“What Are The Challenges of Treating Mentally Impaired Patients in The Era of a Pandemic?” : Qualitative Exploration Caregivers


 Introduction: Caregivers provide support for mental disorders in the form of care such as assistance in daily life activities, but during a pandemic it is a challenge in itself. Objective: To explore the caregiver's experience in caring for clients with mental disorders in remote areas during a pandemic. Methods: Using a phenomenological qualitative research design with 25 participants. The sampling technique used was purposive sampling with data collection techniques using in-depth interviews and field notes then analyzed using IPA (Interpretative Phenomenological Analysis). Results: This study found 6 themes, namely: Caregiver Workload and Tension, Threats to Caregivers' Physical and Psychological Well-Being, The Need for a Continuing Family Role, Holistic Care, Coping Strategy, Communication is getting harder.Conclusion: our research provides unique findings about the experience of treating mental disorders needs during the COVID-19 pandemic. Caregivers of mental disorders struggle with parenting difficulties during the pandemic, which poses a threat to their well-being and potential harm to the mental disorder survivor-caregiver relationship.


Introduction
The delivery of healthcare is being challenged as the coronavirus disease 2019 (COVID-19) sweeps across the globe [1]. led to a rapid increase in cases world wide, by imposing widespread national or citywide lockdowns and strict social distancing measures [2]. These measures to reduce the spread of COVID-19 have inevitably created challenges for the delivery of health care services to people with longterm care needs such as mental illness management .
Distress and fear in the larger community due to isolation and quarantine, essential during a pandemic. People with mental disorders have been shown to experience higher levels of stress, anxiety, and depression. People with the disorder are generally more susceptible to COVID-19 [3]. They may not understand information about COVID − 19 and may have di culty following safety procedures such as wearing masks and maintaining personal hygiene. Those with mental disorders may also have limited access to health services and hospitals [4].
Hence, concern that client health outcomes will be negatively affected is a current disruption facing the delivery of health care services.The World Health Organization (WHO) has around 450 million people with mental disorders in the world with the proportion of years of living with disabilities (YLD) of 14.4%. The prevalence of households with household members with schizophrenia or psychosis in Indonesia is 7%, with the highest prevalence (11%) in Bali Province and the lowest (3%) in the Riau Islands Province.
Meanwhile, the prevalence of mental-emotional disorders in the population of East Java Province aged ≥ 15 years is 6.82% (4) .The prevalence of Mojokerto Regency, in this case, is less than 5%.
The severity of mental disorders, behavioral symptoms, time spent caring for, being a female caregiver, and reducing work have all been associated with increased caregiver burden [5]. The needs of caregivers and people with mental disorders were numerous even before the pandemic, including, building capacity in health services, mental-friendly services, and cost-effective services [6]. Although there is not much literature on the treatment of mental disorders during disasters around the world, very little is known about the experiences of caregivers of mental disorders during the COVID-19 pandemic. In this paper, we describe the experiences and needs of caregivers of people with mental disorders during the COVID-19 pandemic and lockdown in a city in Indonesia. We present their challenges during the COVID-19 pandemic.

Method
The qualitative interview data that support the ndings of this study are available from the corresponding author upon reasonable request. Participant aregivers were recruited from a mental health service set up by a non-governmental organization, in Mojokerto, Indonesia. mental disorder patients registered in the database and viewed between 21 December 2020 to 21 January 2021 Purposive sampling was used to include different socio-economic backgrounds, severity, and types of mental disorders, and to obtain an equal gender distribution (both caregivers and persons with disabilities). Monthly household income is used to determine socioeconomic status. The inclusion criteria are: 1. Caregiver who is a permanent employee; 2. Aged 20-75 years; 3. Provided assistance to clients with mental disorders at open houses; 4. Provided care assistance for more than one month.

Data Collection
Individual semi-structured interviews were conducted with 25 participants from December 2021 to January 2021. Participant demographic data were collected at the start of each interview, gender, diagnosis of mental disorders, and level of current caregiver assistance required. We complete data collection to the point when no signi cant new ndings emerge, and information redundancy is achieved (ie, at the 15th interview). Because of the measure of social distancing, the second author conducted face-to-face interviews using health protocols, each lasting about one hour. Interviews were audio recorded with participant consent. The writing of memos that captures the interviewer's direct interpretation and questions about the interviewee's answers during the interview was also used as a Page 4/18 source of additional data. Ethical approval for this research through the ethics committee of Universitas Airlangga and verbal consent from the participants were received.

