How do people with long‐term mental health problems negotiate relationships with network members at times of crisis?

Abstract Background Social network processes impact on the genesis and management of mental health problems. There is currently less understanding of the way people negotiate networked relationships in times of crisis compared to how they manage at other times. Objective This paper explores the patterns and nature of personal network involvement at times of crises and how these may differ from day‐to‐day networks of recovery and maintenance. Method Semi‐structured interviews with 25 participants with a diagnosis of long‐term mental health (MH) problems drawn from recovery settings in the south of England. Interviews centred on personal network mapping of members and resources providing support. The mapping interviews explored the work of network members and changes in times of crisis. Interviews were recorded, transcribed and analysed using a framework analysis. Results Three key themes were identified: the fluidity of network relationality between crisis and recovery; isolation as a means of crises management; leaning towards peer support. Personal network input retreated at times of crisis often as result of “ejection” from the network by participants who used self‐isolation as a personal management strategy in an attempt to deal with crises. Peer support is considered useful during a crisis, whilst the role of services was viewed with some ambiguity. Conclusions Social networks membership, and type and depth of involvement, is subject to change between times of crisis and everyday support. This has implications for managing mental health in terms of engaging with network support differently in times of crises versus recovery and everyday living.


| INTRODUCTION
Social interventions for mental health recovery and management have increasingly been viewed as an alternative to more traditional means of management especially in relation to those from underserved communities. 1 Clinical treatment models of social interventions, 2 forming the bases of a purported biopsychosocial model have seemingly failed to prioritize the "social" elements; however, interventions which prioritize participation have suggested positive outcomes associated with asset-based approaches, trusting relationships and resource-seeking to enhance community participation. 3 Social participation interventions, such as social prescribing or community referral which have been seen as a means of improving access to psychological treatments and other resources which support mental health, bring to the fore the need to illuminate the role, properties and function of network mechanisms. 4 A network perspective offers opportunities to explore the ways in which the quality of social relationships may impact on mental health 5 and to address the latent assets and resources which may be available to people in need of condition management and support which lie outside the formal health-care delivery system. 6 Support from social networks has been shown to make a contribution to improved health outcomes for people with long-term conditions and in the genesis of mental health (MH) problems and utilization of services. 7,8 The utility of social network resources depends on successful activation of connections that can provide access to relevant information or support. 9 Exploring the role and function of social ties is relevant for understanding the support and resources that are leveraged in the trajectories of those experiencing MH problems in everyday life recovery and in times of crises. Previous research suggests that one response to crisis is to identify those most able to provide support from a larger group (selective activation) with the consequence that those able to secure "adequate" network resources seemingly report better outcomes than those who "injudiciously" select network ties. 7 A "social safety net," comprising community organizations and health-related network ties has the potential to reduce the utilization of MH services 10 by providing emotional and direct alternative support for self-management activity. People, animals and material objects are key to providing support and linking people to needed resources in a person's personal network. For example, online peer support has been found to provide benefits through social connectedness, feelings of group belonging and the sharing of strategies and narrative for coping with the challenges of living life with a MH problem. 11 Diverse networks (including strong and weak ties) may be better placed (compared to more restricted network types) to support long-term condition management, because of the availability of increased opportunities for negotiating relationships with network members and resources. 6 Connections to and interaction with objects, places, pets and activities are also likely to be relevant to understanding the crises and recovery "work" of those with a MH problem. 12 However, relatively little is understood about the way in which network members provide support and resources for management, and the difference in how people negotiate network support requirements at different times (eg, in times of crisis versus recovery). Here, we utilize network mapping as an heuristic device to explore people's personal networks to examine the support available to manage MH and explore relationships with different network members at times of crisis.
Crisis represents a negative event in life. However, it can also be an opportunity for growth. 13 For the purposes of this study, crisis is defined as the point at which mental distress becomes overwhelming or unmanageable to the extent that the experience of it disrupts everyday life. It is a multifaceted process which can be understood as a trajectory that can be recognizable but is not necessarily linear. 14

| METHOD
The project forms part of a larger programme of research carried out through Wessex CLAHRC exploring self-directed support, people's social networks and links to local community resources in the management of LTC. At the beginning of the study, a Patient and Public Involvement event was held at a local recovery college, and people with MH problems helped co-produce the project and its design. The main changes that occurred as a result of this consultation were that networks in times of crisis were to be considered alongside day-today networks. SW carried out semi-structured interviews and mapping with participants in a community-based context on the South Coast Hampshire. SW then independently coded the data whilst regularly discussing the emerging themes with AR, IV and AK who also independently coded six interviews to enhance rigour. The whole team met regularly to discuss on-going analysis and to discuss, explore and confirm emergent codes.
Twenty-five participants were recruited, of which nineteen were female and six male. † All participants were white British; ten were married with the remainder single, eight lived alone; ten were unemployed, nine in occupation, including voluntary (n = 1), three were retired and three considered themselves disabled; eleven considered themselves to live in an affluent area with the remainder less so with three stating their area as deprived. For further demographic information, see Table 1.

