Men's experience of their partners' postpartum psychiatric disorders: narratives from the internet

Abstract

Objectives Postpartum psychiatric disorders (PPPD) can be serious and disabling, and may lead to long-term adverse consequences. Partners of women with PPPD are also affected by the illness, but their experiences are seldom described. The aim of this study was to explore men's experience of women with PPPD.

Methods Eleven written narratives from the internet were used to analyse men's perceived experience of their partner's PPPDs. Data were analysed using content analysis.

Results The men revealed a major disruption in their lives. They expressed fear, confusion and anger; they were also extremely concerned about their partners, and felt unable to help in overcoming the disorder. Most of the men described making sacrifices in order to hold the relationship and the family together. Although the disorder improved over time, they were left to face an uncertain future with a woman who seemed to be very different from the person they had known previously. Most of the men gained maturity and increased self-esteem, but for some the result was divorce, custody disputes and loneliness.

Conclusions The men in this study experienced the woman's PPPD as a difficult time, when everything familiar was turned upside down. Health professionals should pay more attention to men's mental health in the postpartum period. Furthermore, information regarding the possibility of these disorders should be given to expectant couples in prenatal classes. Further research is needed to ascertain how and to what extent this should be included in the education.

Introduction

Becoming a parent is generally associated with great joy, but sometimes the picture is darkened when failing mental health becomes apparent in the woman during the transition to parenthood.¹ Postpartum psychiatric disorders (PPPD) are serious and disabling, and these conditions may lead to long-term adverse consequences for women and their families.^2–5

Psychiatric disturbances associated with childbirth are usually distinguished in three different conditions. Baby blues is a state characterised by tumultuous feelings of being physically and mentally fragile, instability of mood and disturbed sleep; the prevalence is 50–80% of newly delivered women.^6,7 Postpartum depression affects about 7–15% of women who have recently given birth, with symptoms of depressed mood including concentration difficulties, extreme fatigue, anxiety and suicidal ideation.^8–12 Postpartum psychosis is a condition affecting 1–2 in 1000 women close to birth, where the woman displays acute psychotic symptoms such as anxiety, hallucinations and delusions.^6,8

Another person involved in PPPD is the woman's partner, who is also attempting to adjust to the transition to parenthood, to the presence of the new baby, as well as the distress of the partner's illness.^13–16 Partners of women with PPPD also have a high rate of psychiatric disorders¹⁷ and indicate that one third of the interviewed men described having mental disorders simultaneously with their partners. Fathers may be depressed if mothers show signs of depression.¹⁸ By contrast, the father may compensate for the sake of the child when mothers are depressive¹⁹ and one third of the men were described as supportive partners.

Only three studies concerning solely men's experiences were found in the literature review. In an interview study with eight men, Meighan et al²⁰ found that the illness strongly affected the men's lives and relationships with the women. They were deeply worried and had difficulty coping with the situation. They were afraid, confused, angry and frustrated; but at the same time they had to take the major responsibility for their families in order to keep the family together. Similar results were found in an interview study in which 13 partners of women with postpartum depression were interviewed.²¹ According to Tammentie,²² the traditional perception of male characteristics is that a man should be physically and emotionally strong and self-contained, and this view impedes men's ability to show their vulnerability and seek help for their problems.

In an earlier study by Engqvist et al,²³ examining women's experience of postpartum psychosis, it was found that the reality of life for the partner changed drastically during the time of illness; however, very little research has been conducted concerning the experience of men. We consider it important that the partners' experience is also brought to light, for the benefit of primary healthcare staff when providing care for women with PPPD. Therefore, the focus of this study was to gain a deeper insight into the situation of these men, including their reactions, attitudes and coping strategies. The aim of the study was to explore men's experience of having a partner suffering from PPPDs.

Methods

An inductive, explorative, qualitative design was chosen, using the internet as a source of data.²⁴ In recent years, there has been an increase in individuals' use of the internet to share personal narratives, obtain support and seek reassurance from others with similar experiences.^25–28 Using the internet as a data source is supported by Robinson,²⁹ who states that internet narratives tend to be more detailed than verbal narratives, because the secure feeling of being anonymous allows individuals to share their innermost thoughts and feelings, particularly in the light of the stigma associated with mental illness.