Data Analysis
Data analysis began immediately after each interview. The interviews were transcribed verbatim for analysis. Using the ID analytical guideline, we inductively coded the transcribed interviews and memos.
Initial and focused coding approaches were adopted for a systematic coding process. Constant comparison strategy was also used to facilitate the systematic process. During the coding process, we focused on generat-ing themes that correspond to knowledge needs among health care professionals, with our epistemological stance on health care disciplines [7]. NVivo12 (QSR International) was used to manage the interview data and assist the coding process. The quality of data analysis (ie, rigor) was assured in the 4 aspects in the ID guideline: epistemological integrity, representative credibility, analytic logic, and interpretive authority.

Caregiver Workload and Tension
Providing 24-Hour Care For the mentally ill, sending the mentally ill for medical treatment usually serves as a break from their overwhelming caregiving duties. Therefore, during the pandemic, they have to provide longer treatment with less rest time.
It really felt like I was taking care of him 24 hours a day at home. When I have to take it out or when the physiotherapist came to our house, I could sit on the side and rest while watching him… but I couldn't rest because social distancing measures came into effect. even in people with mental disorders (Participant 4).

The Addiction of People with Mental Disorders Increases
Caregivers revealed that people with mental disorders became increasingly dependent during the pandemic, where sufferers more often asked for help when the caregiver was there, especially for caregivers who did not go out and work because of the pandemic.
He becomes more demanding, if he sees me around, he will call me more often, or just call me no matter what happens just because I am here… He may keep asking for food every 2 hours… Or invite him to play in the room. (Participant 22) Taking on the Role of a Rehabilitation Therapist In addition to providing daily essential care, participants also realized the importance of rehabilitation in the recovery of people with mental disorders. To compensate for the amount of exercise that survivors can do in rehabilitation centres, caregivers seek to take on additional roles as rehabilitation therapists. However, it is challenging for caregivers to do so, due to their lack of competence and con dence in providing rehabilitative care. Therefore, people with mental disorders are reluctant to do rehabilitation exercises with them.

Potential Risks of Physical and Verbal Abuse Victims of Mental Disorders
There is a worrying phenomenon of increasing physical and verbal con icts with mentally ill patients, as participants will lose control of their emotions and become aggressive as the duration of treatment becomes longer. There are more and more con icts going on today. Holistic Care Treatment efforts are in the form of psychopharmacology Participants stated that the strategy of giving drugs to clients with mental disorders was carried out in various ways. Some are given directly, some are given with the delivery of drugs are vitamins, through the patient's sugar, through food, and through drinks. This is done by the caregiver for the shelter because not all clients with mental disorders are aware and willing to take medication regularly.
In this study, information was obtained from participants regarding drug administration strategies "...Like Ms. D doesn't want to take medicine, so the medicine is put in sugar..." (Participant 24).

Therapeutic communication
Participants apply nonverbal therapeutic communication by evoking emotional responses, with clear and concise language, applying appropriate timing and relevance. Caregivers often use non-verbal communication techniques when communicating with clients with mental disorders. This type of communication is haptic or by touching, embracing, and holding hands that is done to build a trusting relationship.
"They are more comfortable when there is a polite touch, because they will be more trusting" (Participant 25) The use of verbal type of therapeutic communication delivered by Participants mentioned the existence of such as inviting in interesting conversations, motivation, seduction to feel at home and conveying messages little by little. Verbal therapeutic communication carried out by halfway caregivers such as starting conversations that attract participants' attention, motivation to carry out daily activities, and conveying religious knowledge little by little according to the situation and conditions experienced by the client.

Psychosocial therapy
Patients must be able to re-adapt to their social environment, be able to take care of themselves, be able to be independent and not depend on others.
"I must also be able to provide psychosocial therapy so that they are able to be independent, as well as teach their families" (participant 13) Psychoreligious Therapy.
The results of the study indicate that there is an effort to care for halfway house caregivers with psychoreligious therapy. Psychoreligious therapy treatment efforts such as ve daily prayers, prayer, religious lectures, and tattoo therapy.
"We treat clients with mental disorders like family and treat clients with mental disorders like friends" (Participants 6 and 10).

Coping Strategy
Making peace with the situation Coping strategies used by caregivers when nding obstacles in caring for clients with mental disorders, namely making peace.
"We try to make peace with the situation when we experience di culties in treating clients with mental disorders" (participant 5).

