprocity has been conducted m settings which may have low demands for residents to pro&le support to others, such as hospitals [lo], SRO hotels [7], and BCH [29] In contrast, the supportive housing settings m which this research was conducted have a philosophy which emphasizes resident mvolvement and contnbutlons to the household Such programs provide a desirable, naturalistic milieu m

which staff can coach residents m interpersonal skills and encourage mutual support These are mterven- trons which can help ex-patients to build stronger networks, with less dependency on family and professionals [5]

Whatever the reasons for the different findings m this study, compared with earlier research, the finding of reciprocity m social relatlonshlps for psychlatnc patients IS an important one It suggests that reapro- cal relatlonshtps are possible for former patients In so doing, it re-focuses our attention on residents’ strengths and msplres optlmlsm

Context of social network transacttons

Another dlstmctlve feature of our findings 1s the evidence we found pertaining to the nature of the different housing settmgs [4] Previous studies with this population have shown the value of accounting for the context of social network transactions [40,41] On the one hand, our results (see Table 6) show that residents of BCH do not slgmficantly differ from residents of GH or SA m terms of network size On the other hand, residents of GH and SA reported supportive transactions with more fnends and pro- fesslonals, reported a greater frequency of support provided and received, and showed slgmficantly more community integration than the residents of BCH Furthermore, the residents themselves perceived enhanced independence and self-empowerment after moving mto GH and SA GH and SA that facilitate forming fnendshlps, developing mterper- sonal problem-solvmg skdls, and cultlvatmg personal mastery over actlvltles of dally hvmg appear to offer a better housing environment than BCH However, given the small sample sizes for different types of housing programs and the cross-sectional research design, firm conclusions about the effectiveness of different types of housing programs cannot be drawn from this study Current trends m housing for psychlatrlc patients have shown an evolution from patients m mstltutlons and residents m professionally-run transltlonal housing services to tenant-citizens fully integrated m self-selected, normal community housmg [54] Indeed, consumers clearly prefer permanent, accessible, affordable, decent housing in independent or shared apartments, with support services only if desired [S3] Future research IS needed on the full range of housing alternatives for ex-patients

It 1s also possible that differences between housing types m frequency of support provided and received are due to characterlstlcs of the residents We m- eluded a measure of independent functlonmg to check for this possible influence, and we found that residents of BCH were less independent than residents of SA and GH Since the residents of SA and GH had Just moved mto these programs, it seems unlikely that the programs had influenced mdependent functlonmg m such a short time While mdependent functlonmg was not slgmficantly related to either frequency of supportive transactions provided

Social network transactlons 443

(r = 0 16) or frequency of supportive transactlon received (r = - 0 12), housing typmg was con- founded with level of functlonmg of the residents Further research IS needed to disentangle these settmg and mdlvldual influences on social network transactlons

Social network transactions and adaptation to commu- tuty lrfe

Several findmgs stand out from the regresslon analyses First, provldmg emotlonally supportive transactions to network members was posltlvely related to posltlve affect, commumty mtegratlon, and mastery These findmgs are consistent with hess- man’s [34] assertlon that provldmg support can benefit people and remforce the Importance of a mutual ald approach to mterventlon We also found that provldmg unsupportlve transactlons to others was related to negative affect These findmgs support Nelson’s [55] hypothesis, denved from the two-factor theory of emotional well-bemg, that supportive transactlons are related to posltlve affect and unsupportlve transactlons are related to negative affect

descnbe condltlons over which they had no control and would then proceed to complete the Mastery scale m a way that mdlcated that they believed they were m control of their lives Future research nught benefit from usmg scales that tap residents’ perceptions of control m specific concrete areas, such as residents’ perceptlons of control m deaslon-makmg m their homes Finally, none of the social network transactlon measures was related to mdependent functlomng Further research IS needed to examme how social mteractlon processes Influence autonomy or dependence

Impbcatrons for pohcy and future research

With regard to community mtegratlon, the regresslon analysis showed that recelvmg unsupportlve transactlons from network members (emotlonal and soaal) was posltlvely related to this variable More- over, mne of the 16 possible correlations between the frequency of network transactlons and commumty mtegratlon were posltlve and slgmficant Bmrlarly, Moxley [44] found that several measures of provldmg or recetvmg support were related to patients’ commumty mtegratlon While the findmgs that unsupportlve transactlons are positively related to commumty mtegratlon might seem puzzlmg at first glance, these results probably reflect the fact that conflict 1s a part of commumty hfe In other words, bemg Integrated mto the commumty hkely entalls both supportive and unsupportlve transactlons with network members Moreover, the measures of supportive and unsupportlve transactlons assess the frequency of mteractlon, which m a way are mdlces of commumty mtegratton

