For users of psychiatric services who have severe mental disorders, social support is key to living a meaningful life within their community (1). It provides access to emotional, material, and cognitive support, including help with managing diseases and limiting the consequences of stressful situations (2–5). It helps to reduce symptoms (6,7), avoid multiple inpatient admissions (8), and improve access to health care service providers (9).
Psychiatric service users, like the general population, access social support through their personal social networks. A person's personal social network (or ego network) is the web of his or her social relationships, i.e. the people he or she is in contact with and the contacts between those people (10,11). The personal social network can have a direct or indirect impact on health or well-being, including through the provision of social support (12,13). Personal social networks have often been used in social support studies to operationalise social support (10).
The size, composition (e.g. relatives and professionals), and structure of a person’s social network are likely to determine the support a person receives. In the general population, a large social network is associated with increased access to social support (14,15) and a diversified network offers more support of all types (16,17). Individuals who are embedded in a cohesive network, in which a large number of the contacts know each other, seem to receive more support (14,17,18), although other studies, on more specific populations (migrants), found no association between network cohesion and social support (19).
We know less about the influence of the personal social network on social support for psychiatric service users. For instance, one study showed that relationships with life partners, friends, and peers are more supportive than those with family and professionals (Nelson et al., 1992). The presence in the social network of people who are aware of the person's mental health problems is predictive of a broader array of perceived support functions (23). Another study, which looked at network density (the ratio of actual to possible relationships) and social support, found no association between them (24). Research on access to social support for psychiatric service users has tended to focus mainly on the association between support and service utilisation or symptomatology, rather than on the actual provision of support (8,20,25–27). Moreover, previous studies have mainly investigated the effect of the whole network characteristics on the support provided. For service users, however, social support is the product of individual and collective factors, and the interactions between them: the provision of support does not depend only on the characteristics of the network of the person receiving support (the “ego” in personal network terminology) or on the characteristics of the social contact providing support (the “alter”). It also depends on how an alter is embedded in the personal network of the ego he or she is supporting. In other words, the support that a specific alter provides to an ego is not independent of the support that other alters provide to that ego. When an alter is connected to many other alters, he or she is more likely to provide support than if he or she is disconnected from other alters (28). For example, a study of the general population found that the more ties an alter has to the other alters in an ego’s network, the more likely the alter and ego are to provide support to one another in relation to labour and housing issues (18). Another way to illustrate this interdependence of alters has to do with the composition of the alters in a network: alters in a network composed mainly of other similar alters are more likely to be supportive than those connected to dissimilar alters (17,18,29).
Few studies, however, have actually examined the interdependence of the social support provided to psychiatric service users by alters. Social support has mostly been analysed from the perspective of the ego, without taking into account the different roles played by different alters in supporting the ego. The structure of a network is likely to influence the provision of support by each alter in at least three different ways. Having many ties with the ego’s other alters (degree centrality) provides a particular alter with more and better information, the capacity to respond more effectively in the event of a crisis, and, potentially, a better understanding of the ego’s needs. Moreover, for an alter, strategic contact with alters from the ego’s different social circles (e.g. family, friends, work, or leisure) who do not have other contacts with each other (betweenness centrality) can also increase the support offered to the ego by providing faster access to information and making it possible to coordinate the actions of the other alters. We might, therefore, expect more central alters to be more supportive than less central alters (hypothesis H1).
Furthermore, being connected to other alters who are similar in terms of alter role (relatives and friends, mental health professionals, or other professionals) increases an alter’s level of investment in the ego and in the other alters, because similar alters have shared interests and needs (30,31). We can, therefore, expect alters with more relationships with other similar alters to offer more support (hypotheses H2).
The connectivity within an ego’s network is also likely to have an impact on the support offered by the alters. Network cohesion (or distributed connectivity), i.e. the presence or extent of ties among alters, may increases the level of pressure of the group on alters to provide support. Network centralisation (or centralised connectivity), i.e. the extent to which it contains a small number of central alters, may also improve the coordination of the delivery of support. Thus, an alter embedded in a cohesive network is likely to offer more support because of the influence of other alters and an alter embedded in a centralised network is likely to offer more support as the support it offers is coordinated with the other alters (hypothesis H3).
Taking these arguments from the existing literature into consideration, we aim to explore how the pattern of relationships between alters is associated with the support they provide to an ego (a psychiatric service user). We ask three main questions about the determinants of the social support provided to psychiatric service users:
(RQ1) Are alters in more central network positions more supportive?
(RQ2) Are alters with more relationships with other similar alters more supportive?
(RQ3) Are alters embedded in more cohesive networks or in more centralised networks more likely to offer support?
Those questions are important from a health services and community health perspective. They may help to explain why the level of support offered to service users with severe mental disorders by certain types of alters may differ depending on the structure of the service users’ personal networks. Furthermore, in the context of community care, studies like this one can help design interventions to support specific alters in their efforts to help service users with severe mental disorders to live meaningful and integrated lives within the community.
It should also be mentioned that the data collected within the framework of this study is rare given the cost of this type of collection. We recruited people suffering from severe mental health problems in a variety of life contexts, using a random sample (at the level of service providers and service users). We collected the structure of their personal social networks and the importance of the support provided by each member of their networks, from the users' point of view. This is a unique form of data collection.