Praying
The next adaptive coping strategy is praying by saying istighfar, Al Fatihah, dhikr, and taking lessons from events that have occurred.
"We have basic education in Islamic boarding schools so praying is one of the coping methods we do when we face di culties in treating clients with mental disorders" (participant 9).
According to the words of the kiai Expressing remembering the advice of the kyai when he was at the Islamic boarding school, remembering the nurse oath that had been uttered, intending to carry out work for Allah SWT "I always remember what the kiai said about all doing anything for the sake of Allah" participant 2 "We also remember the nurse's oath that she once said when she graduated from nursing education, so there is guilt if the client does not carry out her role as a caregive" (Participant 3).

Support System
Coping strategies by seeking support are usually obtained from husbands, psychiatrists, and caregivers.
"I will usually tell the problems and di culties during treatment to someone who is considered capable of providing solutions and support" (Participant 1).
The results of this study also identi ed a coping strategy shown by the caregiver by avoiding.
"When I feel uncomfortable with the client it is better to leave and not respond to the client" (participant 4).

Communication is getting harder
There is no good feedback from clients Someone with a mental disorder will be very di cult to communicate with if the patient is in an unstable condition, especially when the patient lacks communication due to restrictions on meeting people. So they will remain in their previous state.
"…I try to always invite communication, but since the pandemic and rarely meet people for communication, it makes it di cult for them to provide feedback when communicating"(Participant 2) There is social isolation in the patient The condition alone in the room causes the patient to be affected by his own thoughts, especially the patient who has not been able to control his mind and himself. Outside activities are starting to be limited and meetings with fellow patients are also limited, making all of this di cult.
"….I feel for myself how di cult it is to treat mental disorders during a pandemic, because treatment with drugs is not enough, but socialization is very helpful" (participant 3)