Data collection

The words postpartum or postnatal disorder, postpartum or postnatal psychosis, postpartum depression, narratives and stories were keyed into the search engines Google, Alta-Vista and Yahoo to search for life stories concerning PPPD and men. The men's narratives were often linked to internet sites concerning information, support and assistance to women suffering from PPPD. Of the 17 narratives that were found, 11 met the criterion for inclusion, i.e. having a spouse or a partner with a postpartum psychiatric illness, and these narratives constitute the study samples. The narratives do not follow a standard format and vary in length from 208 to 3507 words, totalling 16 292 words altogether.

Data analysis

The 11 narratives were read a number of times to obtain an overall impression. Keeping the aim of the study in mind, the basic narratives were examined by identifying relevant sentences, phrases or particular examples which revealed the experience, i.e. identification of meaning units. In this phase of the analysis, the meaning units were decontextualised and condensed; the text was thereby abstracted to a higher logical level.³⁰ These meaning units were then labelled with a code correlated to the content of the units. The codes were derived from the narratives, and more conceptual words reflecting the content could also be used. The codes with their attached meaning units were then compared to find differences and similarities. In this phase of the analysis, concerned with recontextualisation, themes were identified by bringing together codes (with their adherent meaning units) where the content was similar. The descriptions of the discerned themes were then examined to explore variation in the themes and thereby form subthemes.³⁰ Direct quotes taken from the texts were then used to support the descriptions of themes and subthemes.

Ethical considerations

Gaiser and Schreiner³¹ point to the possibility of obtaining data from the internet. One question to be addressed is whether it is ethical to download narratives from the internet and analyse them, as has been done in this study. According to Polit and Beck²⁴ and Robinson,²⁹ it is justifiable. The storytellers are anonymous and cannot give their names and identities, nor is it possible to consider obtaining their permission for this study. Presumably the narrators use a pseudonym if they do not want their names used. As these narratives are published on public websites, one can assume that the narrator relinquishes his control over the stories.²⁹ A second question of interest is the narrator's feelings about the use of his story, if he reads the article based on his experiences. It is quite possible that he would feel proud and happy that his experiences have been used for a good purpose. It is hard to believe that a man would feel his experience has been misused. In our analysis as well as the presentation of the results we have made every effort to be respectful towards the narrators.

Results

The men's descriptions of their experiences are described in themes in a temporal order, starting with themes relating to the early stage of the illness and ending with those relating to later stages. The overarching themes that emerged from the analysis are presented in Table 1.

Table 1.

Overview of themes and subthemes

Theme	Subtheme
Days filled with stressful reactions	Disappointment
	Frustration
	Being shut out
	Apprehension
Continued interference with everyday life	Desperation
	Accusation
	Disturbed relationship
Acceptance of reality and finding solutions	Alleviation
	Problem-solving approach
Life starts to return	Confidence
	Pride
	Trusting
Coping with the past	Maturity
	Hostility

Days filled with stressful reactions

The men describe strong reactions and feelings in the initial period of the illness related to difficulty in understanding what is happening. In addition, there is a change of lifestyle, disturbed routines and an increased responsibility.

Disappointment

In connection with the coming birth and the arrival of the baby, the men have great expectations of becoming a father and sharing parenthood with the woman, but these expectations are shattered. The pregnancy might have been uneventful and the men knew their partner would become a ‘great mother’; so when this illness nevertheless occurs, it comes as a complete surprise.

I was so excited to start our new family and I felt complete for the first time in my life. That's why I was so confused when my wife wanted nothing to do with our son. Do you know how soul-wrenching it is to listen to the woman you love more than anyone in this world say she doesn't want to be with you and your infant son? (7)

Frustration

A strange, nagging feeling emerges in the men: they wondering if their partner is merely nervous and anxious, and not accustomed to being a new mother. They are frustrated and do not have any idea what is happening; and they get very little information from the doctors and healthcare staff they visit and try to get help from. Often, in a first attempt to get an understanding of the fact that the woman's behaviour has changed beyond recognition, the men turn to the internet for information. They state that this is the most difficult time they have ever experienced. They are unprepared for what is happening with their partner; during the pregnancy they received no information from antenatal care or in antenatal education classes. They feel helpless and some of them cry, maybe for the first time in years.