| The sample
Participants in this study were considered eligible if they were aged over 18 and had been diagnosed with a MH problem by either secondary care services (22) or their GP (3). Participants were recruited via venues which included a local recovery college and communitybased non-statutory MH support groups. As these groups already involve a degree of self-management, it is possible that participants may represent a more motivated group of people with MH problems.
Potential participants who responded to adverts of the study placed in the aforementioned venues were recruited to the study. A † Information on sexual preference was not gathered, but where participants disclosed a significant other, they were of the opposite gender. consent form was signed once the participant was conversant with the study. Convenience sampling was used and those that came forward for selection, if they met the inclusion criteria, were included regardless of gender or demographic status. There was a purposive element to this, however, as a formal diagnosis of a MH problem as an adult was a pre-requisite for inclusion in the study.

| Data collection
Face-to-face semi-structured interviews were carried out, by the lead author, between October 2015 and April 2016 at a location convenient to the participant. Participants were asked to map social networks using a concentric circle diagram which was adapted from previous studies. 15 Participants placed network members on the map. They were asked to consider the inner circle as most essential to their MH, the middle circle as very important and the outer circle as less important than the other two circles. Network members could be people, places, activities or objects, in fact anything that the person considered to be valuable to them in terms of managing their MH. No maximum number of network members was prescribed, and participants were able to list as few or as many as they considered relevant to their situation.
In addition to their day-to-day maps, participants were asked to indicate how the map would change in a crisis. Four participants created another map to indicate crisis networks, but the majority of participants used different colour pens to circle or underline the network members that would remain in the network in crisis and arrows to indicate where network members might move between circles of importance. Interviews lasted between 25 and 100 minutes and explored the role and key attributes of individual network members to MH management on a day-to-day basis and during crisis, thus detailed information was collected about the contributions each member made to MH management at these times.
Ethical approval was obtained from the University of Southampton research governance office.

| Data analysis
We took an inductive approach for the analysis. Data comprised of audio recordings and verbatim transcripts of 25 semi-structured interviews; field notes were taken at the time of interviews and the network maps were completed at the time by each participant. Data were categorized firstly by participant, interrogated to address the

| RESULTS
Here, we present data and emergent themes most pertinent to management of crisis.

| The fluidity of network relationality between crisis and recovery
With some people operating in crisis mode for much of the time, participants described crisis as a fluid experience, which from recognizing triggers from past experience had to be managed in the moment. Participants suggested that the direction of travel in this situation is not always the same, some found that crisis could be averted by certain activities or interactions and others found that reaching out for help and not getting it could precipitate crisis unexpectedly.
All participants reported reduced networks in times of crisis (see Table 2). Those members most often leaving (sometimes temporarily) or moving to the periphery of a personal network in crisis were members representing a source for social involvement (eg, engagement with a voluntary organization).
Members most likely to remain in contact during crisis, tended to be spouses or very close family members. They were described by the participants as those who were reliable whatever the circumstances and were able to accept them despite their MH problems and allow the participant to "be themselves." we'll just sit with it and it will be OK. The possession of a crisis management plan is part of modern day MH care and reflecting the anticipation of crises in the future, some of the participants who had previously experienced a MH crisis, managed network members in such a way as to help maximize the chances of being prepared for another crisis should it occur.
One such measure was taking steps to protect the most valued relationships from the consequences of being in crises. This included limiting the amount of information shared with others due to the fear of overburdening them with support expectations, being aware of the responsibilities that they already carry and concern for their wellbeing: a very close friend, his wife has got cancer at the moment so I find I have to be careful because I could overload him with stuff, he's got his own issues. P23 In periods of non-crisis, whilst managing intense emotions seemed to be a daily endeavour many participants described spreading the load by getting support from a variety of different network members.
Participants with a diverse day-to-day network seemed more geared towards this end than those that did not. This diversification "strategy" seemingly acted to prevent individuals from becoming overburdened should they be exposed to the work of supporting someone The value of this relationship cannot be described as strategic, as a resource, but rather as carrying intrinsic value through sense of self and concern for others, which is contrasted with the strategic use of services.
As such, this cannot be seen as rationing support.
Relationships were not always viewed so positively, and some were seen as more precarious. Participants indicated that the emotional work required in close relationships was sometimes too hard to cope with: if mum answers the phone she will sense in my voice and The changing nature of networks from day-to-day to crisis is presented in Figures 1 and 2. brother remains, a situation she stated was due to his having had MH issues too so he was able to understand how she felt. Advice seeking is added to the map and described as something undertaken predominantly when in crisis to provide reassurance from multiple points at this time.
Whilst the second map is reduced in scale, it is still relatively diverse. This was the case for 16 participants and may indicate that diversity of networks as best for illness management might still hold in a crisis situation, although in a more condensed form.