Discussion
We identi ed the experiences of caregivers of stroke families during the COVID-19 pandemic, and these experiences were categorized into 6 themes: di culty of care services, workload and additional caregiving tensions, threatened relationships between caregivers and stroke survivors, threats to caregivers' physical health. and psychological well-being, and the need to continue in a nurturing role [5].
One of the impacts of the COVID-19 pandemic on caregivers of mental disorders is the increased physical burden. Closure of rehabilitation and child care centers in Hong Kong. means that people with mental disorders are no longer able to receive therapy, resulting in a decrease in their function and an increase in dependence on caregivers [4]. This situation is exacerbated by social isolation and the act of working from home, as participants have to provide longer care for their family members with reduced informal and formal support. hours of care are known to be generally higher for single caregivers and those living with care recipients, therefore making them more susceptible to burnout from trying to meet work and increasing demands for care simultaneously in their homes and jobs during the pandemic [2]. Support service retirement also leaves participants without the opportunity to take a break from their piled up parenting duties, because they reported poorer physical health and fatigue when caring for people with mental disorders during the COVID-19 pandemic [8].
In addition, because people with mental disorders and people with multiple comorbidities are more susceptible to COVID-19 infection, caregivers feel obligated to be involved in Hygiene practices such as disinfecting the environment more often add to the burden of their caregiving duties. Participants also experienced psychological improvement and emotional burden during the pandemic [3]. While many caregivers of mental disorders are already experiencing psychological stress in connection with their extraordinary caregiver role, the uncertainty surrounding the COVID-19 pandemic has increased the suffering of participants, placing them at higher risk for anxiety and depression. Participants reported similar concerns about infection and transmission of COVID-19 with previous studies, as and concerns over unemployment, reduced income, and increased spending on hygiene products [9]. Studies show that social support can reduce the psychological distress and risk of patient abuse and act as a buffer against physical and mental illness [10]. While participants in this study previously had the opportunity to take a break from parenting duties and relieve stress by meeting up with family and friends, social distancing measures have isolated participants and limited the support they receive from their social support network, contributing to stress higher [11].
In this study, the alarming situation of increasing the risk and frequency of harassment is revealed. Social isolation, increased patient dependence, and time demands during a pandemic have been shown to increase patients' susceptibility to abuse from caregivers, which is similar to the accounts of participants in this study [12] , [13]. Economic pressures and forced closeness with family members during quarantine can also lead to an increased risk of aggression and domestic violence [14].
Our ndings further suggest that ill-treatment of people with mental disorders has preceded, and that current parenting di culties may have exacerbated the situation [15]. Despite the shocking di culties, the caregivers expressed their commitment to continuing the role of care for their mentally ill patients, as a way to repay the care they had received themselves from the survivors [16]. This is similar to the ndings of previous studies, where caregivers maintained a nurturing role despite deteriorating health.
Indonesia's traditional culture in the future emphasizes collective interests and values of lial piety committed to the family, and plays a key role in making decisions to provide care for family members [17] , [18]. Quitting the parenting role would thus be seen as a departure from the expectations of the spouse [19].
Coping strategy is de ned as a certain process accompanied by an effort in order to constantly change the cognitive and/or behavioral domains to manage and control external and internal demands and pressures that are predicted to burden and exceed the abilities and resilience of the individual concerned [20]. The results of this study indicate that the coping strategies used by caregivers are adaptive. The results of this study indicate that there are adaptive coping strategies used by caregivers when nding obstacles in caring for clients with mental disorders. Caregivers try to make peace with the situation when they have di culty in providing care to clients with mental disorders [21]. This is done so that caregivers do not feel stressed and burdened with the work they are doing. This is in line with Fitriani's research which states that caregivers' perceptions of their burdens can also affect various aspects of daily life which in turn can affect the quality of life [22].
Deliberations and discussions are constructive activities carried out by caregivers as a form of coping strategies for caregivers. Deliberations are usually carried out by the caregivers of the halfway house directly face to face or through the WhatsApp group application. Deliberations and discussions conducted by caregivers are positive things that must be carried out so that they do not become a burden on the caregiver in caring for clients with mental disorders which then affect the caregiver's quality of life.
The next adaptive coping strategy is praying by saying istighfar, Al Fatihah, dhikr, and taking lessons from events that have occurred. This is in line with research by Al andi et al (2018) which states that religious coping affects a person's cognitive patterns to nd solutions to di cult situations they face.
Some caregivers have basic education in Islamic boarding schools so praying is one of the adaptive coping methods they do when facing di culties in caring for clients with mental disorders. Participants in this study mentioned adaptive coping strategies by remembering positive things. Remembering the advice of the kyai at the Islamic boarding school, remembering the nurse's oath that was once uttered, intending to do work for the sake of Allah SWT, remembering the patient's development, self-re ection, and returning the problem to God Almighty. This is in line with the results of Dewi's research (2018) which identi ed a spiritual coping strategy by submitting and returning all the problems she experienced to God in accordance with the Book of Al-Quran Surah Yusuf verse 86.
The results of this study identify the existence of an adaptive coping strategy by seeking support. Caregiver will tell the problems and di culties during treatment to a person who is considered capable of providing solutions and support. In this way, it is hoped that the problem will be resolved soon and not burden the caregiver [23]. This is in line with Ribe's (2018) statement which states that seeking social support for caregivers with mental disorders can reduce the risk of mental health problems and reduce the level of perceived burden [24].
The results of this study indicate that there are di culties in the communication aspect felt by the caregiver. Yusuf (2019) explains that severe mental disorders are disturbances in thoughts, behavior and feelings that are manifested in the form of a set of symptoms and or signi cant behavioral changes, and can cause obstacles in carrying out human functions. Damage to social interactions experienced by schizophrenic patients is a problem due to positive and negative symptoms that must be immediately addressed with therapeutic communication so that self-isolation does not occur [25], [26]. In patients with mental disorders experience emotional disturbances that are shown through affect and mood. Affect is an external expression of one's emotions that can be seen from one's face [27].

Conclussion
To the best of our knowledge, our research provides unique ndings about the experience of treating mental disorders needs during the COVID-19 pandemic. Caregivers of mental disorders struggle with parenting di culties during the pandemic, which poses a threat to their well-being and potential harm to the mental disorder survivor-caregiver relationship. The pandemic has also exposed gaps in their stroke care knowledge and rehabilitation skills due to the suspension of formal support services, as well as their need for critical resources to protect themselves effectively from COVID-19. Support for caregivers is urgently needed to reduce their caregiving burden during the pandemic and to maintain their caregiving role.

Con ict of interest statement
The authors declare that the research was conducted in the absence of any commercial or nancial relationships that could be construed as a potential con ict of interest Author contribution statement the author contributes to providing knowledge about how caregivers treat mental patients properly, so that mental patients can recover and return to society properly Contribution to the eld Community and psychology nursing science helps the community in improving their health status, among others, by empowering the community itself. the better and more participative the community is, the more people care about health. This study examines how the role of the caregiver in providing services to people with mental disorders, the caregiver strives for people with mental disorders to recover without recurrence and return to society, can be accepted by society. In this case the caregiver must be able to make mental disorders able to function again and independently in carrying out daily activities.

Ethics statements
Studies involving animal subjects Generated Statement: No animal studies are presented in this manuscript. Studies involving human subjects Generated Statement: The studies involving human participants were reviewed and approved by Komite Etik Fakultas Keperawatan Universitas Airlangga.