At the emergency room I was overcome with a feeling of loss and cried for the first time in many years. It felt like the life that we had built together was falling apart. (4)

The men are frustrated in their attempts to relate to a changed woman they do not seem to be able to reach; their efforts to help are of no use. Even if they have received information from healthcare staff they cannot utilise it. When seeing a doctor, they experience that they get very little help. They want to support their partner, but are usually pushed away from her and feel lonely.

I felt very frustrated because it seemed like there was nothing I could do to help. I wasn't able to help with the feeding and I also couldn't convince my wife that the baby was fine. (4)

The men try to cope with the situation by with-drawing and pulling back, especially concerning attention and affection from the woman. Still they admit they miss their wife very much and they miss their earlier relationship.

I had to withdraw to a huge degree my expectations of what to expect in terms of attention and affection. (10)

Being shut out

The initial feeling of trying to help gradually changes, and more negative feelings emerge. The men experience sadness and even hate, and their lives are miserable. They blame themselves and feel as if they are the cause of this mess without understanding what is wrong.

She seemed to only hate me and everything I did. I hated going home. I felt like an outsider in my own home. … I had no idea what I had done wrong. (10)

It is a terrible experience to see the woman and mother holding her newborn baby without love or affection, displaying callous treatment rather than a desire to care for the baby. The men find it difficult to leave the woman at the hospital and come home to an empty house alone with the baby. They do not know how to deal with the situation.

Those were very tough days. … It was so tough to see Mom hold her daughter and there be nothing. No love, no affection, no caring. It was so tough. (6)

The men constantly feel that they cannot reach the woman when they try to help. They feel shut out and cannot maintain their role as a father and husband; they can only stand beside her and watch her suffering. The woman may be self-destructive and cut herself, and several men describe their partners wanting to commit suicide. Comments like this scare the men tremendously.

Nothing in my life prepared me to hear those words [suicidal thoughts] from the woman I loved so much. Nothing had prepared me to deal with how quickly our wonderful life with our new baby had spiraled down into thoughts of suicide. (4)

Apprehension

A constant feeling of anxiety pervades the men, especially in the early phase of the illness, when they have persistent thoughts about why the woman does not sleep, but is pacing up and down during the night, washing and cleaning. They do not recognise the woman's behaviour, which makes them unsympathetic. They puzzle over why the woman's behaviour is so strange, and are overwhelmed by thoughts of the future and how this illness will end.

I thought my wife not being able to sleep and doing loads of washing at 4am, my constant feeling of helplessness and anxiety, and feeling like the most hopeless father and husband on the face of the planet, was what everyone went through the first time around. (1)

The men are confused. They describe their feelings and thoughts about the changes in their partner during the time of illness; they also notice that the woman's feelings for them have changed and they feel unloved. They frequently wonder why their partner is not happy about their baby. They do not recognise the woman any longer and cannot understand the reason for this, which makes their feelings about the situation even more complicated.

I felt so lost and confused I didn't know what to do. It was like a stranger had come and replaced my warm and loving best friend with a woman with dead eyes and a cold heart. (11)

Continued interference with everyday life

After the first stressful phase, there is a brief or prolonged phase, where continuous fluctuation in the woman's condition dominates the men's lives. Some days the woman feels better and it seems as if life is returning to normal, but the next day this is gone.

Desperation

Feelings of desperation pervade the men. They try to help the woman in every way, being nice and kind to her, but they are also angry and disappointed over how things have worked out. The men try to be quiet and speak gently, but when this does not help they have thoughts like: ‘Show some backbone, will you?’ (1) The desperation is not just related to the women's behaviour, but also concerns the men's own feelings and difficulty in coping with the situation. When the woman expresses words such as wanting to kill herself and the baby, a feeling of desperation emerges.

I also had no idea how to get help. Nothing in my life has come close to causing as much worry, desperation, anger, frustration, despair, and fear as dealing with PPD. (2)

Accusation

The men express that they are angry and disappointed towards hospital staff and doctors, and blame them for not being interested, not caring and for lacking knowledge about this disorder. They are convinced that the women would get better treatment somewhere else but do not know where to turn. Taking care of the woman and the baby at home is difficult and they blame themselves and society when they cannot manage it all alone at home.