Given the small sample size and the cross-sectional design used m this study, lmphcatlons for pohcy can, at best, be only tentattvely suggested from the data Given the findmgs that support IS related to various measures of adaptation to commumty hvmg and that GH and SA provide more support than BCH, GH and SA appear to be more desirable types of housmg for this population than BCH These findmgs support the current pohcy of developmg more supportive housmg programs m the community [I] Future research companng these three different types of hvmg arrangements IS needed Moreover, larger sample sizes and longltudmal designs are reqmred to determme the posltlve and negative outcomes result- mg from partlclpatlon m these different types of settmgs

Another pohcy Issue relates to the strong findmg of reclproclty of support Mental health workers ought to restructure their programs and services for this population to nurture or even remove professional lmpedlments to the prohferatlon of mutual ald and naturally-occurrmg Interpersonal problem-solvmg among residents Explonng relations between pro- fesslonals and residents might prove mterestmg. It IS possible that what residents find most valuable 1s reliable, clear, and direct mformatlon about the effects of medlcatlon and perhaps about formal commumty services, all m the context of an empathic relatlonshlp (271

Provldmg emotlonal support to others was poa- As to future research, we were encouraged by the tlvely related to feelings of mastery Again, this usefulness of abandomng the umtary conceptlon of findmg 1s consistent with Rlessman’s [34] assertlon social support for the more contextuahzed and com- that provldmg support to others 1s Important for prehensive framework we employed. Like Dakof and one’s well-bemg We also found that provldmg un- Taylor (271 m their study of cancer patients’ supports, supportive social transactlons (1 e excludmg others we see the emprncal value of mvestlgatmg various from one’s social life) was positively related to mas- functions of social support, both supportive and tery While this findmg appears to be counter-mtu- unsupportlve, provided by and gven to family, ltlve, it may mean that residents who exert control fnends, and professionals However, we did not seek and set hmlts regarding when and with whom they the perceptlons of residents’ network members and Interact feel more m control of their lives Howebgr, thus lack a truly transactlonal approach Relatedly, the relatIonshIp between mastery and provldmg un- we do not have a contextualized understandmg of the supportive social transactlons should be Interpreted role reclproclty plays m relatlonshlps which promote cautiously, as we do not know whether mastery refers mdependence or dependence Smce residents reported to autonomy, control over family pressures, or some that glvmg 1s as important as recelvmg, further other dlmenslons of residents’ well-being Indeed, we mvestlgatlon of the functions and perceived meamng found that durmg the mtervlews residents would of reciprocity Is necessary

444 GEOFFREY NELSON et al

Acknowledgemenrs-This research was supported by grants from Wllfnd Launer Umverslty, the Umverslty of Water- loo, and the Ontano Muustry of Health, Commumty Men- tal Health Branch We thank the residents and staff of the vanous housing programs for their partlclpatlon, Donna Cameron, Gary Edwards, Len Froze, Karen Hayward, and Ruth Slater for conducting the mtervlews, Jamce McCarthy for scoring, coding, and entermg the data, as well as for her role m IntervIewing, and the three anonymous mtervlewers for their helpful comments