| Isolation as a means of crises management
Isolation appeared as a characterizing feature of managing crisis.
Isolationism was considered to have both a positive and a nega-

| Leaning towards peer support in times of crises
The foregrounding of the relevance of peer support, where peers represent someone with lived experience of MH problems rather than formal peer workers housed with services, was a feature of crisis network configuration. Peer support was noted in 18 participant day-to-day networks and 14 crisis networks. In two instances, the peers' position within the network remains unchanged; in four cases, they decrease in importance; and in two cases, they increase in importance during crisis (see Table 3). Eleven networks had peers positioned within the inner circle and of these, 8 remained there during crisis suggesting that peer support remains useful throughout crisis in a way services did not appear to.
Peer network members appear to provide a basis for rootedness and empathy which is meaningful, and emotional support is seen to be useful and sensitively delivered: Here, indicating that he had been encouraged to socialize more whilst in crisis which was unhelpful at the time of crisis but may well have been helpful to ward off the crisis or help him reconnect to others on emerging from crisis. The relationships that are built with individual practitioners within services were also cited as useful by 14 participants.

so I guess the crisis team would be [on the network map],
but it was great that they came out to me every day but I would certainly hold the intimacy that I have with [CPN] being there care wise a lot more than crisis. P17

| DISCUSSION
Social networks provide the structural elements of mechanisms for social interactions through which personal social systems of support are built, and the means through which individuals act and react to network members in their immediate environment. This study has examined the personal social networks implicated in day-to-day support compared to crisis management of those experiencing a mental health problem.
The configuration of networks provided through the mapping exercise illuminated the dynamic nature of a personal network for those with a mental health problem. Our analysis illuminated how compared to dayto-day management, networks change in times of crisis.
Day-to-day networks differed from crisis networks in so far as they tended towards greater diversity (ie, containing a mixture of people, activities, pets and places) and thus capacity for social involvement.
This can enhance self-efficacy, the capacity to self-manage and the leveraging of resources from other people, voluntary and community organizations. 16,17 In times of crisis, interactions with networks members were more selective tend to shrink, with the participants' spouses or friends most likely to remain in the network. Being in touch with fewer but closer social network members was conceptualized by respondents as a means of ensuring the security of continuing acceptance despite the difficulties presented by a crisis. Interaction with fewer close network members might represent the greater ease of managing the permutations of dishonour, shame, enacted and felt stigma which accompany the onset of a crisis. [18][19][20] The apparent reduction in the size of the network also seemed to present the bases of managing crises through isolation-allowing withdrawal and the means to cope on one's own. These results problem. 24 The latter may provide the bases for on-going support and a means of preventing crises through social involvement. Diverse networks are more durable over time and avoid the intense intimacy of friends and family so may be experienced as less stressful. 25 They may provide possibilities to spread the load of support over a large group of people and consistency of relationships which can be returned to once the individual is out of crisis and able to interact again. In this respect, our findings align with studies where the importance of retreating to "safe havens" has been noted 26,27 and in crisis, some respond by managing alone. Isolation led to mixed outcomes for participants in one study, 27 for some the crisis resolved and for others it exacerbated the situation a position echoed by participants in this study. So, whilst this pragmatic coping technique "gets the job done", 28 it has associated costs which then may need addressing.
The finding that isolation and a shrinking network can confer benefits at times of crises warrants further investigation. However, from this study there are suggestions that acceptance of a degree of isolation by those in crises confers a positive means of coping together with the need to focus on reconnecting to social networks members once a crisis has passed. These findings imply that a greater understanding of the individuals' social network is required to avoid the unnecessary pathologizing of something that it likely to enhance recovery and provides greater understanding of the importance of social networks.
This points to the need for services to understand and respect the resources that an individual already has in place in their social networks to help them cope with possible crises. Rather than agreeing with a traditional view that isolation is to be avoided, MH services might need to be aware that the personalized, use of isolation appears to be an essential part of crisis management and should be explored and supported rather than assumed to be a sign of illness. Acceptance of withdrawal, which can be monitored rather than services demanding social interaction at a time when it could be actively damaging, is worthy of consideration. In this respect, isolating behaviour is not necessarily a sign of further illness and may indicate a mechanism of healing and coping. Furthermore, the supportive, accepting and informative role that peers can play may be currently under-utilized and estimated by services. Rather, the latter could provide and be considered an additional resource for supporting those in crisis and lends support to including peer workers who have lived experience of health problems to fulfil roles in MH care orientated to crises management.

| Strengths and limitations
Whilst this study provides important insights into how people negotiate network members in crisis, there are some limitations. Recall of crisis for those not currently viewing themselves as in crisis may become distorted over time resulting in recall bias, and the small sample size limits the generalizability of the findings over larger groups of people. Individuals were predominantly recruited via a local recovery college and as such may not be representative of others in mental distress. All participants were white British and, where a preference was expressed, heterosexual. Thus, results cannot be generalized across minority groups based on ethnicity or sexuality. There is some evidence from other countries that some groups within LGBT communities and ethnic minorities are more at risk from MH crises and in need of supportive networks due to increased health needs coupled with limited access to social resources. 29 Despite this, the study also has strengths. The in-depth examination of the networks of people managing long-term MH issues both day-to-day and in crisis provides a unique opportunity to further understand this area and to consider service crisis response in the light of the findings. It provides an enhanced view of the patient's world which could inform alternative and developing approaches to crisis management in MH services.