The fact that this was told to me by an OBGYN should show society that this is a VERY common illness that they have no clue how to treat. How can a doctor deliver a baby and not be there with the necessary tools to help cure the mother to protect her, the child and the family as a whole and guarantee that this remains the happiest time of their lives? (9)

Disturbed relationship

There is a great deal of pressure on the family and the social pressure and expectations are difficult to handle. A few of the men are unsuccessful in their attempts to deal with the woman's illness, and their marriage ends in a divorce, which is blamed on the illness.

Less than two months after the birth of our daughter, she asked me for a separation. I tried to convince her to go to marriage counselling, but she refused that as well. (3)

The men describe communication between the couple as characterised by disturbed emotions and feelings. This situation is further complicated if the man is distanced by his partner as she takes total care and responsibility for the baby, believing she is indispensable and her partner cannot provide adequate help. This contributes to lowering the man's self-esteem.

Just when I began to trust again an ugly incident would occur that would send me scurrying back down my emotional safety hole. (10)

Acceptance of reality and finding solutions

After periods of initial stressful reactions and prolonged, overwhelming feelings of disappointment, periods of acceptance follow and hope for the future increases.

Alleviation

There is a sense of relief when the men understand they are not alone in having a partner affected by this disorder. They accept that this is not a form of attention-seeking, emotional manipulation or a case of personality problems starting to appear, but an illness with a great deal of emotional pain and torments. They comprehend that no woman chooses to become depressed and sick; this is a very definite illness, which may result in devastating consequences if left untreated.

When my wife was assessed, and we found out that she had scored top marks on the Edinburgh Postnatal Depression scale, I was actually quite relieved that someone could put a name to what was wrong. (1)

The men understand that the strange events occurring during the time that has passed are a consequence of the disorder. Mood changes, tensions, the excessive caring for the baby, and the strange talk; sometimes this has been verging on unreality. Now that they realise they are important for the woman and the baby, they make every effort to care for the dad.

My wife began to ask for time away from the baby, and the spark that had been missing for so long finally began to flicker behind her eyes. We started to accept that most of what we experienced in terms of our distance and anger wasn't either of our faults. (10)

Problem-solving approach

When the diagnosis is received the men try different ways of solving the problems in connection with the woman's illness, such as persuading the woman about medication and care, and about the importance of being responsive to prescriptions and help. Sometimes they are successful in this, but not always. While the woman is hospitalised, some of the men take care of their baby, sometimes alone, sometimes with the help of relatives and friends. All the time they try to keep calm and unaffected by the woman's mood changes, waiting for the ‘storm’ to settle. They commonly have to deal with outbursts of anger as well as feelings of sadness as they attempt to process and deal with everything that happens.

The hardest part of it all is the drastic change in mood./…/When she praises me I take it with a grain of salt because I know that it can turn on a dime. (5)

After receiving information about the diagnosis from doctors and staff, the men are able to absorb this information and find help and support.

I called her [the doctor] and she explained to me what was happening, how these kinds of things can happen. She talked me through what I needed to do. (6)

Life starts to return

Life returns when the men perceive that the illness and their life situation is manageable again. The men come to the conclusion that this has been a useful period in their lives, where they have learned something for the future.

Confidence

When the initial periods of the illness come to an end, the men return to being positive, excited and looking forward to the future again. With a feeling of confidence they regain their strength. They realise care and medication saved the woman's life.

I credit them with saving her life. I also credit her doctor with taking the time to explain things to us /…/ and know that there was hope. (8)

Pride

The couple can start to address the problems and make necessary arrangements with the healthcare service again. The men realise that this illness affects the whole family and that they must be involved in the care and planning for the future together, as a family, sharing each other's pain and joy, and making sure that the future will be brighter.

My wife eventually took it upon herself to see a counsellor and when she took that initiative, I don't think I've ever been prouder of anyone in my whole life. (7)

Trusting

As time passes, the men's self-esteem grows. From the beginning, they have a hard time trusting the woman because they are afraid that she will hurt their child. When the course of the illness stabilises the men are able to support and help the woman, but also know when to leave her to herself. The couple start to build up trust again, even if this is difficult.

The next few months were a slow process of trusting her again and accepting that most of what we experienced in terms of our distance and anger wasn't either of our faults. (10)

Coping with the past

When the illness comes to an end, the men ask themselves what have they learned and how they should go on.

