Author
TRACY Elizabeth M.; BIEGEL David E.;
Personal social networks and dual disorders: a literature review and implications for practice and future research.
Journal citation/publication details
Journal of Dual Diagnosis, 2(2), 2006, pp.59-88.
Summary
This review of 36 studies is organised around three themes: the structural characteristics of social networks; network composition; and the impact of social networks on the treatment and recovery of people with mental and/or substance use disorders. It finds that social networks can have both positive and negative effects, and that further research is needed, especially in relation to dual disorders where there is very little specific research. Some recommendations for practice are made.
Context
For individuals who suffer from both a mental illness and a substance abuse problem, establishing positive social support services and re-establishing pre-substance abuse social networks can be 'an important and challenging feature of treatment programs'. Those with dual disorders are at higher risk of poor treatment outcomes because of factors such as poor treatment adherence and difficulty in accessing relatively separate services for their mental health and substance abuse problems. There is, however, very limited empirical evidence on the social networks of these people. This review aims to bring together what does exist with the findings of the separate literatures on social networks and mental illness, and social networks and substance abuse.
Methods
What sources were used?
The following databases were searched from 1990 onwards: PsycINFO, Social Sciences Index, Social Work Abstracts, Sociological Abstracts and Current Contents Connect. Available reference lists, government websites, and researchers currently working in the field were also used although no specific details are given.
What search terms/strategies were used?
These are not discussed.
What criteria were used to decide on which studies to include?
Social support was defined as 'verbal or non-verbal information or advice, tangible aid or action that is provided by social network members or inferred by their presence and that has beneficial emotional or behavioral effects on the recipient.' A social support network thus 'refers to a set of relationships which provide nurturance and reinforcement for efforts to cope with life on a daily basis.' Within these definitions, studies were selected if they covered people with diagnosed substance use and/or mental disorders, and reported empirical data on social networks and/or social support.
Who decided on their relevance and quality?
This is not discussed.
How many studies were included and where were they from?
Thirty-six studies, listed in Table 1 which gives details of subjects, research design and findings. Most were quantitative, using cross-sectional (31%) or longitudinal survey (36%) designs. Only six used qualitative methods. Geographical origins are not indicated.
How were the study findings combined?
The review is narrative and organised around three main themes.
Findings of the review
The authors note the paucity of evidence, with only seven studies directly focusing on social networks and dual disorders. It is for this reason that they also cover the literatures of social networks of adults with substance disorders, and with mental illnesses.
Structural characteristics of social networks
Findings across all three of the literatures show that social networks are fairly small in size when compared to those of people without substance abuse and/or mental disorders. In three dual disorder studies, average pre-treatment social networks consisted of 5.3 people (395 participants), 6.26 people (130 participants) and 6.7 people (168 participants).
In respect of the composition of social networks, the substance abuse literature generally focuses on the number of abusers they contain. Abusing members of networks can facilitate or encourage continued drug use, while their presence may lead to isolation from non-abusing members. One qualitative study showed that divisions can occur in the social networks of drug users attempting to kick their habit, with some supporting recovery and others criticising the user's earlier lifestyle.
Among those with mental illness, studies 'often point to the preponderance of natural networks of family and friends', although the networks of people with severe illness may consist largely of formal relationships with professionals. Participation in self-help programmes is one way of developing and strengthening network connections, while dual disorder clients who agree to live in structured environments are more likely to develop stable, non-substance using networks.
Types of support
The size of networks is not necessarily a useful predictor for their usefulness. Among substance abusers, support for sobriety is vital, with partners and close family members being particularly important. However, families may have adverse effects: they may be instrumental in precipitating abuse or, through negative attitudes, hinder treatment and recovery. Limited ability to form interpersonal relationships, especially among among female substance abusers and possibly as a result of past sexual trauma, can affect treatment effectiveness.
People with mental illness who are satisfied with their support networks generally report fewer symptoms (especially of depression) and better quality of life, while lower levels of support are associated with more severe symptoms and less likelihood of recovery.
Among people with dual disorders, specialised 12-step, self-help groups have been associated with improved well-being and reductions in both symptoms and substance abuse, although one study showed no such association. Support from family members can, as in the substance abusing population, have both positive and negative effects, with stressful family interactions leading to treatment relapse and increase substance use.
Treatment and recovery
Social network members, as already indicated, can support or undermine recovery, especially in relation to substance abuse. For example, much attention has been paid in the substance abuse literature to the adverse effects on recovery of network members who are also abusers. Although fellow abusers are likely to remain in the network, fewer numbers have been associated with better outcomes. More positively, among those with dual disorders, studies have shown that families can help professionals in engaging unmotivated ill relatives, while their involvement in treatment has a positive impact on outcomes.
Other factors that have been show to have a positive relationship with treatment outcomes are having a larger rather than smaller social network, experiencing more frequent and 'multiplex' social contacts, having more close, confidant network members, and involvement in a self-help group.
Authors' conclusions
'The literature we have reviewed.report[s] generally consistent findings regarding the structural characteristics of social networks, the types of support, and the effects of social networks in treatment and recovery.' However, the literature has limitations. There is a general lack of studies that focus specifically on people with dual disorders, and those that do exist have dealt with people suffering from severe mental illnesses. Social networks are conceptualised and measured in a variety of way, and most of the studies are cross-sectional, which limits causal analysis and the ability to assess the impact of social networks over time. In addition, few studies have addressed issues of race, ethnicity or gender, all of which have potentially important influences on social networks.
The authors advise that studies are needed on the role of social networks in relation to clients' readiness for, access to, entry into and participation in treatment, as well as in relation to support for recovery. More information is also needed on social networks in relation to a wider range of mental disorders. Experimental studies should be conducted to evaluate the impact of substance abuse and mental health treatment programmes on the size, composition and social support provided by the social networks of people with dual disorders. They should explore a wider range of issues, including race; ethnicity; gender; the impact of trauma (especially among women); and the role of families in facilitating or hindering treatment and recovery. Finally, there need to be evaluations of structural or functional social network interventions to support recovery and relapse prevention.
Implications for policy or practice
An understanding and assessment of social networks 'is important to understanding addictive behaviors' and can help both the practitioner and the client identify sources of support as well as sources of stress, peer pressure and non-support that might affect recovery. Interventions to mobilise or re-build networks can be a useful part of the treatment programme, and social skills training may help the client in developing and sustaining them.