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Shumaker S A and Brownell A Toward a theory of social support Closmg conceptual gaps J Sot Iss 40, 1 l-26, 1984 Tholts P A Social support as coping assistance J Consult chn Psycho1 54, 41&423, 1986 Barrera M Social support in the adJustment of preg- nant adolescents Assessment issues In Socral Networks and Socral Support (Edlted by Gottheb B H ), pp 69-96 Sage, Beverly Hills, 1981 Rook K S The negative side of social mteractlon Impact on psychologlcal well-bemg J Pers Sot Psv- chol 45, 1097-1108, 1984 Coyne J C and DeLongis A Going beyond social support The role of social relatlonshlps m adaptation J Consult elm Psychol. 54, 454460, 1986 Shmn M , Lehman S and Wong N W Social mteraction and social support J Sot Iss 40, 55-76, 1984 Flare J , Becker J and Coppel D B Social network interactions A buffer or a stress? Am J Commun Psycho1 11, 423439, 1983 Dakof G A and Taylor S E Vlctlms’ perceptlons of social support What- IS helpful from whom4 J Pers Sot Psvchol 58. 80-89. 1990 Shuster’T L , Kessler k C and Aseltme R H Sup- portive mteractlons, negative rnteractlons, and depressed mood Am J Commun Psycho1 18, 423-438, 1990 Parks S H and Plhsuk M Personal support systems of former mental patients resldmg m board-and-care faclh- ties J Commun Psycho1 12, 230-244, 1984 Vaughn C and Leff J The Influence of family and social factors on the course of psychlatnc illness A compan- son of schlzophremc and depressed neurotic patients Br J Psychuzr 129, 125-137, 1976 Kanter J , Lamb H R and Loeper C Expressed emotion m famlhes A crItIca review Hosp Commun Psychzat 38, 374-380, 1987 Seeman M C The famllv and schlzouhrema Humane Med 4, 96100, 1988 - Caplan P J Don’t Blame Morher Mendmg the Mother-Daughter Relanonshrp Harper & Row, New York, 1989 Rlessman F Restructurrng help A human services varaduzm for the 1990s Am J Commun Psycho1 18. i21-230, 1990 Rook K S Reciprocity of social exchange and social satlsfactlon among older women J Pers Sot Pqchol 52, 145-154, 1987 Maton K I Patterns and psychological correlates of material support within a rehglous settmg The bldlrec- tlonal support hypothesis Am J Commun Psycho1 15, 185-207, 1987 Blake R Normahzatlon and boarding homes An exam- matlon of paradoxes Sot Work Hlfh Care 11, 75-86, 1986 Segal S and Moyles E Management style and mstl- tutlonal dependency m sheltered care Sot Psychlal 14, 159-165, 1979 Eckenrode J and Gore S Stressful events and social supports The slgmficance of context In Socral ?Vet- works and Social Support (Edlted by Gottheb B H ), pp 43-68 Sage, Beverly Hills, 1981. Nelson G and Earls M An action-onented assessment of the housing and social support needs of long-term psychlatnc clients Can J Commun Ment Hlth 5, 19-30, 1986 Goldstein J M and Caton C L The effects of community environment on chrome psychlatrtc patients Psy- chol Med 13, 393-199, 1983. _ _ Holman T and Shore M F Halfway house and family mvolvement as related to commun;ty adJustment fo; ex-residents of a psychiatric halfway house J Commun Psycho1 6, 123-129, 1978

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43 Kennedy C Commumty mtegratton and well-bemg Toward the goal of commumty care J Sot fss 45, 65-17, 1989

44 Moxley D P Explonng the vahdity of soctal network mdtcators for use m psychosoctal rehabthtatton Psy- chosoc Rehab J 11, 3-10, 1988

45 Earls M and Nelson G The relattonshtp between long-term psychtatnc chents’ psychologtcal well-bemg and then perceptions of housmg and soctal support Am J Commun Psycho1 16, 279-293, 1988

46 Dtener E and Emmons R A The Independence of posmve and negative affect J Pers Sot Psychol 47, 1105-1117, 1985

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49 Pearhn L and Schooler C The structure of copmg J Hlth Sot Behao 19, 2-21, 1978

50 Rappaport J , Setdman E , Toro P A , McFadden L. S , Ret&l T M , Roberts L J , Salem D A, Stem C H and Ztmmerman M A Fuushmg the unfimshed busmess Collaboratrve research wtth a mutual help orgamzatton Sot Pal 16, 12-24, 1985

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53 Carhng P J MaJor mental Illness, housmg, and supports The promtse of commumty mtegratton Am Psycho1 45, 969-975, 1990

54 Blanch A K , Carhng P J and Rtdgway P Normal housmg wtth specrahzed supports A psychtatnc reha- brhtatton approach to hvmg m the commumty Rehab Psycho1 33, 47-55. 1988

55 Nelson G Women’s hfe strams, socral support, copmg, and posmve and negatrve effect Cross-secttonal and longrtudmal tests of the two-factor theory of emottonal well-bemg J Commun Psycho1 18,239-263, 1990

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Social network transactions of psychiatric patients