Maturity

The men describe that they are more grateful and mature, and have gained more insight into life as a whole. They have learned patience, tolerance and hope for the future. The illness has forced them to grow up quickly in order to cope and master the situation. Other lessons learned are how to get support and how to reach out to people and relatives for help. There might still be hard feelings due to the woman's harsh words and treatment, but the relationship grows stronger. The men can consider the idea of future births; there is an increased knowledge that this illness might happen again, but now they know where to turn.

My view of how my life was going to go was shaken. I had to confront my fears, my frustrations, and my disappointments and carry on. I found new strength and confidence that has stayed with me through other serious problems. (4)

Hostility

Some men have coped ineffectively; there are still many hard feelings and they perceive themselves as being bad in their wife's eyes. They can only understand this in terms of their own fault, their own mistakes, how lonely they have been during the time of the illness and how horrible the time has been. They question their own sanity.

I can't say or do anything without it being taken the wrong way and being told how horrible I am to her. She thinks that everything is my fault, no matter what it is, and that I am mean, cruel, and abusive, you name it. (5)

Discussion

The aim of this study was to explore men's experience of having a partner suffering from PPPD. The main results of the study are that the men experienced disappointment, confusion, exclusion and great concern for the woman; they felt unable to help their partner overcome PPPD, which created frustration and anger. The majority of men described making many sacrifices to keep the relationship and the family together. Regaining trust and confidence in the woman required time and was extremely difficult. Even though the PPPD improved over time, the men were left to face an uncertain future with a woman who seemed changed from the person they had previously known. When they looked back, most of the men felt they had gained maturity and increased self-esteem, but for some the result was divorce, custody disputes and loneliness. The process of reactions the men described could be understood in the light of the theory of crisis.³² PPPD usually appears very suddenly, and in such a situation it is normal to go into a crisis, which follows certain stages, similar to the experience of the men in this study. There are four very distinct stages: crisis phase, reaction or recoil phase, resolution phase and reorientation phase. The themes in this study describing ‘days filled with stressful reactions’ and ‘continued interference with everyday life’ could be understood in relation to the first phase, where the theory of crisis describes ineffective, disorganised behaviour that interferes with daily living. The theme of ‘acceptance of reality and finding solutions’ relates to the reaction or recoil phase, where the theory of crisis describes acknowledgement of the situation and attempts to use a problem-solving approach. The theme of ‘life starts to return’ could be compared with the resolution phase in the theory of crisis where the person starts to perceive the crisis situation in a positive way. The last theme in this study ‘coping with the past’ could be related to the reorientation or post-crisis phase, which describes a higher level of maturity; or, in the case of persons coping ineffectively, signs of depression, abuse of alcohol or drugs, or social maladjustment.³²

The results also illuminate that the multifaceted PPPD not only affects the woman herself, but also her husband and family. Before the birth the men had great expectations of the time after the delivery with the newborn baby and shared parenthood, but these expectations were not fulfilled. Their lives were filled with disappointment and frustration. These findings concur with those of a study³³ conducted in Australia, in which the results indicated that men with a partner suffering from PPPD scored higher than a comparison group on depression, non-specific psychological problems and fatigue. The authors suggested that more attention from health professionals to men's mental health in the postpartum period may benefit the entire family. Therefore, it is important for expectant couples to be taught and informed about PPPD in prenatal education or before discharge from hospital, and to be given advice on what steps to take if they encounter one of these disorders. However, this obviously involves a balancing act; the expectant parents need to be informed but not frightened. Prenatal education must not merely focus on the woman's concerns but also on those of the expectant father. Premberg and Lundgren³⁴ found fathers had a secondary role in childbirth education.

The men found it difficult to maintain the relationship with their partner and felt shut out. They heard accusations and hard words from the woman, and their home was no longer a place of peace and friendship. They stated that their usual relationship with the woman was disturbed, and often they were also excluded from the care of the baby. This concurs with findings in a study conducted by Muchena,³⁵ which imply that the situation is further complicated if the woman takes total care and responsibility for the baby, believing she is indispensable. Such a situation may further reduce the man's self-esteem. This is a time when the man may be feeling unsure, anxious and depressed. An indication of the most common theme expressed by men to post-partum women was resentment, due to the lack of appreciation for their attempts to offer emotional or practical assistance to their partners.³⁶ The men feel they are shut out by the woman, but at the same time the women also feel lonely and isolated.²³ Accordingly, there are many barriers to break down if the relationship is to be repaired.

The content of prenatal education, at least in Sweden, focuses almost exclusively on the birth and areas concerning pregnant women.³⁴ The authors suggest the classes to be more concerned with the problems of expectant fathers. This study reinforces that men feel excluded by the woman and play second fiddle in the care of the child, which complicates the situation and the relationship further in an already complicated time.³⁴ Groups for expectant fathers could be designed to strengthen men's role in the transition to fatherhood and to build male networks.³⁴ Such networks would also be favourable for men, especially if the women were to be stricken with PPPD.

In most Western countries the father is present at the time of delivery which is a great advantage for the couple and for bonding with the newborn baby. In a study conducted in Greece it was shown that participation of fathers during childbirth yielded a greater bond between the couple, and their relationship was strengthened.³⁷ Additionally, the bond with the child and the father was also strengthened; and this could perhaps also strengthen the father if a situation of PPPD occurs.

In a literature review it was reported that while becoming a parent is generally a rewarding life experience, this major life transition can be a trigger for depression and/or anxiety.³⁸ The transition to parenthood causes significant changes and has an influential psychological effect on both mothers and fathers. The authors point to the importance of fathers, their mental health and their impact on child health and child behaviour. If the mother is incapable of caring for the baby, showing no interest or interaction, scientific studies show the importance of the father taking over, to interact and care for the child.^19,39

Using narratives from the internet might be questioned as we cannot guarantee the narratives were written by the men themselves. But the penetrating and substantial narratives indicate that this was the case. We cannot guarantee the narratives describe a ‘historic truth’, but the meaning experienced by the men. There is a chance the narratives are touched up. However, people always tell what they want to tell⁴⁰ also if the narrative is told face-to-face, therefore one can expect the narratives were build on the men's own experiences. Irrespective of the narratives describing an ‘historic truth’ they have something to say to the reader concerning being a partner to a woman suffering from PPPD and are thereby ‘narrative truth’. The meanings reported respond to the partners' experiences. The men are unknown to the researchers and do not allow for further probing for accuracy of their narratives.

Strengths and limitations

The number of narratives in this study is small but the findings are illuminating. This study does not claim to make any generalisations; nevertheless, the results can be transferred to similar situations and contexts. The use of internet narratives give the study more strength as the men relating their narratives were not affected by any person or influenced by any external factors such as the healthcare system or staff as far as we know. Appropriate social distance between the interviewer and respondent are claimed as a guarantee for quality in interviews. Using narratives from the internet does not involve any negative interviewer effects at all. They could pour out their hearts and narrate their narratives as they wished. Research on the internet has been mainly quantitative but there is increasing interest in using the internet for qualitative studies with sensitive topics and vulnerable groups.⁴¹

Clearly, the study points to the fact that presence of PPPD adds tremendous strain to the already stressful postpartum period, to the relationship with the woman, and to the bond with the newborn child. In addition, it highlights a lack of adequate resources to provide help for postpartum men.

The strength of this study is that the men relating their narratives were not affected by any person or influenced by any external factors such as the health-care system or staff. If interviews had been conducted face-to-face one can imagine that the men's responses might have been affected if their wife/ partner was hospitalised or had just been discharged from hospital. Therefore, it is possible that the narratives from the internet might be more true to the real feelings of the men, making them freer to say what they really want to express. According to Robinson,²⁹ this could be true; she states that internet narratives tend to be more detailed than verbal narratives, and the secure feeling of being anonymous allows individuals to share their inner-most thoughts and feelings. A limitation of the study is that the men behind the narratives are unknown; they cannot be reached to be asked further questions or to check whether or not they agree with the results.

Conclusion

With the limitations of collecting narratives from the internet and the small sample size in mind this study contributes to knowledge about the partners' experience of the period when their women suffered from PPPD. The period of the woman's illness gave rise to many negative feelings, draining the men's energy and confidence, and undermining their relations with the child and the woman.

The results indicate that health professionals need to pay more attention to men's mental health during the postpartum period. This will benefit the entire family. It is important for expectant couples to be taught about and informed of these disorders in prenatal classes, or before discharge from hospital, and to be given advice on what steps to take if they encounter one of these disorders. It is also important for primary healthcare staff who provide care for women with PPPD to be aware of the men's feelings and give them support and help, so that they in turn can find the strength to support their partners during the progress of the illness.